HospiMedica International November 2019 by Globetech

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2019

Vol.37 No.5 • 10-11/ 2019

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DAILY CLINICAL NEWS

ISSN 0898-7270

Smart Devices to Detect Cardiac Arrest

AI Improves Efficiency and Accuracy of Breast Cancer Imaging

new study reveals how a smart speaker can spot a heart attack by detecting agonal breathing, a brainstem reflex that arises in the setting of severe hypoxia. Developed by researchers at the University of Washington (UW; Seattle, USA; www.washington.edu), the

rtificial intelligence (AI) can help shorten digital breast tomosynthesis (DBT) reading time while maintaining or improving accuracy, claims a new study. Researchers at the University of Pennsylvania (UPENN: Philadelphia, PA, USA; www.upenn.edu),

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iCAD (Nashua, NH, USA; www. icadmed.com), and other institutions have developed a deep learning AI system that is capable of identifying suspicious soft-tissue and calcified lesions in DBT images. The system was trained on a large DBT data set, following Cont’d on page 7

MRI Breakthrough Cuts Down Scan Time to A Minute

New Technique Predicts Risk of Cancer new study describes a technique to detect macromolecular alterations at the cellular level that can be used to predict and quantify cancer risk at extremely early stages. Developed at Northwestern University (NU; Chicago, IL, USA; www.northwestern. edu) and Argonne National Laboratory (ANL; Lemont, IL, USA; www.anl.gov), the new method is based on high-throughput optical

Cont’d on page 4

Cloud-Based System Monitors Vital Signs n innovative wireless device communicates with smartphones or third-party customized applications, sending raw vital signs data to the cloud for computation. The DynoSense (San Jose, CA, USA; www.dynosense.com) Vital Signs Measuring System collects a variety of input data representing a range of health metrics, including electrocardiogram (ECG) readings, respiration rate (RR),

new multicontrast MRI A technique called echo planar image mix (EPIMix) can

Image: Courtesy of Abbott Vascular

cut down the time for a scan to about one minute. EPIMix is capable of acquiring an entire MR image in only a fraction of a second and generating highquality images that provide reduced imaging time, decreased motion artifact, and display of rapid physiologic processes of the body. See article on page 3

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Integrated Platform Improves Spine Surgery n innovative multiple technology operating room (OR) platform helps surgeons adopt a more efficient and less disruptive minimally invasive surgery (MIS) approach in all spine procedures.

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MRI Breakthrough Cuts Down Scan Time to A Minute new multicontrast magnetic resonance imaging (MRI) technique can cut down the time needed to complete a scan to about 70 seconds, claims a new study. Developed by researchers at Karolinska Institutet (KI; Solna, Sweden; www.ki.se), Karolinska University Hospital (Stockholm, Sweden; www.karolinska.se), GE Healthcare (GE, Little Chalfont, United Kingdom; www.gehealthcare.com), and other institutions, the echo planar image mix (EPIMix) MRI technique combines contrast T1-FLAIR, T2weighted, diffusion-weighted images (DWI), apparent diffusion coefficient (ADC), T2-weighted, and T2-FLAIR images into one multicontrast MRI technique. To assess if EPIMix has comparable diagnostic performance as routine clinical brain MRI, the researchers conducted a prospective study of a consecutive series of 103 patients’ brain MRI from January 2018 to May 2018 using a 1.5T or 3T scanner. Two neuroradiologists assessed both EPIMix and clinical scans and categorized the images as abnormal or normal and described diagnosis, artifacts, diagnostic confidence image quality, and comparison of imaging time. In all, 82 patients were evaluated. The results revealed that diagnostic performance was comparable between EPIMix and routine clinical MRI, with a sensitivity of 95% and 93%, and a specificity of 100% and 100%, respectively. Disease category match between EPIMix and clinical routine MRI was 90% for one reader and 93% for the other. Imaging time was 78 seconds for EPIMix, as compared to 12 minutes 29 seconds for conventional 3T MRI. Image quality was generally rated lower for EPIMix. The study was published on April 1, 2019, in the Journal of Magnetic Resonance Imaging. “I have worked with MRI technology for a long time and with the problem of how difficult it is for patients to lie still for the camera. So, one day, I asked myself if there was any way to use rapid echo planar imaging (EPI) with other MRI types needed for brain scans,” said senior author Stefan Skare, PhD, of the KI department of neuroradiology. “In this way, the whole examination is faster and less sensitive to patient movement. Initially, I just wanted to test the concept. I didn’t think it would be such a major breakthrough.” EPI is capable of acquiring an entire MRI in only a fraction of a second; in single-shot EPI, all the spatial-encoding data of an image can be obtained after a single radio-frequency excitation, resulting in high-quality images comparable to conventional MRI, but with major advantages over conventional MRI that include reduced imaging time, decreased motion artifact, and the ability to image rapid physiologic processes of the human body.

HospiMedica International October-November/2019

Image: Dr. Stefan Skare’s algorithm improves MRI acquisition times (Photo courtesy of Catarina Thepper / Karolinska Institutet).

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New Technique Predicts Risk of Cancer cont’d from cover

microscopy technique and the ANL supercomputing Mira system. Using the open-source Angora software simulation tool, the computational electrodynamics technique converts static partial wave spectroscopy (PWS, an analysis of intracellular activity based on single snapshots), into dynamic PWS, which conveys information about a cell’s inner processes by observing that cell’s evolution through time. By employing dynamic PWS, the researchers were able to measure the intracellular nanoscale structure and macromolecular dynamics of living cells, sensitive to changes as small as 20 nanometers, and with millisecond temporal resolution. With Angora finite-difference time domain (FDTD) computations, the researchers explored higher-order chromatin structure and dynamics changes attributable to cellular fixation, stem-cell differentiation, and ultraviolet (UV) irradiation. They discovered a new phenomenon called cellular paroxysm, a synchronous, nearly instantaneous burst of intracellular motion that occurs early in the process of UV-induced cell death. The researchers suggest the technique could be used to study the field effect, which posits that cancer detection can be accomplished by properly analyzing seemingly normal tissue located some distance from afflicted lesions, such as a buccal swab to identify lung cancer, or a Pap smear to detect ovarian and cervical cancer. PWS could determine the degree of randomness of nanometric fluctuations of density within the cell, which in turn could be correlated to the presence of a cancer deeper in the body whose “field” includes the cell under analysis. A study describing the PWS method was published in the April 2019 issue of Nature Communications. “Rigorously solving Maxwell’s equations on nanometer-size voxels ultimately allows

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Angora to create full-color pixels at the image plane. These pixels can then be analyzed for spectral content,” explained Professor Allen Taflove, PhD, of NU. “After optimizing Angora for Mira, we’ve been able to solve for more than one trillion vector electromagnetic field components, which we think is unique among such software. Furthermore, by distinguishing between 20-nanometer fluctuations and 50nanometer fluctuations, Angora far exceeds the capabilities of conventional microscopes.” “The combination of our experimental and Angora computational studies has given us confidence that dynamic PWS provides the means with which to obtain nanoscalesensitive, millisecond-resolved information within living cells without the need for any staining,” concluded Professor Taflove. “The impressive spatial-temporal resolution capabilities of dynamic PWS open the door for high-fidelity, high-throughput, early-stage cancer screening, and possibly even novel cancer therapies.” Spectroscopy, primarily in the electromagnetic spectrum, is a fundamental exploratory tool in the fields of physics, chemistry, biology and astronomy, allowing the composition, physical structure, and electronic structure of matter to be investigated at atomic, molecular scale, and macro scale, and even over astronomical distances. Image: Nanoscale structure alterations of live cells observed using PWS optical microscopy (Photo courtesy

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ISSN 0898-7270 Vol.37 No.5 • Published, under license, by Globetech Media LLC Copyright © 2019. All rights reserved. Reproduction in any form is forbidden without express permission. Teknopress Yayıncılık ve Ticaret Ltd. Şti. adına İmtiyaz Sahibi: M. Geren • Yazı işleri Müdürü: Ersin Köklü Müşir Derviş İbrahim Sok. 5/4, Esentepe, 34394 Şişli, İstanbul P. K. 1, AVPIM, 34001 İstanbul • E-mail: Teknopress@yahoo.com Baskı: Postkom A.Ş. • İpkas Sanayi Sitesi 3. Etap C Blok • 34490 Başakşehir • İstanbul Yerel süreli yayındır. Yılda altı kere yayınlanır, ücretsiz dağıtılır.

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Smartphone Technology Measures Blood Pressure Optically maging facial blood flow patterns and analyzing them using artificial intelligence (AI) can predict blood pressure (BP) with 95% accuracy, according to a new study. Researchers at Hangzhou Normal University (Zhejiang, China; www.hznu.edu.cn) and the University of Toronto (UT; Canada; www.utoronto.ca) conducted a study that recruited 1,328 normotensive adults in order to develop a contactless technology – transdermal optical imaging – which can detect imperceptible facial blood flow changes using a smartphone camera. The technology works by detecting light reflected from blood vessels behind facial skin. Smartphone cameras are sensitive enough to pick up the specific shade of hemoglobin in the blood cells, and can thus track the blood’s density and motion in the cheeks, nose and forehead. For the study, an advanced AI machine learning algorithm was used to create computational models that predicted reference systolic, diastolic, and pulse pressure from the facial blood flow data; 70% of the data set was used to train the models, and 30% to test and validate model performance. The results showed that on average, transdermal optical imaging predicted systolic blood pressure with nearly 95% accuracy, and diastolic blood pressure with pulse pressure at nearly 96% accuracy. The study was published on August 6, 2019, in Circulation: Cardiovascular Imaging.

In transdermal optical imaging, the face is divided into ten different regions of interests (ROIs) and data is obtained that reflect five independent components of cardiovascular activities associated with the face. The five components reflect different spatiotemporal dynamics of facial blood flow changes, which can be used to study human physiological and psychological activities. Image: A new study claims that specific areas of the human face can be used to optically measure BP (Photo courtesy of Kang Lee/ UT).

Integrated Platform Improves Spine Surgery cont’d from cover

The NuVasive (San Diego, CA, USA; www.nuvasive.com) Pulse OR platform combines neuromonitoring, surgical planning, rod bending, radiation reduction, and imaging and navigation functions to improve operative workflow, reduce variability and increase surgical reproducibility. Independent device access allows OR staff to view the various technologies’ imaging and insights, simultaneously and in real time. In addition, the open, modular architecture of the system allows the use of flexible technology packages and selection of the exact tools needed to address specific pathologies in spine surgery procedures. The Pulse OR platform includes a range of hardware and software modules, including: Image transferring for both 2D- and 3D-imaging that combines camera, array, and workflow technologies to improve line of sight, ease of use and surgical efficiency in the OR. Pulse also leverages the Siemens Healthineers (Erlangen, Germany; www.healthcare. siemens.com) Cios Spin 3D mobile C-arm; Surgical Planning with Integrated Global Alignment (iGA), a preoperative planning software that incorporates alignment parameters, implant integration, surgical modeling, and other tools to help create a reliable plan prior to stepping into the OR; An automated nerve detection system with standardized setup and clinically validated alerts that help reduce variability and allow for faster neuromonitoring and interpretation of neural information; Radiation reduction via LessRay, an imaging system designed to take low-quality, low-dose images and improve them to look like conventional full-dose images, at 80% dose reduction compared to standard fluroscopy. Rod bending with Bendini, a technology used to create patient-specific rods, which are bent exactly to implant locations, expediting manual rod manipulation through computer-assisted bend instructions, all without leaving the OR. “The Pulse platform is uniquely engineered to equip surgeons with a single platform of integrated technologies necessary to perform all spine surgeries, including minimally invasive approaches,” said J. Christopher Barry, CEO of NuVasive. “Pulse provides an intuitive surgeon experience by anticipating user needs and fusing these technologies to create a seamless, optimized OR workflow, while addressing a broad range of clinical challenges. This is a pivotal step in our strategic vision to deliver end-to-end solutions that enable predictable clinical and economic outcomes in spine surgery.”

HospiMedica International October-November/2019

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Wide Bore CT Enhances Oncologic Radiotherapy Treatment novel 85cm wide bore computed tomography (CT) imaging unit offers enhanced and efficient CT radiotherapy treatment (RT) planning capabilities. The Fujifilm (Tokyo, Japan; www.fujifilm.com) FCT Embrace is designed to improve accuracy throughout the entire oncology care cycle, by optimally matching the rotational arc of the linear accelerator (LINAC) with that of the wide bore, thus providing precise positioning options for both preliminary simulation and RT treatment planning. Oncology patients can be imaged in their optimal treatment position at the full clinical image quality afforded by 64 slice or 128 slice configurations. The FCT Embrace is comprised of just 4 major parts with 100 components that connect seamlessly using brushless PowerLink slipring technology, thus streamlining installation and maintenance. For radiology and radiation oncology professionals who face logistical complexity while making high-stakes care decisions, the FCT Embrace also features a modular platform to seamlessly serve the needs of a wide range of medical specialties, spanning oncology, pediatrics, geriatrics, orthopedics, and emergency care. The 85-cm bore is one-sizefits-all, comfortably accommodating virtually any patient, from bariatric to pediatric; and procedure, from prone breast board to large biopsy needle placement. Additionally, the bore aperture is conveniently suited to RT treatment

planning software, easing the transition from radiology to oncology. Innovative 4D gating technology accounts for patient movement while breathing, allowing more targeted treatment options. The FCT Embrace also offers the industry’s widest table at 49 cm, minimizing the risk of falling and maximizing comfort for a wide range of patients, including bariatric patients weighing up to 300 kilograms. “Our goal is to simplify the workflow of radiation oncology professionals. We are delivering on this promise with the FCT Embrace, a onestop solution for the entire radiation therapy workflow offering CT imaging, simulation, treatment planning, and more,” said Alan Glenn, vice president of sales at Fujifilm. “Its sheer size at 85-cm bore optimally matches the rotational arc of the linear accelerator to offer easier and precise positioning options for simulation while providing an open patient experience. The modular platform maximizes synergies of care.” “In 1936, we took our first steps in the development of X-ray film; and in 1983, we pioneered the first digitized radiography system in the world,” said Johann Fernando, PhD, Chief Operating Officer of Fujifilm Medical Systems USA. “Once again we are innovating with the launch of the FCT Embrace, a solution that provides the most slices ever seen on an 85cm bore system. Designed to improve radiation oncology care, this advanced solution boosts patient comfort and security by offering the widest tabletop currently available.”

