EMJ Innovations 8.1 2024

Volume 8.1 February 2024

Innovations

Review of

GIANT Health 2023 Infographic

Interviews

James Bevan and Madhuri Hegde discuss planetary health education and advancements in genomics

Spotlighting lung cancer, our infographic explores the potential of artificial intelligence in healthcare

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Contents 4

Editorial Board

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Welcome

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Foreword

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Congress Review Insights From The Global Innovation and New Technology (GIANT) Health Event 2023, 4th–5th December 2023

Congress Features Revolutionising Women's Health: A Call for Collaboration and Innovation Abigail Craig

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Striving for Net Zero in Healthcare Darcy Richards

Abstract Highlights Innovation in Healthcare: Highlights from 2023

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Interviews James Bevan Madhuri Hegde

Infographic AI in Early Diagnosis of Cancer

Feature The Transformative Potential of Patient-Generated Health Data Khan

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Articles A 3D-Printed Forearm Trainer for the Practice of Ultrasound-Guided Arterial and Venous Line Placement Chambers et al.

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Impact of the National Suicide Hotline Number on Care of Outpatient Psychiatric Patients Sheth et al.

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Editorial Board Editor-in-Chief Prof Mike Bewick

iQ4U Consultants, London, UK

Editorial Board Dr Olusola Michael Adeleke

King's College London, UK

Prof Dolores Cahill

School of Medicine and Medical Sciences, University College Dublin, Ireland

Dr Nick Guldemond

Integrated Care & Technology, Institute of Health Policy & Management, Erasmus University Rotterdam, the Netherlands

Prof Christian Jürgens

Traumatology, Orthopedics and Sports Medicine, Rehabilitation-Center, BG Hospital Hamburg, Germany

Dr Vandita Kakkar

Department of Pharmaceutics, University Institute of Pharmaceutical Sciences, Panjab University, Chandigarh, India

Dr Kinan Muhammed

Great Western Hospitals NHS Foundation Trust, Swindon, UK

Maj Dr Hannah Sophia

Translational Medicine, MedTech AI Consultant, UK

Dr Noedir Stolf

University of São Paulo Medical School, São Paulo, Brazil

Dr Axel Sylvan

msk.ai/myrecovery, London, UK

Dr Rachel Thomas

The Priory Hospital, London, UK

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Aims and Scope EMJ is an online only, peer-reviewed, open access general journal, targeted towards readers in the medical sciences.

We aim to make all our articles accessible to readers from any medical discipline.

EMJ allows healthcare professionals to stay abreast of key advances and opinions across Europe.

EMJ aims to support healthcare professionals in continuously developing their knowledge, effectiveness, and productivity.

The editorial policy is designed to encourage discussion among this peer group.

EMJ is published quarterly and comprises review articles, case reports, practice guides, theoretical discussions, and original research.

EMJ also publishes 18 therapeutic area journals, which provide concise coverage of salient developments at the leading European congresses. These are published annually, approximately 6 weeks after the relevant congress.

Further details can be found on our website: www.emjreviews.com Editorial Expertise EMJ is supported by various levels of expertise: • • • •

Guidance from an Editorial Board consisting of leading authorities from a wide variety of disciplines.

Invited contributors are recognised authorities from their respective fields.

Peer review, which is conducted by EMJ’s Peer Review Panel as well as other experts appointed due to their knowledge of a specific topic.

An experienced team of editors and technical editors.

Peer Review On submission, all articles are assessed by the editorial team to determine their suitability for the journal and appropriateness for peer review.

Editorial staff, following consultation with either a member of the Editorial Board or the author(s) if necessary, identify three appropriate reviewers, who are selected based on their specialist knowledge in the relevant area.

All peer review is double blind.

Following review, papers are either accepted without modification, returned to the author(s) to incorporate required changes, or rejected.

We are always keen to hear from healthcare professionals wishing to discuss potential submissions, please email: editorial.assistant@emjreviews.com To submit a paper, use our online submission site: www.editorialmanager.com/e-m-j Submission details can be found through our website: www.emjreviews.com/contributors/authors Reprints All articles included in EMJ are available as reprints (minimum order 1,000). Please contact hello@emjreviews.com if you would like to order reprints.

Distribution and Readership EMJ is distributed through controlled circulation to healthcare professionals in the relevant fields across Europe.

Indexing and Availability EMJ is indexed on DOAJ, the Royal Society of Medicine, and Google Scholar®; selected articles are indexed in PubMed Central®.

EMJ is available through the websites of our leading partners and collaborating societies.

EMJ journals are all available via our website: www.emjreviews.com Open Access This is an open-access journal in accordance with the Creative Commons Attribution-Non Commercial 4.0 (CC BY-NC 4.0) license.

Congress Notice Staff members attend medical congresses as reporters when required.

This Publication ISSN 2513-8634 EMJ Innovations is published once a year. For subscription details please visit: www.emjreviews.com

We welcome contributions from professionals, consultants, academics, and industry leaders on relevant and topical subjects.

All information obtained by EMJ and each of the contributions from various sources is as current and accurate as possible.

However, due to human or mechanical errors, EMJ and the contributors cannot guarantee the accuracy, adequacy, or completeness of any information, and cannot be held responsible for any errors or omissions. EMJ is completely independent of the review event (GIANT Health Event 2023) and the use of the organisations does not constitute endorsement or media partnership in any form whatsoever.

We seek papers with the most current, interesting, and relevant information in each therapeutic area and accept original research, review articles, case reports, and features.

Front cover and contents photograph: London, UK, home of the GIANT Health Event 2023 © fenlio / stock.adobe.com

Editorial staff have final discretion over any proposed amendments.

Submissions

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EMJ Podcasts The EMJ Podcast aims to provoke conversations around the latest trends and innovations in healthcare, provide engaging and educational content for healthcare professionals, and hosts conversations with physician entrepreneur, Jonathan Sackier.

Listen today www.emjreviews.com

Welcome letter Editor Evgenia Koutsouki Editorial Manager Anaya Malik Copy Editors Noémie Fouarge, Kirsty Hewitt

Evgenia Koutsouki

Editorial Co-ordinator Natasha Meunier-McVey Editorial Assistants Victoria Antoniou, Helena Bradbury, Abigail Craig, Ada Enesco, Evan Kimber, Darcy Richards Creative Director Tim Uden

Dear Readers, Welcome to EMJ Innovations, our first journal for 2024. This journal highlights key technological advancements in medicine over the past year.

In this issue, we are proud to feature coverage of the Global Innovation and New Technology (GIANT) Health Event 2023 held in London, UK. Of particular interest are two feature articles discussing technological advancements in women’s health, and innovative approaches to achieving a net zero National Health Service (NHS) in the UK.

Design Manager Stacey White Senior Designer Roy Ikoroha Designer Steven Paul Junior Designers Dillon Benn Grove, Shanjok Gurung Head of Sales Robert Hancox Director of Performance Keith Moule Chief Operating Officer Dan Scott Chief Commercial Officer Dan Healy Founder and Chief Executive Officer Spencer Gore

Editor

We have also handpicked noteworthy abstracts across congresses that we attended over the last year, choosing to highlight those that represent the key steps in innovation and technology. Prevailing trends include the use of artificial intelligence, and particularly ChatGPT (OpenAI, San Francisco, California, USA), across several disciplines, from radiology to reproductive medicine. It is no surprise that new approaches in telemedicine and diagnostics are also among the prevailing themes.

Demonstrating our commitment to showcasing technology to elevate the quality of healthcare, we present an article on the use of a 3D-printed forearm trainer for practising ultrasound-guided line placement in blood vessels. Another article showcases new applications for telemedicine, examining the impact of a national suicide hotline number on outpatients in psychiatric care.

We remain dedicated to bringing you all the latest news in medical innovations. Ahead of our 2025 issue, we eagerly anticipate your manuscripts that discuss the latest technological advancements in medicine!

Contact us Editorial enquiries: editor@emjreviews.com Sales opportunities: salesadmin@emjreviews.com Permissions and copyright: accountsreceivable@emjreviews.com

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Reprints: info@emjreviews.com Media enquiries: marketing@emjreviews.com

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Stay up to date with new advancements across European healthcare Visit EMJ for our comprehensive collection of peerreviewed research articles, latest interviews, and features across a range of therapeutic disciplines.

Visit EMJ

www.emjreviews.com

Foreword I have great pleasure in welcoming you to the current issue of EMJ Innovations.

We present our coverage of the highly successful Global Innovation and New Technology (GIANT) Health Congress held in London, UK, on the 4th–5th December 2023, along with innovative research, highly commended abstracts from several therapy areas, and a visually engaging infographic.

EMJ had the privilege of engaging in enlightening conversations with two distinguished field experts, James Bevan and Madhuri Hegde, who shared valuable perspectives on healthcare innovations. Bevan delved into the integration of planetary health and sustainability in medical education, before providing an overview of his ongoing research investigating the potential link between climate change and meningitis outbreaks in Angola.

Hegde discussed her role as Senior Vice President and Chief Scientific Officer at Revvity, shedding light on advancements in genomics.

Our articles span a wide range of topics, from the emergence of a 3D-printed forearm trainer for ultrasound-guided arterial and venous line placement, to the impact of the national suicide hotline number on the care of outpatient psychiatric patients. Ghazanfar Khan, General Practitioner, National Health Service (NHS), Yorkshire, UK, contributes a compelling feature article, spotlighting the transformative potential of patient-generated health data. His insights prompt clinicians to develop specific workflows for handling such data.

Finally, our infographic delves into the promising realm of artificial intelligence (AI) in the early diagnosis of cancer, with a specific focus on lung cancer. This invaluable educational resource summarises the use of AI in screening and diagnosis, while also addressing the challenges associated with implementing AI on a large scale.

I would like to thank all of our valued contributors, and I hope you enjoy this issue of EMJ Innovations.

Professor Mike Bewick Director and Founder of iQ4U Consultants, London, UK; Interim Dean St Mary’s University Medical School, Twickenham, London

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Congress Review

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GIANT 2023

GIANT 2023 Insights From The Global Innovation and New Technology (GIANT) Health Event 2023

Location:

London, UK

Date:

4th–5th December 2023

Citation:

EMJ Innov. 2024;8[1]:10-11. DOI/10.33590/emjinnov/10301409. https://doi.org/10.33590/emjinnov/10301409.

The Global Innovation and New Technology (GIANT) Health Event of 2023, held on 4th–5th December in London, UK, was a convergence of healthcare providers, investors, and healthtech experts. Established in 2015, GIANT is dedicated to entrepreneurs, aiming to provide them with market access and expertise. Focused on enhancing global health through healthtech support and the promotion of healthcare innovation, this event facilitates participation in a rapidly expanding global community of healthcare professionals and businesses.

GIANT, through its extensive network of healthtech innovators, supports all individuals within healthcare, fostering the invention and adoption of new health technologies, with the mission to innovate, accelerate, and collaborate.

The event comprised five conferences, each spotlighting an innovative area of healthcare. On 4th December, the ‘NHS National ICB Congress/ Mental’ featured world-leading innovators and providers discussing new technologies for diagnosing and treating mental health conditions. Sessions covered topics such as barriers and facilitators to introducing digital therapies into the National Health Service (NHS); digital technologies for anxiety, depression, and psychosis; and unmet needs in mental health research and service provision. The ‘Net Zero Technology Show’ discussed the environmental impact of healthcare, before focusing on how the NHS is implementing sustainable care models.

The final conference, the ‘Women’s Health Tech

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Show’, addressed overcoming barriers in female health, fertility, and menstrual care; FemTech; and revolutionising primary care to support females with perinatal pelvic floor health issues.

On 5th December, the ‘Future Hospital Show’ delved into artificial intelligence and digitisation in healthcare, through talks delivered by field experts. The ‘NHS ICS/ICB Congress’ encouraged attendees to network and learn from the leaders of the UK’s new Integrated Care Systems, exploring the dramatic changes and innovations in the UK health sector. Sessions included discussions on the new NHS funding landscape, the revolutionary use of cannabinoids in medicine through nano-technology, and cost-saving technologies. The final show, the ‘Discovery Park Pitching Event', provided start-ups with an opportunity to pitch to investors on stage, covering successes and challenges of spinning out of academic research, fundraising dos and don’ts, and the increasing importance of female health.

"The event comprised five conferences, each spotlighting an innovative area of healthcare."

The GIANT Health Event stands as the UK’s premier healthcare innovation festival, housing five distinct shows. Attendees are urged to connect, network, learn, and engage in business

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GIANT 2023

with hundreds of world-class speakers, witness immersive innovation presentations, and observe the UK’s leading health-tech start-ups pitching to investors. GIANT's vision is to enhance global

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health and wellbeing by facilitating healthcare innovation, and supporting health-tech entrepreneurs and investors. ●

"GIANT, through its extensive network of health-tech innovators, supports all individuals within healthcare."

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Revolutionising Women's Health: A Call for Collaboration and Innovation Authors:

Abigail Craig, EMJ, London, UK

Citation:

EMJ Innov. 2024;8[1]:12-14. DOI/10.33590/emjinnov/11000012. https://doi.org/10.33590/emjinnov/11000012.

Dame Lesley Regan, Women's Health Ambassador for England, delivered a presentation highlighting the need for a women's health strategy during an informative session focusing on women’s health technology at the Global Innovation and New Technology (GIANT) Health Event 2023, London, UK. Regan emphasised the historical neglect of women's health within the medical field and the disparities in healthcare access and outcomes. Despite women constituting 51% of the population and 49% of the workforce, their health has not received the attention it deserves, Regan stated.

DRIVING CHANGE IN THE UK Regan began by pointing out the existing variations in healthcare access, highlighting the government’s ‘levelling up’ initiative aimed at addressing disparities. She stressed the urgent need for a shift towards preventive healthcare, highlighting the imbalances in spending, with a disproportionate focus on disease intervention rather than prevention. Data from mid-2023 highlighted these differences, with 124 billion GBP being spent treating disease, compared to 12 billion GBP on prevention. Regan petitioned the ‘tech giants’ in the room to aid in pushing the preventative agenda, calling for a life course approach to women’s health that addresses health needs in each decade.

Results of a public consultation that received over 100,000 responses, revealed that women felt unheard, lacked access to information, and faced challenges in accessing suitable healthcare. Specifically, 84% of respondents felt they were not adequately listened to; a significant number of people were disappointed by the way menopause was catered for; and just one in five women felt supported by the services available. The proposed Women’s Health Strategy, the first influential women’s health report, aimed to address these issues, as well

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as priorities for the first year focusing on creating women’s health hubs, improving information provision, supporting access to women’s health in the workplace, and addressing pregnancy loss and fertility treatment access.

