How does the device look like?

Nanox website, investor presentations, social media, press releases and promo pieces are all littered with designs and photos of various versions of the fancy but fake multi-source Nanox.ARCs.  But you will never find the single-source device that Nanox claims to have submitted for FDA clearance in January 2020.  Not once.

So, how do we know for sure what the device is supposed to look like?  Is it the ugly one that supposedly took the radiograph of the CEO's hand at RSNA 2020 or some fancy multi-source one with just one tube activated?   Has Nanox ever stated, in writing, how the device looks like?

Yes.  A presentation slide helps here - this one, Slide 22, is taken from the January 2021 JP Morgan presentation deck.

It states:

On the left the hand of Ran Poliakine, Nanox s CEO, as was taken during the 2020 RSNA live demo, using the Nanox single source device with the Nanox tube;

So the ugly device from the RSNA 2020 live demo is indeed the device Nanox claims to have submitted for FDA clearance. 

Update April 5, 2021:  Nanox got clearance for a Nanox.Cart (the ugly device).

Another market-moving tweet

Nanox tweets that is going to change the world, and the stock jumps 15%.

The market is oblivious to the irony that it is investors who have been waiting for months for "FDA approval," whatever that is supposed to mean.  As of today, no Nanox x-ray system is legal anywhere in the world. 

Expect FDA approval in early 2020 (quoted November 2019 conversation with the CEO)

Note also that all my research so far indicates that it is not true that two-thirds of the world cannot reach medical imaging and that one-third of the world waits too long to get a scan.  The availability of low-cost x-ray systems (both stationary and portable/mobile) and ultrasound devices has solved this problem years ago.

 

Update April 5, 2021:  Nanox got clearance for a Nanox.Cart (the ugly device).

Importance of using the right terminology

Nanox and its promoters want you to believe that FDA clearance, also known as premarket notification or 510(k), and FDA approval are the same thing.  Here is what the Code of Federal Regulations, the US administrative law, states:

Submission of a premarket notification ... and a subsequent determination ... that the device intended for introduction into commercial distribution is substantially equivalent ... does not in any way denote official approval of the device. Any representation that creates an impression of official approval of a device because of complying with the premarket notification regulations is misleading and constitutes misbranding. ( 21 CFR Part 807.97 ) 

So, Nanox is misleading and misbranding on slide 3 of its investor presentation:

And on its investor calls.

And one more thing.  Notice the device is "intended for introduction into commercial distribution."  But Nanox claims it does not intend to introduce into commercial distribution the device it has submitted, the single-source Nanox.Arc, according to its latest prospectus.

Subject to receiving regulatory clearance, the first version of the Nanox.ARC that we expect to introduce to the market will be a 3D tomosynthesis imaging system [not the single-source device].  If cleared by the FDA, we expect to commercialize the multi-source Nanox.ARC and we may seek alternatives for commercialization of our single-source Nanox.ARC. (page 79)

If the device was not intended to be marketed in January 2020, then the premarket notification was redundant, and the Third Party should have immediately rejected it, if it knew that the device was not intended to be marketed.  Did the Third Party know what Nanox was writing in its draft registration statements filed with the SEC?  And that is one of the reasons why the submission was likely fraudulent, if Nanox submitted anything to anyone for clearance.

Update April 5, 2021:  Nanox got clearance for a Nanox.Cart (the ugly device).  So, what were the Third Party and the FDA told?  More hints when the FDA published the summary document, around May 1st...    

Side by side

Nanox tweets "It's time to move forward. It's time for Nanox."

Maybe it is the Twitter limitation, but it is not clear what Nanox meant to write.

On the left, we have Hologic EPEX digital x-ray system, introduced in 1999.  On the right, we have a device that simply cannot take Chest PA, the most common medical x-ray image worldwide, even if it weren't fake.

Is Nanox finally admitting that the latest version of its multi-source device, the one that Nanox is promoting here, is the equivalent of an ancient x-ray machine?

The Hologic system had an introductory list price of $395,000.  Nanox says free, $10,000, or tens of thousands of dollars, depending on the day.

Please let me know, if you know the clearance, or 510(k), number for the Hologic device.  The Nanox device has not been submitted for clearance, according to Nanox.  Therefore, it cannot be promoted.  "For demonstration purposes only" does not really cut it, but that's for the FDA to decide, of course.

Update:  Here is how one more modern and cleared x-ray machine looks like (list price is below $10,000, I believe, detector excluded).  X-ray is not x-ray, it seems.

Foolish misdirection

Nanox stock is up more than 15% today.  The catalyst may have been a nice promo that claims that Nanox, the healthcare disrupter, is about to receive FDA clearance within a month and start distributing its new X-ray device.

Quite interesting, given that Nanox claims that it has not submitted its magic device for FDA clearance yet.  Nanox claims instead that it has submitted another, a "single-source," device that it does not intend to market or ship or distribute or offer for subscription or service.    

Here are some of the factual inaccuracies and false implications in the promo:

• Nanox has a new kind of X-ray
• X-rays are kind of boring
• [X-ray devices] are very expensive
• MRI devices use or create X-rays
• A CT scanner costs about a million, 2 million, 3 million dollars
• Nanox has made a radical new discovery
• The traditional X-ray devices and CT scanners create X-rays by heating the machine up over 1,000 degrees Fahrenheit, might be 2,000 degrees Fahrenheit
• X-rays devices and CT scanners are incredibly hot machines and have to be cooled down
• The expense in X-rays devices and CT scanners is in cooling the devices down
• Nanox can create X-rays without having to manufacture all this heat and cool the machine down
• Nanox proposed machine is far cheaper (to manufacture), $10,000 instead of a $1,000,000
• Nanox will radically disrupt the market, and is also going to expand the market
• We are going to see a lot more X-rays
• The proposed Nanox machine (a rudimentary tomosynthesis device) can generate images that are comparable to MRI images or CT images, not just to traditional X-ray or tomosynthesis images.

Update (March 13/14, 2021):    thedudemd  @ Stocktwits disagrees that the factual inaccuracies are factual inaccuracies and argues that 

a)  "Traditional xray tubes used in cts do get incredibly hot; so much so that scanners automatically shut down if tube gets overheated,"  and   

b)  "ct scanners do cost millions of dollars."