Beamforming Technology Powers New Ultrasound System new ultrasound system with innovative image reconstruction architecture facilitates the examination of high-risk pregnancies and early diagnosis of abnormal fetus conditions. The Samsung Medison (Seoul, Korea; www.samsungmedison.com) HERA is a new premium ultrasound platform that is based on Hyperaperture Enhanced Reconstruction Architecture (HERA), which allows an 11-fold increase in processing power and 10-fold increase in data transfer speed, compared to the company’s previous system. System features include a wide, rotatable control panel that uses a swivel mechanism that provides a range of movement of 550 mm from left to right, and 219 mm from top to bottom. Another innovation is a single crystal probe technology called S-Vue. The HERA system also uses Crystal Architecture, which includes CrystalBeam beamforming technology and the CrystalLive advanced post-processing engine. Other features include ShadowHDR, a shadow suppression algorithm that is designed to improve images of highly attenuated regions, such as fetal head and spine; HQ-Vision, which provides higher resolution images; MV-Flow, a solution that offers a detailed

view of blood flow relative to the surrounding tissues or pathology, with enhanced spatial and temporal resolution; and LumiFlow, which adds a continuous and volumetric three-dimensional (3D) vascular image. “Samsung is proud to introduce a new premium ultrasound system HERA W10 and a form factor innovation ultrasound HERA I10, as well as solutions that greatly improve the efficiency of hospitals,” said Dongsoo Jun, CEO of Samsung Medison and president of health and medical equipment at Samsung Electronics (Seoul, Korea). “Samsung will continue to provide the best solutions possible and bring meaningful changes in the healthcare industry.” In addition to the HERA W10, Samsung is unveiling a prototype of the HERA I10, a next-generation chair-type ultrasound system designed to meet the unique needs of obstetrics and gynecology. The HERA I10 provides a comfortable experience for both the doctor and the patient by eliminating the need for the patient to shift her body, automatically adjusting for proper positioning. It also ergonomically reduces the force required to move the control panel back and forth and the resistance force on the wrist. HospiMedica International October-November/2019

Bimodal Contrast Agent Advances Medical Imaging new study details a two-in-one probe made of a contrast agent for magnetic resonance imaging (MRI) and a dye for photoacoustic imaging (PI). Developed at the University of Mons (Belgium; https://web.umons.ac.be) and the Center of Microscopy and Molecular Imaging (CMMI; Charleroi, Belgium; www.cmmi.be), the bimodal agent combines the MRI gadolinium agent Gd-PCTA, and an organic fluorophore dye called ZW800-1. AL-lysine derivative joins the two via conventional protein end connections. The L-lysine derivative also possesses a third connectivity, which can be of used to add another biovector, such as a peptide that specifically recognizes a biological disorder. This could make the bimodal probe trimodal. The bimodal probe enhances MRI contrast as strongly as a commercial MRI agent, while at the same time providing a photoacoustic signal

AI Improves Efficiency and Accuracy of Breast Cancer Imaging cont’d from cover

which its performance was tested by having 24 radiologists, including 13 breast subspecialists, each read 260 DBT examinations with and without AI assistance. The examinations included 65 cancer cases. The results revealed that radiologist performance for the detection of malignant lesions increased from 0.795 without AI to 0.852 with AI, while reading time decreased by 52.7%, from 64.1 seconds without to 30.4 seconds with AI. Sensitivity increased from 77% without AI to 85% with AI, specificity increased from 62.7% without to 69.6% with AI, and recall rate for non-cancers decreased from 38% without to 30.9% with AI. The study was published on July 31, 2019, in Radiology: Artificial Intelligence. “Overall, readers were able to increase their sensitivity by eight percent, lower their recall rate by seven percent, and cut their reading time in half when using AI concurrently while reading DBT cases,” said lead author Professor Emily Conant, MD, chief of breast imaging at UPENN. “The concurrent use of AI with DBT increases cancer detection, and may bring reading times back to about the time it takes to read digital mammography alone.” DBT acquires multiple images over a limited angular range to produce a set of reconstructed images, which can then be viewed individually or sequentially in a cine loop, and in a 3D image of the breast, which can viewed in narrow slices, similar to CT scans. While in conventional 2D mammography overlapping tissues can mask suspicious areas, 3D images eliminate the overlap, making abnormalities easier to recognize. It is estimated that 3D DBT will replace conventional mammography within ten years.

similar to the original PAI probe. The probe can thus provide hybrid images with a high anatomical resolution provided by MRI, and precise localization of the contrast agent thanks to PAI. Preliminary relaxometric and photoacoustic characterizations indicate that the bimodal agent fulfills its function. The study was published on June 26, 2019, in the European Journal of Inorganic Chemistry. “The aim is to improve the image by combining photoacoustic imaging and magnetic resonance imaging by using a bimodal probe,” said Professor Sophie Laurent, PhD, of the University of Mons. “The organic dye enables PAI, thanks to its fluorescence in the near infrared (NIRF), and the gadolinium complex based on PCTA is ideal for MRI with radio-frequency pulses. The combination leads to a precisely localized, high-resolution bimodal image.” Image: A bimodal contrast agent provides hybrid images (Photo courtesy of Getty Images).

Infrared Imaging Technology Advances Cancer Diagnosis new study shows how a widefield photothermal sensing (WPS) microscope can provide ultrafast chemical infrared (IR) imaging of biological and material specimens. Developed by the Chinese Academy of Sciences (Shenyang, China; http://english.imr.cas.cn), Purdue University (Lafayette, IN, USA; www. purdue.edu), Boston University (MA, USA; www.bu.edu), and other institutions, the new method allows examination of living cancer cells, rather than desiccated samples, as required by traditional IR spectroscopy. The WPS microscope is based on photothermal detection of differences between the between the hot and cold states of a tissue, achieved by shining both an IR excitation laser and a visible pulsed blue light-emitting diode (LED) probe laser through a sample. To enable high-throughput detection of IR absorption, the researchers developed a virtual lock-in camera, with the exposure frames synchronized to the probe pulses and the IR pulses at the same repetition rate, with precisely controlled time delays. The study was published on July 19, 2019, in Science Advances.

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Study Questions Benefits Of Patient Shielding During Imaging new study claims that patient shielding in diagnostic imaging provides negligible benefits and actually increases risks. A study written by researchers at the University of Colorado School of Medicine (Aurora, CO, USA; www.ucdenver.edu) reviews the historical rationale for patient shielding, explains why the risks that come with patient shielding now outweigh what little benefit still exists, and makes the case for why it is time to abandon the legacy practice of patient shielding in radiology. First introduced as a regulation in 1976 in order to protect patients from the hereditary risks of radiation exposure, the wording has not changed since the initial version was released, despite the fact no hereditary effects have been observed in humans since the regulation was introduced. In addition, as the authors point out, radiation doses during the four decades since the regulation was released have decreased significantly, thanks to advances in imaging technology. For instance, radiation doses to patients undergoing anteroposterior examinations of the pelvis have decreased more than 96% over the last 60 years. They also suggest that as more imaging technologies currently rely on automatic exposure control, patient shields could lead to an increase in radiation doses due to attenuation, and to a decrease in image quality. The study was published in the April 2019 issue of the American Journal of Roentgenology. “It is important to think about how much protection is really being

provided to the patient. For anatomy outside the imaging field of view [FOV], radiation exposure results almost entirely from internal scatter generated within a patient,” wrote study authors Rebecca Milman Marsh, PhD, and Michael Silosky, MSc. “As contact shielding cannot protect against internal scatter, shielding anatomy outside the imaging FOV provides negligible protection to the patient. This holds true for all examinations, including those of pediatric and pregnant patients.” Image: A new study suggests that shielding patients undergoing diagnostic x-rays could be counter-productive (Photo courtesy of Rebecca Milman Marsh / Shutterstock).

Zero Echo Time Skull MRI is Comparable to CT Imaging

new study suggests that zero echo time (ZTE) skull MRI could provide a clinical alternative to computerized tomography (CT) in radiosensitive trauma patients such as children or pregnant

women. Researchers at Gyeongsang National University School of Medicine (GNU; Changwon, Republic of Korea; www.gnu.ac.kr) and GE Healthcare Korea (Seoul, Republic of Korea; www3.gehealthcare.co.kr) conducted a study to probe clinical feasibility, diagnostic image quality, and quantitative measurement capacity of skull MRI with the ZTE sequence in patients with head trauma, as compared to standard CT images. The study included 13 patients with head trauma who were evaluated using both brain CT and skull MRI. To evaluate quantitative analyses between the two imaging modalities, the researchers measured skull thickness and normalized bone tissue signal. The results revealed that both imaging techniques clearly de-

picted skull fractures in all 13 patients. The mean scores for skull MRI and CT were 4.65 and 4.73, respectively, with substantial interobserver agreement. There were no differences in skull thickness, and normalized bone tissue signals among the three layers of the skull were relatively consistent. The study was presented at the American Roentgen Ray Society (ARRS) annual meeting, held during May 2019 in Honolulu (HI, USA). ZTE MRI provides enhanced bone contrast and can forestall concomitant CT and its attendant ionizing radiation. The signal is acquired with near-zero echo time after application of the RF pulse, and by using radial space filling strategies, algebraic reconstruction, and extrapolation of oversampled acquisitions, can produce images with high signal-tonoise ratio (SNR) and scan-time efficiencies at near-isotropic resolution. The inverse-logarithmic rescaling of ZTE images provides contrast between soft tissue and bone comparable to that at CT. HospiMedica International October-November/2019

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Medical Imaging

Miniaturized Musical Instrument Improves Ultrasound Imaging new study shows the bandwidth of air-coupled ultrasonic transducers can be enhanced without sensitivity loss by connecting resonating pipes of various lengths to a central cavity, mimicking a pipe organ. Researchers at the University of Strathclyde (United Kingdom; www.strath.ac.uk) have developed a piezoelectric micromachined ultrasonic transducer (PMUT) modification that consists of a polyvinylidene fluoride thin film over a stereolithography designed backplate. The design was inspired by a pipe organ, where the resonant frequency of each pipe is mainly determined by its length. The -6-dB bandwidth of the coupled PMUT is 55.7% and 58.5% in transmitting and receiving modes, respectively, about five times wider than a custom-built standard device. The designs were developed and tested using mathematical models and computer simulations to speed up the process, and were printed using three-dimensional (3D) additive manufacturing techniques. The researchers added that while development is at an early stage, the technology could have significant implications in the design of hearing aids, in underwater sonar, and in nondestructive evaluation (NDE) of safety critical structures such as nuclear plants. The study was published in the October 2018 issue of IEEE Transactions on Ultrasonics, Ferroelectrics, and Frequency Control. “Musical instruments have a wide variety of designs, but they all have one thing in common; they emit sound across a broad range of frequencies. So there is a treasure trove of design ideas for future medical imaging sensors lying waiting to be discovered amongst this vast array of designs,” said study co-author Professor Tony Mulholland, PhD. Whereas standard ceramic piezoelectric transducers use thickness mode reso-

nances, PMUTs have a thin flexible film to transmit and receive ultrasound waves, and have a better performance in air because the flexible film is easier to couple with the media, with a more closely matched mechanical impedance. And as the film stores much less kinetic energy than bulk piezoceramic, PMUTs have larger bandwidths when in resonance. Image: A miniature “pipe organ” piezoelectric device improves ultrasound imaging (Photo courtesy of Botong Zhu/University of Strathclyde).

Software Suite Helps Deliver Complex RT Regimens new suite of data-focused integrative oncology software enables precision radiation therapy (RT) treatment regimens, while simplifying and streamlining the delivery of care. The Elekta (Stockholm, Sweden; www.elekta.com) MOSAIQ Plaza software solution is a patient-centric, integrative operating system designed to work seamlessly with Elekta’s RT systems. Key features of the suite include: Elekta SmartClinic, which enables process visualization and automated streamlined care coordination with fewer clicks and portability. Monaco HD treatment planning, designed to deliver fast and accurate treatment plans with the aid of smart sequencing and true multicriterial optimization. IBM Watson for Oncology, a powerful tool that augments clinicians’ expertise with evidence-based decision support, providing patients with data-driven care, regardless of where they are treated. Voice Automation, which integrates Palabra (Seattle, WA, USA) cutting-edge voice recognition technology and customizable templates with MOSAIQ, reducing the time needed to create accurate patient notes. Care Collaboration, which supports tumor boards and multidisciplinary meeting experiences with cross-specialty data visualization. “We believe that clinicians and patients around the world should have access to life-changing, life-saving care. Achieving this goal requires advanced radiation therapy solutions,” said Richard Hausmann, CEO and President of Elekta. “Our focus on precision radiation medicine reflects our commitment to innovating solutions that enable personalized radiation therapy that can rapidly be adapted to changes in tumor size and shape, and use intelligent data processing to streamline treatments.” Elekta’s RT systems compatible with MOSAIQ Plaza software include the Elekta Unity, a high field magnetic resonance radiation therapy system that allows clinicians to see and track difficult-to-visualize soft tissue anatomies during radiation dosing; the Leksell Gamma Knife Icon, a precision for intracranial stereotactic radiosurgery solution with CBCT imaging; the Versa high definition dynamic radiosurgery (HDRS) platform, which offers precision RT treatments throughout the body in standard treatment time slots; and Venezia, a gynecologic brachytherapy applicator designed to treat advanced cervical cancer.

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PHANTOMS

WIRELESS ULTRASOUND

Parker Laboratories

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MedGyn

The Aquasonic CLEAR has no fragrance or color and is meant for diagnostic and therapeutic medical ultrasound procedures. Hypoallergenic, bacteriostatic and non-irritating, it is water-soluble and does not contain formaldehyde.

The Sono404 Phantoms enhance the accuracy of QC measurements by ensuring all transducers and settings are tested across the clinical range. It includes closely spaced pin targets, ideal for testing high-frequency transducers.

The TC2 uses wireless communication for image transmission and features a double-head probe design with convex and transvaginal probes on each end. The ultrasound probe can be easily connected to a tablet or smartphone.

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Upper GI X-Rays Unhelpful After Sleeve Gastrectomy new study suggests that routine radiologic gastrografin upper gastrointestinal (GUGI) inspection is of little value, and should therefore be abandoned. Researchers at Case Western Reserve University (CWRU; Cleveland, OH, USA; www.case.edu) and Jesse Brown VA Medical Center (Chicago, IL, USA; www.chicago.va.gov) conducted a study involving 197 patients who underwent laparoscopic sleeve gastrectomy (LSG) between 2012 and 2017, and who had a routine GUGI series on postoperative day one or two, in order to minimize morbidity and mortality by identifying a developing leak. Twelve patients had more than one GUGI study because of delayed transit of contrast seen on initial examination. In all, two leaks (1%) were found, and both of them occurred after hospital discharge in symptomatic patients, and both were detected not by GUGI, but by computed tomography (CT). There were three false positives (1.5%), with laparoscopic examination determining that there was no leak. Since these results indicate there were no true positive values, the positive predictive value and sensitivity of the approach was zero, and the negative predictive value was 100%, with a specificity of 98.5%. The study was published on October 31, 2018, in JAMA Surgery. “We no longer obtain postoperative day one gastrografin upper gastrointestinal studies on our sleeve gastrectomy patients, as all negative studies were determined to not have a leak as measured against clinical assessment standard,” said lead author Dominic Vitello, BSc, of CWRU. “Postoperative studies to determine a leak after laparoscopic sleeve gastrectomy should be based on symptoms of tachycardia, shoulder or abdominal pain, or other worrisome clinical criteria.”