"Just one in five women felt supported by the services available."

Regan shared the success of virtual health hubs, emphasising their potential to enhance efficiency, reduce inequalities, and support the National Health Service (NHS) workforce by creating ‘one stop shops’. The health hubs are already established in 42 integrated care systems, supported by women’s health champions. Further success was achieved surrounding menopause care, with women now able to access 1 year of hormone replacement therapy for the price of a single prescription.

In her closing remarks, Regan made a call for equity in women’s healthcare and encouraged advocacy for change, emphasising that a willingness to try different approaches is crucial for better outcomes.

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GIANT 2023

INSIGHTS FROM EXPERTS: STRATEGIES FOR INNOVATION IN WOMEN’S HEALTH Regan then invited several field experts, amongst whom were reproductive scientists, medical school founders, and CEOs of biotech companies, to join her for a panel discussion.

Stephen Smith, former Professor of Obstetrics and Gynaecology, Cambridge University, UK; and former Dean of the School of Medicine at Imperial College, London, UK, began by referring to his research focusing on menstrual dysfunction and gynaecological problems.

Asif Ahmed, Founder and Executive Chairman of MirZyme Therapeutics, Birmingham, UK, previously worked to identify two protective mechanisms to prevent pre-eclampsia. Finally, Teodora Popa, Programme Director of the MSc for Reproductive Science and Women’s Health, University College London, UK, outlined her ongoing research projects focusing on genetics. Specifically, Popa’s research on genetic differences between male and female embryos, challenges assumptions in the field.

Findings suggest females are at a disadvantage even before birth in the fertility sector, as male embryos are more favourably selected during in vitro fertilisation, suggesting ‘biology is sexist’.

One of the primary missions of the panel was to address barriers hindering meaningful progress in women’s health. A notable challenge is the fragmentation in women’s health services, which necessitates the integration of different sectors to provide comprehensive and cohesive care. Further challenges, specific to the NHS,

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included high-tech integration. Due to being free at the point of access and significant funding issues, the panellists stressed that the NHS cannot compete with biotechnology companies.

Therefore, these sectors must work together to implement real change.

Listening to patients, especially women, was underscored as a critical aspect of healthcare delivery and medical education. The importance of education in women’s health, particularly in fertility awareness, was stressed. Addressing fertility education could be a key strategy to potentially prevent a significant number of in vitro fertilisation cases through increased understanding that fertility is finite. Education, both for healthcare professionals and the general public, is a fundamental step in overcoming these barriers. Integrating women’s health education into schools and promoting early awareness are key strategies in ensuring better understanding of fertility.

The panellists emphasised the need to increase innovation and investment in women’s health. They stressed that collaboration with private industries, including big companies, specifically, will be the most successful approach. Additionally, they highlighted the importance of addressing conditions like preeclampsia through digital diagnostics and health transformation. The panel revisited the recently announced 25 billion GBP investment in women’s health hubs, expressing hope for positive outcomes within a 2-year period.

Emphasising early intervention, particularly in schools, the panel underscored the importance

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GIANT 2023

of normalising health check-ups and awareness.

They welcomed small businesses and innovation, urging collaboration and participation in health hubs. The panel also encouraged universities to play a role in promoting student engagement with business and innovation. A suggestion was made to incorporate business-oriented components into medical school curricula.

In summary, the panel proposed changing mindsets in healthcare and education, and integrating health hubs as strategies to actively improve women’s health services.

CONCLUSION Further questions from the audience centred around strategies to integrate tech and innovation into medical education, and normalising sex education in schools. In conclusion, the discussion called for continued advocacy, collaboration, and innovation to overcome barriers and advance women’s health. This panel discussion offered a comprehensive view of the challenges and opportunities in women’s health, highlighting the need for an holistic approach, education, and collaborative efforts to drive meaningful progress. ●

"Integrating women's health education into schools and promoting early awareness are key strategies in ensuring better understanding of fertility."

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GIANT 2023

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Striving for Net Zero in Healthcare Authors:

Darcy Richards, EMJ, London, UK

Citation:

EMJ Innov. 2024;8[1]:15-17. DOI/10.33590/emjinnov/11000005. https://doi.org/10.33590/emjinnov/11000005.

CLIMATE and emissions were key themes explored in the Net Zero Technology Show, which took place as part of the Global Innovation and New Technology (GIANT) Health Event, on the 4th December 2023, in London, UK. Experts came together to present on the relationship between climate and healthcare, alongside the innovative approaches being taken to achieve a net zero National Health Service (NHS).

INTRODUCTION Amidst escalating concerns surrounding climate change and its impact on health, this timely session explored how, conversely, healthcare also has a detrimental impact on the climate, perpetuating the problem.

Jonathan Groome, Nuffield Health and Barts Health NHS Trust, both in London, UK, opened the session by painting the bleak picture of the impact of climate change on the planet, and on our health. Record ocean temperatures; the loss of 1.7 million lives of children <5 years of age; an increase in heat-related mortality in those >65 years of age; increasing food insecurity; loss of work hours; unsafe levels of carbon dioxide (419 parts per million [ppm] as of December 2023, which is 69 ppm greater than the safe level of 350 ppm); and resource limitation, resulting in conditions that spark the rise of conflict, were some of the poignant realities related to climate change that were highlighted. Groome explained that these climate change consequences will ultimately exacerbate pre-existing healthcare inequalities.

"The actions required to make significant differences must be implemented urgently."

In addition to the impact of climate on health, Groome emphasised how polluting the healthcare industry is producing 4–5% of global emissions.

He discussed how climate change will have health or economic impacts for everyone, and that whilst we can still do something to effect change, the actions required to make significant differences must be implemented urgently.

In fact, the threat climate change now poses is not to the planet, but to our survival within it. Groome poignantly remarked that as true healthcare professionals, knowing the impacts of the interplay between climate and healthcare, there is a duty of care towards the planet, as well as to patients.

The session also explored how the NHS is looking to achieve their ambitious commitment of reaching net zero by 2040 for directly controlled emissions, and 2045 for indirect emissions that can be influenced. Whilst the target for this is earlier than the UK government’s target of 2050, Sarah Ouanhnon, Greener NHS Programme, NHS England, London, UK, stated that this target is realistic.

TACKLING THE PROBLEM The NHS was the first healthcare system to declare a climate emergency and a net zero target; however, the route to achieving net zero in a service as vast and complex as the NHS will not be easy. To tackle emissions, the Greener

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NHS strategy, as presented by Ouanhnon, is looking at every individual hospital function to identify what and where changes can be made.

Energy and Hospital Estates

In terms of energy efficiency, the strategy considers hospital estates and facilities to determine how to increase the energy efficiency of buildings. Ouanhnon highlighted the use of solar panels for energy provision, and developing new standards for what net zero buildings will look like for future hospitals, as examples of tackling energy efficiency.

Emissions Related to Medicines

Discussing the impact of medicines on healthcare-related emissions, Ouanhnon spotlighted inhalers and anaesthetic/medical gases as two groups of medicines representing 5% of all NHS emissions. Compared to other types of inhalers, dry powder inhalers not only have a lower carbon footprint, but are also

clinically safe, and appropriate for most patients.

Therefore, offering patients dry powder inhalers as alternatives could lead to emission reduction.

When considering anaesthetic gas emissions, Ouanhnon highlighted a review which revealed that of the three most commonly used in practice, desflurane had a much higher emission profile than sevoflurane. Moreover, in most cases, sevoflurane was found to be as effective and as appropriate as desflurane. These findings led to a change in practice, and subsequently, a large decrease in anaesthetic gas-related emissions over the last 4–5 years. Following this review, the NHS committed to stop using desflurane by early 2024. Ouanhnon commented that this is the first time a healthcare system has ceased the use of a drug for environmental reasons. The above are examples of how reviewing day-to-day processes in healthcare can result in a significant change towards achieving a more environmentally friendly service, without compromising patient safety or quality of care.

"Approximately 60% of healthcare emissions come from global supply chains, which provides a huge opportunity to impact emission reduction."

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GIANT 2023

The Role of Supply Chains

One of the major contributors to NHS emissions is the supply chain for goods and services.

Groome noted that approximately 60% of healthcare emissions come from global supply chains, which provides a huge opportunity to impact emission reduction. In light of this, the NHS has set a roadmap to engage suppliers to reduce their carbon footprint. By 2027, the NHS will no longer do business with suppliers who do not have a net zero target, and since April 2023, the NHS have required that carbon reduction plans must be in place for suppliers of contracts over 5 million GBP.

Models of Low Carbon Care and Indirect Emissions

In addition to direct emissions within hospitals, emissions that occur around them must also be considered, such as how the workforce commutes, and how patients travel to attend outpatient appointments. Solutions to tackling this could be engaging staff in methods of active travel, and considering where virtual outpatient appointments could be appropriate for patients.

Luke O’Shea, University College London Hospital (UCLH), NHS Foundation Trust, London, UK, explored a shift toward low carbon care models, and tackling areas of waste that carry fixed carbon and financial costs within the service, such as unfilled theatre lists and unattended appointments. When reflecting upon low carbon

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care, O’Shea referred to virtual care pathways.

He noted that UCLH conducts >400,000 virtual appointments per year, discussing that whilst they work well and reduce emissions, there are additional factors to consider, such as implementing appropriate video technology, and creating new patient communication documents, to improve the quality of virtual outpatient appointments.

Spirited by the exponential rise in key technology areas, there is hope that by 2030, the challenges that seem niche or difficult to overcome now will have solutions. Imploring the audience, O’Shea stated: “The more that we do now, the bigger the impact we have longer term.” Referring to a famous Nelson Mandela quote, he added: “It always seems impossible until it’s done,” concluding that this is also true of achieving net zero within the NHS.

CONCLUSION Whilst the outlook for climate change and the impact on health is startling, this session highlighted there is hope that significant change in reducing healthcare-related emissions can be made. The strategies the NHS is taking in its aim for a net zero health service by 2040 inspire a belief that greener healthcare is achievable, but funding and government intervention will be required. ●

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Abstract Highlights

Innovation in Healthcare: Highlights from 2023 The following scientific highlights have been selected to showcase key findings across several therapeutic areas.

The research abstracts summarised were presented at various congresses EMJ had the pleasure of attending, and were all award-winning, late-breaking, or highly commended innovative abstracts.

EMJ Innov. 2024;8[1]:18-26. DOI/10.33590/emjinnov/10307465. https://doi.org/10.33590/emjinnov/10307465.

Citation:

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Abstract Highlights

ChatGPT Can Improve Imaging Report Readability for Patients NATURAL language processing models could be used to provide concise summaries of radiology reports so that they are more accessible for patient interpretation, according to awardwinning research presented at the European Congress of Radiology (ECR) 2023, which took place in Vienna, Austria, between 1st–5th March 2023.

Researchers explored whether ChatGPT (OpenAI, San Francisco, California, USA) could be used to reword radiology reports to increase readability, reduce complexity, and explain medical jargon in an understandable format for patients. To do this, the team used a mixture of 30 CT-positive and normal scan reports (abdominal CT [n=10], chest CT/CTPA [n=10], trauma pan CT scan [n=10]).

Selection took place at random over a 1-week period from a tertiary hospital medical imaging department. Of the selected scans, six were reported by a consultant radiologist, 14 by senior radiology registrars, and 10 by junior registrars.

Following selection, ChatGPT was tasked with completing a revised version of the report conclusions. It was asked to do this without changing the meaning of the original, and to revise the report so that it could be understood by a person aged 14 years. Reports were evaluated using the Flesch Kincaid Reading Ease (FKRE) score. After calculating the mean

and standard deviation of FKRE scores, a paired t-test was used to compare the means of the original radiologist and ChatGPT reports. The simplified reports were reviewed by a consultant radiologist and radiology registrar to ensure accuracy and context retention.

The results revealed that following ChatGPT simplification of original reports, average FKRE score increased from 20.3 (standard deviation: 17.1) to 65.2 (standard deviation: 15.7), equating to a change in reading level from that expected of university educated graduates to a level appropriate for 12-year-old school children.

Whilst the overall report readability improved, there were six reports for which no readability improvement occurred. In these instances, two reports were from trauma pan scans with multiple positive findings, and two other reports were short and deemed not suitable for simplification.

The researchers concluded that natural language processing models such as ChatGPT can create simplified summaries of radiology reports to optimise their readability and interpretation by patients. A limitation is that additional inappropriate and potentially incorrect information can be added into reports by these models. Thus, there does remain a requirement for oversight by a radiologist. ●

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Abstract Highlights

Deep Learning Models Predict Outcomes Following Liver Transplant DEEP learning models can efficiently predict major adverse cardiovascular events (MACE) following liver transplantation (LT), according to new research presented at the European Association for the Study of the Liver (EASL) Congress 2023, held in Vienna, Austria. The team, from the University of Texas Health Science Center in Houston, USA, and Mayo Clinic, Jacksonville, Florida, USA, aimed to develop and validate deep learning models’ ability to predict post-transplantation MACE among patients undergoing LT.

the deep learning model against other machine learning models, such as logistic regression, random forest, and light gradient-boosting machine, was assessed using a cohort of 18,304 LT recipients (mean age: 57.4 years; 60.9% male; 39.1% female). Models’ optimisation was done using five-fold cross validation on 80% of the cohort (training set), and the performance of the models was assessed using the remaining 20% (testing set), based on the area under the receiver operating characteristic curve and the area under the precision-recall curve.

The authors identified patients who received an LT between January 2007–March 2020, and built multiple predictive models for the risk of developing any of the post-transplantation MACE, including myocardial infarction, atrial fibrillation, pulmonary embolism, heart failure, cardiac arrest, and stroke as an outcome.

A MACE is primarily predicted using the Bidirectional Gated Recurrent Units (BiGRU) deep learning sequence processing model in different prediction interval lengths up to 5 years after the LT index date, using patients’ demographics and retrospective diagnosis, medications, and procedures to claim data recorded back to 3 years before the LT index date. Performance of

Using different prediction intervals (0–30 days, 0–1 year, 0–3 years, and 0–5 years) after the LT index date, and compared to the three machine learning models, the top-performing model was the deep learning model, BiGRU, which achieved an area under the receiver operating characteristic curve of 0.833 (95% confidence interval: 0.8127–0.8522), and area under the precision-recall curve of 0.560 (95% confidence interval: 0.5205–0.6058) for a 30-day prediction interval after LT. The team concluded that this model will help clinicians to identify high-risk candidates for further risk stratification or other management strategies, to improve LT outcomes. ●

"Performance of the deep learning model against other machine learning models was assessed using a cohort of 18,304 LT recipients."