Tubes or devices/machines?  The Fool contributor said that the traditional x-ray device or traditional CT scanner was being heated up over 1,000 degrees Fahrenheit, which is clearly not true.  These systems operate at room temperature.

But let's talk tubes.  Both the traditional and the proposed Nanox tubes use the exact same inefficient mechanism of generating x-rays, whereby nearly 99% of the heat is generated at the anode and nearly 99% of the energy used to generate x-rays gets wasted as heat.

Interestingly, the filament in the tiny incandescent Christmas tree lightbulb gets even hotter - 2,200 degrees Kelvin to 3,200 degrees Kelvin -  or 3,500 degrees Fahrenheit to 5,300 degrees Fahrenheit!  Each one filament operates at about 2.5 V consuming about 0.4 W, and there are hundreds of them on the tree.  Christmas trees must get incredibly hot and burn up instantly, no?

  

Photo by Jason  Krieger from FreeImages.com

Regarding costs - maybe the latest and greatest CT scanner could cost over $2 million, but you can buy a used one for $80,000, as described here and here.   Of course, the proposed fake five-source Nanox.Arc is in no way comparable to even the oldest, cheapest and abused CT, as it cannot generate axial slices, even in theory.  Moreover, it is not even submitted for clearance, according to Nanox.  The device that Nanox claims to have submitted for clearance is a single-source device that cannot be cleared.

Update June 3, 2021:  The Nanox single-source device that got cleared was the Nanox.Cart.

Why Nanox.Arc has no chance for clearance

Nanox has a nice video on its front webpage titled "Understanding Nanox technology & vision"  It is extremely misleading, and, thus, extremely useful to regulators.  It proves that Nanox.Arc has no chance for FDA clearance, not this year and not ever.

How so?  Well, about 40 seconds into the video, the mesmerizing voice proclaims:

Years of dedicated development by Japanese and Israeli scientists have achieved a novel X-ray source and device that bring hope by being more affordable by orders of magnitude than the conventional X-ray technology used today.

Oops.  See, the FDA clearance pathway is only for a device that is substantially equivalent to a legally marketed device.  A novel device will be immediately rejected, as it fails the RTA checklist, and must go through either a De Novo classification request or a PMA approval submission.  Either one takes years.

Incidentally, according to the same segment in the video, the device below represents the X-ray technology used today:

Unfortunately, that is a sketch of an MRI device, which has nothing to do with X-ray technology - note the "chimney," which is actually part of liquid-helium cooling system (the superconducting electromagnets require very low temperature to operate).

Thanks to ThreadEnhancer @ AuntMinnie for the novel tip.

The video was published sometime in February or March, 2020, that is, after the supposed January 2020 submission for clearance of the single-source device.

Update:  The MRI device in the sketch is a stylized Siemens MAGNETOM.

Update (March 13, 2021):  The video, of course, is not the only place where Nanox explicitly describes Nanox.Arc as novel.

Update April 5, 2021:  Nanox got clearance for a Nanox.Cart (the ugly device).  Nanox.Arc (a multi-source one) still has no chance of clearance, unless Nanox admits that the device is not novel. 

Cost confusion

How much does the fancy Nanox.Arc 2.0 cost to manufacture?

The original press release says $10,000, and it can do, among others:

• Real-time 3D imaging 
• Multi-spectral layering 
• Digital sync with treatment tools

CEO reiterated $10,000-$15,000, except for the first 100 units, on the Q4 2020 results call.

But Slide 41 in the January 2021 presentation says:

Costs tens of thousands of dollars

So, $10,000 or tens of thousands dollars?

Neither.

Any functional device that can do real-time 3D imaging, even basic tomosynthesis, will require a built-in detector that costs well over $100,000.

If we remove the real-time requirement and are willing to strap and completely immobilize the patient for over 4 minutes while taking the 45 projections for the tomosynthesis, then we can maybe possibly, however unlikely, get to $20,000, using the lowest-cost DR detectors, and assuming extra cheap hot-cathode dental tubes, HV generator, PC, etc.

Update:  The combined selling price of the three "analog" systems (which are actually quite digital, in fact) that are supposed to be replaced by Nanox.Arc 2.0, as shown in that slide, is less than $500,000, not "Millions of dollars" as the slide claims (actually, less than $400,000, if one leaves out the redundant Canon/URS U-arm machine)

Update:  Why is cost important?  First, the company has about $200 million in cash only, which will barely cover production and deployment of about 1,000 "working" non-fake machines.  Second, payback becomes moot (in the same presentation, Slide 27, the company claims $27,000 in estimated "minimum" annual revenues per machine) 

Update:  Of course, even if Nanox.Arc 2.0 were not fake, its design does not permit taking a Chest PA image, which is the most common x-ray procedure (but it can be easily done with either the Canon or the Shimadzu machine on the slide) 

Yes, We sCam!

 

Nanox tweets an interesting excerpt today, stating that the company 

has already made 25 of its ARC systems at a partner facility in Israel.

It is interesting, because the CEO and CFO forgot to mention that number three days ago at the investor call, even though they were asked what exactly happened to the 10 prototypes that were supposedly being assembled for partners during the investor call in November 2020.   The latest prospectus, filed February 12, 2021, states on page 1 that the company has only 1 working prototype (even if true, it is likely the ugly single-source device, not shown, here: added March 25, 2021).

Here is the cropped photo from the tweet, showing the supposed 25 systems:

It actually shows 8 Nanox.Arc "systems" only, and none of them is functional (3 don't even have a rudimentary skeleton Arc).

Just another day at Nanox - yes, we scam!

Thanks to K @Yahoo for the slogan idea.

Update (March 12, 2021):  Only one of these 8 unfinished and fake devices looks like the latest version of Nanox.Arc (even though it is very hard to see from this perspective) - 3 don't have an Arc and the other 4 have the black half-arc skeleton of Nanox.Arc 2.0.