LSG is currently the most frequently performed bariatric procedure worldwide, with leak rates between 0% and 5.5%. The leaks are due to the long staple line and high intraluminal pressure, which synergize to create them. Such leaks are difficult to manage, and 80% of them occur after hospital discharge. Many surgeons believe GUGI can aid earlier identification and intervention, but others claim the procedure is controversial, adding to health care cost and increasing radiation exposure. Image: A new study suggests that radiographic imaging to detect leaks after bariatric surgery may be unnecessary (Photo courtesy of Getty Images).

Oral Stents Immobilize Tongue During Radiotherapy ew tongue displacing stents provide custom oral positioning with repeatable tongue deviation during radiotherapy (RT). The POLL Medical (Beaverton, OR, USA; www.poll-medical.com) GrayDuck Stent is a customized tongue-displacing dental stent (CTDS) aimed at improving RT treatment and outcomes by sparing the tongue, taste buds, and salivary glands from unnecessary radiation. The stent provides rigid and reproducible immobilization of the tongue, restraining movement in one of several positions; laterally (left or right), depressing (downward), or a combination thereof. The anterior portion can also be attached to a thermoplastic facemask. The GrayDuck CTDS is distributed worldwide via CIVCO Radiotherapy (Orange City, IA, USA; www.CivcoRT.com). The CTDS is intended to be used for repeat positioning of the patien-

t’s tongue and jaw while undergoing or receiving a course of external beam radiation therapy (EBRT) for cancer and other diseases. Requiring less than 10 minutes, the ethylene-vinyl acetate (EVA) stent is customfitted by placing it in hot water for two minutes before placing in the patient’s mouth to custom form the teeth. Reproducible positioning of the patient over multiple rounds of RT demands reliable immobilization for an accurate and consistent treatment setup. The use of low-temperature thermoplastic materials in order to effectively immobilize movement reduces the amount of time that it may take to receive RT and minimizes unwanted side effects such as damage to the skin, the upper digestive tract, and rampant caries due to damage to saliva glands. HospiMedica International October-November/2019

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Medical Imaging

MRI Reveals Stroke Impact on Basal Brain easuring iron content in the brain using magnetic resonance imaging (MRI) could provide a clearer understanding of the consequences of a stroke, according to a new study. Researchers at Centre Hospitalier Universitaire (CHU) de Bordeaux (France; www.chu-bordeaux.fr), Neurocentre Magendie (Bordeaux, France; https://neurocentre-magendie.fr), and other institutions in France conducted a study to assess longitudinal changes in the substantia nigra (SN) in 181 patients who had suffered an ipsilesional supratentorial infarct, using an MRI technique called R2*. Study participants were evaluated once at 24–72 hours after the stroke (baseline visit), and again one year later. The SN was segmented bilaterally to calculate an R2* asymmetry index (SN-AI); greater SN-AI indicated greater relative R2* in the ipsilateral compared with contralateral side. The 95th percentile of R2* was then compared according to infarct location. The results revealed that one year after a baseline, some of the patients showed higher iron content in the SN. High iron content was found to be associated with worse long-term outcomes, particularly when it was found on the same side of the brain that the stroke occurred. The study was published on March 12, 2019, in Radiology. “Overall, the SN is strongly involved in motor control, but also in regulation of emotions, cognition, and motivation. Usually, stroke doesn’t directly affect the SN but, by interrupting circuits, stroke can induce secondary degeneration of that area,” said senior author Professor Thomas Tourdias, MD, PhD, of CHU Bordeaux. “We showed that imaging of iron can also be used to image degeneration remotely from stroke in disconnected areas. This finding could be clinically useful, because it shows that a simple magnetic resonance imaging method such as R2* can provide a more comprehensive picture of the consequences of an infarct.” The SN is a basal ganglia structure located in the midbrain discovered in 1784 by Félix Vicq-d’Azyr. It is the largest nucleus in the midbrain. Humans have two SN, one on each side of the midline. It plays an important part in brain function, including eye movement, motor planning, rewardseeking, learning and addiction. Many of the SN’s effects are mediated through the striatum, and the SN also serves as a major source of GABAergic inhibition to various brain targets. The SN is critical in the development of many diseases and syndromes, including Parkinson’s disease, which is characterized by the loss of dopaminergic neurons in the SN.

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Image: The Visual R2* SN changes from baseline to one year follow-up (Photo courtesy of Thomas Tourdias/ CHU Bordeaux).

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ECG MONITOR

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The Eagle series is intended to administer oxygen or other breathing gases. The disposable masks are designed for short-term or emergency respiratory support/ventilation in hospitals, transport vehicles and other clinical settings.

The iE 10 allows for horizontal or vertical view and a built-in rechargeable battery offers up to four hours of continuous work. Other features include up to 300 seconds of rhythm analysis and onboard storage for up to 1,500 files.

The Kool-Kit contains three high-quality cooling blankets and wraps, and self-sealing hoses keep water from spilling. The flow design of the blankets/wraps ensures therapy will be constantly delivered regardless of the patient.

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Smart Devices to Detect Cardiac Arrest cont’d from cover

proof of concept tool is installed as an app into a smartphone or a support vector machine (SVM) such as a Google Home or Amazon Alexa speaker in order to monitor breathing and call for help if needed. The SVM was trained using real agonal breathing as captured from calls to Seattle Emergency Medical Services by bystanders, who recorded them by putting their phones up to the patient’s mouth so that the 911 dispatcher could determine whether the patient needed immediate cardiopulmonary resuscitation (CPR). In all, the researchers collected 162 calls between 2009 and 2017 and extracted 2.5 seconds of audio at the start of each agonal breath, for a total of 236 clips. Various machine-learning techniques were used to boost the dataset to 7,316 positive clips. For the negative dataset, they used 83 hours of audio data collected during sleep studies, yielding 7,305 sound samples, containing typical sounds that people make in their sleep, such as snoring or obstructive sleep apnea (OSA). They then used machine learning to create a tool that could aid an SVM detect agonal breathing 97% of the time from up to six meters away. The study was published on June 19, 2019, in npj Digital Medicine. “This kind of breathing happens when a patient experiences really low oxygen levels. It’s sort of a guttural gasping noise, and its unique-

ness makes it a good audio biomarker to use to identify if someone is experiencing a cardiac arrest,” said co-corresponding author Jacob Sunshine, MD, of the UW School of Medicine. “Cardiac arrests are a very common way for people to die, and right now many of them can go unwitnessed. Part of what makes this technology so compelling is that it could help us catch more patients in time for them to be treated.” “A lot of people have smart speakers in their homes, and these devices have amazing capabilities. This could run locally on the processors contained in the Alexa. It’s running in real time, so you don’t need to store anything or send anything to the cloud,” said co-corresponding author Shyam Gollakota, PhD, of the UW School of Computer Science and Engineering. “We envision a contactless system that works by continuously and passively monitoring the bedroom for an agonal breathing event, and alerts anyone nearby to come provide CPR. And then if there’s no response, the device can automatically call 911.” Out-of-hospital cardiac arrest is a leading cause of death worldwide. Rapid diagnosis and initiation of cardiopulmonary resuscitation (CPR) is the cornerstone of therapy for victims of cardiac arrest. Yet a significant fraction of cardiac arrest victims have no chance of survival, because they experience an unwitnessed event, often in the privacy of their own homes.

Cloud-Based System Monitors Vital Signs cont’d from cover

body temperature, arterial hemoglobin oxygen saturation (SpO2), perfusion index (PI), an optical photoplethysmogram (PPG) for pulse rate (PR), heart rate (HR), and heart rate variability (HRV), and others. In contrast to traditional systems, the raw data is analyzed and the results computed not in the device itself, but rather in the cloud. An intelligent analytic engine that interprets the metrics offers clinically based insights that make it easier to maintain optimal health. A Health Relationship Management Services (HRMS) platform allows healthcare specialists to aggregate and interpret the health data and information in order to create actionable, personalized individualized health care plans. In addition, using medical decision support algorithms (MDSA), healthcare companies can supply more comprehensive clinical and financial outcomes, creating a unique experience for people with high-risk health factors or chronic conditions. In addition, DynoSense offers DynoCapture, a Software-as-a-Service (SaaS) platform that includes an innovative health scoring system, called DynaScore, which predicts clinical exacerbation days in advance of a critical event. Care providers have access to the DynoCapture dashboard, where they can monitor periodic measured status from the de-

vice, surveys, user habits and even receive alerts of unusual or troubling changes in a member’s routine. Members also have the option to communicate via text and video to receive support from healthcare experts. “We are on the path to take advantage of the shift to advanced AI based monitoring systems and digital therapeutics methods to improve health and wellness,” said Saeed Azimi, founder and CEO of DynoSense. “As a person with my own chronic health condition, I have come to understand the power of receiving informed preventive and self-empowering alerts that are coupled with my clinical V

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Post Processing Method Increases MRI Assessment Accuracy novel magnetic resonance imaging (MRI) scanning technique improves degenerated spinal disc analysis accuracy from 70% with current methods to 97%, according to a new study. The decay variance technique, developed by researchers at the University of New South Wales (Sydney, Australia; www.unsw.edu.au), the University of California, San Diego (UCSD, USA; www.ucsd.edu), and St. George Hospital (Sydney, Australia; www.seslhd.health.nsw.gov.au/SGH), is based on aggregation of the deviation in the intensity of T2 quantitative relaxometry of sulfated glycosaminoglycans (S-GAG) content within intervertebral discs (IVDs) over a multi echo MRI sequence. The researchers hypothesized that variability in the rate of signal decay over multiple MRI echo encodes information on the tissue states that could help distinguish between a healthy and a degenerate IVD. To test the new technique, the researchers subjected 25 New Zealand white rabbits to annular puncture to induce disc degeneration in 50 noncontiguous lumbar IVDs. Sixteen weeks later, the rabbits underwent multi echo T2 MRI scanning and were then euthanized. The degenerated IVDs were subsequently stained and examined histologically. They then evaluated the difference between measured and expected signal decay for each echo in the multi echo T2 MRI sequence, and correlated the results with histologically graded IVD degeneration. Quantitative T2 relaxation maps were prepared, and decay variance maps were created using a post-processing tool that aggregated the deviation in the intensity of each echo signal from the expected intensity, based on the previous rate of decay. The maps showed a clear and well-demarcated nucleus pulposus with a consistent rate of decay in healthy discs, and progressively more variable decay in the degenerate IVDs. The study was published on August 1, 2019, in JOR Spine. “Current techniques see how quickly or slowly individual atoms line up with a magnetic field after a strong burst of radio waves – this is called signal decay,” said senior author orthopedic surgeon Ashish Diwan, MD, of St. George Hospital. “Back pain affects about one in six Australians but in 95% of cases, doctors can’t find any cause. This not only makes it very hard to treat individual patients, but also makes it very hard to find new cures for back pain,” said lead author Kyle Sheldrick, MD, of UNSW. “Experts think degeneration of the spinal discs is a cause of back pain, but current tests for disc degeneration don’t work very well. Patients with discs that look healthy on MRI often have severe back pain, and patients with discs that look very degenerate on T2 MRI often have no back pain, so better technology is needed.”

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Image: Dr. Ashish Diwan (left) and Dr. Kyle Sheldrick (right) (Photo courtesy of UNSW).

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PATIENT MONITOR

INCUBATOR

Hans Rudolph

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Ginevri

The SmartLab with Insight software is designed for measurement/analysis of respiratory signals. The base module can accept up to 3 sensor modules. Optional items include an oximeter, CO2 sensor, temp, humidity and digital I/O.

The Smartsigns Compact 1000 Series offers clinicians a comprehensive set of invasive and NIV measurements. Features include colorcoded waveforms, four modules of availability and customize configurations.

The OGB Polytrend features a hood, base and other main components with easy disassembly for cleaning and disinfection. It also includes practical encoder that allows for the setting of all parameters and surfing of various displays.

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Electrotherapy Stimulator Treats Anxiety, Insomnia And Depression new stimulation device delivers micropulses of electrical current across the patient’s brain, resulting in a reduction in anxiety levels, insomnia, and depressive mood. The Innovative Neurological Devices (Carmel, IN, USA; www. cervella.us) Cervella Cranial Electrotherapy Stimulator (CES) is designed to deliver a very low-level current to the patient’s cranium via a pair of conductive treatment electrodes incorporated which are seamlessly integrated into Bluetooth-enabled noise-canceling stereo headphones. The headphones are controlled via an app installed on a smart device, which is used to adjust the intensity level, frequency, and duration of the treatment. The app also allows the patient to automatically store treatment history for review by the patient’s healthcare provider. Following a treatment session, which typically lasts 30 minutes, patients experience a reduction of anxiety levels and insomnia, leading to improved sleep patterns. Longer-term use has been clinically validated to have a positive effect on reducing a patient’s depressive mood. During treatment, patients can listen to music via a dedicated Bluetooth connection or use the active noise reduction feature of the headset, which allows use during study, work, or play; Cervella is thus designed to fit into the patient’s lifestyle, not the other way around. “For many years, CES devices have been clinically validated as a safe and effective alternative to drug-based therapies, without the side-effects that often exist with the use of antidepressants,” said Bart Waclawik, President and CEO of Innovative Neurological Devices. “By making the Cervella device appear indistinguishable from ordinary over-ear head-

phones, patients will have the freedom to use the device in anxiety-inducing situations without curious looks from onlookers.” According to clinical and research studies, the micro current delivered by CES results in several effects on the brain, including modulating the default mode network (DMN), endogenous brain oscillations, and changes in neurotransmitter levels such as serotonin. The efficacy of CES as a treatment option for anxiety, insomnia, and depression is well demonstrated and documented through numerous clinical trials conducted over several decades. Image: The CES and earphones are designed to help treat emotional disorders (Photo courtesy of Innovative Neurological Devices).