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Creative Commons Attribution-Non Commercial 4.0

Abstract Highlights

Prognostic Value of Hyperaemic Stenosis Resistance THE Hyperaemic Stenosis Resistance (HSR) index was shown to have theoretical advantages for the detection of ischaemia-inducing high-risk coronary lesions, according to data presented at EuroPCR 2023, held in Paris, France, between 16th–19th May 2023. The HSR index represents the ratio between the hyperaemic pressure drop across a stenosis, as well as the flow through it. While it aims to indicate stenosis severity to guide revascularisation, its diagnostic and prognostic value is unclear, which is why researchers evaluated this in patients with stable chronic coronary syndromes. This is the first study to determine the HSR’s prognostic value, and its potential to identify which lesions would benefit from revascularisation accurately.

A total of 853 patients and 1,107 vessels were included in the study, derived from the Inclusive Invasive Physiological Assessment in Angina Syndromes (ILIAS) Registry. Results showed a higher area under the curve (0.71; 95% confidence interval [CI]: 0.66–0.75) for the presence of ischaemia on non-invasive stress test for the HSR, compared to coronary flow velocity reserve (0.63) and fractional flow

reserve (0.66). They further identified the optimal cut-off value for HSR to be 0.80 mm Hg/cm per second, which is similar to previous study results.

"Researchers evaluated this in patients with stable chronic coronary syndrome."

Further survival analysis showed statistical association between HSR as a continuous variable and target vessel failure at 5-year follow-up (hazard ratio: 1.40; 95% CI: 1.06–1.84; p=0.016), as well as an independent association between abnormal HSR based on the cut-off value of 0.80, and 5-year target vessel failure (hazard ratio: 2.48; 95% CI: 1.49–4.13; p<0.0005).

The team further showed through sensitivity analysis that an HSR-first approach identified increased risk of adverse clinical outcomes more adequately in lesions initially deferred from revascularisation, compared to coronary flow velocity reserve and fractional flow reserve.

This led the team to conclude that their study affirmed the theoretical advantages of HSR. ●

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Abstract Highlights

Electronic Creatinine Alert System: A First Step Towards Preventing Hospital-Acquired Acute Kidney Injury ACUTE Kidney Injury (AKI) is a common complication in critically ill and non-critically ill patients, for which there is currently no specific treatment. Early recognition is crucial to prevent progression to advanced stages and the need for kidney replacement therapies. Electric alert systems are emerging as a tool capable of alerting clinicians to potentially harmful situations. This retrospective study aimed to analyse the incidence of AKI in a tertiary hospital using an Electronic Creatinine Alert System (ECAS), which alerts clinicians to serum creatinine changes in real time, enabling early interventions. Results were presented at the European Renal Association (ERA) Congress held in Milan, Italy between 15th–18th June 2023.

The retrospective study analysed 46,149 patients discharged from a tertiary referral hospital between 1st January 2019–31st December 2021.

The exclusion criteria were discharges from critical care units, patients admitted to the emergency room, patients with AKI criteria on admission, patients admitted to the nephrology department, and patients with Stage G5 chronic kidney disease or on kidney replacement therapy. The ECAS alerted patients following an increase of ≥0.3 mg/dL of serum creatinine or an elevation of ≥1.5 times the baseline creatinine value.

A total of 69,0002 discharges were analysed, with the majority of patients included having AKI

Stage 1 (69.7%), followed by Stage 2 (21.3%), and Stage 3 (9.0%). The median age of the included participants was 75 years, and 62% were male. The ECAS was activated in 13.5% of discharges, with an increasing trend over the years (11.8% in 2019, 12.4% in 2020, and 12.1% in 2021). Geriatrics (14.2%), cardiology (11.9%), general surgery (9.9%), infectious diseases (9.2%), and cardiac surgery (7.2%) were the departments with the highest ECAS activations.

Results indicated that the ECAS activations were associated with poor outcomes. Patients who activated the ECAS experienced significantly longer hospital stays compared to those who did not (6 days versus 13 days; p<0.001).

Moreover, the survival distributions for the ECAS activation were statistically different (X2=5.522; p=0.019) and kidney recovery at discharge was significantly lower in the patients with AKI 2 (18.5%) and AKI 3 (8.5%), compared to patients with AKI 1 (73%; p<0.001).

Overall, the results suggest ECAS as a suitable electronic alert system for rapid AKI identification. The findings prompt the adoption of a nephrology rapid response team for early AKI detection before creatinine elevation, incorporating methods such as point-of-care ultrasonography and acute kidney stress biomarkers to enhance early intervention strategies. ●

"Electric alert systems are emerging as a tool capable of alerting clinicians to potentially harmful situations."

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Abstract Highlights

Use of Artificial Intelligence in Predicting Rheumatoid Arthritis USING extremity MRI to predict early rheumatoid arthritis (RA) can lead to more timely treatment, and the possible prevention of chronicity. Recent research presented at the European Alliance of Associations for Rheumatology (EULAR) Congress 2023, held in Milan, Italy, suggested that using artificial intelligence (AI) to interpret images may prove more accurate than visual screening. A team from Leiden University Medical Centre, the Netherlands, developed a deep learning AI method that automatically analyses extremity MRI scans in order to predict RA at an early stage.

The research involved MRI scans of the hands and feet of a total of 1,974 patients, of whom 1,247 had early onset arthritis (EAC) and 727 had clinically suspect arthralgia (CSA). Of the EAC group, 538 patients developed RA in 2 years, and 113 of the patients with CSA also developed RA. MRI scans were pre-processed automatically, and a self-supervised deep learning model was pre-trained to fill in blacked-out parts of the images. The model was then fine-tuned to predict RA development, its accuracy evaluated under the receiver operator curve (AUC).

Results showed that deep learning models have the ability to predict RA development accurately.

On the test set, the model obtained a mean AUC of 0.683 in the EAC group, and 0.727 in the CSA group, using MRI scans of the hands (wrist and metacarpophalangeal joints). Models trained separately on the wrists and feet received a mean AUC of 0.679, 0.647, 0.664; and 0.688, 0.669, and 0.715, for the EAC and CSA group, respectively. These accuracies were close to the expert-level using Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS), with reported AUCs of 0.74 and 0.69 in predicting RA in CSA. The team concluded that automatic RA prediction using an AI interpretation of MRI scans is possible, as this new visualisation method confirms the significance of inflammatory features, but also has the potential to highlight new imaging biomarkers. Researchers added that including the MRI data of healthy controls, as is done in RAMRIS-based prediction, may improve the ability of AI to predict RA development even further. ●

"Including the MRI data of healthy controls may improve the ability of AI to predict RA development even further."

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Abstract Highlights

Telemedicine Effective for Multidisciplinary Narcolepsy Care RESULTS from the TENAR randomised controlled trial presented at the European Academy of Neurology (EAN) Congress in Budapest, Hungary, have provided insights into the use of telemedicine for the care of people with narcolepsy. Narcolepsy, a rare central hypersomnia associated with endocrine and psychosocial problems, poses unique challenges that require a comprehensive, multidisciplinary approach. The TENAR trial, conducted by researchers from IRCCS Institute of Neurological Sciences of Bologna, Italy, and the University of Bologna, Italy, sought to assess the efficacy of telemedicine in managing narcolepsy compared to traditional in-office visits.

The trial included individuals with narcolepsy aged over 14 years, and compared a multidisciplinary care approach, encompassing neurological, endocrinological, and psychosocial care, delivered through telemedicine versus in-office visits over a 1-year period. The primary outcome was the control of sleepiness, measured by the Epworth Sleepiness Scale (ESS) at 12 months, with a non-inferiority margin of 1.5 points. Secondary outcomes included: control of other symptoms, treatment compliance, metabolic control, quality of life, feasibility, patient and family satisfaction, safety, and disease-related costs.

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Of the 208 individuals selected, 202 successfully completed the study at 12 months. The baseline variables were well balanced between the telemedicine and in-office outcomes. The primary outcome, ESS score improvement, showed a 1.3 mean point improvement in both groups, and there was no statistical difference between the groups. Secondary outcomes, including BMI improvement, demonstrated similar positive trends in both telemedicine and inoffice management, with no statistical difference between the groups.

"Of the 208 individuals selected, 202 successfully completed the study at 12 months."

The preliminary results of the TENAR trial indicate the viability in terms of feasibility, effectiveness, and safety of multidisciplinary care procedures for narcolepsy. These findings highlight the possibility of redefining the approach to narcolepsy, and the potential of telemedicine to enhance accessibility, improve patient outcomes, and reduce associated costs. ●

Creative Commons Attribution-Non Commercial 4.0

Abstract Highlights

ChatGPT: A Potential New Tool to Answer Patient Questions About Fertility

CHATGPT (OpenAI, San Francisco, California, USA) may be a useful tool for patients seeking factual and unbiased information regarding fertility and fertility treatment, according to new research presented at the 39th Annual Meeting of the European Society of Human Reproduction and Embryology (ESHRE), held in Copenhagen, Denmark.

"Out of the ten answers, six scored 5 or more, and three received a score of 3–4."

ChatGPT is a language model that uses deep learning to generate human-like text.

Researchers from Monash University, Melbourne, Australia, examined the quality of information provided by ChatGPT, using ten common patient questions as prompts. Three questions related to fertility awareness (impact of female/male age on fertility and fertile window in the menstrual cycle), one to the chance of success with in vitro fertilisation, one to elective egg freezing, one to the benefits of add-ons, one to polycystic ovary syndrome and pregnancy, one to choosing a fertility clinic, and one to how many in vitro fertilisation cycles should be attempted.

The two authors scored the quality of the information generated by ChatGPT using a scoring matrix with a range of 0–7, where higher

scores indicate higher quality. Text was rated against humanistic answers based on how well it corresponded (0–3), evidence of commercial bias or controversial claims (no=0, yes=1), use of accurate statistics, and whether it was stated that medical advice should be sought (no=0, yes=1).

The scores returned by the experts were closely aligned, with only one point difference for one of the answers. Out of the ten answers, six scored 5 or more, and three received a score of 3–4. Only one answer, the answer to the question about the benefits of add-ons, scored less than 3. This was also the only question where the response had evidence of commercial bias, and one of only two that made claims that could be considered controversial. While the scoring method used in this study is exploratory in nature, the use of expert evaluation can be used to fine-tune the parameters of machine learning models, and improve their performance.

People seeking fertility-related information rely heavily on online sources, such as clinic websites, consumer advocacy organisations, patient support groups, and social media.

Overall, the study concluded that the quality of information generated by ChatGPT was high, with little evidence of commercial bias, suggesting that ChatGPT may be a useful tool to answer patient questions about fertility. ●

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Abstract Highlights

Harnessing Generative Artificial Intelligence Data for Skin Disease Classification RESEARCHERS have successfully employed generative artificial intelligence (AI) techniques using probabilistic models (DPM) in an effort to address the shortage of labelled training data for real-world dermatology applications. Results of this research were presented at the European Academy of Dermatology and Venereology (EADV) Congress in Berlin, Germany, and indicate the potential of this approach in augmenting training datasets and improving skin disease classification. Thus far, research efforts in dermatology have struggled with limited access to training data, due to privacy constraints and strict data sharing policies. Researchers propose using DPMs for image augmentation within supervised machine learning pipelines, with the objective to complement existing validation datasets and overcome challenges posed by the lack of real-world dermatological data.

"High-quality images were isolated through the development of a data curation pipeline."

The study fine-tuned DPMs on six different disease conditions, including basal cell carcinoma and melanoma as malignant classes; actinic keratosis and atypical melanocytic nevus as pre-malignant classes; and lentigo and seborrheic keratosis as benign classes.

High-quality images were isolated through the

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development of a data curation pipeline in order to address the variation in generated image quality.

The results obtained indicated that the generative data augmentation approach maintains a comparable classification accuracy to visual classifiers, even when trained on fully synthetic skin disease datasets. Inclusion of synthetic images in a hybrid dataset, alongside the original images, improved performance, and yielded a top-3 accuracy of 85.01%. This outperformed datasets comprising of only original images (84.48%), or only synthetic images (84.09%), indicating that DPMs are effective in generating high-quality images and improving augmentation of datasets, without compromising classifier performance.

The findings of the study showcase the generative capabilities of DPMs in creating macroscopic skin disease images. By conditioning probabilistic diffusion-based generation on text prompt inputs, fine-grained synthetic images were possible. Researchers also propose a closed-loop data augmentation pipeline to automatically generate images whilst complementing real-world skin disease datasets. This research emphasises the reliability of synthetic images as data sources for skin disease classification, offering a potential avenue for medical applications and data sharing without compromising confidentiality. ●

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Interview

Interviews The EMJ team had the pleasure of speaking to James Bevan, who detailed his commitment to the inclusion of planetary health and sustainability topics into medical education, and Madhuri Hegde, who discussed advanced genomic technologies and her work directing three COVID-19 testing laboratories.

James Bevan School of Primary Care, Population Science and Medical Education, Faculty of Medicine, University of Southampton, UK Citation:

EMJ Innov. 2024;8[1]:27-32. DOI/10.33590/emjinnov/10307043. https://doi.org/10.33590/emjinnov/10307043.

Q1

What sparked your decision to leave your corporate role as a sustainability consultant to undertake a medical degree before embarking on a career in public health medicine?

I did my chemistry degree at Bath University, UK, where most undergraduates do a year in industry placement. Between the second and third year of my degree, I worked in a sustainability consultancy, which was part of a wider company called Jones Lang LaSalle (JLL), a big property advisory company. I worked there for a year and loved it. Then, I did my final year at Bath, and after a brief spell at PwC (London, UK) as an accountant, I went back to JLL, and worked for a few years as a sustainability consultant. While I was there, I felt that as a society we were not taking sustainability seriously enough. Our team, and a lot of clients, took it very seriously, but it felt like the wind of change wasn't strong enough to lead to the massive reductions in emissions we needed. On a more existential level, I thought: “What can I do to help?”. I had always thought

about going to medical school, so at the age of 26, I applied, thinking that if I didn’t get in, I could continue on with this career I was quite enjoying. This led me down a slightly odd career path, because I had a unique background of sustainability consulting, but was also developing lots of medical knowledge. Only once I started at medical school did I realise that there is a big overlap. I knew that there were health impacts, but I didn't quite understand the interactions between the two at that point, and that is where my career changed. It was in part by design and in part by accident, which is probably how most people get into their jobs.