Update (March 25, 2021): Another photo surfaces (posted by TerraPharma1 @ Twitter, likely coming from the company - CEO collages it) from the supposed March 16 "company event at the factory [that] celebrated many more devices at the production floor" (Slide 11 and 15:11 into Oppenheimer presentation on March 17, 2020).  Not even one of these devices is completed (to reiterate, the CEO claimed on the November 2020 results call that the company was assembling 10 devices, and latest Prospectus dated February 2021 says only one working prototype, likely the ugly single-source device, even if true) 

Here is the actual March 5 photo (edited by Bloomberg):

And, just so we keep everything together, the one posted by John Nosta @ Twitter
 

The production Nanox.Arc has no detector?

So John Nosta puts a tweet out that shows that Nanox.Arc has no detector, and therefore, cannot make any images.  Stock goes up 15%.

Here is the fake, non-functional device that (supposedly) goes into production, with no clearance or any regulatory approval pending, in all its glory:

John Nosta is the same evangelist who in August 2019 posted the photo of the completely-fake 12V-battery-operated Nanox.Arc 1.0 that could emit electromagnetic waves, but only in the visible spectrum.  According to Nosta, it could fit in a suitcase (it must be a gigantic suitcase!)  and would emit "lower" radiation (which is correct, as visible light is lower in the energy spectrum than x-rays, but can't penetrate most human organs and is therefore useless for diagnostic purposes).  

Update:  In case it is not clear, here is where the detector goes in Nanox.Arc 2.0 (which is the finalized production-ready design, per CEO investor presentation post RSNA 2020 demo).

Cropped snapshot from the Making of Nanox Arc video 

Update:  Added zoomed view of Nanox.Streak and Nanox.Thread:

Update:  Apparently some people are confused where this picture was taken, and believe it is at Foxconn, where the volume production was initially supposed to take place.  The picture was taken in Israel, however (notice the green EXIT sign above the door in Hebrew יְצִיאָה - thanks google translate!).  

Due, in part, to travel restrictions as a result of the COVID-19 pandemic, we expect to manufacture a small number of Nanox.ARC units in Israel on a purchase order basis that will be used for the acceptance tests under our MSaaS agreements, demonstrations, regulatory approvals and for the initial global deployment, among other purposes. (page 5, prospectus)

Update:  Added a link to Nosta's August 2019 tweet and a few words about it.

Update:  Ok, ok, this could be the detector.  Added a question mark to the title of this post...

Update April 21, 2021:  Based on inspection of the latest Nanox video, the device in Nosta's tweet has no detector.  What looked like a possible detector in the view from this angle is likely just a part of the support frame.

zoomed-in snapshot from the new video

Nanox is faking it and stealing

Nanox posted a promotional video today titled "NanoxCLOUD Demo Flow" and then removed it (after some comments on it emerged).  It appears Nanox stole some sample CT images made 15 years ago from a French DICOM viewer vendor and used them to make the video, in violation of the owner's terms of use which prohibit commercial use.  A snapshot from this video has previously appeared in Nanox investor presentations, but the resolution was too low to make any conclusions. 

Here are two shapshots of interest (red ovals for the fun stuff).

Update February 19, 2021:  Note that the findings in the diagnostic report, obtained with the help of Artificial Intelligence (AI), mention "T2 hyperintense white matter lesions," which is mAgIc, since it is impossible to see such lesions in an x-ray or CT scan (white matter hyperintensities are lesions in the brain that show up in an MRI scan as areas of increased brightness when visualized by T2-weighted magnetic resonance, I am told, see also)

Update February 23, 2021:  Nanox is apparently telling people that this video was not supposed to be published.  Unfortunately, Nanox has already shown the stolen images in the past.  Here is Slide 33 from Nanox September 2020 presentation to investors.  What do you see in the lower right corner?  Stolen images.

Tricky terminology

Nanox has a problem with the terminology it is using - is it innocently incompetent or intentionally misleading?  

Nanox typically, but not always (see below), claims to have submitted for FDA clearance (aka 510(k)) rather than FDA approval (aka PMA).  In its draft registration statement filed July 30, 2020, the company states:

In response to the feedback we received from the reviewer, we are conducting standard functional and safety tests to support the 510(k) application, and expect to submit the results from these tests in the third quarter of 2020. (page 1)

Just two weeks later, that statement became:

As part of the review process, in March 2020, we received an additional information request, referred to as a major deficiency letter, from the Review Organization which, among other things, required us to provide additional data and other information to complete the application and to address certain deficiencies highlighted by the reviewer, including the results of certain performance tests. In response to the feedback we received from the Review Organization, we have conducted additional product testing and expect to submit the results from these tests, along with our response, to the Review Organization, in the third quarter of 2020. (page 1)

Ok, feedback sounds less ominous than a request for additional information, but why, oh, why did Nanox have to mention a major deficiency letter?  Why didn't it just put a "deficiency letter," without the "major?" See,

FDA refers to PMA ... deficiency letters as “major deficiency letters” and 510(k) ... deficiency letters as “additional information letters” or “requests for additional information.” (page 2)

And, yes, the reviewer - the Third Party - can send "requests for additional information," according to the overview published by the FDA. 

So, again, why not just write "a request for additional information?" Why confuse anyone reading the filing (and Prospectus) with the addition of the "major deficiency letter," which would imply seeking FDA approval rather than clearance?

Here is an excerpt from the busy Slide 3 titled "Nanox at a glance" in Nanox investor presentation dated January 14, 2021 stating that Nanox expects FDA approval, although this appears to refer to an upcoming submission of the fancy multi-source device (in which case, approval is impossible in Q1 2021, because it takes years of human trials, unlike simple clearance within 90 days).

Update April 5, 2021:  Nanox got clearance, in the beginning of Q2 2021, for a Nanox.Cart (an ugly device).

Planned spontaneity

There are two reasons why the scan of the CEO's hand at RSNA 2020 was not spontaneous as he pretended.

Reason 1:  About 9:20 into video the DICOM tag displayed on top of the radiograph says "Ran_3" - meaning, this was the third time they tried this (the CEO's name is Ran, of course).

Reason 2:  The video overlay with the CEO's name comparing his hand with the hand of Roentgen's wife was prepared well in advance.  It appears briefly in a frame before his radiograph actually shows on the display at about 8:06 into the video.