Bariatric Fundus Embolization Viable for Severely Obese Patients ransarterial embolization of the gastric fundus in severely obese adults can suppress appetite and induce weight loss for up to 12 months, claims a new study. Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu), Mount Sinai Hospital (New York, NY, USA; www. mountsinai.org), and other institutions conducted a prospective study that recruited 20 severely obese adults (16 women; mean age 44 years) with a mean body mass index (BMI) of 45 kg/m2 to evaluate the safety and efficacy of bariatric embolization, an image-guided procedure that aims to induce metabolic changes by targeting the endocrine functions of the gastric fundus, which play a role in stimulating appetite. Bariatric embolization was performed successfully in all participants,

with no major adverse events. The mean excess weight loss was 8.2% at one month, 11.5% at three months, 12.8% at six months, and 11.5% at 12 months. Hunger or appetite decreased for four weeks after embolization, increasing again thereafter, but without reaching pre-embolization levels. Study participants also showed evidence of metabolic change, with decreases in hemoglobin A1c and total cholesterol (independent of weight loss), and concomitant increase in high-density lipoprotein (HDL) levels. The study was published on April 2, 2019, in Radiology. Transarterial bariatric embolization of the gastric fundus delivers embolic microspheres into the gastric arteries to induce localized ischemia and modify appetite hormones, leading to weight reduction; early clinical trials have produced promising short-term results in animal models. HospiMedica International October-November/2019

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Critical Care

Pelvic Floor Disorders Associated with Childbirth Delivery Method new study suggests that vaginal childbirth substantially increases the probability a woman will develop a pelvic floor disorder, such as incontinence, later on in life. Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu), and the Greater Baltimore Medical Center (GBMC; MD, USA; www.gbmc.org) conducted a study that recruited 1,528 women within five to 10 years of their first birth, who were followed up annually for up to nine years. Recruitment was based on mode of delivery; 778 delivered all of their children via cesarean birth, 565 had at least one spontaneous vaginal delivery, and 185 had at least one delivery involving forceps or vacuum-assistance. Information was collected at the time of enrollment, including date and age at first birth, body mass index (BMI), birth delivery mode, genital hiatus size, and whether they had developed any prior pelvic floor disorder; delivery groups were then matched for age and years since first delivery. Main outcomes and measures included presence of stress urinary incontinence (SUI), overactive bladder (OAB), and anal incontinence (AI). Some women already had developed pelvic floor disorders at the time of study enrollment, while others developed the conditions over the course of the study. The results showed that cesarean delivery substantially reduced the risk of pelvic floor disorders, most notably pelvic organ prolapse, while operative delivery increased the risk. For pelvic organ prolapse, the magnitude of these differences grew over time. By 15 years after a first delivery, prolapse of the uterus or vaginal wall beyond the vaginal opening was seen in 9% of women who had delivered by cesarean, 30% in those who had at least one vaginal delivery, and 45% in those who had at least

one operative delivery. The researchers also found that a large percentage of new cases of urinary and bowel incontinence developed in the first five years after delivery, while pelvic organ prolapse tended to develop many more years after childbirth. A third discovery was that the genital hiatus size is significantly associated with all pelvic floor disorders, but most significantly with pelvic organ prolapse. According to the researchers, this suggests that the genital hiatus size is a marker that can identify women at high risk of developing pelvic floor disorders with aging. The study was published on December 18, 2018, in JAMA. “We knew that these disorders are more common after childbirth, but now after following these women for 10 years, we have a good sense of how delivery mode impacts a woman’s risk of developing a pelvic floor disorder,” said senior author Professor Victoria Handa, MD, MHS, of JHU. “Ultimately this research will help us identify which women should be targeted for prevention strategies, and will hopefully improve our ability to deliver the right type of care to the right person.” Image: New research suggests how women give birth can affect future pelvic disorders (Photo courtesy of iStock).

Multimethod Approach Identifies Pharmacologic Nonadherence n assessment of pharmacy refill data and technology measures can improve accurate identification of nonadherence among chronic kidney disease (CKD) patients, claims a new study. Researchers at Johns Hopkins University (JHU; Baltimore, MD, USA; www.jhu.edu), the U.S. National Institutes of Health (NIH, Bethesda, MD, USA; www.nih.gov), and other institutions conducted a study involving 87 adolescents and young adults (AYA) with CKD prescribed antihypertensive medication, their caregivers, and 17 participating medical providers. Five adherence measures were used, including healthcare provider report, AYA report, caregiver report, electronic medication monitoring (MEMS) pillboxes, and pharmacy refill data. The results revealed that both healthcare providers and electronic pillboxes classified 34.5% of patients as nonadherent, although they disagreed about which patients were actually nonadherent. AYA patient reports, caregiver reports, and pharmacy refill data all classified 50-61% of the patients as nonadherent. The study was published in the December 2018 issue of Pediatric Nephrology. “In general, providers are already doing assessments of patients’ adherence levels, and most clinical practices have the ability to access pharmacy refill data, so this is a very feasible thing to start doing in a clinical setting,” said lead author Cozumel Pruette, MD, of JHU Children’s Center. Estimates by the World Health Organization (WHO, Geneva, Switzerland; www.who.int) indicate that only about 50% of patients in developed countries follow treatment recommendations. Low rates of adherence for asthma, diabetes, and hypertension are thought to contribute substantially to the human and economic burden of those conditions. Major barriers to compliance include the complexity of modern medication regimens, poor “health literacy” and lack of comprehension of treatment benefits, undiscussed side effects, the cost of prescription medicine, and poor communication or lack of trust between patient and health-care provider.

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The GE Aisys Carestation digitally controls and measures ventilation, vaporization and gas delivery. Featuring a modular design with upgradeable components, its displays are attached to a movable arm with 360-degree rotation.

The NAVI-60 provides a real-time accurate image of the vasculature on the surface of the skin. It benefits hospitals by reducing healthcare costs, improving infection control, and increasing patient safety and satisfaction.

The eXtend XT offers the complete range of ventilation modes and a large range of monitoring capacities. Developed to enhance critical care, its user-friendly interface and wide screen make it easy to use for all in patients.

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Stress-Related Disorders Associated with Multiple Cardiovascular Disease Risk new study reveals that stress-related disorders may increase the risk for cardiovascular disease (CVD), especially during the first year after diagnosis. Researchers at the University of Iceland (HI; ReykjavĂk; www.hi.is), Karolinska Institutet (KI; Solna, Sweden; www.ki.se), and other institutions conducted a population based, sibling controlled cohort study in order to assess the association between stress-related disorders and subsequent CVD risk. The study participants included 136,637 patients in the Swedish National Patient Register with stress related disorders, including post-traumatic stress disorder (PTSD), acute stress reaction, adjustment disorder, and other stress reactions; 171,314 unaffected full siblings of these patients; and 1,366,370 matched unexposed people from the general population. The main outcome measures included primary diagnosis of incident CVD, including specific subtypes such as ischemic heart disease, cerebrovascular disease, emboli/thrombosis, hypertensive diseases, heart failure, arrhythmia/conduction disorder, and fatal CVD, as well as 16 individual diagnoses of CVD. The results revealed that among the exposed patients, their unaffected full siblings, and the matched unexposed participants, the crude incidence rate of any CVD was 10.5, 8.4, and 6.9 per 1,000 person-years, respectively, during 27 years of follow-up. Compared with their unaffected siblings, exposed patients had almost twice the risk for any CVD during the first year of follow-up. The association was independent of sex, familial characteristics, history of

somatic or psychiatric disorders, and psychiatric comorbidities. Associations were stronger among those who were younger at index date, and also between stress-related disorders and early-onset CVD. The presence of psychiatric comorbidity did not alter these associations, with the exception of fatal CVD. The results were similar when compared with the population-matched cohort. The study was published on April 10, 2019, in BMJ. PTSD is the most severe and widely studied form of stress related disorder, characterized by re-experiencing, avoidance, negative cognitions and mood, and hyperarousal following the traumatic event. Image: New research suggests that stress can increase the risk of various cardiovascular issues (Photo courtesy of Shutterstock).

Viscoelastic Heart Patch Treats Myocardial Infarction n adhesive epicardial patch could increase the mechanical integrity of damaged left ventricular tissues following a heart attack, claims a new study. Developed by researchers at Brown University (Providence, RI, USA; www.brown.edu), Fudan University (Shanghai, China; www.fudan. edu.cn), Soochow University (Suzhou, China; www.suda.edu.cn), and other institutions, the ionically crosslinked transparent gel-point adhesive patch (GPAP) is a viscoelastic material that combines both fluid and solid properties. The fluid properties are retained up to a certain amount of stress, at which point the material solidifies and turns stiffer, which can accommodate the cyclic deformation of the myocardium and left ventricular remodeling following acute and subacute myocardial infarction (MI). To determine the optimum mechanical properties of the GPAP, the

researchers developed a computer model of the beating heart of a rat, which captured the mechanical dynamics of both the heart itself and the patch when fixed to the heartâ&#x20AC;&#x2122;s exterior. After analyzing simulated modelling data, the researchers developed a GPAP with a low dynamic modulus that provided nearly optimal mechanical support to the remaining cardiomyocytes. The patch also outperformed other patches whose mechanical properties had been selected on an ad hoc basis. The study was published on April 15, 2019, in Nature Biomedical Engineering. Cardiomyocytes carry out the contractile function of the heart, and the majority of them are terminally differentiated post-mitotic cells that exhibit very limited regenerative potential, and as a result the heart has insufficient regenerative capacity after injury or in diseased states, such as after a MI. HospiMedica International October-November/2019

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Critical Care

Central Venous Catheter Placement Technique Prevents Dislodgement new study describes a central venous catheter (CVC) placement technique that could help prevent confused patients from pulling it out or dislodging it easily. Researchers at Beth Israel Deaconess Medical Center (BIDMC; Boston, MA, USA; www.bidmc.org) and Boston University School of Medicine (BUSM; MA, USA; www.bumc.bu.edu/busm) published a case report of a 77-year-old patient with waxing and waning mental status who required dialysis for chronic kidney failure. The patient was in a confused state of mind and repeatedly pulled out his hemodialysis catheters. Since he was unsuitable for an arteriovenous fistula (AVF) access and the medical literature offered no solution, the physicians developed a novel technique. They placed a right external jugular vein CVC, tunneling subcutaneously to exit from the patient’s upper back, near the midline, just below the neck. It was out of reach to the patient, but not in an area where it would cause pressure on the skin when lying on his back. As a result of the successful placement, the researchers suggest that clinicians should consider the new technique when patients, and in particular confused patients, are at risk for central line dislodgement. The study was published on December 25, 2018, in Annals of Internal Medicine. “Sometimes patients inadvertently dislodge or pull out central venous catheters; in other cases, they are removed intentionally by patients who are confused. Although this occurrence is uncommon, it is not rare, and it may have negative consequences,” concluded study authors Robert Brown, MD, of BIDMC, and Ducksoo Kim, MD, of BUSM. “For example, removing a catheter this way carries the risk for serious bleeding and air embolism, and may interfere with hemodialysis, administration of fluid calories, and other critical care treatments.” CVCs can be placed in veins in the neck (internal jugular vein), the

chest (subclavian or axillary vein), the groin (femoral vein), or through veins in the arm (when they are known as a peripherally inserted central catheter (PICC) line. They can be used to administer medication or fluids that are unable to be taken by mouth or would harm a smaller peripheral vein, obtain blood measurements, such as central venous oxygen saturation, measure central venous pressure (CVP), or for dialysis. Image: A new study claims placing a CVC that exits in the back can prevent inadvertent dislodgment (Photo courtesy of Shutterstock).

High Negative Pressure Limits Dispersion of Airborne Contaminants aintaining a high negative pressure in hospital isolation rooms effectively limits the dispersion of airborne contaminants, according to a new study. The study, part of a doctoral dissertation by a researcher at the University of Eastern Finland (UEF; Viestintä; www.uef.fi), was designed to determine the containment capability of hospital airborne infection isolation rooms (AIIRs) by measuring air change rates of the patient room and anteroom, pressure differences, contaminant removal, and contaminant transmission during door openings and human movement. The researchers used a tracer gas method to simulate the release of infectious agents from a patient. The results showed that high air change rates do not ensure efficient removal of infectious agents in the breathing zone, but that local in AIIR airflow patterns are more important. Applying high mean negative pressure between the AIIR and the surroundings significantly limited particle transmission outside of the AIIR. The dissertation was presented at UEF on December 14, 2018, and published in the December 2018 issue of Annals of Work Exposures and Health. “Generally, a healthcare worker does not stay in the anteroom more than 2–3 minutes, thus to achieve at least 90% contaminant removal, the minimum air change rate requirement of 40 liters per hour would be needed after entering the anteroom,” said dissertant Anna Kokkonen, MSc. AIIRs are single-occupancy patient spaces designed to isolate airborne pathogens to a safe containment area. AIIRs are a specialized application of a hospital’s heating, ventilating, and air conditioning (HVAC) system, where the airflow supplied into the room is balanced with exhaust airflow to create negative differential pressure with respect to an adjacent space, usually the hallway or an anteroom, so that no airborne particulates escape into nursing staff or public areas. The exhaust air is expelled through dedicated ductwork to rooftop ventilation stacks, where atmospheric air provides sufficient dilution to make the resulting air safe.

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Critical Care

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Blood Thinners Significantly Reduce Heart Failure Sequel Risk sing blood thinners in patients with congestive heart failure (CHF), coronary artery disease (CAD), or irregular heart rhythms can reduce the risk of subsequent thromboembolic events, claims a new study. Researchers at the University of California, San Diego (UCSD, USA; www.ucsd.edu), Université de Lorraine (Nancy, France; www.univ-lorraine.fr), and other institutions conducted a mulicenter, placebo-controlled study that randomized 5,022 patients who were discharged from a hospital or an outpatient clinic after treatment for worsening CHF between September 2013 and October 2017. The patients were randomly assigned to receive either 2.5 mg of rivaroxaban (Xarelto) given orally twice daily or placebo, in addition to their standard therapy. The main outcomes and measures were a thromboembolic composite of myocardial infarction, ischemic stroke, sudden/unwitnessed death, symptomatic pulmonary embolism or symptomatic deep venous thrombosis (DVT), or all of the components except sudden/unwitnessed deaths, since not all of these are caused by thromboembolic events. The results showed Rivaroxaban was associated with 2.4% reduced risk of thromboembolic events when compared to the placebo (from 15.5% to 13.1%) when sudden/unwitnessed deaths were included, and from 7.6% to 6.1% without. The study was published in the April 2019 issue of JAMA Cardiology. “We initially wanted to know if we could improve outcomes in patients after an episode of worsening heart failure using a low dose of blood thinner. While this strategy didn’t accomplish that goal, it was associated with a significant reduction in the risk of clinically important

Image: A new study claims blood thinners can reduce potential cardiovascular dangers in HF patients (Photo courtesy of Fotolia).