Q2

The integration of planetary health and sustainability topics into medical education is a key focus of yours. Could you tell us a bit about your role at the University of Southampton, UK, and how you envision wider rollout of these topics into medical education in the UK?

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I first started getting involved in medical education at Southampton, just after finishing my medical degree. I did my elective at Mount Sinai Hospital in New York, USA, where I worked with a public health paediatrician called Perry Sheffield, who had been a figurehead in integrating climate change and sustainability into the undergraduate medical curriculum at the Icahn School of Medicine at Mount Sinai. They were leading the way with planetary health education with their “climate change curriculum infusion project,” and I thought this was a great idea. I went away from that elective thinking maybe I could install that at Southampton. We barely had any teaching on climate change and sustainability at that point, so I approached Paul Roderick, who was head of Public Health Education at the time, and suggested we replicate this project at Southampton. He was very enthusiastic! I later got a role at the university as a planetary health senior teaching fellow, and since 2021 we have tried to integrate planetary health and sustainability across the medical curriculum. As a result, we are one of only four medical schools globally to rank with an A in the curriculum part of the Planetary Health Report Card (PHRC), so we have done quite well. I should stress it is not because of me as an individual, but the university who have employed me to come and integrate this, as well as the fantastic population and

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planetary health education team, Kalyanaraman Kumaran and Inna Walker.

With regard to a wider rollout in the UK, I am working on driving momentum on this. Last year I wrote an article discussing why every medical school needs a planetary health teaching fellow. This is in no way me trying to blow my own trumpet, but the rationale behind it is that without a dedicated person, there is not necessarily the expertise in medical faculties to know about planetary health or sustainability.

There might be expertise, but they do not have time or the bandwidth to talk about it. The idea of having a dedicated fellow is that it accelerates that change. Anyone can replicate what we have done and integrate it across the course at their institution. I work just over 1 day a week for Southampton University, and we have seen quite a lot of change there. It is both because of my employment and because the faculty has really bought into it. If you have faculty who are motivated, and just a little bit of money, I think it can be quite feasible to do that.

"Environmental degradation exacerbates already existing health inequalities experienced by the poorest people in society."

Creative Commons Attribution-Non Commercial 4.0

Interview

Q3

Q4

This is something I am working on with the Global Consortium on Climate and Health Education (GCCHE), alongside colleagues in the UK and the USA. Now, medics are aware of climate change and its impact on health; however, that awareness was not there when I started medical school. I think 2013 was when the term planetary health was coined, and since, there has been a huge rise in the amount of research. However, education typically lags behind research and appears to only slowly be taken up globally. Although there is no evidence on this, I suspect the countries which will feel the worst health effects are teaching about this the least.

One thing we anticipated in the International Medical Education Collaboration on Climate and Sustainability (IMECCS) was that faculty would not be interested in introducing these topics into their curricula, and that we would get some pushback from medical educators. What we found was the opposite, educators have been very supportive when approached, and eager to get this into their curriculum. Doctors, on the whole, are quite sensitive to the global influences on health, and want to teach about it.

The other barrier to this is educator awareness or knowledge of these topics. Doctors teaching today were not taught about planetary health and sustainability when they were at medical school, as it has only really been a formed topic for the last 10 years. They might have had a bit of education and some awareness, but lack the confidence to teach it, or the bandwidth to increase their teaching load. It takes a lot of time to do the research, and for people who teach on medical courses, who are often busy clinicians who do not have time to do that, I think those are the main barriers to implementing it. This is where IMECCS comes in.

Do you see a roadmap for including planetary health and sustainability into medical curriculums across the globe?

Environmental degradation exacerbates already existing health inequalities experienced by the poorest people in society. Historically, these people have also been responsible for the least emissions. Now, these populations are, to some degree, going to be the most vulnerable to environmental degradation. We are going to see some health consequences in the UK, but it is going to be absolutely dwarfed in comparison to many low- and middle-income countries, particularly in South Asia, Sub-Saharan Africa, and low lying island states, where these effects are being felt already. The health infrastructure in those countries are particularly vulnerable to shocks caused by environmental change. We need to teach medical students and doctors to be prepared for those changes. They need to be aware of this, so they can put pressure on their healthcare leaders to build resilience within global and local healthcare systems. What I mean by that is building hospitals, supply chains, and primary care practices that are not vulnerable to extreme weather events such as floods, storms, and droughts.

What, if any, barriers do you foresee in the uptake of these topics into traditional medical curriculums?

Q5

What are the potential implications for neglecting planetary health and sustainability in medical education and practice?

First, you have the impact that environmental degradation has on health. We need to prepare the doctors of the future to be able to face these challenges, and treat patients with diseases that arise or spread because of climate. If we do not do that, they will not be equipped to protect their patients’ health in the context of environmental change.

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The other side is the healthcare sustainability side. Healthcare has this paradoxical impact on health, because as we deliver healthcare to people, we are also causing environmental degradation. And we know that this impact on the environment has an impact on health.

So, through the delivery of healthcare, we are paradoxically impacting global health. We need to teach doctors to reduce that impact, work more sustainably, and reduce healthcare emissions.

Healthcare is responsible for about 5% of global emissions, equivalent to aviation or shipping.

We often talk about aviation and shipping being awful for the environment, but we very rarely, if ever, talk about how bad polypharmacy or unnecessary surgeries and interventions are for the environment. I am not saying that we should be restricting medications or surgery from people who need it, but sometimes an intervention that is good environmentally can also be good for health, or the converse, and we need to think about that. That is what we try and teach the medical students about: thinking about things in a more holistic planetary way, rather than just the patient in front of them, but always with the underpinning that practice needs to be evidence-based, good clinical medicine.

are aiming to improve already existing teaching sessions, rather than adding sessions. The aim of IMECCS was to have an open resource bank that is accessible across the world. We have not collected data on how people have used it yet, but we know that most people using it are trying to implement a planetary health curriculum.

Q6

Q7

I started up IMECCS a couple of years ago with Perry Sheffield, who I mentioned earlier. The idea was: how can we overcome these barriers I mentioned easily? Perry had already developed the “climate change curriculum infusion project” and we thought we could make it into a usable product for medical schools to add to the curriculum. Essentially, we wanted to make a one stop shop. Anyone who is interested can come to our website or resources and see all these materials to insert into existing teaching sessions. The idea was that we would provide these lecture slides with scripts and references, so that we can overcome barriers of lecturers not knowing about the topic. They do not need to do their own research, and there is no need for more space within the medical curriculum, because we

I am not actively involved in the PHRC, but it is a brilliant student-run organisation that has catalysed change in this area. They have been one of the main drivers for accelerating faculty putting planetary health in their curriculum, because you can rank medical schools against each other and every doctor in the world is competitive, leading to a strive for better year on year performance. If your medical school is not doing well, you are going to want to improve things. It is built off this competitiveness and replicates Environmental Social and Governance (ESG) reporting in the corporate world, hopefully without the greenwashing. The PHRC has driven change massively, and I am incredibly impressed with them.

You are the international lead for the IMECCS and a working group chair with the GCCHE. What do these roles entail?

The GCCHE, at that point, was just forming.

Now, it is a much more powerful organisation.

Hundreds of climate and health experts signed up to help with this project, which essentially does a very similar thing to IMECCS, only bigger and better, I think. They provide resources in a similar way, which have been peer-reviewed and go through a very stringent process, and some of the content was provided by world experts on these topics. I am one of the co-chairs on one of the working groups, and part of that process is trying to get the word out about the GCCHE, and engaging with interested parties across the world. We have ‘office hours’, which are like a troubleshooting session every month or 6 weeks.

Anyone can log in to the office hour and ask us questions about how they can overcome barriers at their local institution, and implement planetary health and sustainability education.

The PHRC is currently in use in over 105 medical schools across 15 countries.

Could you explain what the PHRC is.

"Healthcare has this paradoxical impact on health."

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Interview

Q8

Q9

The number one way in which we can reduce healthcare related emissions is by preventing ill health. In the last few decades, we have become very good at keeping people alive; however, we have not necessarily increased the length of life that people live disease-free. Our population is much more multimorbid, and these people need to use healthcare a lot more. Now, if we can prevent people from getting ill and live longer without illness, then we will reduce those emissions. This, I think, is nicely reflected by The Royal College of Surgeons, who came out and essentially said the number one way to reduce surgical emissions is to reduce surgery. It makes sense, but needs a cognitive change in how we manage health.

In 2022 I completed the diploma in tropical medicine and hygiene from the London School of Hygiene and Tropical Medicine. This was the best educational experience of my life. I met so many interesting, motivated doctors and was lectured by genuine world experts every day. I can’t recommend this course more to anyone thinking about it. Following the diploma, I got this job at UCLH, where part of my time was spent working on clinical trials, and the other part of the job I was free to work on projects that interested me.

Where do you feel the greatest impact on sustainability and planetary health can be made in clinical practice?

Public health is key to reducing our emissions, and a healthy population will lead to lower emissions. That is obviously not completely feasible in all aspects. Once you have reduced the illness as much as you can, you need to think about what interventions can be good for the patients and good for the planet. These interventions help carry ‘co-benefits’. We know that prescription medications in primary care have the biggest emissions impact due to raw material extraction, manufacturing, and delivery of these medications. If we can reduce the amount we are prescribing, that is, reduce polypharmacy, then that reduces emissions. When we are prescribing medications as doctors, we need to think of evidence-based, effective ways in which we can avoid prescribing medications in a way that is good for the patient as well as the planet. I am in no way saying that we should not prescribe something because of its environmental impact if it is clinically needed, but there are plenty of evidence-based solutions out there. It is just not necessarily the cultural norm for us to be prescribing them.

"The number one way in which we can reduce healthcare related emissions is by preventing ill health."

As well as planetary health and sustainability, you have a research interest in infectious disease and you recently worked as a clinical research fellow at University College London Hospitals (UCLH) NHS Foundation Trust and the Hospital for Tropical Diseases, London, UK. What was your role there?

In the clinical research role, I was mainly involved in the SUPERNOVA study. This randomised controlled trial was looking at the effectiveness of a novel monoclonal antibody in protecting immunocompromised individuals from developing severe COVID-19. It was a real insight into the inner workings of clinical trials; I loved it (despite the relentless paperwork)!

I also worked on various other projects, including working with the brilliant RESPOND team at UCLH. This is a team of doctors and nurses who over the last few years have been going out to the community and providing care to refugees and asylum seekers living in contingency hotel accommodation in North London. Specifically, I worked on trying to design a study that could estimate the efficacy of their offering in terms of reducing stress on local healthcare infrastructure, while serving the needs of this vulnerable population.

While at UCLH, I also helped with the setting up of an observational study which will be using metagenomics to assess if the algorithms we use to detect viral haemorrhagic fevers (e.g., Ebola, Lassa, Marburg virus) are effective tools.

This may also become increasingly important as climate change alters the epidemiology of these diseases.

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Q10

Are you currently working on any projects or interested in any innovations that you feel will be pivotal to improving planetary health and sustainability in the future?

I am not working on any research as such at the moment, but I am due to start a research project as part of my Masters looking at whether the recent meningitis outbreaks in Angola could be due to climate change.

Other than that, I have been working with a student group at Southampton called ‘Students for Planetary Health’, which works on lots of different projects around planetary health. To date, we have focused a lot on education, but are now trying to get students linked with clinicians so they can work on healthcare sustainability and get engaged in the idea of research and the creativity behind it. In medical school, it is very easy to think that there is no creativity in medicine, so I want the students to realise how rewarding academia is and the importance of creativity within that. I try to take a slight step back and get students to think about their own projects and help them along the way. It is very much in the early stages at the moment, but that is something I am keen for students to get engaged with.

Q11

You are now studying for an MPhil in Population Health Sciences, and have been accepted as a Fellow of Higher Education.

Where do you see your career heading over the next 5 years?

I am a public health registrar, so to a certain extent, my career is laid out for me. Public health training is great, as it can lead to lots of different career avenues. The MPhil, which is a funded Masters, is a part of it. For me personally, I am interested in a career in the field of

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epidemiology and outbreak response, particularly in the context of extreme weather events. So, combining my interests of infectious disease and planetary health, I am interested in how we can prepare healthcare systems or populations for environmental shocks, and how can we reduce the impact of infectious disease following these events.

Q12

Do you have any advice for practicing healthcare professionals or medical students looking to become involved in public and planetary health?

One thing I would say is something I did at medical school, which really set me on my way. If you are interested in something, give it a Google.

Look up people who might be a link or a new contact, and if you have time and capacity, email them and say: “I am really interested in working with you. Can I come and work with your research team over the summer holidays?”. Having done that, I worked for Public Health England on sustainability topics when I was a medical student, I did some research with Harvard School of Public Health, and did my elective at Mount Sinai. All these things were just me reaching out over email saying I was interested and asking to get involved. You will send out 20 emails and get two responses, but those two responses can easily completely change your career trajectory, and I got some great advice along the way from people who could not take me on, but who I still kept contact with. So, send that email, because you might be the person they are looking for, or you might get advice that could completely change how your career goes.

Secondly, planetary health is a growing specialty and something that is great to get into now, because there are relatively few experts with many years of experience and there is a lot of funding going into it. ●

Creative Commons Attribution-Non Commercial 4.0

Interview

Madhuri Hegde Senior Vice President and Chief Scientific Officer, Revvity, Inc., Waltham, Massachusetts, USA

Citation:

EMJ Innov. 2024;8[1]:33-37. DOI/10.33590/emjinnov/10309197. https://doi.org/10.33590/emjinnov/10309197.

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At the time, in India, there was not a concentrated effort on specialisation available in genetics. My interest in genetics really stems back to sixth grade, when I first saw DNA extraction on an educational video. My family background is very much in medicine, education, and entrepreneurship. I think I got the best of both worlds, and that really stemmed my interest in genetics.

I think it really goes back to when I finished my Master's degree in 1992 and I enrolled for my PhD, which I ended up completing at the University of Auckland, in New Zealand. New Zealand was one of the early countries that started doing newborn screening, and Diane Webster, who is considered one of the leaders in the world of newborn screening, was there at that time. I was able to benefit from this exposure. However, my research interest has been primarily in neuromuscular disorders.