The weight of a human, CE Marking, and the rest

The fake battery-powered Nanox.Arc 1.0 body scanner can withstand a human, according to a photo shown in June 2020 Haaretz article.

 

Nanox CEO and founder Ran Poliakine, January 15, 2020.source: Haaretz/LUZ Corporate Photography

So, what did the CEO tell the Israeli publication:

"The Nanox.ARC was distantly inspired by the sickbay of the 1960s television series Star Trek, where “Bones” McCoy would swipe a device over a patient to get a complete instant medical picture."  OK, so Nanox.Arc is fiction?

"On a practical level, the research and development was born of a failed project at the Japanese company Sony to develop LED screens."  Not OK - it was a failed project, but nothing to do with LED (light-emitting diodes)

"compared to just $10,000 and 70 kilos for the Nanox"  Not OK.  Nanox is now saying tens of thousands of dollars, and weight is no longer discussed.

"The company has applied for permits to the U.S. Food and Drug Administration, Europe’s CE and Israeli regulators."  Really, really not OK!!! There are no such "permits."  Nanox is now saying it has not submitted for FDA 510(k) clearance of the magic device, and that it has not submitted for CE Marking, and that means that it cannot register with the Israeli Ministry of Health.  

"Nanox is readying to install a device at Jerusalem’s Hadassah Medical Center to be used for developing novel early-detection and screening protocols to promote global preventive healthcare practices. Research is scheduled to begin the first quarter of 2021."  Not OK.  It is not happening.

"A [Sony] team worked on the idea [for a novel LED screen] for seven years at a cost of more than $1 billion. The project never yielded the screen because Sony canned it after Panasonic got to the market with a similar, lower-cost device. But along the way the team designed tiny silicon chips capable of creating consistent and exacting screenshot images, Poliakine said."  Not OK at all.  The story is quite a bit different, there was no $1 billion, and there are no such chips "creating consistent and exacting screenshot images."

"X-ray technology was developed at the end of the 19th century and to this day uses the same basic technology, based on heating a metal filament to 2000 degrees Centigrade."  Not OK.  The metal filament thing was invented in 1913 by General Electric (the former employer of Nanox Advisory Board chair).  Until then, X-ray technology used Nanox, that is cold-cathode, technology.

"The filament emits electrons that collide with an anode to create x-rays. The process uses a lot of electricity to keep the device cool."  Not OK.  Nanox process needs just as much electricity to keep the device cool.

"Nanox uses a proprietary silicon chip embedded with 100 million microcones that generate x-rays There are no moving parts, no need for cooling and no need for lots of electric power."  Not OK.  Nanox proposed tube performs exactly the same and uses the same power as a cheap Chinese tube unsuitable for medical imaging.  And, nope, Nanox does not have a novel tube that can be used in a commercial device. 

"Nanox ... employs 60 people, 38 in its Israel R&D center ad the rest at production facilities in Japan, the U.S. and South Korea."  Not OK.  Nanox has no production facilities anywhere.

Update March 25, 2021:  The original $1 billion thing seems to come from the June 2019 press release by Nanox predecessor (the current Nanox was incorporated in December 2018 but did not start "operations" until September 2019, per prospectus)

Update September 28, 2021: The April 2020 Hadassah press release says:

Over $1 billion and 15 years of development have been invested in revolutionizing the X-Ray source...

So, 7 years at Sony and 8 years at Nanox and Nanox predecessor?  Nope.  First, all Sony did was to send 6 "engineers" to the offices of Candescent to "learn" about the tech after it signed an agreement with it in November 1998 - there is no evidence that any independent devlopment.  Second, NanoX Imaging (Nanox predecessor) was "a multinational start-up established in 2012," but it was developing x-ray detectors not sources!

Fooling one or the other, or both

Someone liked this comment I made:

The draft registration statement filed by Nanox in early February states that the company is planning to file for clearance, meaning it did not file in January. Same draft registration statement says the company has "not produced a working prototype of the Nanox.Arc" (a later draft registration statement says it was produced in February). 

A single-source unit may have been available for a century, but the FDA and the EU say it must pass certain safety and effectiveness thingies, including HVL and S-Values and non-fake images. And the company should not lie to the FDA or the Third Party or the investors about what x-ray source is used in the unit.  Yes, the FDA has approved devices that also use a dental tube (including a 2 mA one for limited intended use such as extremities, which is worse than Nanox' 11 mA from the hand drawing), but at least that dental tube is not crappy.  

Nanox tried to fool the FDA, or tried to fool the investors, or both.

Update April 5, 2021:  Nanox got clearance for a Nanox.Cart (the ugly single-source device).  So, both the FDA and investors were fooled?  More hints will come around May 1st, when the decision summary is expected to be published by the FDA.  

How SK Telecom promotes its investment

If the lie is big enough, and if you repeat it, maybe people will start believing it.

Someone posted a link to the June 2020 press release by SK Telecom as a proof that Nanox is not a fraud.

The press release states:

Nanox developed the innovative Nanox System, which is composed of the Nanox.Arc, a novel digital X-ray device.

Oops.  Novel!  Apparently, nobody told SK Telecom that a novel X-ray device cannot be cleared by the FDA, because clearance requires a substantial equivalence to an already legally marketed device.  So being  novel, the device is clearly (pun intended!) not equivalent to anything on the market already, and so cannot obtain a 510(k) clearance. 

So, if SK Telecom did not lie about the novel thing, then Nanox regulatory strategy goes poof.  Because Nanox has been telling investors that it plans to 

submit an additional 510(k) application with respect to the multi-source Nanox.ARC, which, if cleared, will be our commercial imaging system

 

But how exactly is Nanox device novel?  Well, it is fake and non-functional.  That's its novelty.  The press release helpfully supplies its picture.