Infections Increase Risk of Readmission Among Stroke Survivors

Smart Pill Bottle Fights Prescription Drug Abuse

atients with ischemic stroke who acquire an infection during hospitalization have an increased risk of being readmitted within 30 days, according to a new study. Researchers at Columbia University (New York, NY, USA; www.columbia.edu) and Columbia University College of Physicians and Surgeons (New York, NY, USA; www.ps.columbia.edu) conducted a study of the U.S. 2013 National Readmission Database, which included 319,317 adults hospitalized for ischemic stroke. The study assessed the relationship between common infections (defined as sepsis, pneumonia, and urinary tract infection) during hospitalization and 30-day readmission rates. The researchers also reviewed tissue-type plasminogen activator (tPA) administration. The results revealed that 29% of the stroke patients had an infection during their index hospitalization, and 12.1% were readmitted within 30 days. Patients with infection during their stroke admission had 21% higher odds of being readmitted than patients without infections. When analyzed for specific types of infections, the researchers found more common infections, such as urinary tract infections, increased the risk of 30-day readmission by 10%, possibly because urinary tract infections are more common than pneumonia. The study was published on November 1, 2018, in Stroke. “It appears that ischemic stroke patients who develop a urinary tract infection in the hospital may be candidates for earlier follow-up and closer monitoring by their healthcare team,” said lead author epidemiologist Amelia Boehme, PhD, MPH, of Columbia University. A UTI is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter inserted into the bladder through the urethra to drain urine, which are indicated in between 15-25% of hospitalized patients. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter.

n advanced pill bottle that incorporates novel sensor technology sends wireless alerts when it detects tampering, overdose, or unsafe storage conditions. Under development at King Abdullah University of Science and Technology (KAUST; Thuwal, Kingdom of Saudi Arabia; www.kaust. edu.sa), the new pill bottle is based on a flexible sensor made of an anisotropic conductive tape that coats the bottle, acting as a touch sensor. Fabricated of silver particles sandwiched between two layers of adhesive copper tape, the material is nonconductive in its normal state; but when pressed by a finger, the double-layered tape creates an electrical bond that sends a signal to an external reader warning that someone is attempting to break into the bottle. The conductive tape could be used on its own, or as part of a modular sensor system. For example, the researchers also incorporated a threedimensional (3D) printed lid that uses light-emitting diodes (LEDs) to count the number of pills dispensed, and flexible, low-cost paper-based humidity and temperature sensors taped to the underside of the bottle. If the inside of the pill bottle becomes dangerously moist, or the temperature is elevated beyond the recommended level, a control module analyzes the signals and delivers an SMS warning via Bluetooth. The study was published on April 9, 2019, in Flexible and Printed Electronics. Estimates by the World Health Organization (WHO, Geneva, Switzerland; www.who.int) indicate that only about 50% of patients in developed countries follow treatment recommendations. Low rates of adherence for asthma, diabetes, and hypertension are thought to contribute substantially to the human and economic burden of those conditions. Major barriers to compliance include the complexity of modern medication regimens, poor “health literacy” and lack of comprehension of treatment benefits, undiscussed side effects, the cost of prescription medicine, and poor communication or lack of trust between patient and health-care provider.

events caused by thrombosis – stroke, heart attack and sudden cardiac death,” said lead author Professor Barry Greenberg, MD, of UCSD. “Although there was some increase in bleeding risk with low-dose rivaroxaban, major bleeding, which was the primary safety endpoint of the study, was not significantly increased.” Rivaroxaban, a novel oral anticoagulant (NOAC), is a highly selective Factor Xa inhibitor that acts against both free Factor Xa and Factor Xa bound in the prothrombinase complex. It does not inhibit thrombin and no effects on platelets have been demonstrated. As such, it allows predictable anticoagulation, but does not require frequent laboratory monitoring, dosing adjustments, or dietary restrictions, and incurs fewer drug interactions than warfarin. On the other hand, it does not have specific reversal agents, and may require dosage adjustment based on patient renal function.

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Critical Care

High Flow Ventilator Improves Respiratory Distress Care comprehensive patient ventilation solution integrates noninvasive ventilation (NIV) and high flow therapy (HFT) in a single device. The Royal Philips (Philips, Amsterdam, The Netherlands; www. philips.com) V60 Plus ventilator offers both NIV and HFT on the same ventilator, limiting disruption and saving time. Designed specifically for noninvasive modalities, the V60 Plus delivers NIV performance with advanced delivery technologies and alarms. Philips proprietary AutoTrak technology automatically adapts to changing breathing patterns and dynamic leaks, and includes auto-adaptive leak compensation, inspiratory triggering, and expiratory cycling for patients with a range of respiratory support needs. The V60 Plus includes HFT for patients in need of consistent and humidified oxygen when weaning from NIV; average volume assured pressure support (AVAPS), which targets tidal volume in a pressure-limited mode to provide extra reassurance, similar to volume-limited mode; pressure control ventilation (PCV), which can be used when full control of the patient’s breathing pattern is required; and continuous positive airway pressure (CPAP) with a C-Flex option that offers three levels of flow-based expiratory pressure relief. “When treating respiratory patients in intensive and emergency care settings, it’s critical for clinicians to be able to wean efficiently or to quickly escalate care depending on their patient’s condition and specific needs. This often means complex workflows and alternating devices in time-sensitive situations,” said Jim Alwan, business leader of Philips hospital respiratory care. “We are excited INTERACTIVE to offer a comprehensive noninvasive DIGITAL EDITION solution that enables quick therapy and interface transitions, so clinicians can focus on providing for their patients while spending less time setting up equipment.” “We are delighted with the high flow function of the V60 Plus. It saves us a lot of time and space as we can use the same equipment for both NIV and high flow,” said Peter Lindberg, RN, of St. Goran Hospital (Stockholm, Sweden). “When you need to wean patients from NIV to HFT, it is very simple with the one device. Additionally, the cannula is high quality, easy to adjust, soft against the patient’s skin, and V60 flow is much quieter than our standalone high flow system.” HFT delivers respiratory gases at a high flow rate to assist patients’ own spontaneous breathing. It does this by creating positive pressure in the airways, keeping them open. The high flow rate improves the effective exchange of gases by delivering oxygen and removing carbon dioxide (CO2), making breathing easier and relieving the patients’ respiratory muscles. The

respiratory gases can also be warmed and humidified to help clear secretions. Image: The Philips V60 Plus enhances patient outcomes with less invasive respiratory care therapies (Photo courtesy of Philips Healthcare).

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Biologic-Based Materials Aid Reconstructive Surgery ovel reconstructive materials support soft tissues in plastic and reconstructive surgery patients requiring repair or reinforcement. The TELA Bio (Malvern, PA, USA; www.telabio.com) Restella reconstructive bioscaffolds are based on a polymer interwoven through layers of biologic tissue in a patented “lockstitch” pattern, which creates a unique embroidered construction with controlled stretch that is highly permeable. The bioscaffolds can support a variety of surgical techniques and procedures, with an emphasis on ventral hernia repair and abdominal wall reconstruction. Restella is available in a range of sizes – up to 25×40 cm (1,000 cm2) – thicknesses, and degrees of reinforcement, and can be trimmed to size. The sterile polymer is embedded in a biologic extracellular matrix (ECM) derived from ovine (sheep) rumen, which has been optimized in order to reduce foreign body response, minimize inflammation, and enable functional tissue remodeling through hundreds of pores that allow fluid transfer through the scaffold, with no evidence remaining of interlayer seroma after a short period of just four weeks. The interwoven polymer also helps provide tissue support, along with improved handling and loadsharing capability.

Ruminant animals such as sheep, cattle, goats, deer, and llamas have a four-chambered stomach, which include the reticulum, rumen, omasum, and abomasum. Structures in each chamber are unique, with the reticulum sporting a honeycomb pattern, the rumen characterized with thousands of papillae that increase surface area, and the omasum and abomasum with numerous folds of tissue. The rumen itself serves as a large fermentation vat in which microorganisms break down feed the animal cannot. As part of this process, they produce by-products, such as volatile fatty acids (VFAs), which the animal absorbs and uses as energy. Image: The Restella reconstructive bioscaffold (Photo courtesy of TELA Bio).

Intracranial Coiling Device Assists Aneurysm Embolization n adjustable remodeling device acts as a temporary bridge to aid in aneurysm coiling while minimizing the risk of coil protrusion or prolapse. The Rapid Medical (Yokneam, Israel; www.rapid-medical.com) Comaneci is a temporary device used to mechanically assist in the embolization of intracranial neurovasculature aneurysms with embolic coils. The fully visible aneurysm device is composed of a wire mesh stent permanently affixed to the end of a pusher wire. It is delivered using an endovascular approach; once in place, the internal core wire is withdrawn distally, thus expanding the mesh and blocking the neck of the aneurysm temporarily. Once the coiling procedure has been successfully completed, the device is removed from the parent artery. Features include a non-occlusive design that maintains blood supply to the brain; stable position and microcatheter support; adjustable proprietary FlexiBraid technology that provides incremental shaping control; high vessel compliance; and 100% radiopaque wires that provide real-time feedback. Three sizes are available; Comaneci, with a net length of 32 mm, suitable for vessels with a diameter of 1.5 - 4.5 mm; Comaneci Petit, with a net length of 24 mm, suitable for vessels with a diameter of 1.5 - 3.5 mm; and Comaneci 17, with a net length of 22

mm, suitable for vessels with a diameter of 0.5 - 3 mm. “The neurovascular field is the future of endovascular treatment, and in many ways resonates with the cardiology of two years ago. Neurovascular treatment will be the next cardiology, so that was basically the notion with which we started the company,” said Ronen Eckhouse, CEO of Rapid Medical. “I am excited about having the Comaneci in the United States,” said Professor Peter Nelson, MD, chief of interventional neuroradiology at NYU Langone Medical Center (New York; USA; www.med.nyu.edu). “It should be a valuable alternative for ruptured and unruptured wide neck aneurysms, typically requiring balloon assistance for coil embolization, since it provides temporary protection of the parent artery during aneurysm coiling, without arresting flow.” Wide-neck aneurysms are defined as having a neck greater or equal to four mm or a dome-to-neck ratio of less than two. They are often untreatable by surgical clipping, as many wide- neck aneurysms are in vessels deep within the brain that are not amendable to being treated by open brain surgery. Coiling wide neck aneurysms, on the other hand, could lead to coil protrusion and/or embolization, as it is difficult to achieve and maintain sufficiently dense coil packing of the aneurysm to permanently exclude blood flow. HospiMedica International October-November/2019

Virtual Reality Simulators Help Determine Neurosurgeon Expertise irtual reality (VR) simulators may soon be capable of classifying surgical expertise with high precision, claims a new study. Researchers at McGill University (Montreal, Canada; www. mcgill.ca) and Amirkabir University of Technology (Tehran, Iran; https://aut.ac.ir) conducted a study that included 50 participants in order to identify surgical and operative factors – as selected by a machine learning algorithm – that could be used to quantify psychomotor skills and generate data sets that could be used classify levels of expertise in a VR surgical procedure. For the study, the participants conducted tumor resections using the NeuroVR, a VR simulator that records all instrument movements in 20 millisecond intervals. Study participants were recruited from four stages of neurosurgical training. They were classified as expert (neurosurgery staff), seniors (neurosurgical fellows and senior residents), juniors (neurosurgical junior residents), and medical students, all of whom participated in 250 simulated resections. Through an iterative process, performance metrics associated with instrument movement and force, resection of tissues, and bleeding generated from the raw simulator data output were selected to most accurately determine group membership. The results showed that a K-nearest neighbor algorithm had an accuracy of 90% (45 of 50), a naive Bayes algorithm had an accuracy of 84%, a discriminant analysis algorithm had an accuracy of 78%, and a support vector machine algorithm had an accuracy of 76%. The K-nearest neighbor algorithm used six performance metrics to classify participants, the naive Bayes algorithm used 9 performance metrics, the discriminant analysis algorithm used 8 performance metrics, and the support vector machine algorithm used 8 performance metrics. The study was published on August 2, 2019, in the Journal of the American Medical As-

Wound Closure System Outperforms Staples and Sutures novel skin closure system reduces incision-related problems, provides greater range of motion, reduces pain, and results in superior scar quality. The ZipLine Medical (Campbell, CA, USA; www.ziplinemedical.com) Pre-placement RE-aligning LOw-tension Closure (PRELOC) system is a non-invasive and easy-to-use skin closure device that replaces sutures, staples, and glue for surgical incisions and lacerations. A breathable monofilm base, which is applied before the incision, facilitates re-approximation of incision edges. Once the zipped tags are pulled, tension in the surrounding skin is bridged over and around the incision, resulting in a low-tension and uniform distribution of closure forces, unlike point load forces typical of staples and sutures. And since no skin piercing is involved, there is a reduced risk of surgical site infection (SSI) and needle stick injury. The transparent materials facilitate monitoring of the area surrounding the incision, as well as supporting retraction for access and visualization of the surgical site. After the incision has healed, the device is easily removed by simply peeling it off from the skin; no extra instruments or special skills are required, reducing the need for an additional patient return visit for staple or suture removal. In a health economics retrospective chart review study conducted in 130 total knee replacement (TKR) patients, those receiving staples had more incision-related phone calls to the clinic, incision-related emergency room (ER) admissions, incision-related clinic visits, and antibiotics prescribed due to complications than the patients with the Zip closure device. The clinic cost for a problem staple patient was almost double that of the Zip group, while the opportunity cost for a problem staple patient was quadruple that of the Zip group (USD 228 versus USD 50, respectively). The study was published on March 20, 2019, in Cureus. “The results of this study provide insight on how a simple change in the closure methodology can lead to potential downstream cost savings, especially in a bundled payment model,” said lead author Roger Emerson, MD, of the Texas Center for Joint Replacement (Plano, TX, USA).

HospiMedica International October-November/2019

sociation (JAMA). “Physician educators are facing increased time pressure to balance their commitment to both patients and learners,” said senior author Rolando Del Maestro, PhD, of the McGill Neurosurgical Simulation and Artificial Intelligence Learning Centre (NEURO). “Our study proves that we can design systems that deliver on-demand surgical assessments at the convenience of the learner and with less input from instructors. It may also lead to better patient safety by reducing the chance for human error both while assessing surgeons and in the operating room.” Current training for surgeons is largely confined to classroom lessons and viewing cadaver-based teaching, with limited hands-on time actually spent on cadavers by students themselves. Image: A new study claims VR simulators can help categorize neurosurgeon expertise (Photo courtesy of Helmut Bernhard/ NEURO). S TOR Y IBU APPL R T O DIS ED T IT INV

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Virtual Reality Platform Creates Surgical Plans n innovative 360-degree virtual reality (VR) technology allows surgeons to walk inside their patients’ anatomy and create a surgical plan. The Surgical Theater (Mayfield Village, OH, USA; www.surgicaltheater.net) Precision VR medical visualization platform is designed to work on multiple levels of interaction with the aid of the Oculus (Irvine, CA, USA; www.oculus.com) Rift or HTC (Taoyuan, Taiwan; www.htc.com) Vive VR headsets. The VR models are constructed and rendered based upon CT and MRI scans, culminating in a patientspecific 360° virtual tour which can be used to create an intuitive, immersive approach to patient engagement, surgical planning, resident in training education, and multidisciplinary collaboration. Neurosurgeons can navigate their patients’ anatomy and simulate complex operations before making an incision and residents can hone their surgical techniques and situational awareness of the patient’s brain anatomy, optimizing performance and skill before entering the operating room. Other applications include spine, ENT, thoracic, cardiac, and gastrointestinal applications. An Enterprise solution enables hospitals to achieve deployment on a system-wide scale, including satellite locations, while complying with security policies, with all 360° VR cases stored in the hospital’s data center. “Our Precision VR Enterprise Solution is providing 360-degree images that allow patients and surgeons to walk inside the CT and MRI, which has been proven to provide better communication of medical information between surgeons and patients and surgeons and their peers,”

said Moty Avisar, CEO and co-founder of Surgical Theater. “This ‘walkin’ experience is now available on a system-wide-scale, enhancing efficiency in the consultation and surgical planning workflow for multiple specialties.” VR technology provides an immersive, multisensory, and 3D environment that enables users to have modified experiences of reality by stimulating the visual, auditory, and proprioception senses. VR has already been used to help treat anxiety disorders, support physical rehabilitation, and distract patients during wound care. Image: A VR system assists neurosurgeons plan surgery (Photo courtesy of Surgical Theater).