Following your undergraduate degree, you completed an MSc focusing on microbiology and genetics, which shaped the rest of your career. What inspired this choice?

I did my Master's degree at the University Department of Chemical Technology in Mumbai, which is a premier institution in India. There, I had the right mentors who gave me that direction to go into genetics. Genetics has always fascinated me, and I consider myself very fortunate to have been able to finally find my way to this discipline.

Your research interests include newborn screening. How did your passion for this field develop?

My PhD advisor, Don Love, had just returned from England having completed their postdoc with Kay Davies, and identified the utrophin gene, which at that time was a novel discovery.

This piqued my interest in Duchenne muscular dystrophy. My research career has always been

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in the area of neuromuscular disorders, but at the same time as working in the hospital, I had exposure to newborn screening, and, specifically, to some of the early disorders that were screened in newborns, such as phenylketonuria. After leaving New Zealand, following my PhD, I went on to do my postdoctoral fellowship at Baylor College of Medicine in Houston, Texas, USA, where I had a much bigger exposure to genetics, genomics, and newborn screening.

transition from academia to industry was very timely, and I think I have learnt a lot. In academia, where we use products from different companies, we really don't know what goes into developing a solution; the tremendous amount of work, expertise, quality control, and regulatory aspects.

I consider myself lucky that I have been able to see how Revvity develops a product, and how it comes to market. That's a huge learning point for me.

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Q4

What inspired you to make the switch from academia to industry in 2016?

It is a continuation of my journey after completing postdoctoral training at Baylor College of Medicine. I was recruited by Emory University School of Medicine in Atlanta, Georgia, USA, where I divided my time between running my research lab, of which I was a funded investigator, and running the Emory genetics laboratory.

The Emory genetics lab was one of the premier genetic testing labs in the USA, and, at that time, we also received samples from all over the world.

It was very much a global exercise, but we did not have labs in the rest of the world.

For a long time, genetics, and especially genetic testing, has stayed in the world of academia. I think that Revvity, Inc. (Waltham, Massachusetts, USA; previously affiliated with PerkinElmer), is one of the very few companies that really took on the initiative in the rare disorders screening space (newborn screening), and in getting the relevant tools to perform the screenings through the U.S. Food and Drug Administration (FDA) approval processes. Obviously, I was very aware of what Revvity was doing at that time. At Emory University, we were also the confirmatory testing lab for any positive results detected by newborn screening. We had our clinics downstairs, where we used to see babies and paediatric patients come through. The time was right to take all the work that we were doing in academia into the industry.

Revvity also approached me at the same time, as they had a lot of interest in going beyond newborn screening and step into the world of next-generation sequencing. If you look back now, after 7 years, it's really interesting to see where we are today; for example, we also have cell and gene therapy in our portfolio. So, my

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You are currently Senior Vice President and Chief Scientific Officer at Revvity, formerly affiliated with PerkinElmer.

You also head Revvity Omics, a network of laboratories offering services across the globe.

How important is access to advanced genomic technologies, in your opinion?

In the last two decades, and especially the last decade, it feels like we have switched from old technologies to new technologies overnight.

As someone who runs clinical labs, and has run academic research labs, I understand firsthand that the access to the key technologies that enable the labs’ work, and how these technologies come to market, is very important.

There are two ways to look at it: firstly, from the diagnostics perspective; at Emory, as I mentioned, we used to get samples from all over the world, and now I’m running a global network of laboratories. At Revvity Omics we stress our ‘in country for country’ commitment, which refers to the importance of understanding regional needs, and making these technologies accessible in each region or country.

"We are in a very exciting phase of genomic and omics technologies."

Inside Revvity, there is an engine where diagnostics and life sciences come together, and that line is always blurred. We are now thinking about the entire pipeline, from the individual, whether it be preventative testing or symptomatic testing, all the way to gene therapies, and the entire lifecycle of the different products that need to come to market, with the omic-based technologies and innovation behind it. We keep that engine very alive and active by looking at new technologies and debate them to understand

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what is needed. I am fortunate to have the opportunity to bring that knowledge to the company because I have come from an academic setting.

We are in a very exciting phase of genomic and omics technologies. These technologies are going to not only shorten the time to diagnosis, but also facilitate development and monitoring of new therapeutics, such as biomarkers. As these assays are developed and the technologies evolve, we must also remain alert and adapt accordingly.

Q5

Revvity was the first clinical laboratory to offer whole genome sequencing commercially. How was this new service received initially, and how does it impact patients today?

Around the time I came to Revvity, a revolution of whole genome sequencing had begun, and genome sequencing became relatively affordable.

There were also some National Institutes of Health (NIH)-funded projects at that time, such as the BabySeq Project, which is quite well known, and Genomics England had also kicked off its 100,000 Genomes Project. There were also a lot of smaller companies, core laboratories, doing research-based whole genome sequencing.

There was no single clinical laboratory that could offer whole genome sequencing on a clinical basis for healthy newborns, so we launched two programmes: the healthy newborn genome sequencing programme, and a clinical genome sequencing programme in our clinical laboratory in the USA. At Revvity, we are very fortunate that we have our blood cord tissue storage channel, ViaCord, through which we launched whole genome sequencing for healthy newborns. In the second or third trimester of their pregnancies, families using ViaCord services were introduced to the possibility of having their babies’ samples tested via whole genome sequencing at birth.

"This is truly a turning point for paediatric patients as the earlier you detect a condition, the earlier you can intervene."

This was a novel approach, so a lot of processes had to be put in place, such as institutional review board approval, consent forms, proper information on how each gene causes disease, and why we look at certain genes and not others.

From a testing standpoint, giving families the opportunity to choose whether they wanted to use our whole genome sequencing services or not, instead of having to enrol in a project, makes this a real-world experience. Hopefully the outcome of these projects is going to show that newborn genome sequencing is useful and necessary. It is an ecosystem, because whole genome sequencing is not just one test; it has so many components. We are also doing clinical whole genome sequencing in certain cases when samples of sick babies or children come to us.

Q6

You have recently launched ultrarapid genomic testing (urWGS) to aid with the treatment of critically ill patients in the neonatal and paediatric intensive care setting.

Can you outline how this technology could revolutionise healthcare?

This is truly a turning point for paediatric patients as the earlier you detect a condition, the earlier you can intervene, which is the primary goal.

When you have a baby or a child in the intensive care unit, you want a result as fast as you can, so that you can intervene early, and prevent any further damage. This is where ultrarapid genome sequencing comes in. We've been doing this for a while now; the turnaround time is about 5 days, and we can have turnaround results in 48 hours.

It is also important to take into consideration that doing ultrarapid genome sequencing in a clinical setting and in a commercial laboratory is different to doing it in an academic setting where the turnaround can be 6 hours, but this would probably cost around 100,000 USD. You have to blend both the viability of running such a test with the accessibility and timely delivery of results, so that physicians can intervene. With the ultrarapid also comes the delivery of a written report within that specified time, and then the follow-up with a genetic counsellor who calls out the result and discusses it with the physician. This is very important, as there are over 7,000 rare disorders and you cannot expect this information to be at a doctor’s fingertips. It is our responsibility to give them that information, so that they can act on it.

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Q7

As both a medical geneticist and American Board of Medical Genetics and Genomics (ABMGG) certified diplomat in clinical molecular genetics, how do you approach your role at Revvity?

The teams at Revvity are high-functioning, with experts in different areas of technology, such as mass spectrometry, sequencing, and cell and gene therapy. What I am able to bring to the table as a trained medical geneticist is the patient perspective. On a day-to-day basis, in clinical cases, I look at data. We know that a certain gene has a function in the body, and we need to take that further to what is next. I work closely with the team on improving the products we have and the technologies we are looking at, which is an important part of what we do as a company, so we can keep fine-tuning our approaches and be alert to any emerging technologies. We can then talk to different groups and start motivating them to look into developing new products and solutions.

Q8

Which aspects of human genetics warrant further research?

Sequencing, and especially next-generation sequencing, is evolving. Firstly, we are moving from short-read to long-read, which is going to improve diagnosis, given that, even today, we can diagnose only 50% of the cases that come to us, and there is still a lot of discovery left to do. Secondly, this is going to facilitate all the discoveries that will happen in the future. Some

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advancements have taken place in certain recent methods, such as mass spectrometry, that really stand out. Thirdly, the field is very quickly shifting into looking at therapeutic answers for these diagnoses, with data interpretation, variant interpretation, and amelioration of clinical symptoms Some interesting topics are evolving: how protein–protein interactions happen, whether some therapies are interchangeable, and whether old drugs can be repositioned and repurposed. I think this is going to be an emerging area, which we all have to watch very closely.

Q9

During 2020–2022, you directed three COVID-19 testing laboratories for the National Health Service (NHS) in the UK and the California Department of Public Health in the USA, which together processed approximately 16 million samples. How did you tackle such a huge task during the pandemic, and how do you think this experience has shaped your career since?

The credit goes to the entire team at Revvity, as we really came together, and everyone pitched in.

It was a tremendous team effort, with everyone working towards the same goal. Obviously, running two labs in two different countries was not a trivial thing to do, but we had a good cadence set up for our interactions in these labs, and in how we were going to carry out the testing. Revvity also developed a COVID-19 assay that, following an FDA review, earned the recognition of being the most sensitive assay on the market, which played a significant role.

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Additionally, the company was able to provide end-to-end automation from sample to reporting.

You can only imagine how many different teams were participating: assay development, manufacturing, software team, automation team, quality, regulatory, and clinical team, and so on.

We all went through this period where we were reading the news and learning how things kept evolving. Our understanding of COVID-19 is still evolving now, both around the active disease and long COVID. This creates challenges for the labs, especially around the speed at which results are provided. The tremendous strain on the laboratories’ throughput was an interesting challenge to tackle, and I think we have all learned that we can only progress if we help each other, through extensive collaboration.

All of the people I interacted with, including my colleagues in the field, vendors, providers, and our contracting organisation, were working towards one common goal, which is probably the most important learning point: to keep that focus, and keep going, in spite of adversity.

Q10

You have chaired many international societies and councils, been appointed as Senior Vice President & Chief Scientific Officer of Revvity, and received numerous awards recognising your impressive contributions to the field of human genetics. To date, which of your achievements are you most proud of?

It's very hard to pick one, but if there's a single achievement I had to name it would be the people who trained with me and have gone on to develop their careers. I think it’s really amazing to have the opportunity to pass knowledge on and pay it forward. I have been fortunate to train postdoctoral fellows, who have excelled and have now completed training and left to join different organisations. Within the global Revvity Omics force, we have labs in different countries, and to see that passion in each one of the professionals there is just truly amazing. I feel that my contribution is being able to train people who are really carrying the flag forward, and I feel very good about that.

Q11

What is next, both for Revvity and your own career?

The way Revvity was brought together, and the name itself (from ‘revolutionise’ and ‘vita’, meaning life in Latin), explain our passion in revolutionising healthcare. Our teams are energised and so well poised to take on these challenges. Now that we are a more streamlined company, it gives us more freedom to be able to look more broadly across the life sciences and diagnostics portfolios and focus on innovation. With my own career, I have really enjoyed my time here at Revvity, and I hope to continue to contribute to Revvity’s purpose of expanding human boundaries through science.

I'm really looking forward to that. ●

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AI in Early Diagnosis of Cancer Citation: EMJ Innov. 2024;8[1]:38-39. DOI/10.33590/emjinnov/11000002. https://doi.org/10.33590/emjinnov/11000002.

AI in Oncology

AI Subtypes in Health

‘The science of developing machine technologies that are capable of performing tasks usually associated with intelligent beings, including problem solving and learning’1

Physic Medical AI

AI has the potential ‘to fundamentally transform the practice of medicine and the delivery of healthcare’2

Virtua

AI could be pivotal in helping cancer care as part of the European Digital Strategy3

Spotlighting Lung Cancer5

Two Main Types of Lung Cancer

Total cancer-related deaths6 Small Cell

Non-small Cell

Small Cell Carcinoma (Oat Cell Cancer)

Adenocarcinoma

Combined Small Cell Carcinoma

Squamous Cell Carcinoma

21% pie charts Highest mortality worldwide Diagnosed at Stage I7 20% pie charts Large-Cell Carcinoma

Early diagnosis remains challenging

Key AI: artificial intelligence; AUC: area under the curve; CNN: convolutional neural network; HIPAA: Health Insurance Portability and Accountability Act; HCP: healthcare professional; LDCT: low-dose CT; NLST: National Lung Screening Trial; SCLC: small cell lung cancer; SCC: squamous cell carcinoma.

References 1.

Joiner IA, Artificial Intelligence: AI is Nearby Emerging Library Technologies (2018), Kingston up-on Hull: Chandos Publishing, pp.1-22.

2. Bajwa J et al. Artificial intelligence in healthcare: transforming the practice of medicine. Future Healthc J. 2021;8(2):e188-94.

3. European Commission. Europe’s beating cancer plan: communication from the commission to the European Parliament and the Council. 2022. Available at: https://health.ec.europa.eu/system/files/2022-02/eu_cancer-plan_en_0.pdf. Last accessed: 7 December 2023.

4. Farina E et al. An overview of artificial intelligence in oncology. Future Sci OA. 2022;8(4):FSO787.

5. Gandhi Z et al. Artificial intelligence and lung cancer: impact on improving patient outcomes. Cancers (Basel). 2023;15(21):5236.

6. Jacobs C, van Ginneken B. Google’s lung cancer AI: a promising tool that needs further valida-tion. Nat Rev Clin Oncol. 2019;16(9):532-3.

7.

Bidzińska J, Szurowska E. See lung cancer with an AI. Cancers (Basel).

2023;15(4):1321.

8. Ballard DH et al. The role of imaging in health screening: screening for specific conditions. Acad Radiol. 2021;28(4):548-63.

9. Yeh MC et al. Artificial intelligence-based prediction of lung cancer risk using nonimaging elec-tronic medical records: deep learning approach. J Med Internet Res. 2021;23(8):e26256.

10. Zhang K, Chen K. Artificial intelligence: opportunities in lung cancer. Curr Opin Oncol. 2022;34(1)44-53.

11. Chauvie S et al. Artificial intelligence and radiomics enhance the positive predictive value of digital chest tomosynthesis for lung cancer detection within SOS clinical trial. Eur Radiol. 2020;30(7):4134-40.

12. Teramoto A et al. Automated classification of lung cancer types from cytological images using deep convolutional neural networks. Biomed Res Int. 2017;2017:4067832.