Only for angels (humans too heavy for this "body scanner") 

The table clearly can't support a human being.  The Arc is immobile and cannot move along the table (even though it is labeled BODY SCANNER on the side).  The whole thing is powered by a 12V battery (to light up a few LEDs for the photographer and the greedy investors and advisors).  There are no functioning x-ray sources or detectors in the device.  Nanox says on its tech webpage that this is version 1.0 of the device, and claims:

Cold cathode tubes allow the use of a single high voltage power supply and a ‎single high voltage supply line (connecting all the anodes in the system). Digitally ‎controlling each tube enables the system to be significantly reduced and saves ‎power supply cables, installation space, and so on.‎ ‍

Which could be true, indeed, if 12V is high voltage, if and those cold cathode tubes do not generate x-rays but simply multi-spectral light.

The press release also shows an animation gif of the levitating scan, that must generate antigravitons.  Nanox has not provided information as to which version of Nanox.Arc that is.

Roentgen discovered X-rays in 1895, Nanox discovered levitation in 2019.

Update:  Apparently at least one radiologist agrees about Nanox.Arc.

These are the facts

Ugly
source:  RSNA2020 live demo

1. Nanox has not submitted anything for FDA approval.
   
   
2. It is illegal to market a Class II MEDICAL device, such as an x-ray diagnostic system, in the United States without clearance (or De Novo grant) pending (there are limited exceptions, but they don't apply here).
   
   
3. Nanox now claims to have submitted an x-ray system for FDA clearance in January 2020 and that it does not intend to ever market that system. That "system" is very ugly, and is completely different from what Nanox has been showing in its investor presentations. The one shown in investor presentations has not been submitted for clearance, approval, or De Novo grant. There are reasons to believe that Nanox did not submit anything for clearance in January 2020, or, if a submission happened, it was fraudulent.

These are the facts. They are indisputable.

Fake (notice the XANON label)
source:  November 2020 Investor Presentation, Slide 3 

Update April 5, 2021:  Nanox got clearance, not approval, for a Nanox.Cart (the ugly device).

Random youtube comments

Some random comments, slightly edited, on youtube [and elsewhere]:

• If the FDA approves or clears a device that violates the laws of physics, would you still buy the stock of the maker of that device? What is more likely - that new laws of physics are discovered or that the FDA made a mistake? By the way, Nanox will not be asking for FDA approval, but for CLEARANCE (according to its SEC filings), which is a big difference.
• You don't need heat to "generate" electrons. For example, you can use photons to kick electrons out of metal.
• Almost 100% of the heat generated in an x-ray tube comes from the electrons heating the anode - only very little heat comes from the electron generation, be it from a cold or hot cathode.
  
  
• The more-powerful the x-rays are, the safer they are, ironically. Because the overall exposure in the soft tissues can be lower for the same quality of the image.
  
  
• Nanox tech paper and tech web page show absolute ignorance of x-rays and basic physics and engineering.  The scientific advisory board should be ashamed.
  
  
• Generating a good diagnostic "3D" image requires tens to thousands of images, that is exposures, but that's ok, because the overall radiation dose can still be quite low, if you have good detectors. That is why tomosynthesis and tomography machines are approved and cleared by the FDA.
  
  
• Someone made a good point about the lamb bone image possibly being exactly the same (same position/orientation) in the RSNA2020 demo. Modern x-ray console software has the ability to automatically straighten, auto-rotate and "line-up" an image, but it is a good point anyway and needs to be reviewed.
  
• If Nanox.Arc were real, it would be already deployed in a veterinarian "hospital" or even undergoing human trials.
  
  
• X-rays were discovered with a cold-cathode (gas-discharge) tube in 1895. Electrons from both the cold-cathode and hot-cathode generate heat when they hit the anode. About 99% of all the electricity used by an x-ray tube ends up in heat, regardless of the cathode. There is a lot of research being done now to find ways to generate x-rays without all this waste heat.  Nanox cold-cathode "technology" does not and cannot address that problem at all.
  
  
• Image noise is everywhere. Underexposed x-ray images are especially noisy. That's what cheap Chinese tubes do. Mechanical noise in the live RSNA 2020 demo comes from the tilting gantry, also known as Arc.
  
  
• The machine in the back of the warehouse is not an MRI machine. It is a Canon CT machine (although the radiologists think it is an inflatable prop, just like the company). Nanox will say they have it so they can use it as a predicate and compare Nanox.Arc images with the CT images in preparation for 510(k) submission of the multi-source Nanox.Arc. You cannot use someone else's "online" clinical images in a 510(k) submission - the FDA will reject such a submission.
  
  
• The Nanox industry presentation was on the original RSNA 2020 schedule, but, with the permission of the organizers, it was rescheduled to a later day.
  
  
• Ceramics might absorb too much radiation? Isn't that good? Plus, ceramic tubes are usually easier to manufacture in volume and last longer. So, almost all x-ray tube manufacturers also make ceramic x-ray tubes. But Nanox cannot manufacture them - Nanox ceramic tubes are fake.
• Nope, you don't need more voltage than 40kV to x-ray an adult hand, especially if you use a decent DR detector and no filtration (which is illegal, but so what!). However, the recommended exposure setting for tube voltage with a DR detector is indeed higher (and grid is also recommended).
• You would be surprised to know that the FDA has cleared diagnostic x-rays systems that use 2mA dental tubes. So, yes, Nanox can buy a cheap Chinese hot-cathode tube for $70, label it Nanox.SOURCE and offer it for sale for $100. Don't mix voltage with power - not the same!
• You don't need a great deal of energy to liberate electrons: https://en.wikipedia.org/wiki/Work_function .  As you can see from the work function, you don't need much voltage to liberate electrons. And, yes, nano-Spindt electrodes can do it with less than 50V in the real world.
  
  
• Nanox CEO cannot read about "atomic physics" - he studied art and calls himself a "technologist."
  
  
• Real scanners do use many KVP, much higher than 40kV.
  
  
• The detectors they have shown are Konica's AeroDr and DRTECH's Exprimer. I think they also use a cheap Chinese one ($25,000?).
  
  
• You can get plenty of cancer-inducing radiation even from one tube. For a CT-like reconstruction, you need to cover roughly 180 degrees, at the minimum, with your x-ray source(s).
  


• Yes, Nanox.Arc 2.0 is not functional - it cannot "scan" an adult.
  