Endoscopic Shuttle Insert Delays Gastric Emptying n innovative device provides a non-surgical weight loss solution for adult individuals suffering from obesity. The BAROnova (San Carlos, CA, USA; www.BAROnova.com) TransPyloric Shuttle (TPS) is a mechanically constructed device the size of a small peach (5.6 cm in diameter), made of solid silicone components that is designed to delay gastric emptying by slowing the passage of food through the pylorus, causing patients to feel full sooner and stay full longer. The TPS is designed to be inserted and removed trans-orally using standard endoscopic techniques, and is intended for a 12-month treatment cycle, allowing patients the opportunity to achieve more durable lifestyle changes and health benefits. In a randomized, sham-controlled study that enrolled 302 patients from nine investigational centers, patients treated with the TPS device lost on average 3.4 times (9.5%) more weight than the sham-control group (2.8%) at 12-month follow up, and 40% lost over 10% of their

body weight. Improvements in blood pressure and other cardiometabolic risk factors, as well as quality of life, were also observed with TPS treatment. The most common adverse events were gastrointestinal, such as stomach pain, nausea, vomiting, and dyspepsia. “Endoscopically delivered intragastric devices can help close the obesity treatment gap and offer alternative options for qualified patients who are not eligible, or unwilling, to undergo metabolic and bariatric surgery,” said senior investigator Wayne English, MD, of Vanderbilt University. “The TPS device design addresses some of the limitations with the first-generation intragastric devices and offers longer treatment duration, which is clinically attractive.” Slow gastric emptying increases stomach distension, which activates stretch receptors. The vagus nerve carries the afferent signals related to stomach distension to the nucleus tractus solitarii (NTS) in the medulla, facilitating satiety by projections to the appetite-regulating nuclei of the hypothalamus. HospiMedica International October-November/2019

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Surgical Techniques

Mobile 3D C-Arm Ensures Optimal Intraoperative Quality new mobile C-arm delivers precise intraoperative three-dimensional (3D) images, enabling surgeons to perform corrections on the go and confirm their results. The Siemens Healthineers (Erlangen, Germany; www.healthcare.siemens.com) Cios Spin Mobile 3D C-arm integrates seamlessly into the clinical routine, providing 3D computed tomography (CT)-like imaging for orthopedic, trauma, vascular, and spine surgery, supporting both standard and 3D imaging in a wide variety of procedures. The system’s 25 kW power output (with up to 250 mA tube current) helps address the challenge of imaging large patients and dense anatomy in order to enable precise clinical evaluation of images. In addition, an energy storage unit (ESU) buffers energy to triple the applicable power. The system is equipped with advanced flat panel detector (FPD) technology with a 16x16x16 cm volume, metal artifact reduction, and isocentric technology. Retina 3D scan technology is built-in, with a range of optional software packages available, including an Easy 3D package that ensures fast, efficient setup, and image acquisition, and the Screw Scout package, which enables system software to recognize and automatically label screws in the X-ray image, saving time and effort for the surgeon. The NaviLink 3D digital navigation software provides easy-to-use connectivity to surgical navigation. If, for example, screws need to be repositioned, the surgeons can make adjustments directly during the surgical intervention. As orthopedic surgery may often require the use of tens of screws, all of which must be localized before the surgeon can assess them, the Screw Scout can enable Cios Spin software to recognize them in the 3-D intraoperative image automatically and label their positions, saving time and effort for the surgeon. Cios Spin is also provided with an antimicrobial coating

that prevents bacteria from proliferating on the system parts. “Siemens Healthineers is proud to offer the Cios Spin, a dynamic new mobile 3D C-arm that illustrates our expertise in mobile X-ray imaging,” said Robert Dewey, vice president of surgical solutions at Siemens Healthineers North America. “This system will help our customers improve the quality of patient care using precision medicine as well as reduce the additional costs imposed by revision surgery.” Conventional 2D imaging can make it difficult to get minimally invasive surgery right the first time, and often requires post-operative computed tomography (CT) to reveal if all implants or repositioned bone fragment are in exactly the right place. If not, revision surgery is often needed. Image: The Cios Spin Mobile 3D C-arm (Photo courtesy of Siemens Healthineers).

Transseptal System Facilitates Cardiac Chamber Access new surgical approach involving transseptal puncture (TSP) and atrial navigation addresses the growing need for precise and efficient access to the left heart chambers. The Transseptal Solutions (Netanya, Israel; www.transseptalsolutions.com) TSP Crosser access system combines a steerable sheath, a dilator, and a flexible puncturing needle into a single integrated system for controlled left atrium access during transseptal catheterization procedures. The flexible puncturing needle and the steerable sheath form a built-in steering mechanism that allows pre-puncture deflection and orientation. During the procedure, a radiopaque loop wire is positioned at the distal end of the sheath to help localize the fossa ovalis. Once the fossa ovalis is located and the TSO Crosser is positioned in the desired puncturing location, the fossa ovalis can be punctured an the chamber accessed; once inside the left atrium, the sheath can be repositioned up to 180° bidirectionally. The system is indicated for use in a wide variety of procedures where access to the left atrium is desired, including mitral valve repair or replacement, paravalvular leak closure, left atrial appendage (LAA) closure, and electrophysiology (EP) ablation treatment. “Transseptal catheterization is a critical step for structural heart and electrophysiology interventions. The availability of advanced tools and techniques is essential to perform accurate

HospiMedica International October-November/2019

transseptal puncture as part of challenging LA interventions,” said Elad Sapir, CEO of Transseptal Solutions. “The flexible puncturing needle allows deflection and orientation using the steerable sheath to provide adjustable positioning for puncturing the fossa ovalis and ensuring the TSP Crosser successfully reaches its target location within the left atrium anatomy.” TSP was developed in 1959 to allow direct measurement of left atrial pressure. Over the

next several decades, with the growing acceptance of retrograde catheterization of the left ventricle and the expanding use of echocardiography, experience with TSP declined. After introduction of catheter ablation for atrial fibrillation (AF) and percutaneous transcatheter techniques for the treatment of valvular and congenital heart disorders, widespread adoption and further modification of the TSP technique ensued. Visit us at MEDICA® 2019

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Surgical Techniques

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Aortic Stenosis Device Improves Valve Hemodynamics novel catheter-based device mechanically scores calcifications at multiple locations on the aortic valve, restoring leaflet flexibility. The Pi-Cardia (Rehovot, Israel; www.pi-cardia.net) Leaflex Performer catheter is a transfemoral catheter that uses two unique mechanical structures for scoring valve calcifications. The deflectable transfemoral delivery catheter is inserted via a 16Fr sheath, positioned in the aortic root using fluoroscopic guidance. The device consists of a proprietary expander placed in the left ventricular outflow tract that lifts the aortic leaflets into contact with three scoring arms. The distal tip also features an atraumatic pigtail for safe positioning in the left ventricle, and also allows for monitoring of left ventricular pressure. Mechanical expansion yields directed scoring of calcifications within the leaflets, and rotation of the arms allows scoring to be performed at different sections of each aortic valve leaflet. The scoring lines disrupt calcium deposits, creating multiple targeted fractures at optimal locations of valve calcification, causing them to separate. The unique scoring method helps to regain leaflets flexibility while preserving native valve integrity, thus providing a durable treatment option. It also serves as a preparatory step for improving the outcome of future valve implantation in heavily calcified and bicuspid aortic valves. The design of the device is based on extensive clinical research on calcium growth patterns in thousands of human aortic valves, resulting in a mechanism of action and curative technology fundamentally different from traditional balloon aortic valvuloplasty, whereby the annulus and supporting anatomy are simply stretched to yield short-

Image: The Leaflex Performer catheter (Photo courtesy of Pi-Cardia).

Functionalized Magnetic Beads Help Treat Preeclampsia

Perfusion System Increases Donor Lung Availability

new study suggests that using magnetic beads in a microfluidic device can improve the angiogenic balance in preeclampsia and enhance blood vessel wall function. In a proof of concept study, researchers at Université Paris Descartes (France; www.univ-paris5.fr), Sorbonne University (Paris, France; www.sorbonne-university.com), Cochin Hôtel-Dieu Hospital (Paris, France; http://hopitaux-paris-centre.aphp.fr), and other institutions functionalized magnetic beads with vascular endothelial growth factor (VEGF) in order to capture sFlt-1, a molecule released by the placenta into the woman’s bloodstream that rises to high levels during preeclampsia, and which is responsible for blood vessel wall dysfunction by binding to VEGF and placental growth factor (PIGF). Using a specific and competitive apheresis approach using a microfluidic device, magnetic beads were functionalized with VEGF from human trophoblastic cells, and characterized to evaluate their surface ligand density and recognition capabilities in order to capture sFlt-1, thus releasing endogenous PlGF and restoring the physiological angiogenic balance. Using blood from women with preeclampsia, the researchers showed that the magnetic beads reduced sFlt-1 by 40% and freed up twice as much PIGF, reducing the sFlt-1/PlGF ratio by 63%. The study was published on May 13, 2019, in Hypertension. Preeclampsia is a complication of pregnancy characterized by hypertension and kidney dysfunction that can cause severe complications for both the mother (including seizures, stroke, renal failure, and liver dysfunction) and the infant (such as low birth weight, preterm delivery, and stillbirth). The condition also increases a woman’s risk for cardiovascular disease (CVD) later in life. Currently, there is no cure, and only childbirth can alleviate the symptoms. About 10 million pregnant women develop preeclampsia annually, causing approximately 500,000 fetal and neonatal and 76,000 maternal deaths.

novel lung preservation system can temporarily ventilate, oxygenate, and perfuse lungs in order to better determine if they are viable for transplant. The Xvivo Perfusion System (XPS) with STEEN Solution (Xvivo Perfusion, Gothenburg, Sweden; www.xvivoperfusion.com) is intended to house donor lungs and preserve them prior to transplantation in patients with end-stage lung disease. The system consists of the XPS perfusion cart, XPS cart software, and an cardiac bypass system with a centrifugal pump, a heater/cooler unit, and a ventilator. The system also includes STEEN solution, a sterile, non-pyrogenic, non-toxic physiological salt solution containing human serum albumin and dextran, and fluid path and non-fluid path disposables. The system mimics in-vivo conditions by flushing and preserving the lungs with temporary continuous normothermic perfusion. The ventilated lung is perfused with a 15% deoxygenated suspension of red blood cells (RBCs) in STEEN solution, while critical parameters of gaseous exchange, pulmonary vascular resistance, and other key variables under normothermic conditions are monitored for up to four hours, during which time lung functions can be evaluated and assessed for viablity as a transplantable organ. If the lungs meet functionality criteria and pass the transplant surgeon examination, they are transplanted into a recipient. “Sadly, too many patients on transplant lists die waiting for suitable lungs,” said Benjamin Fisher, PhD, director of the division of reproductive, gastro-renal, and urological devices at the FDA (Silver Spring, MD, USA) Center for Devices and Radiological Health (CDRH). STEEN solution contains human serum albumin to provide normal oncotic pressure, preventing edema formation; dextran, a mild scavenger which coats and protects endothelium from subsequent excessive leucocyte interaction and thrombogenesis; and an extra-cellular electrolyte composition (lowK +) that reduces free radical generation and avoids vascular spasm under normothermic conditions.

term hemodynamic improvement. In addition, since the valve remains patent, it does not preclude future transcatheter aortic valve replacement (TAVR), if the need arises. The device is currently undergoing first-in-human studies in Europe. “As much as TAVR improves and becomes a routine procedure in lower surgical risk patients, it is still an implant with unknown durability, so there are many cases where taking this new approach of aortic valve repair to defer TAVR may make a lot of sense,” said Erez Golan, Founder and CEO of Pi-Cardia. “TAVR is also an expensive procedure, which restricts its use to specific centers and specific cases. In today’s budget sensitive environment, waiting lists for TAVR are common even in the most developed countries, let alone in emerging markets, where TAVR may not be a viable option for most patients.”

HospiMedica International October-November/2019

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Surgical Techniques

Brain Access Systems Displace and Remove Subcortical Tissue wo minimally invasive surgical devices facilitate the treatment of subcortical and skull base lesions, intraventricular tumors and cysts, and hemorrhagic stroke. The NICO (Indianapolis, IN, USA; www.niconeuro.com) devices are designed to support minimally invasive parafascicular surgery (MIPS), and include BrainPath access sheathes for minimally disruptive access and the Myriad device for the automated tumor removal, collection, and biological preservation of brain tissue. BrainPath consists of a reusable, sterilizable obturator and a disposable sheath matched by friction fit. The sheath provides surgical access to the subcortical space using an approach parallel to brain fiber tracts, thus reducing the potential for tissue damage that may cause deficits after surgery. After the creation of an appropriate craniotomy and the subsequent dural incision, the BrainPath sheath assembly is inserted into the brain tissue and advanced to the desired location, with depth bands placed on the obturator and sheath used as a visual reference during placement. Once the desired location has been reached, the sheath is advanced into position and the obturator removed. The sheath remains in the brain to serve as a protective portal that maintains access to the surgical site during tissue removal or fluid evacuation. The Myriad system, an automated, multi-functional aspiration tool used for precise resection, suction, clot evacuation, and tumor removal can then be deployed to remove the diseased tissue. The Myriad system consists of a system console, handpieces, and ancillary products. All the handpieces have a side mouth cutting and aspiration aperture located just 0.6 mm from the blunt end, which allows for tissue removal without injury to adjacent structures. The NICO Myriad handpieces are available in 11, 13, 15, 17 and 19 gauges, and a variety of lengths. “The goal of NICO has always been to create technology that could

create less deficits and faster recoveries in brain surgery,” said Jim Pearson, president and CEO of NICO Corporation. “The clinical evidence shows this is possible, and we believe that is directly related to finding less disruptive ways to access the brain that were not possible before. And we believe it will revolutionize the intracranial neurosurgical market.” “Brain metastases are the most common central nervous system neoplasms. In these selected patients, all lesions were subcortical and buried beneath important white matter tracts,” said Professor Jefferson Chen, MD, PhD, director of neurotrauma at the University of California Irvine (UCI, USA). “The fact that we were able to safely reach all locations speaks to the utility of the BrainPath and Myriad technologies. Careful attention to the application of BrainPath allows one to reach subcortical tumors and remove them using the Myriad in a minimally disruptive manner.” Image: The NICO BrainPath obturators and Myriad aspiration system (Photo courtesy of NICO).