Eme

thcare

Choosing the right problems

cal AI Machine learning

Continuous monitoring

Data collection and processing

AI Development Pathway

al AI

Model contruction: - Training - Validating - Testing

Deep learning Model development

Accurately detecting/ categorising lung nodules

Minimising radiation exposure Benefits of AI in Screening

Personalising screening Minimising radiation exposure schedules

LDCT interpretation in regions with a shortage of skilled radiologists

Screening

Diagnosis

- LDCT screening is the gold standard for lung cancer detection - Nodules can act as early indicators - Early diagnosis in high-risk populations can reduce the death rate by 20% - CNNs, a class of deep-learning artificial neural networks, have identified high-risk patients, and predicted 1-year lung cancer rate with excellent accuracy (overall AUC: 0.90)10

- Predictive models combine CT images with AI algorithms - The DL Cade system=higher nodule detection rate (86.2% versus 79.2%) per CT examination than that of a double reading by two radiologists11 - 298 histopathological images analysed using deep CNNs classified adenocarcinoma, SCC, and SCLC with accuracies of 89%, 60%, and 70%, respectively12

erging issues and directions Lack of large datasets of clinical data to train models Lack of resources, proper training, and education among HCPs Patient privacy, data security, and compliance with regulations can be complex

A framework for AI model deployment in healthcare could ensure patient safety, while maintaining ethical standards Creation of standardised dataset of lung cancer and longitudinal data through collaboration of healthcare institutions

Feature

The Transformative Potential of Patient-Generated Health Data Authors:

*Ghazanfar Khan1-3 1. General Practitioner, National Health Service (NHS), Yorkshire, UK 2. Consultant, World Health Organization (WHO), Geneva, Switzerland 3. Specialist Adviser, Design Council, London, UK *Correspondence to g.khan@doctors.org.uk

Disclosure:

Khan is a National Health Service (NHS) doctor based in Yorkshire, UK. He was previously a Consultant for the World Health Organization (WHO), Geneva, Switzerland, where he led initiatives on primary health care and COVID-19. Khan is a former Visiting Scholar at Harvard Medical School, Boston, Massachusetts, USA (2021–2023), where he undertook research on patient-generated health data in primary care.

This work is not yet published and involved no financial remuneration. Khan also served as Head of Clinical at Mendelian, London, UK, a rare disease start-up using electronic health records to accelerate diagnosis (2021–April 2023). The above roles have no influence on this article and the opinions written in this piece are the author's own views and do not represent any institution or organisation.

Received:

31.03.23

Accepted:

12.05.23

Keywords:

Biomarkers, digital health, health systems, patient-generated health data (PGHD).

Citation:

EMJ Innov. 2024;8[1]:40-42. DOI/10.33590/emjinnov/10301344. https://doi.org/10.33590/emjinnov/10301344.

INTRODUCTION From wearable devices to smartphone apps, there has been an explosion of technology in recent years that promises unique insights into users’ health and wellbeing. For the digitally savvy, it has become increasingly common to track multiple aspects of their health, from dietary habits and activity levels to mental health symptoms and menstrual cycles, to name but a few. Many clinicians might have seen this increasing use first hand, in part driven by the use of remote consultations during the COVID-19 pandemic. History of palpitations? Here is an ECG reading from my smartwatch. How did the antidepressant help your mood?

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Here is an app with a record of my emotional state over the past month, with helpful moodrelated emojis to boot.

This type of information, encompassing not only digital biometrics, but also symptom tracking, medical history, and self-reported health status, is collectively known as patient-generated health data (PGHD).1 It represents a nascent field that could transform healthcare in years to come.

From treatment monitoring to tailored healthcare information, PGHD could drive a more personalised, holistic model of clinical care, rather than a ‘one size fits all approach’.

In addition, by capturing longitudinal health

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data in the ‘real world’, PGHD can offer unique insights into the natural history of diseases, which can be difficult to gather during isolated clinic appointments. Proponents suggest that this could identify as yet undiscovered digital biomarkers that could allow for treatment and care earlier in the disease course.1 Despite this promise, the growing adoption of PGHD raises questions on its use in already overstretched health systems. How do we use PGHD to improve patient care in a meaningful and equitable way, without drowning in an avalanche of healthcare data?

LEVERAGING PATIENT-GENERATED HEALTH DATA FOR PATIENT BENEFIT To answer the question of how to leverage PGHD to benefit patients, we need to understand where PGHD can add the most value. During the COVID-19 pandemic, PGHD apps, like the ZOE symptom tracker (ZOE, London, UK), for COVID-19, played a useful role in understanding the spread of the virus.2 As such, PGHD could clearly be a useful adjunct to more traditional epidemiological methods in mapping the spread of infectious diseases in ‘real time’.

If we take a broader public health perspective, there are other important use cases for which PGHD could be transformative too. This includes non-communicable diseases such as cardiovascular disease, cancer, and respiratory conditions. The World Health Organization (WHO) estimates that non-communicable diseases account for 74% of all deaths globally.3 Importantly, the risk of developing these conditions can be reduced by health prevention, such as exercising and stopping smoking. A recent global report highlighted the importance of addressing such risk factors as our best hope for reducing the future burden of cancer.4 PGHD could be a powerful way to encourage and monitor these factors, such as improving exercise uptake or providing tailored lifestyle advice that could ‘nudge’ patients towards healthier behaviour.

MAKING SENSE (AND USE) OF THE DATA Despite this potential, most PGHD tools at present are limited in their scope and impact.

This includes standalone apps that often do not even integrate into the patient’s electronic health record, let alone their overall care. Also, despite promising research on emerging PGHD-derived biomarkers, there is a lack of high-quality, realworld studies that can help to differentiate between the types of data that will have the greatest benefit for clinical care.

In addition, the integration of PGHD into the daily workflows of clinicians remains limited. This is, in part, due to constraints of overstretched health systems, including creaking infrastructure and archaic electronic health record (EHR) systems. In many settings, it can be difficult to share PGHD, whether it be a compilation of blood pressure readings or a smartwatch ECG, directly into EHRs. This is a key barrier for routine clinical use.

To overcome this, improving interoperability between PGHD applications and EHRs is vital. The development of the SMART on Fast Healthcare Interoperability Resource (FHIR) interoperability standard is an important milestone in this regard.5 This open source framework allows for ‘plug and play’ of health applications directly into EHRs, allowing patients to share data with clinicians, and vice versa.

Adoption is mainly confined to the USA at present, but there is growing interest from the National Health Service (NHS) and other national health systems.

PATIENT-GENERATED HEALTH DATA IN THE CLINIC Given these challenges, time-poor clinicians may well view PGHD as more of a ‘wellness culture’ fad than a technology that truly heralds promise for patient care. How can we counter such concerns, and promote the use of PGHD in the clinic? To complement the advances in interoperability, it is imperative that we also develop PGHD-specific workflows for clinicians.

A good first step could be to combine validated PGHD types in routine clinical practice. This includes using longitudinal, multimodal data to

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inform care, a pragmatic short-term goal whilst research on novel data types is ongoing.

Take the example of patients presenting with insomnia without a clearly identifiable cause. In such cases, sleep tracking from wearables (biometric data) could be combined with symptom tracking (i.e., lifestyle factors) and a 9-question Patient Health Questionnaire (PHQ-9) depression screen (a type of patientreported outcome measure that gives a snapshot of a patient’s health) to identify underlying causes.

Another potential area is the remote monitoring of patients using PGHD-based mobile apps, which is an emerging model in some health systems. For example, patients with hypertension can be offered a personalised plan to titrate their medication, with information shared with clinicians in real time. This method combines symptom tracking and biometric information to promote adherence and shed light on adverse side effects.

References 1.

2.

Nittas V et al. Electronic patientgenerated health data to facilitate prevention and health promotion: a scoping review protocol. BMJ Open. 2018;8(8):e021245.

Menni C et al. Symptom prevalence, duration, and risk of hospital admission in individuals infected with SARS-CoV-2 during periods of omicron and delta variant dominance: a prospective

THE FUTURE PGHD is here to stay, and it is likely to become a cornerstone of digital healthcare delivery in years to come. As clinicians, we have the opportunity to help shape this emerging field, together with patients, to herald a paradigm shift towards more holistic and personalised care.

However, there remain key barriers to this aspirational goal. These include a nascent interoperability infrastructure, unanswered questions on clinical benefit, and challenges in access to digital technologies for underserved populations.

To overcome these issues, we need a rigorous focus on the clinical utility of PGHD and its equitable integration into existing health systems. Without such a patient centred approach, rather than fulfilling the transformative potential of PGHD, we risk a fragmented digital landscape that fails to meet the needs of those we serve.

observational study from the ZOE COVID Study. Lancet.

2022;399(10335):1618-24.

3.

4.

World Health Organization (WHO). Non-communicable diseases: factsheet. 2022.

Available at: https://www.who.int/ news-room/fact-sheets/detail/ noncommunicable-diseases. Last accessed: 9 May 2023.

Global Burden of Disease (GBD) 2019 Cancer Risk Factors

Collaborators. The global burden of cancer attributable to risk factors, 2010–19: a systematic analysis for the Global Burden of Disease Study 2019. Lancet.

2022;400(10352):563-91.

5.

Sayeed R et al. SMART Markers: collecting patient-generated health data as a standardized property of health information technology. NPJ Digit Med. 2020;3:9.

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A 3D-Printed Forearm Trainer for the Practice of Ultrasound-Guided Arterial and Venous Line Placement Authors:

Mary E. Chambers,1 David F. Schartung,1 *David Resuehr1,2 1. Heersink School of Medicine, University of Alabama at Birmingham, USA 2. Department of Cell, Developmental & Integrative Biology, University of Alabama at Birmingham, USA *Correspondence to resuehr@uab.edu

Disclosure:

The authors have declared no conflicts of interest.

Received:

14.04.23

Accepted:

05.10.23

Keywords:

Ballistic gelatine, blood vessel trainer, central line training, intravenous (IV) injection, ultrasound-guided vascular access, ultrasound (US) phantoms, 3D printing.

Citation:

EMJ Innov. 2024;8[1]:43-50. DOI/10.33590/emjinnov/10300398. https://doi.org/10.33590/emjinnov/10300398.

Abstract As sonography (US) continues to become a mainstay in medicine, both as a screening device and as a procedural tool, the use of task-based sonographic trainers (i.e., phantoms) in medical training has become increasingly necessary. This is especially true for what has been termed ‘the global use of US’, or the use of US as an imperative tool during structural planning and placement of peripheral and central lines within patients in emergency and hospital settings. However, despite the frequency and technicality of US-guided procedures involving arterial and venous line placement, the benefit of such hands-on US simulation training for employees and professional students alike is often outweighed by cost. The current market for US trainers displaying human forearm anatomy and branching vessels comes at a high price tag of over 2,000 USD per model. The authors’ experiment utilises 3D printing techniques and biodegradable ballistics gel to create a cost-effective, versatile, and yet realistic peripheral line simulator in order to cultivate real-time learning of arterial/ venous arm anatomy, while providing mechanical practice for needle driving and US technique, all at a fraction of the commercial price.

Key Points 1. Using ultrasound (US) guidance for procedures such as peripheral intravenous (IV) line placement, consistently yields better patient outcomes. As US-guided procedures become more clinically prevalent, the need for effective training methods has grown. US phantoms have proven to be invaluable tools for hands-on practice. Phantoms enhance learners' confidence, proficiency, knowledge base, and skillsets for various US-guided procedures. Furthermore, these educational tools offer replicability, affordability, and reusability, making them accessible to many learners and institutions.

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2. This study utilised 3D printing technology and biodegradable ballistics gel to develop a realistic, reusable, and cost-effective phantom forearm for the purposes of aiding training of healthcare professionals in performing US-guided IV access.

3. Beyond US-guided IV access training, these phantoms have numerous potential applications in the medical field. These include training vascular surgeons, practising haemodialysis access procedures, simulating emergency vascular access techniques, conducting vascular research and device testing, educating patients, and facilitating radiological interventions. The adaptability of these phantoms makes them valuable tools for healthcare professionals across different specialties, enhancing medical education, research, and patient care.

INTRODUCTION Ultrasonography (US, also known as sonographic imaging, ultrasound) is an important medical imaging technique that uses high-frequency sound waves to create images of internal body structures. It is non-invasive, painless, and does not involve ionising radiation, making it a safe and effective diagnostic tool in a wide range of medical applications. Previously described by Bercoff1 as “a disruptive technology in the medical device arena,” the realm of US within healthcare remains ever-growing, as practitioners continually innovate and repurpose the devices’ real-time anatomical imaging to provide more accurate and timely care.1 Ranging in its application from cardiographic imaging to that of obstetrics, vascular Doppler, venous access, or even emergency Focus Assessment with Sonography in Trauma (FAST) exams, US continues to show its potential as a real-time investigative and diagnostic technology capable of empowering its users with accurate, processable information, allowing for both emergent diagnosis and lifesaving interventions.2 Useful in times where tissue oedema, trauma, obesity, or variances in vasculature might impede intravenous (IV) access, US has changed the way that practitioners approach complicated patient anatomy in the acute setting.3 As has been illustrated by multiple studies, the use of US in peripheral intravenous (PIV) line placements systematically provides better outcomes for patients.4 When studied in the paediatric population, it was found that US-guided IV access had an overall success rate of 80%, compared to traditional attempts with a success rate of only 64%. In the same study, US-guided line placements were found to require less overall time (6.3 minutes versus 14.4 minutes), in addition to fewer needle insertion attempts

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(one versus three), and fewer needle redirections while under the skin (median: two versus 10) compared to traditional techniques.5 In addition to these immediate outcomes, the use of US for line placement poses another benefit: avoidance of central line placement for accessonly purposes. In a study comparing central venous catheters to PIVs in patients in the intensive care unit, the incidence of bloodstream infections within PIVs was much lower than that of central lines (0.5 versus 2.7 per 1,000 catheter days). Furthermore, while PIVs tended to acquire localised instances of infection, phlebitis, or haematoma, central venous catheters characteristically displayed more diffuse effects, putting patients at risk for more serious systemic illness. With these factors in mind, it is clear that practitioner use of US technology can aid in providing both better immediate and long-term outcomes for patients, from both a comfort and an infectious standpoint.2 As US-guided procedures become increasingly widespread in modern clinical practice, training medical professionals to be adept in these skills while using safe, standardised methods has become all the more imperative. While hospital-based learning remains a great way to facilitate these skills, quality of student training must also be considered alongside the medical facility’s primary objective, to standardise patient care and maximise outcomes.6 In a study by Passaperuma et al.,7 patients across various specialties were asked to rate their comfort levels with medical students assisting in their care. Patient comfort levels in medical student involvement were found to steadily decline with varying levels of invasiveness, with only partial comfortability (3.5 out of 5) being attributed to students’ involvement in minimally invasive procedures, such as peripheral IV placement.7

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With patient beneficence in mind, the need to strive for other teaching modalities that can realistically teach the skills needed for US-guided procedures remains.