  
• The agreement signed by the CEO of USARAD for the distribution of the 3,000 Nanox systems is illegal, I believe, because the Nanox system has not been submitted for clearance. And, yes, he himself admitted to have lied about whether he saw 3D images from Nanox in 2019. He makes false claims and pretends to cry during the RSNA 2020 "demo," because he is an investor in Nanox and wants to sell his stock at a high price. He is not a good radiologist, despite his certification - he failed to notice the mismarked hand radiograph during the live demo and lied about the recommended exposure settings for hand radiographs, among others. Also, he knew, or must have known, that the simulation results he presented were completely bogus, because the first thing one learns about cone-beam CT is the noise problem.
  
  
• The filament of a hot-cathode tube is heated over 1,000 degrees Celsius and uses very little electricity, as low as, say, 5W.
  
  
• Compared to a cheap Chinese hot-cathode tube, the proposed Nanox tube has the SAME size and shape, uses the SAME electrical energy for the same X-ray generation, requires JUST AS MUCH cooling, and is LESS precise in delivering that electron "beam." But, of course, Nanox cannot manufacture such a cold-cathode tube - I believe its demos use cheap LOW-POWER Chinese hot-cathode stationary-anode tubes that can operate at "room temperature." So, no, the Nanox tube is NOT LEGITIMATE - it does not exist as a functional device.
  
  
• SK Telecom President says that the proposed Nanox tube is VERY expensive. Yes, the cheap Chinese tubes can create "near-equivalent" images with a good DR detector (and the FDA has already cleared devices with only one 2mA hot-cathode tube), but Nanox is using them in its devices without the required filtration because they are so low-powered, which means they are unsuitable for medical imaging because they are unsafe (more likely to cause cancer!).
  
  
• Nanox cannot manufacture that "chip" commercially - it has no access to facilities to do so. Same about the tubes.
  
  
• Nanox and its predecessors have been trying to license these proposed tubes to other entities since RSNA 2015 (yes, for more than 5 years!), with zero success, per Nanox CEO and SK Telecom President.
  
  
• Nanox never planned to do a phantom scan with the single-source device - Nanox had already prepared the hand radiograph of the century video overlay (as revealed briefly in a frame in the video). In fact, the DICOM tag shows that the hand radiograph was the CEO's THIRD ATTEMPT ("Ran_3").
  
  
• The introduction of the Nanox.Arc by the CEO at RSNA 2020 was illegal and in violation of RSNA rules, as Nanox.Arc has not been submitted for 510(k) clearance yet.
  
  
• How many tubes in the Nanox.Arc as demoed - 5 or 6? What do those tubes look like?
  
  
• Nanox.Arc table cannot withstand the weight of an average adult - it is made of cheap thin wobbly plastic. Thus, the three light-weight phantoms used in the RSNA 2020 demo.
  
  
• Nanox.Arc cannot be used for mamo tomosynthesis - the devices cleared by the FDA require breast "squishing." No breast squishing means no 510(k).
  
  
• The animal bone scan with the Nanox.Arc was fake - it was prepared in advance, as evidenced by the wrong orientation (by 180 degrees) in the DICOM file.
  
  
• The reconstruction at the end of the RSNA 2020 demo was a misleading simulation - for example, it assumed no noise, while noise is the biggest problem with cone-beam CT. It also assumes giant x-ray detectors that don't exist and will cost millions, if ever built.
  
  
• Each of these opinion "leaders" in the Nanox "opinions video" said at least one thing that was false or non-nonsensical. Not a surprise here - they are paid by Nanox.  Money blinds and corrupts many people.
  
  
• We agree that tomosynthesis is computationally simple (matrix addition instead of matrix inversion) and very old (older than hot-cathode), but in recent years there has been increase in research and publications about it, because in certain cases, such as mammo or MSK or even chest, it COULD potentially generate good diagnostic images with less radiation dose than CT. Agree about the orientation, but you should take a good look at the RadiAnt DICOM viewer thumbnails in one of the frames of the recorded live stream from RSNA 2020. A side note: Nanox used a trial version of that DICOM viewer - they are too cheap to even pay for a $150 license.
• Did Nanox white paper on mammography disappear? The paper was called "Potential benefits of Nanox technology in Mammography" and was shown in Nanox virtual booth at RSNA 2020. Let me know, if you can find a link to a publicly available copy (I already have the actual file from RSNA 2020).

Added January 12, 2021:

• Please do not spread misinformation!  Where to begin... According to Nanox presentation at RSNA 2020, the single-source Nanox.Arc DOES NOT ANYTHING LIKE the multiple-source Nanox.Arc "but with one tube," as you claim.  The single-source device looks like the ugly device here, not the fancy and fake picture you are showing in the video!   On a side note, I have STRONG reasons to believe that Nanox has not submitted anything for clearance, either directly to the FDA or through a Third Party. Ok, back to the FDA:  The FDA is required to to respond within 30 days after the Third Party makes the recommendation (which recommendation should have occurred by early October 2020 at the latest, if Nanox response were satisfactory).  Here is what happens in the real world:  If Nanox had submitted for clearance, as it claims, the chance that the FDA is going to clear the device is now close to ZERO.  Similar DOES NOT MEAN substantial equivalence.  The device needs to be is AS SAFE AND EFFECTIVE.  Predicate is important, indeed.  Now, can you find a predicate for the ugly device?  Or maybe you can find one for the fancy fake Nanox.Arc device that cannot support the weight of an adult on the table (made of wobbly flaky non-structural plastic) and that cannot take proper chest PA, the most common radiological investigation in general radiology? Let's make it simple for you:  Since 510(k) is a preMARKET notification, the FDA or the Third Party should immediately reject any device that the submitter does not intend to MARKET.  And what did Nanox say about its plan to market the single-source Nanox.Arc device? Cold cathode companies?  Roentgen discovered x-rays using a COLD CATHODE tube (Crookes gas discharge one).  Cold-cathode tubes were the dominant tube technology, until GE (Coolidge) destroyed them in 1913   Every radiologist should know that!  Embarrassing.