Appendectomy May Reduce Parkinson’s Risk new study suggests that the normal human appendix contains pathogenic forms of -synuclein, which affect the risk of developing Parkinson’s disease (PD). Researchers at the Van Andel Research Institute (VARI; Grand Rapids, MI, USA; www.vai.org), the Centre for Addiction and Mental Health (CAMH; Toronto, Canada; www.camh.ca), and other institutions conducted two independent epidemiological studies that analyzed datasets from the Swedish National Patient Registry in order to determine the capacity of the appendix to modify PD risk and influence pathogenesis. The study included 1,698,000 individuals followed for up to 52 years, for a total of nearly 92 million person-years. The results showed that the risk of developing PD was 19% lower among those who had their appendix surgically removed in childhood. Further analysis suggested people who developed PD despite an earlyin-life appendectomy tended to have symptoms appear 3.6 years later than similarly aged patients, and that people living in rural areas benefited most. The researchers then examined appendix tissue from 48 healthy people; in 46 of them, they found intraneuronal -synuclein aggregates and an abundance of -synuclein truncation products known to accumulate in Lewy bodies, the pathological hallmark of PD. They also found that the healthy human veriform appendix contained Lysates of human appendix tissue that induced rapid cleavage and oligomerization of full-length recombinant -synuclein. They therefore propose that the normal human appendix inherently contains pathogenic forms of -synuclein that can affect the risk of developing PD, and that whether the appendix was inflamed or not was negligible. The study was published on October 31, 2018, in Science Translational Medicine. “Our results point to the appendix as a site of origin for Parkinson’s and provide a path forward for devising new treatment strategies that leverage the gastrointestinal tract’s role in the development of the disease,” said senior author Viviane Labrie, PhD, of VARI. “Despite having a reputation as largely unnecessary, the appendix actually plays a major

HospiMedica International October-November/2019

part in our immune systems, in regulating the makeup of our gut bacteria and now, as shown by our work, in Parkinson’s disease.” The appendix is a narrow, elongated, blind-ended extension of the large intestine that projects from the cecum, near the juncture with the small intestine. More correctly known as veriform appendix due to its worm-like hollow shape, the appendix is present only in humans, certain anthropoid apes, and the Australian wombat. The appendix is rather well known despite its small size and obscure location, both because of its propensity to be easily infected by bacteria, leading to appendicitis, and because it’s function remains unclear.

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AIRWAY MANAGEMENT

CEILING PENDANT

Advanced Instrumentations

Ambu

Amico

The OT-30 features stainless steel construction, accessory rails on both sides and hydraulic mechanism for height adjustment. It is regularly used in operating rooms, same day surgical centers and labor and delivery centers.

The VivaSight-SL provides continuous visual monitoring of endotracheal tube and endobronchial blocker placement throughout the procedure. It is considered ideal for use during routine and difficult intubation procedures.

The V Series Ceiling Pendant comes with a hinged back door to provide easy access to all internal components, allowing for easy maintenance. Its electric braking system allows for easy maneuverability and no drift when engaged.

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Aortic Valve System Minimizes Paravalvular Leakage new transcatheter aortic valve replacement (TAVR) system for patients with severe stenosis offers controlled delivery and repositionability. The Boston Scientific (Natick, MA, USA; www.bostonscientific.com) LOTUS Edge aortic valve system features a proprietary braided Nickel-Titanium (Nitinol) frame and an adaptive seal technology that conforms to patients’ anatomy in order to create a secure seal, virtually eliminating paravalvular leak (PVL). The system is designed for strength, flexibility, and complete control during placement to ensure precise, stable, deployment and reduced procedural complications. The deployment technology also allows easy retrieval, repositioning, and redeployment. Additional features include bovine pericardium lining materials, a flexible delivery catheter that helps improve trackability, proprietary depth guard technology designed to reduce left ventricular outflow tract (LVOT) interaction and permanent pacemaker (PPM) rates by minimizing the depth of the valve during deployment, and radiopaque markers that enable the operator to confirm locking in one view. LOTUS Edge is available in 23, 25, and 27 mm outer diameters and a standard height of 19 mm. “Bringing the much-anticipated LOTUS Edge valve system to market allows us to provide patients who aren’t good candidates for traditional surgery a safe and effective treatment alternative to restore proper function to their severely narrowed aortic valve,” said Kevin Ballinger, executive VP and global president of interventional cardiology at Boston Scientific. “This technology is a fundamental component of our expanding portfolio and demonstrates our continuing commitment to category leadership

within the fast-growing structural heart treatment landscape.” Aortic valve disease results in dysfunction of the aortic valve, one of the four valves that control the flow of blood in and out of the heart. It is the most common valvular heart disease in the world, affecting approximately seven percent of the population over age 65. TAVR prosthetic aortic valve replacement, without the need for open heart surgery or cardiopulmonary bypass, has proven effective in high-risk and inoperable patients, and could soon become the standard of care, even in moderate and low surgical risk patients. Image: The LOTUS Edge aortic valve system (Photo courtesy of Boston Scientific).

Ligating Veins before Arteries Increases Surgery Survival Rates ying off effluent veins before arteries during thoracoscopic lobectomy for lung cancer may reduce tumor-cell dissemination and thus increase survival, claims a new study. Researchers at Sichuan University (Chengdu, China; www.scu.edu.cn), Third Military Medical University (Chongqing, China; www.tmmu.edu.cn), and other institutions conducted a study in 78 patients (74.4% older than 60 years) with non–small cell lung cancer who underwent thoracoscopic lobectomy. The aim of the study was to compare outcomes of different sequences of vessel ligation on the dissemination of tumor cells. The main outcomes and measures were changes in folate receptor–positive circulating tumor cells (FR+CTCs) after surgery, and 5-year overall, diseasefree, and lung cancer–specific survival. The results revealed that incremental changes in FR+CTCs were seen in 65% of the artery-first group, and in 31.6% in the vein-first

group. While survival outcomes were not available because of the limited follow-up period, a retrospective analysis of the Western China Lung Cancer database (2005-2017) also found poorer survival with the artery-first procedure. At five years, the hazard ratio for poorer overall survival was 1.65, for disease-free survival it was 1.43, and for lung-cancerspecific survival, it was 1.65. The study was published on May 1, 2019, in JAMA Surgery. “Numerous studies have demonstrated that surgical manipulation could promote the dissemination of tumor cells into the circulation. The vein-first approach eliminates repeated squeezes and turning over of the tumor bearing lobe during surgery,” concluded lead author Lunxu Liu, MD, of Sichuan University, and colleagues. “Ligating effluent veins first may reduce tumor cell dissemination and improve survival outcomes in patients with non-small cell lung cancer.” HospiMedica International October-November/2019

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Surgical Techniques

Self-Powered Implant Short-Circuits Hunger Pangs new study describes how a battery-free implanted device gently stimulates vagal afferent fibers to reduce food intake and achieve weight control. Developed by researchers at the University of Wisconsin (WISC; Madison, USA; www.wisc.edu) and the University of Electronic Science and Technology of China (Chengdu, China; https://en.uestc.edu.cn), the vagus nerve stimulation system is comprised of a flexible, biocompatible, battery-free nanogenerator that is attached to the surface of stomach, generating biphasic electric pulses in response to gastric peristalsis. The electric signals generated by the device stimulate vagus nerve afferent fibers in order to reduce food intake and realize weight control. In a rat model, the researchers achieved a 38% weight loss in just 15 days, which was maintained for a period of 100 days without rebound. When the researchers removed the devices after a period of 12 weeks, the rats resumed their normal eating patterns and their excess weight returned. A potential advantage of the new device over existing vagus nerve stimulators, according to the researchers, is that it is a smart, selfresponsive system that does not require external charging. The study was published on December 17, 2018, in Nature Communications. It has been known for a century that the vagus (tenth cranial) nerve, a mixed parasympathetic nerve containing both afferent and efferent nerve fibers, acts as a signal bridge to transport information between the central nervous system and the body. Neuromodulation, as a non-de-

structive, reversible therapeutic strategy, can manipulate body functions by stimulating or influencing neurophysiological signals through the neural networks to achieve therapeutic purpose. Image: Graduate student Guang Yao (L) and Professor Xudong Wang (R) with the implantable device (Photo courtesy of Sam Million-Weaver/ WISC).

Rerouting Nerves During Amputation Reduces Phantom Limb Pain novel surgical procedure developed for advanced prosthetics can prevent or reduce debilitating phantom limb and stump pain in amputees, according to a new study. Researchers at Ohio State University (OSU; Columbus, USA; www.osu.edu) conducted a study in 22 patients in order to evaluate the results of primary targeted muscle reinnervation (TMR) for below-the-knee amputations. The procedure involves rerouting the severed motor nerves by surgically transferring them to the motor points of the denervated target muscles, which, after reinnervation, can contract in response to neural control signals intended for the missing limb. The operation of the prosthesis thus occurs in response to attempts to move the missing limb, making control easier and more intuitive. All subjects denied neuroma pain following amputation. Each patient was followed on an outpatient basis for one year to evaluate early symptoms of neuroma or phantom limb pain, patient satisfaction, and functionality. The researchers also found that over the course of three years, none of the patients developed symptomatic neuromas, and only 13% of those who received primary TMR reported pain six months later. In addition, by creating the additional control sites, TMR eliminated the need to switch the prosthesis between different control modes. The study was published in the January 2019 issue of Plastic and Reconstructive Surgery. “A significant amount of pain in amputees is caused by disorganized nerve endings, i.e. symptomatic neuromas, in the residual limb. They form when nerves are severed and not addressed, thus they have nowhere to go,” said senior author Ian Valerio, MD, of the department of plastic and reconstructive surgery at OSU. “Attaching those cut nerve endings to motor nerves in a nearby muscle allows the body to re-establish its neural circuitry. This alleviates phantom and residual limb pain by giving those severed nerves somewhere to go and something to do.” “TMR allows for more individual muscle unit firings through the patient’s thoughts. It provides for better intuitive control, resulting in more refined functional movements and more degrees of motion by an advanced prosthetic,” concluded lead author J. Byers Bowen, MD, of OSU. “When done at the time of initial amputation, there is minimal health risk, and recovery is similar to that of traditional amputation surgery.” Approximately 25% of major limb amputees will develop chronic localized symptomatic neuromas and phantom limb pain in the residual stump or limb. Previous studies show that secondary targeted reinner-

HospiMedica International October-November/2019

vation successfully treats and, in some cases, resolves peripheral neuropathy and phantom limb pain in patients who have undergone a previous amputation.

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SURGICAL DISPLAY

HEALTHCARE TERMINAL

Sun Nuclear/Gammex

Barco

Advantech Europe

The MICRO+ MR fixed laser system is for any MR environment up to 3T, and comes with a remote control. Its design allows power to pass through a noise filter prior to connecting, retaining no interference with MR image quality.

The MDSC-2324 features full HD resolution and a wide color gamut. Purpose-built for the operating room, it offers an easy-to-clean design, smart mechanics and detailed images in the procedure room.

The HIT-R151B features a multi-function touch screen, WiFi, RFID, handset, smart card reader and a 5MP camera. Offering programmable keys on the front panel, its super slim, ergonomic design makes it ideal for healthcare.

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New Artificial Intelligence Platform to Analyze NHS Radiological Scans novel artificial intelligence (AI) system intended for the United Kingdom National Health Service (NHS; London; www.nhs.uk) will automate nationwide radiological interpretation across multiple clinical pathways, including oncology, cardiology, and neurology. The AI project is a joint effort of Nvidia (Santa Clara, CA, USA; www.nvidia.com) and King’s College London (KCL; United Kingdom; www.kcl.ac.uk), which will build and train the AI platform to interpret radiological scans for hospitals across the UK. The technology would thus free up overworked specialists and could also lead to breakthroughs across the medical imaging landscape, from determining the root cause of various cancers to helping classify specific neurological impairments and identifying optimal treatment plans. At the core of the first stage of the project is a graphics processing unit (GPU)-powered two-petaflops Nvidia DGX-2 supercomputer, combining 16 interconnected GPUs, which Nvidia claims is currently the world’s most powerful AI system. The project will also employ the Nvidia Clara AI toolkit, an open-source NiftyNet image-analysis neural-network, and a host of supplemental imaging technologies from existing NHS partners such as Kheiron Medical (London, UK; www.kheironmed.com), Mirada (London, UK; www.mirada.tv) and Scan.

As security and governance of data in clinical environments is of the highest importance, and since AI models within the project will be built from patient data from across the entire UK-wide NHS system, the center has decided to employ federated learning, which keeps data within its own, secure domain, while allowing algorithms to be developed at multiple sites using data located at hospitals around the UK. The federated learning approach is designed to ensure a robust and secure system that more than complies with government data-privacy requirements. Image: The DGX-2 two petaFLOPS supercomputer system (Photo courtesy of Nvidia).