One such method of teaching sonographic skill includes the use of US trainers, or ‘phantoms’, in lieu of real human subjects. These phantoms can be made using animal tissue, elastomeric latex, or agar/guar gum based gelatines.8,9,10 In order to properly mimic human anatomical structures, a US phantom should maintain certain characteristics, such as displaying similar echogenicity to human tissues, being readily available, being inexpensive, and proving tactile feedback to users.11 Additionally, a phantom trainer should ideally be reusable, avoiding the generation of needle track marks after use.

Through the use of US phantoms, learners can receive hands-on, interactive practice without any danger and discomfort for a living patient.10 Previous studies have shown that the use of US phantoms significantly improves not only the confidence and proficiency of novice learners, but also their underlying knowledge base. 12,13 Additional studies have also found quantifiable improvements in techniques involved in nerve blocks,14 lumbar facet joint injections,15 and general needle-dexterity16 in students who have been trained on US phantoms. These findings of increased competency and skill have further added to the emphasis on US education within the medical school curriculum, as countless studies continue to mark the importance of such teaching modalities within the preclinical setting.17,18 Given the growing popularity of US within critical and primary care, many companies have begun manufacturing US phantoms for various skill-training purposes, including practising hip joint injections, central venous access, and nerve blocks. However, their use in the medical education setting is often outweighed by cost, as phantom models can range in price to upwards of 1,000–4,000 USD.19,20 In addition to cost, (commercial) phantoms are also limited in their use due to non-modifiable characteristics, such as phantom opacity to match the knowledgebase of the learner, or materials prone to tracking marks following repeated needle sticks.

This paper aims to develop a realistic, affordable, and reusable arm phantom for training medical providers in the technique of US-guided forearm IV access. Currently, existing versions of such devices are cost-prohibitive to many learners and institutions, and often do not display accurate, distinguishable arterial and venous anatomy within. The authors propose a new, realistic model of the human forearm using 3D printing alongside ballistics gelatine to ensure standardised, affordable learning for healthcare professionals, all at a fraction of the commercial price.

MATERIALS AND METHODS A rendering of a human forearm and elbow was created by imaging a human arm with a Revopoint POP 3D Scanner (Revopoint3D Technologies Inc., Shenzhen, China). This rendering was then edited in Meshmixer (Autodesk, San Francisco, California, USA), using Boolean difference, plane cut, and remeshing functions to create a hollow forearm mould for superficial structures (Figure 1A). Next, a Lulzbot Taz 6 3D printer (LulzBot, Fargo, North Dakota, USA) using Verbatim polylactic acid filament (Verbatim, Charlotte, North Carolina, USA; 215ºC, 15% infill) was used to print the forearm mould, which was then affixed and painted with latex to account for printing artifacts. A thin coat of vegetable oil was then applied to ease the eventual extraction of gelatine from the mould.

Following the creation of the arm mould, vascular structures were assembled using two different types of latex tubing, which were selected to highlight differences in size, thickness, and compressibility of arteries versus veins. The authors selected slightly more rigid and thicker walled tubing for arteries, and thinner walled, very flexible tubing for veins.

With these materials, two separate branching vessels resembling human forearm vasculature (arterial versus venous) were made by cutting and affixing the tube ends at 30-degree angles with surgical scissors and DERMABOND® glue (Ethicon, Bridgewater, New Jersey, USA) (Figure 1B). These vessels were subsequently filled with red and blue dyed water, capped using latex plugs to mimic arterial versus venous fluid, and suspended within the arm mould using toothpicks (Figure 1C).

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Figure 1: Trainer creation.

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To create the gelatine, 400 mL of water was heated on a hotplate, slowly mixed with 100 g ballistic gelatine powder until the gelatine was dissolved, and volume adjusted to 500 mL total, resulting in a 20% mixture (weight/ volume). The ballistics gelatine mixture was subsequently poured into the forearm mould, with the branching vessels suspended in the gel using toothpicks. The mould was allowed to set overnight in a refrigerator. The resulting phantom was removed from the mould using a basic butter knife (Figure 1D).

vessel wall thickness and compressibility, mimicking the ‘floppier’, more compressible nature of human veins (Figure 2C and 2D) in direct comparison to their thicker arterial counterparts (Figure 2A and 2B).

RESULTS

Simulation of fluid injections and aspirations was possible with this model, allowing for immediate tactile feedback resembling that of entering human tissue and vasculature. Specifically, the model allowed for practice in identifying needle sticks within the long axis view, as well as simulating fluid flow during an injection into the vascular structure (Figure 2E–G). In addition to allowing for the mechanical practice of fluid injection, the authors’ branching vessels also displayed red and blue fluid solutions when aspirated to further characterise arterial versus venous structures to the learner (Figure 3A and 3B).

Utilising 3D printing and ballistics gelatine, the authors’ arm trainer was able to achieve good echogenic appearance of various vessels, in addition to housing these vessels within a contour anatomically similar to that of a human forearm. Using a GE Venue 40 US machine (GE HealthCare, Chicago, Illinois, USA) with 12L linear probe, the model’s embedded vessels were appreciated in both long and short axis views, allowing for visualisation of branching vessel structures and needle stick simulations (Figure 2A–D). These views were found to be relatively clear, and with minimal artifacts such as bubbles in the gelatine.

There was also an appreciable variance in

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Using US, the authors were able to track the model’s vessels along various branching points throughout the forearm, allowing for the user to both review vascular anatomy and practise needle sticks simultaneously. The authors’ model also allowed for visualisation and practice of injecting branching vessels at various depths.

Finally, the authors’ model (Figure 3C–F) was studied in direct comparison to the vasculature

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Figure 2: Simulated vessels and injection.

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of a human specimen, showing similar contour of branching veins within the greater anatomy of the human forearm (Figure 3G–J).

DISCUSSION With 3D printing, latex tubing, and ballistics gelatine, the authors have successfully created a working phantom prototype of a human forearm that can be replicated and altered based on user needs. This model showcases an overall structure mimicking that of a human forearm, and its gelatine can be dyed with varying levels of opacity to match the skill level of its learner. In addition to anatomically sound outer dwelling characteristics (antecubital fossa, lateral and medial epicondyles), the authors’ model also houses multi-branching vascular structures designed to further simulate the true human vasculature of the forearm, allowing for anatomical practice for learners with every use. Concordantly, the branching vessels of the trainer allow for further learning in

G

sonographic tracking along human vasculature, allowing for practice in the localisation of ideal entrance points for IV access along branching and otherwise complicated circulation. Finally, the authors’ decision to use slightly thicker latex tubing for arteries and thinner tubing for veins enabled them to replicate variations in vessel compression realistically. This approach effectively emulated the greater compressibility of veins compared to arteries, a distinguishing feature commonly utilised to differentiate these vascular structures.

In addition to its anatomical likeliness to that of a human subject, the vasculature residing within the model is suspended at various depths in order to allow for practice of superficial versus deep sonographic skills and needle sticks.

With this feature, the user may practise how to navigate around important overlying structures when accessing imperative vessels underneath.

These branching vessels also possess varying qualities in thickness and compressibility, allowing for simulation of compression skills

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Figure 3: Fluid aspiration and comparison of trainer with human arm.

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via US to distinguish between arterial (noncompressible) and venous (compressible) structures. Beyond compressibility, this model allows for the user to check their skills with immediate colour feedback, as arterial structures aspirate with red fluid, and venous with blue.

These aspirations can be viewed by the user in short axis and long axis views, allowing learners to actively practise tactile feedback and needle driving techniques alongside that of US. Beyond the immediate learning benefits of the arm model, the authors’ project highlights another benefit to learners: replicability and affordability. Rendered and created with 3D printing technology, the base to this arm trainer

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is easily re-printable at any facility with a 3D printer and filament, allowing for widespread use of the model within the educational setting. Additionally, having been printed in polylactic acid filament, the printed arm mould is strong and temperature resistant, allowing for multiple castings of new models with repeated effect. The model is also made of a standard ballistics gelatine, which can be bought in bulk, or remelted and repoured into the original mould to renew original, artifact-free phantom architecture. With a base material cost of approximately 50 USD, this model competes with others in the commercial sector, both in initial cost and in reusability.

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LIMITATIONS While the authors were able to create a US trainer of the forearm specifically meant for the practice of US-guided injections, the needleaccepting qualities of the phantom were not evaluated in comparison to that of a human model in real-time. Additionally, though the vasculature simulated within the model was similar in size and compressibility to that of the human arm, the depth of these simulated veins varied significantly from that of a human subject (2.5 compared to 1.8 cm in human subjects).

In conjunction with these subtle variances in vascular depth, the model also sustained some anatomical features that did not translate perfectly into the final edit. While 20% gelatine was used to create the bulk of the model, this material showed occasional signs of artifact through air bubbles. The gelatine used was also unable to perfectly mimic the intricate musculature of the human arm as seen in US. Additionally, the gelatine was found to have needle artifacts following continued use, thus necessitating replacement of the gelatine following many uses.

In practical use, the model was able to both accept and aspirate fluids from veins accordingly.

However, the current model does not possess a method for refilling the vasculature with coloured fluid, nor does it have a way to remove liquids that might have been injected outside of the vascular branches. Though minimal, fluid buildup could lead to further artifacts seen on repeated US scans. With continued use of latex tubing for the vascular structures, it was found that the latex was not always watertight, necessitating switching out of the branching vessels after multiple uses due to leakiness from perforations.

This is a common problem with blood vessel trainers, and the authors have not been successful in solving this issue yet. However, they have recently identified a company that sells a ‘self-healing’ phantom for 468 USD (VATA, Canby, Oregon), which, unfortunately, is once again cost-prohibitive for many users.

It appears that the ‘self-healing’ ability would require a change in the materials used in the manufacturing process, driving the cost up.

Even if the phantoms had self-healing vessels, the authors would still deal with needle tracks

after repeated sticks, which would minimise the benefit of self-healing vessels.

Finally, the arterial and venous structures were not pressurised within the model, and were therefore not able to simulate the fluid ‘flash’ associated with perforating a human vessel with a needle.

CONCLUSION The goal of this project was to develop a realistic, reproducible, reusable, and affordable phantom arm model for training healthcare professionals in US-guided PIVs. Using 3D printing, ballistics gelatine, and readily-available materials, the authors’ team successfully produced a prototype with characteristics that will facilitate training in the PIV insertion procedure. These characteristics include a realistically-shaped, echogenic medium; branching, fluid-filled vessels in anatomic location; ability to aspirate fluid from the vessels with colour feedback denoting artery versus vein; compressible tubing which highlights arterial versus venous response to applied pressure; and relative affordability compared with existing, similar products. Importantly, the authors believe there are many additional potential applications beyond peripheral IV access to explore that the phantom might be adapted for (naturally this will require further experimentation). The authors believe this not only highlights the versatility of the model, but also sparks further interest in its utility. Some potential applications include vascular surgery training, as aspiring vascular surgeons could benefit from using the phantom for training purposes. It could possibly be adapted to replicate different vascular pathologies and surgical scenarios, providing a valuable platform for skill development. For haemodialysis access training, the creation of arteriovenous fistulas and grafts for haemodialysis is a critical procedure. The phantom could potentially be customised to simulate these access points, enabling healthcare professionals to practise and refine their skills. It could also be used for emergency procedures: in emergency medicine, healthcare providers often need to rapidly establish vascular access in critical situations.

The phantom can serve as a tool for training in emergency vascular access techniques, such as intraosseous needle insertion.

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Beyond education and training, the phantom can be used for research purposes, such as vascular research and device testing. It provides a consistent and controlled environment for testing vascular devices, such as catheters, stents, or embolisation materials, before their clinical application. The phantom can also be employed as a patient education tool. It can help healthcare providers explain vascular procedures to patients and their families, enhancing their understanding and reducing anxiety. Finally, radiologists performing vascular interventions, such as angiography or embolisation, can use the

References 1.

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Bercoff J. “Ultrafast ultrasound imaging”, Minin I, Minin O (eds), Ultrasound imaging - medical applications (2011), Rijeka, Croatia: InTech, pp.3-4.

Huggins JT, Mayo PH. Indications for bedside ultrasonography in the critically ill adult patient. 2022.

Available at: https://www.uptodate. com/contents/indications-for-bedside-ultrasonography-in-the-critically-ill-adult-patient. Last accessed: 1 November 2023.

Gregg S et al. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Crit Care.

2010;25(3):514-9.

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Conlon T et al. Getting to know a familiar face: current and emerging focused ultrasound applications for the perioperative setting. Paediatr Anaesth. 2019;29(7):672-81.

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Doniger S et al. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care.

2009;25(3):154-9.

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Zerth H et al. An inexpensive, easily constructed, reusable task trainer for simulating ultrasound-guided pericardiocentesis. J Emerg Med. 2012;43(6):1066-9.

7.

Passaperuma K et al. Do patients’ comfort levels and attitudes regarding medical student involve-

phantom to simulate complex vascular structures and refine their skills in a safe environment.

In conclusion, the versatility of the phantom extends beyond peripheral IV access, encompassing a wide range of applications in medical education, training, research, and patient care. Its adaptability makes it a valuable tool for healthcare professionals across various specialties. Although minor limitations remain, this prototype is a breakthrough in the widespread effort to increase the quality and efficiency of modern medical education.

ment vary across specialties? Med Teach. 2008;30(1):48-54.

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Gibson R, Gibson K. A home-made phantom for learning ultrasound-guided invasive techniques.

Australas Radiol. 1995;39(4):356-7.

9.

Di Domenico S et al. Inexpensive homemade models for ultrasound-guided vein cannulation training. J Clin Anesth.

2007;19(7):491-6.

10. Culjat M et al. A review of tissue substitutes for ultrasound imaging. Ultrasound Med Biol.

2010;36(6):861-73.

11. Kim Y. Ultrasound phantoms to protect patients from novices.

Korean J Pain. 2016;29(2):73-7.