Added January 13, 2021, this one from a chat room:

• @kastenz re do DIODES x-rays exist: [Nanox patents] won't help you here - they are almost completely useless because they are mostly misleading. Nanox predecessor has a research report about exactly how the [nano-cones] are made - they had to published it, because it was a requirement for using the university lab on the cheap with the other grad students. It has nothing to do with MEMS technology - it is a simple lithography and deposition. You cannot produce x-rays with semiconductor technology because of the work function - all you can do is UV. Nanox claims to produce x-rays like everyone else - generating electrons that accelerate with very high voltage, say 55 kV, and then hit an anode, thereby releasing 1% of the energy as x-rays. But yes, most x-ray tubes are diodes, including the proposed Nanox one (as in a vacuum tube diode, not a semiconductor one). Nanox, however, cannot produce a working tube, unfortunately (except for R&D). None of Poliakine's other ventures have been successful - all are complete failures. Nanopores - what is that? The holes/cones are about 100-300 nm or so in diameter [distance between cones 400nm to 800nm depending on the direction], if I remember from my measurements of their only microscope photo (which was hidden in a 2016 tech sales sheet by Nanox predecessor). MEMS use nanotechnology, because to make a functional micron-size mechanical part you need nano-precision. Nanox-proposed cold cathode does not use any mechanical parts - so it is not a MEMS device. The sources Nanox uses in its demos and tests are actually cheap Chinese hot-cathode tubes, based on what I have seen.

Added January 21, 2021:

• ​You have no opinion on the stock? That's news to me - your video description says Nanox (Nano-x Imaging) is revolutionizing the X-ray and this IPO stock will soon explode. Unless you mean explode as in get obliterated... Any radiologist who knows a bit of about x-rays and who listens to any interview or presentation by the CEO should immediately recognize that Nanox is a fraud - 1) Roentgen did not use a tube with hot filament (that was invented by GE much later, in 1913), and 2) 99% of the heat from the tube is not generated by the cathode but by the anode, and just about 1% of the electrical energy is converted into x-rays, regardless of the type of cathode used. I mean, this is basic stuff - and you don't need to know what device the CEO is talking about. Then comes the mass screening with ionizing radiation and all that other nonsense... And finally, the live demo - you saw the device he says he will be shipping this year. Tell me, what can that $50,000+ device be used for? It cannot withstand the weight of an adult and can't even do chest PA. I can't find any predicate for it.
  
• Nobody had seen images from the "tube" in October 2020? Hello? Nanox had those "images" in the prospectus. The problem with those "images" is that they are fake, not that they are regular "2D" images. How do I know? Well, the mAs and left/right labels change each time Nanox reposts these images. You claim to be radiologist, yet you have not noticed those discrepancies? How come? There were "CT" images (well, rotating 3D chest, not really CT slices) generated in the fake video that Nanox changed after MuddyWaters commented on it.
  
  So, did you like the images at RSNA 2020 and did you verify the machine produced them? Those tomosysnthesis images were not done real-time - it is easy to see in the thumbnail sequence of their trial-version DICOM viewer, so I have no idea how they were produced. But, yes, you can do some crappy tomosynthesis with 5 sources (not 6, as the CEO says), but it is useless for diagnostic purposes. And that 11-source simulation at the end was obviously misleading (because the main problem with cone-CT is noise, and SART is not the proper reconstruction algorithm), not to mention those detectors will run into $100,000s [even in high volume]. 
  
  Smaller places need a simple x-ray system first - that's what the World Health Organization says - and it is already cheap.
  
  
• Yes, "nanotubules."   Are you related to Dr. Dawson, the Nanox Advisor - he is the only one in the world that uses that word, and he does not understand it.
  
  Cold-cathode x-ray tube is possible.  Roentgen used one in 1895 to discover x-rays, and it did not have a rotating anode.  Cold-cathode had 100% market share in the x-ray tube market, until GE came in 1913 and destroyed it.  Today, there are cheap x-ray diagnostic systems (for extremities only) on the market that use 2mA hot-cathode dental tubes (tinier and cooler than Nanox' proposed source) without rotating anodes, of course.  But they can't be the primary imaging system, because they can't do regular adult chest x-rays.  Hot-cathode tubes with the performance proposed by Nanox are not expensive or large, and they cost less than $100 (while SK President and Nanox advisor says Nanox proposed tubes are very expensive in that removed video which you can see on my blog).
  
  Nanotubes and nano-pins (aka nano-Spindt) make a poor cathode for an x-ray tube.  The only commercial source for cold-cathode x-ray tubes in medical devices now is Micro-X, and all they could muster is a huge CNT tube that can just do 130ma for 2 seconds.  That is why their stock is down the drain and why Carestream is actively discouraging people from buying DRX-Revolution Nano which contains that tube.
  
  Nanox is not using any chip to control anything digitally.  It looks to me you don't even understand what Nanox is proposing as a cold cathode.  The "chip" is just a bunch of tiny metal pins close to a grid - that's all - there is nothing digital or MEMS about them.  With a Spindt (or nano-Spindt) array you control the tube current with low voltage, just as you do with a hot filament with even lower voltage.  And, of course, Nanox does not have any actual working source based on nano-emitters on a chip  - it cannot make it since it does not have the facilities to do so.
  
  All these opinion leaders you cite have already ruined their reputation, because they said stupid or false things in exchange for money in that video.
  
  But you are correct, irradiating the entire world population with ionizing radiation indiscriminately is not a good idea.  You should suggest that to Nanox CEO, because he disagrees.
  
  
• Yes, theoretically a stationary 5-source tomosynthesis machine that also tilts +/- 30 degrees (the proposed Nanox.Arc 2.0) can indeed produce some images, but they are definitely not slices (because tomosynthesis is additive, unlike CT, which is inverting) and they will be full of horrible blurring and striping artefacts, and, in fact, inferior for diagnostic purposes compared to simple radiographs taken from carefully selected views. 
  
  It is true that tomosynthesis evolved over time since the first attempts in 1920s, but then CT completely overtook it.  Only very recently there has been some increased revival with the approval of specialized breast tomosynthesis devices in 2013, but these are still niche products.  Nanox.Arc, even if it were real, is not the first x-ray imaging device that a hospital or an urgent care facility would acquire... 
  