12. Yoo M et al. Basic ultrasound curriculum for medical students: a validation of content and phantom.

J Laparoendosc Adv Surg Tech A. 2004;14(6):374-9.

13. Jensen J et al. Simulation-based point-of-care ultrasound training: a matter of competency rather than volume. Acta Anaesthesiol Scand.

2018;62(6):811-9.

14. Moore D et al. Novel real-time feedback and integrated simulation model for teaching and evaluating ultrasound-guided regional anesthesia skills in pediatric anesthesia trainees. Paediatr Anaesth.

2012;22(9):847-53.

15. Kwon S et al. The efficacy of lumbosacral spine phantom to improve

resident proficiency in performing ultrasound-guided spinal procedure.

Pain Med. 2015;16(12):2284-91.

16. Mendiratta-Lala M et al. The use of a simulation center to improve resident proficiency in performing ultrasound-guided procedures.

Acad Radiol. 2010;17(4):535-40.

17. Amini R et al. Theme-based teaching of point-of-care ultrasound in undergraduate medical education.

Intern Emerg Med. 2015;10(5):613-8.

18. Birrane J et al. A scoping review of ultrasound teaching in undergraduate medical education. Med Sci Educ. 2018;28(1):45-56.

19. 3B scientific. Blue phantom upper arm tissue insert with brachial and basilic thrombosis. Available at: https://www.3bscientific.com/ us/blue-phantom-upper-armtissue-insert-with-brachial-andbasilic-thrombosis-3012597-bluephantom-bpp-013,p_1397_31344. html?utm_source=google&utm_ campaign=gmc_feed&gclid=CjwKCAjw586hBhBrEiwAQYEnHS9xOpdzi98MwUDLLVJ3nnlU8nkbDBSv4yRxaCCNzLv8AboBt7K8RoC8skQAvD_BwE. Last accessed: 7 August 2023.

20. GT Simulators. Ultrasound neonatal head phantom, George.

Available at: https://www. gtsimulators.com/products/ ultrasound-neonatal-head-phantom-george-kkus-14a. Last accessed: 7 August 2023.

FOR REPRINT QUERIES PLEASE CONTACT: INFO@EMJREVIEWS.COM

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Impact of the National Suicide Hotline Number on Care of Outpatient Psychiatric Patients Authors:

Priyanka Sheth,1 Oladele D. Osisami,1 *Rif S. El-Mallakh1 1. Department of Psychiatry, University of Louisville, Kentucky, USA *Correspondence to rselma01@louisville.edu

Disclosure:

The authors have declared no conflicts of interest. No extramural funding was received for this work.

Received:

16.08.23

Accepted:

04.01.24

Keywords:

Crisis, crisis line, hotline, mental health, psychiatric emergency, suicide.

Citation:

EMJ Innov. 2024;8[1]:51-56. DOI/10.33590/emjinnov/10303949. https://doi.org/10.33590/emjinnov/10303949.

Abstract Background: The Federal Communications Commission (FCC) has selected 988 as the number for mental health crisis and this came into effect in July 2022. It is not clear how aware psychiatric patients are of this event, and how much impact this will have on outpatient psychiatric care.

Methods: Prior to the introduction of 988, the authors performed a study of patients attending the outpatient psychiatric clinic at the department of psychiatry’s outpatient services. The study comprised of a one-page questionnaire to acquire qualitative and quantitative data on patients’ knowledge and acceptance of the change in the access of the suicide prevention number.

Results: A total of 74 outpatient psychiatric patients were surveyed during the course of the study. Most (87.8%) of surveyed individuals denied memorisation of their local mental health crisis or suicide prevention hotline number. Of the 24 individuals who reported previously having called a crisis hotline, over one-third (37.5%) reported difficulty remembering or finding the number. In response to the introduction of a three-digit crisis hotline number, 63.5% (47) of surveyed individuals reported both increased confidence in receiving prompt, effective psychiatric care, and greater likelihood of seeking help with the three-digit number. Finally, 77.0% (57) stated that a three-digit number would be more easily remembered than current options. The majority (89%) of responders were not aware of the 988 hotline number.

Conclusion: Patients believe the 988 number will be a helpful tool in their care.

One year after its introduction, awareness of 988 has barely changed.

Key Points 1. Psychiatric patients believe that the new National Mental Health Hotline Number, 988, is easy to remember and is a good idea.

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2. Prior to the release of 988, only 11% of patients were aware of its existence. One year after the release of 988, only 17% know it is active.

3. These data indicate that better advertising of the existence of 988 is necessary for it to be fully successful.

INTRODUCTION Suicide is a significant cause of death globally.

Every year, 800,000 people take their own life, making up 1.4% of all global deaths.1,2 Suicide ranks as the 18th leading cause of death across the general population, and the second leading cause of death among people aged 15–29 years.3 In the USA, suicide is the 10th leading cause of death, and has increased by 30% since 1999.4 Veterans and youths are experiencing the greatest increased rates.5-8 Additionally, an estimated 9.3 million adults in the USA annually have thoughts of suicide.4 Key risk factors for suicide include an underlying illness, ongoing stressors, a sense of hopelessness, and other complex personal and biological factors.2,9 Suicide prevention is the goal, and can be achieved through psychological interventions,10 medication,11,12 or physical interventions (e.g., hospitalisation).12,13 However, for any of these interventions to work, at-risk patients must first be identified.

Suicide hotlines appear to be an effective strategy.14-17 A National Suicide Prevention Lifeline was established in 2005, as part of a country-wide strategy to reduce suicide rates and support individuals in crisis. Until 2022, the national number was 1-800-283-TALK (8255).

In 2020, it was accessed by more than 3.5 million callers.18 Nonetheless, over 80% of mental health consumers feel that access to telephone triage services is difficult.19 In August 2018, the Congress of the Federal Government passed HR 2345, the National Suicide Hotline Improvement Act, which directed the Federal Communications Commission (FCC) to study adoption of a three-digit number to serve as a single national suicide prevention hotline number.20 In October 2020, Congress passed the National Suicide Hotline Designation Act of 2020 (S2661), which designated 988 as the “universal telephone number for the purpose of the national suicide prevention and mental health crisis hotline

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system operating through the National Suicide Prevention Lifeline and through the Veterans Crisis Line.”21 President Donald Trump signed this into law in October 2020.22 In July 2022, 988 became a nationally available number, and replaced 1-800-283-TALK (8255). It will also be active in Canada in the near future. The original number was immortalised in a song by rapper Logic, which was performed at MTV’s Video Music Awards in 2017, and the Grammy Awards in 2018. Within the 34 days following these performances, calls to the crisis line increased by 6.9% (a significant increase above routine use, P<0.001), and completed suicides decreased by 5.5% (P=0.02).23 This experience highlights two important points for the success of a suicide hotline: suicide awareness, and knowledge of the suicide hotline number. The authors set out to investigate the level of awareness and ease of number recognition in a population of psychiatric patients at risk of developing suicidal ideation.

METHODS This study was performed prior to the introduction of 988. The authors recruited patients attending the outpatient psychiatric clinic at the Department of Psychiatry’s outpatient services. The majority of these patients had participated in previous studies, and knew that research protocols were frequently performed in the clinic they attended. Most patients had received care at this clinic for over a decade, had a mood disorder, and generally lacked an active substance use disorder. The study comprised of a one-page questionnaire to acquire qualitative and quantitative data on patients’ knowledge and acceptance of the change in the suicide prevention number (Figure 1). The data were evaluated quantitatively and qualitatively. Continuous variables were examined with non-paired, two-tailed t-tests.

Categorical data were examined with the χ2-test.

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Figure 1: Questionnaire used in the study.

Do not write your name on this form What gender do you identify as? (Circle Answer) Male Female Non-binary/Non-conforming/Other Do you identify as a transgender person? (Circle Answer) Yes No What is your age? (Circle Range) 18 – 25 26 – 35 46 – 55

56 – 65

36 – 45 Over 66 – 75

What is your heritage? (Circle Answer) European Native American African Asian Other What is your ethnicity? (Circle Answer) Hispanic or Latino Not Hispanic or Latino What is your highest degree or level of education you have completed?

Some high school High school/GED Some college Bachelor’s degree Graduate degree What is your marital status?

Single Married Divorced Widowed What is your diagnosis here?

A. Mood disorder (major depression, bipolar disorder) B. Schizophrenia or schizoaffective disorder C. Anxiety disorder, PTSD, OCD D. Attention Deficit Disorder (ADHD) E. Other

Have you ever called a mental health crisis or suicide prevention hotline?

Yes No In the past year, how many times have you called a mental health crisis or suicide prevention hotline?

0 1-2 times 3-4 5 or more times In the past 5 years, how many times have you called a mental health crisis or suicide prevention hotline?

0 1-2 times 3-4 5 or more times Do you have the number of your local mental health crisis or suicide prevention hotline number memorized?

Yes No How frequently when attempting to call a mental health crisis hotline did you have trouble remembering or getting the number?

Never Occasionally Sometimes Frequently

How frequently when attempting to call a mental health crisis hotline were you unsuccessful in receiving help due to trouble remembering the number?

Never Occasionally Sometimes Frequently How much of a barrier to receiving prompt mental health care do you believe the current 10-digit numbers are?

Not at all Slightly Moderately Quite a bit If there was a 3-digit hotline number available for mental health crises, how much more likely would you be to reach out? a) No difference b) Slightly more likely c) Moderately more likely d) Quite a bit more likely e) Extremely more likely If there was a 3-digit hotline number available for mental health crises, how much more confident would you be in receiving prompt, effective care? f) No difference g) Slightly more confident h) Moderately more confident i) Quite a bit more confident j) Extremely more confident If there was a 3-digit hotline number available for mental health crises, how much more likely are you to remember it during an acute crisis? k) No difference l) Slightly more likely m) Moderately more likely n) Quite a bit more likely o) Extremely more likely If there was a 3-digit hotline number available for mental health crises, how helpful do you think it would be to you in an acute crisis? p) Not helpful q) Slightly helpful r) Moderately helpful s) Quite a bit helpful t) Extremely helpful Are you aware that there will be a new 3-digit number (‘988’) for the crisis line?

Yes No Do you think that 988 is a number that is easy to remember?

Yes No Do you think it is good that there will be a uniform 988 for the crisis line?

Yes No

GED: general educational development; OCD: obsessive compulsive disorder; PTSD: post-traumatic stress disorder.

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RESULTS The majority of subjects approached agreed to participate, with a small number of patients reporting time constraints as the reason for not participating. The fraction of patients who refused to participate was not tracked. Of the 74 psychiatric outpatients surveyed during the 6-month course of the study, 78.4% had a primary diagnosis of a mood disorder (n=58), 18.9% had schizophrenia or a schizoaffective disorder (n=14), and the remainder did not provide that information. Furthermore, 32.4% of individuals (n=24) reported calling a crisis hotline in the past. Of all surveyed individuals, 87.8% (n=65) denied memorisation of their local mental health crisis or suicide prevention hotline number. Of the 24 individuals who reported having previously called a crisis hotline, over 37.5% reported difficulty remembering or finding the number.

In response to the introduction of a threedigit crisis hotline number, 63.5% of surveyed individuals (n=47) reported increased confidence both in receiving prompt and effective psychiatric care, and a greater likelihood of seeking help when a three-digit number was available. Furthermore, 77% of patients (n=57) stated that a three-digit number would be more easily remembered than current options.

Prior to this study, 89% (n=66) of survey responders were not aware of the new federally approved 988 hotline number. At completion, 100% of participants both reported that 988 is an easy number to remember and approved of its choice for the national crisis line.

DISCUSSION The current Lifeline number receives over 3.5 million calls annually. With the introduction of 988, a significant fraction of 911 calls are expected to be diverted to 988 to be managed

by Lifeline. Vibrant (Vibrant Emotional Health, New York, USA), the non-profit company that runs the Lifeline service, estimates that over the first 5 years of 988 service, there will be approximately 4–5 million additional annual calls to 988, due to this diverted volume. More importantly, the availability of a simpler number is expected to result in an additional 4 million

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annual calls, exceeding the current use of the 10-digit Lifeline number and 911.18 Over the first year since its release in July 2022, there have been over 5 million contacts with 988, including 3.6 million phone calls, and more than 600,000 texts and 740,000 chats.24 However, a recent poll performed by the National Alliance of the Mentally Ill (NAMI) found that awareness of the availability of the 988 number is still low (17%), although 63% of Americans reported hearing about it.25 In this study, over one-third of people who had previously used a crisis number (37.5%) reported some difficulty in accessing the available 10-digit numbers.18 All participants in this survey believed that a three-digit number was a good idea, and 77% reported that 988 was an easy-to-recall choice.18 The reason for creating a three-digit crisis hotline number is to facilitate access to mental health services; however, patients must be aware of it. The authors’ study was performed prior to the introduction of 988, but after the law had been signed by President Donald Trump; yet, 89% of surveyors were not aware of its existence.

One year later, the situation has changed only minimally. The increase in the use of the original Lifeline number following its mediatisation during the performance by Logic demonstrates that advertising of 988 will be necessary for society to fully experience the benefit of this new number.21 Additionally, a public knowledge campaign should persist. It may be reasonable for psychiatric providers, or even general practitioners, to have posters in their offices advertising 988. The Substance Abuse and Mental Health Services Administration (SAMHSA) has free resources available for all healthcare providers, including magnets, bumper stickers, wallet cards, posters, and other materials.26 However, they may also consider the utility of sponsoring Internet advertisements targeting individuals searching suicide-related items.

This study has some limitations. The sample is small, with a mood disorder overrepresentation (78.4%). Additionally, individuals were sampled during their outpatient psychiatric visit; thus, acute distress was already being addressed in their visit. Individuals in acute distress were not sampled here, and their survey responses may have been somewhat different in that state.

Similarly, the study did not examine toxicology

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laboratory values, with all patients clinically sober at the time of the study. Drug or alcohol use may play a role in the ability to recall a threedigit number. The questionnaire used (Figure 1) was not validated in any way. Furthermore, it was offered to patients as part of their outpatient visit, but was not exhaustive (i.e., the authors did not seek out patients who were not scheduled, which may have altered the generalisability of the study). This may have reduced reliability.

Finally, the study was performed prior to the rollout of the 988 number. Given that the survey itself was a way to educate patients regarding 988, a second survey would have been more informative about the implementation of 988.

Although the study did not re-examine the patient population, it did compare the prerollout data with the recent NAMI study.25 The

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