  
• Nanox is not seeking FDA approval, but FDA clearance, according to its filings with the SEC.  Also, it is seeking clearance for a single-source device, which seems to transform each time it is shown to the public (compare RSNA 2020 with JP Morgan presentation).  Finally, there are reasons to believe that Nanox never submitted anything for clearance, or, if it did, it was fraudulently.

Added January 22. 2021:

• It is not a matter of choice - the ISRL ETF needs to track the index, by prospectus promises.  The weight is about 2% (divide 100 by 60, the number of companies in the index) - it is an equal-weighted index - and the ETF has some leeway with the weights based on liquidity.  NNOX was pre-determined to be included at the next quarterly rebalancing, once it did an IPO.  The move yesterday was due to OTM call buying, not the inclusion in the ETF at the close.  Funny thing, the more the stock moved up yesterday, the FEWER NUMBER of shares ended up in the ETF (you figure it out why!).  And that is why the stock is down today. 
  
  Also, why would an FDA clearance of a single-source device be important to a company that does not intend to market such a device (or, at least, did not intend at the time of the 510K submission)?
   
• not from youtube, but in the same line:  I have never said that Nanox "never submitted 510k clearance." I have said that I have (several) reasons to believe that Nanox never submitted for 510k clearance, or if it did, it committed fraud.
  
  The law says that FDA has to respond within 30 days to a recommendation by the Third Party whether to clear or not. Check my blog, or just google around.
  
  Nanox stated in its Prospectus that it submitted the single-source Nanox.Arc for clearance in January 2020. The problem is that in a draft registration statement filed with the SEC in February 2020, Nanox stated that it did not have a working Nanox.Arc device. Therefore, Nanox submitted a non-working device for clearance (which is fraud), or Nanox lied in its draft registration statement.
  
  In the same draft registration statement, Nanox also says that it planned to submit for clearance the single-source Nanox.Arc (meaning, it could not have submitted it in January 2020).
  
  And, of course, the single-source device shown at RSNA 2020 does not match the single-source device shown at JP Morgan conference.
  
  A single source tube is redundant (Nanox' proposed tube is a single source) and does not require clearance to be marketed. A single-source x-ray system device is not the same as a single source tube.
  

More (youtube and elsewhere):

• January 23, 2021: The chip proposed by Nanox (proposed, because it is not commercial!) is not a MEMS chip, because there is nothing mechanical about it. A MEMS chip is not made like a semi-conductor chip (otherwise, it will be called a semi-conductor chip).  Nanox has no manufacturing facilities in Japan or Korea [contrary to false claims in Prospectus and investor presentations]. The video [first posted in Nanox virtual booth at RSNA 2020] shows a University of Tokyo facility that prohibits commercial activities and an R&D (not manufacturing!) lab in Korea that is not a clean room and that cannot make chips.
  
  The Nanox ceramic tube is fake, because it cannot be sealed [to maintain vacuum], and because the chip cannot be made by Nanox (due to lack of facilities to do so).
  
  The single-source device is fake because it changed its look [from ugly to fancy] between RSNA 2020 and the JP Morgan presentation [, and size, shape, and functionality changed too].
  
  The FDA does not care about any x-ray tubes [they are Class I devices exempt from premarket notification and clearance]. The FDA cares whether the x-ray SYSTEM (the complete device) is safe and effective. Nanox has not submitted anything for any FDA approval, according to its prospectus.
  
  
• January 25, 2021:  Dear Doctor,  Cathy's IZRL was forced to buy Nanox at the quarterly rebalancing because Nanox did an IPO in August.  That is how passive index funds work.  She did zero due diligence on the stock and had to buy it, even knowing that Nanox is a fraud, that's what the prospectus says.  Cathy does not care whether the stock goes to $1,000 or zero - IZRL has to own it, as promised in the prospectus - Cathy needs to track the benchmark.   Nanox is not designing a CT scanner - you cannot do CT with less than 180 degrees of projections, by definition.  The heating of filament does not create "x-ray imaging," and neither can any silicon chip.  The demo at RSNA 2020 was not live - it was live-streamed across oceans and continents  - big difference (and, of course, the CEO faked it).  January 2020 (510K submission) comes before September 2020, not after!   What you are circling on the presentation is NOT A SILICON CHIP - it is a glass tube that Nanox claims it is no longer using.  Nanox is not seeking an FDA approval, according to its prospectus  (the first presentation slide is intentionally misleading!) - approval takes years of human studies and billions of dollars, while clearance is done within 90 days.  If you want to learn more about how FDA clearance works and how long it takes, look at my blog.  The company is confused about what is the meaning of "field" in "field emitter."  Yes, if the company were not a fraud, all would be great and cancer and appendicitis would be cured for pennies, but it is a fraud.
  
  
• February 1, 2021:  According to Nanox, the FDA is now requesting information about the predicate and intended use for the single-source device only (the fancy, but also fake, Nanox.Arc one has not been submitted yet). If I were the FDA, I would do the same. Why? Because Nanox stated in its Prospectus that it did not intend to MARKET the single-source device , and the 510K submission is a preMARKET notification. I other words, the single-source device has no intended use (and therefore, no predicate).
  
  
• February 1, 2021:  In response Andrew Kamal @Medium, an avid reader of my blog:  So, what exactly is your problem with my blog? You find the single-source device non-ugly or the Nanox.Arc, in general, non-fake? Or you just think that this SUPER NANOX soap is infringing on Nanox' copyrights? Has anyone of those "smart people," who may be paid by Nanox, confirmed that Nanox is not a fraud? Since Nanox is a fraud, you won't find such a confirmation, I am afraid. Ark's IZRL fund had to buy NNOX and did it with zero due diligence because it is a passive fund that tracks an equally-weighted index of all the liquid publicly traded tech Israeli stocks, and gets rebalanced quarterly (NNOX was eligible for the first time). FDA timeline getting close - you sure? You were correct on the big move today, though.

Update:  March 24, 2022:  Tonsley Innovation District said before the launch of the Carestream DRX-Revolution Nano device:

It is expected that the revolutionary machine will be available for commercial sale next year via Carestream Health between $150,000 to $200,000 per unit.

I have not seen a disclosure by Micro-x itself about the ASPs of the Nano or the Rover.