Collaboration Formed to Advance Digital Patient Safety he Doctors Company (Napa, CA, USA; www.thedoctors.com), the largest physician-owned medical malpractice insurer in the United States, and the University of California, San Francisco (UCSF; USA; www.ucsf.edu) have launched a new partnership that will enable leading UCSF researchers to pursue cutting-edge questions regarding evidence-based patient safety practices, safety and information technology–related policy, and artificial intelligence (AI). The Doctors Company–UCSF collaboration will explore the intersection of digital medicine and patient safety, maximizing the strengths of both organizations to make substantive advances in patient safety and digital health through novel research and engagement, with the goal of safer care. The Doctors Company, which insures 82,000 physicians in the U.S, has committed to invest USD one million to help UCSF researchers study the causes of medical errors, strategies to mitigate them, and develop new insights that can advance the practice of good medicine. “We are proud to partner with a world-class institution like UCSF in a mission-based collaboration that has the power to improve medical out-

comes in the transformative sphere of digital healthcare,” said Richard Anderson, MD, FACP, chairman and CEO of The Doctors Company. “The primary goal of the partnership is to discover and disseminate new insights into risk mitigation strategies and patient safety by connecting toptier UCSF researchers and unique resources and expertise from The Doctors Company,” said Julia Adler-Milstein, PhD, who will co-lead the partnership on behalf of UCSF. “It is a rare and exciting opportunity to have two such organizations come together to jointly advance such an important area.” Widespread digitization of the healthcare system, including implementation of electronic health records (EHRs), apps, and sensors, offers new ways to study and address traditional patient safety challenges such as diagnostic and medication errors. There are also new challenges that stem directly from these emerging digital capabilities, including the integration of AI tools into frontline care, the mitigation of alert fatigue, sharing data with patients, preserving the physician-patient relationship in an era of increasing technology use, physician burnout related to suboptimal EHR usability and performance, and cybersecurity issues. HospiMedica International October-November/2019

Apple Opens iPhone EHR Feature to US Healthcare Organizations

Health IT I

pple (Cupertino, Ca, USA; www. has been a focus for us at Cedars-Sinai for some apple.com) will allow any healthcare time. We are thrilled to see Apple taking the organization with a compatible eleclead in this space by enabling access for contronic health record (EHR) to register with its sumers to their medical information on their mobile Health Records feature, which will aliPhones,” said Darren Dworkin, Chief Informalow users to securely and privately download tion Officer at Cedars-Sinai Medical Center their data to a personal health record (PHR) on (Los Angeles, CA, USA). “Apple is uniquely potheir iPhone. sitioned to help scale adoption because they Compatible EHRs are based on Fast Healthhave both a secure and trusted platform and care Interoperability Resources (FHIR), a stanhave adopted the latest industry open standards framework for exchanging clinical data dards at a time when the industry is well posiover the Internet. There are currently about tioned to respond.” 300 healthcare organizations, labs, and clinics Image: Apple PHR organizes Medical records (with over 6,500 locations across the United into a clear, easy to understand timeline view States) that have registered in the Apple (Photo courtesy of Apple). Health Records directory in the Health app. The EHRs that Apple currently supports include Epic, Cerner, NE DES W athenahealth, and CPSI, which are caIGN pable of plugging into the PHR app. Patients can download their EHR after presenting their credentials to the practice or a hospital patient portal. Under a proposed rule from the OfWORLD’S MEDICAL PRODUCT MARKETPLACE fice of the National Coordinator for Health IT (ONC; Washington, DC, USA: www.healthit.gov), certified EHRs will have to include FHIR appliSIGN UP cation programming interfaces (APIs) FOR FREE! that allow patients to access their medical records. Because FHIR allows semantic interoperability, information from multiple Visit us at providers can flow into the appropriate categories in the Apple PHR. Thus a paMEDICA tient should be able to view all of their 2019 medications, problems, lab results, proHall 1-H61 cedures, vitals, and immunizations from different providers in one place. “Our goal is to help consumers live a better day. We’ve worked closely with the health community to create an experience everyone has wanted for years, to view medical records easily and securely right on your iPhone,” said Jeff Williams, COO of Apple. “By empowering customers to see their overall health, we hope to help consumers better understand their health and help them lead healthier lives.” “Putting the patient at the center of Connecting Buyers with their care by enabling them to direct Suppliers Worldwide and control their own health records Reach new sources of supply V I S I T Identify latest products and technologies ® Send inquiries directly to suppliers LINK PRESS COM Receive latest product alerts R E A D E R S E R V I C E P O R T A L Chat live with suppliers

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Health IT

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Artificial Intelligence Could Challenge Role of Doctors rtificial intelligence (AI) systems, which simulate human intelligence by learning, reasoning, and self-correction, have the potential to be more accurate than doctors at making diagnoses and performing surgical interventions, according to a new study. Researchers at the Swiss Federal Institute of Technology (ETH; Zurich, Switzerland; www.ethz.ch), McGill Institute for Health and Social Policy (IHSP; Montréal, Canada; www.mcgill.ca/ihsp), and University Hospital Zürich (USZ; Switzerland; www.en.usz.ch) met to raise the question of whether machines will ever completely replace doctors. Their opinions were published on November 7, 2018, in BMJ. According to Jörg Goldhahn, MD, of ETH, the answer is yes. AI has a near unlimited capacity for data processing and subsequent learning, and can do this at a speed that humans cannot match. In addition, it is not subject to the potential bias seen in human learning due to cultural influences and links with particular institutions. And while the ability to form relationships with patients is often presented as an argument in favor of human doctors, Goldhahn suggests that this may also be their Achilles heel. Trust is important to patients, but machines and systems can be more trustworthy than humans if they can be regarded as unbiased and without conflicts of interest. “The notion that today’s physicians could approximate this knowledge by keeping abreast of current medical research while maintaining close contacts with their patients is an illusion, not least because of the sheer volume of data,” concluded Dr. Goldhahn. “Introducing AI-driven systems could be cheaper than hiring and training new staff. They are also universally available, and can even monitor patients remotely. Doctors as we now know them will become obsolete eventually.” But co-authors Vanessa Rampton, PhD, Branco Weiss fellow at IHSP,

Image: New research explored whether or not artificial intelligence algorithms can replace human doctors (Photo courtesy of Shutterstock)

and Professor Giatgen Spinas, MD, of University Hospital Zürich, disagree. They maintain that machines will never replace doctors entirely, because the inter-relational quality of the doctor-patient relationship is vital and cannot be replicated. While they concur that AI will increasingly be able to perform tasks that humans do today, doctors are better at dealing with the patient as a whole person. Doctors can relate to the patient as a fellow human being, building a relationship that takes into account an individual patient’s preferences, values, and social circumstances. “Computers aren’t able to care for patients in the sense of showing devotion or concern for the other as a person, because they are not people and do not care about anything. Sophisticated robots might show empathy as a matter of form, just as humans might behave nicely in social situations, yet remain emotionally disengaged because they are only performing a social role,” said Dr. Rampton and Professor Spinas.

Patient-Centric Portal Facilitates Direct Imaging Access new imaging portal provides patients with direct access to their exam history, images, and reports anytime and anywhere. The Intelerad (Montreal, Canada; www.intelerad.com) nuage Cloud Imaging Platform is a zero-footprint portal that enables imaging providers to empower their patients with streamlined, self-service access to their exam history, images, and reports. Key features include a flexible cloud-based portal; self-service access to medical images and reports from multiple providers; a modern, simple, and engaging user experience that is easily configurable to the healthcare providers’ brand identity; and secure and tightly controlled information access, with ability to customize through privilege granting. An added benefit is that the nuage Patient Portal allows healthcare providers to remove the costs and inefficiencies associated with burning images to CDs, while simultaneously increasing their satisfaction and engagement. Intelerad also offers a wide range of enterprise workflow and orchestration solutions that encompass the full cycle of healthcare delivery, from image acquisition to follow-up, providing users with an easy-to-use, flexible option to empower patients with ownership of their healthcare information and a personalized medicine experience. “Patients have become empowered consumers and want to take care of their own health records, the same way they would with their online banking. Secure, cloud-based solutions are revolutionizing healthcare, driving operational excellence, and delivering a modern and engaging user experience,” said Christian Bazinet, chief operating officer of Intelerad. “Intelerad is thrilled to extend our broad portfolio of feature- and workflow-rich imaging solutions; nuage Patient Portal is a critical component of our vision to provide a robust, fully integrated cloud imaging platform.” Meaningful Use is one of the main drivers of patient portal technologies, since one requirement is for patients to get access to their healthcare information online.

HospiMedica International October-November/2019

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Health IT

Wearable Technology Can Identify Heart Arrhythmias new study will evaluate the ability of a smartwatch-based pulse algorithm to identify atrial fibrillation (AF) and guide subsequent clinical evaluation. Researchers at Stanford University School of Medicine (CA, USA; med.stanford.edu), Apple (Cupertino, Ca, USA; www.apple.com) and other institutions have recruited 419,093 participants to a prospective, single arm study with the goal of measuring the proportion of study participants with an irregular pulse detected by the Apple Watch. If a sufficient number of episodes are detected, participant will be asked to undergo ambulatory electrocardiogram (ECG) patch monitoring, which will record their heart rhythms for up to a week. Enrollment, which was conducted through an iPhone app, is now closed. Each participant in the study is required to have an Apple Watch (series 1, 2, or 3) and an iPhone. An app on the phone intermittently checks the heartrate pulse sensor for measurements of an irregular pulse. The study will determine the percentage of participants receiving irregular pulse notifications that

New Blood Pressure Monitor Interacts with Amazon Alexa new blood pressure (BP) monitor can ask Alexa to set reminders, compare BP across different dates and times of day, and flag higher-than-usual readings. The Omron Healthcare (Kyoto, Japan; www.omron-healthcare.com) Omron Alexa skill connected blood pressure monitor pairs with Alexa via the proprietary Omron Connect mobile application, allowing users to ask Alexa to connect with and open their app, locate and read back their latest BP reading, calculate their average BP reading over a day, week, or month, and compare readings across different dates and times of day. The Omron Connect app syncs with all of Omron connected blood pressure monitors so users can store, track, and share their heart health data with their doctors so as to optimize treatment plans. Working through the Omron Connect app, the Omron Alexa can also warn users when higher-than-normal BP readings are detected, and provide guidelines and tips in order to ensure accurate BP measurement. The Omron Connect app is compatible with Alexa-enabled devices such as the Echo or Echo Dot, and can be downloaded for free from the Apple iOS or Google Play stores.

HospiMedica International October-November/2019

have AF on ECG patch monitoring; determine how many of those who received an irregular pulse notification go on to get medical attention; and to determine the accuracy of irregular-pulse detection by the watch, compared with the simultaneous ECG patch recordings. The study was published on November 1, 2018, in the American Heart Journal. The Apple Watchâ&#x20AC;&#x2122;s sensor uses green light emitting diode (LED) lights flashing hundreds of times per second and light-sensitive photodiodes to detect the amount of blood flowing through the wrist. Using a unique optical design, the sensor gathers data from four distinct points on the wrist. Powerful software algorithms isolate actual heart rhythm sounds from other noise.

Image: The Apple Watch may soon detect AF and other arrhythmias (Photo courtesy of Stanford University).

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New Medical Monitors Augment Clinical Use new range of medical-grade monitors combine image quality, performance, and safety for a wide variety of hospital and laboratory applications. The Contec Americas (Melbourne, FL, USA; www.contec.com/us) line of medical monitors currently includes seven displays designed for original equipment manufacturers (OEMs) that require versatile, long life solutions. The clinical displays range in size from 15” to 27” and include 5-wire resistive touch and projected capacitive touch (PCAP) options. Monitors in the Legacy group feature the standard 4:3 aspect ratio, in order to help manufacturers protect their existing investments as they transition to widescreen (16:9) format. Conversely, the Modern line boasts a sleek, contemporary look, 16:9 widescreen aspect ratio, high brightness up to 350 nits, wide viewing angles of up to 178 degrees, and true-flat front, IP65 rating for easy cleaning and sanitation. All monitors in both groups meet digital imaging and communications in medicine (DICOM) part 14 image quality, as well as international standard for environmentally conscious design (IEC 60601) compliance to medical safety and performance standards. “We leveraged our 30 years in the medical industry and solicited feedback from customers across many modalities to identify which features and functionality were most important,” said Jeannette Toews, director of displays at Contec Americas. “In addition to image quality and performance, which are critical to accurate diagnosis, we considered the

functional requirements of the equipment and ease-of-use. I’m really proud of the result, which supports a wide range of applications in the life sciences, pharmaceutical, diagnostic, and imaging specialties.” Historically, computer displays, like televisions, had an aspect ratio of 4:3 (width of the display screen to the height). For widescreen LCD monitors, the aspect ratio is generally 16:9, which is more suited for are viewing movies, playing games, and displaying multiple windows side by side. High definition (HD) and ultra HD also use a widescreen aspect ratio. Image: The new medical monitors were designed to meet international standards (Photo courtesy of Contec Americas).

Movement-Tracking System Collects Health and Behavioral Data new study describes how a low-power radio-frequency (RF) tracking system can provide insights about how people interact with each other and the environment. The Marko system, under development at the Massachusetts Institute of Technology (MIT, Cambridge, MA, USA; www.mit.edu), works by emitting RF signals at a constant rate of 30 pulses/second. When a signal rebounds, it creates a map, sectioned into vertical and horizontal frames, that indicates where people are in a three-dimensional (3D) space. The vertical frames capture height and build, while the horizontal frames determine general location. As individuals move about, the system analyzes the RF frames to generate short trajectories, called tracklets. To train the system and tag identities, all users first wear low-powered accelerometer sensors, which are used to label the reflected RF signals as per their respective identities via an algorithm that correlates acceleration features with motion features. When users walk, for instance, the acceleration oscillates, but becomes a flat line when they stop. When the best match between acceleration data and tracklets is met,

the tracklet is labeled with the matching user’s identity. The sensors do not need charging, and, after training, the individuals don’t need to wear them again. The researchers then tested Marko in six locations: two assisted living facilities, three apartments inhabited by couples, and one townhouse with four residents. The study demonstrated the system’s ability to distinguish individuals based solely on RF wireless signals. In one assisted living facility, the researchers monitored a patient with dementia who would often become agitated. By matching her increased pacing with the visitor log, they determined the patient was agitated more during the days following family visits. The study was presented at the annual Human Factors in Computing Systems conference, held during May 2019, in Glasgow (United Kingdom). “With respect to imaging through cameras, it offers a less data-rich and more targeted model of collecting information, which is very welcome from the user privacy perspective,” commented Professor Cecilia Mascolo, PhD, of the department of computer science and technology at Cambridge University (United Kingdom). HospiMedica International October-November/2019

Industry News

ZOLL Medical Completes Acquisition of Cardiac Science cont’d from cover

EMS and fire professionals, and lay rescuers treat victims needing resuscitation and acute critical care. Cardiac Science develops, manufactures, and markets AEDs and related parts, components, and accessories. The company also provides a comprehensive portfolio of training, maintenance, and support services for AED customers. With the completion of the acquisition, Cardiac Science will become part of ZOLL’s Resuscitation division, but will continue manufacturing in its facility in Deerfield, Wisconsin. ZOLL will continue to promote, market, and supply the Powerheart line of AEDs and Rescue Ready services as well as ZOLL AEDs and PlusTrac program management. “We are excited about the alignment of our two companies and our combined ability to place lifesaving technology into the hands of more lay rescuers and first responders during medical emergencies,” said Elijah A. White, President of ZOLL Resuscitation. “This acquisition fits well into ZOLL’s vision of providing integrated, innovative acute and resuscitation care for all.” “Cardiac Science and ZOLL both provide proven AED solutions to broad segments of the public safety market,” added White. “With Cardiac Science now part of ZOLL, we’ll be able to offer our customers more choices and a stronger AED program management infrastructure to ensure that both families of AEDs are ready when needed.”

New-Generation Devices Spur Growth of Global ECG Devices Market he global electrocardiography devices (ECG) market is projected to grow at a CAGR of over 6% over the forecast period 2019-2023, driven primarily by technological advances, which have helped in developing easy-to-use devices with reduced size and enhanced portability. The market growth is further aided by the increasing prevalence of cardiovascular disease (CVD) and their growing awareness. However, the high cost of EVG devices, increasing demand for refurbished ECG devices and lack of skilled clinicians with expertise in ECG could hamper the growth of the ECG market over the forecast period. These are the latest findings of Research and Markets, (Dublin, Ireland; www.researchandmarkets.com), a global market research company. In addition to reduced size and enhanced portability, the new-generation ECG devices also incorporate advanced algorithms, which provide high-fidelity data to support better clinical decisions. Additionally, the latest ECG devices incorporate various workflow improvement features, such as simplified step-by-step operation, touch-screen systems, and better connectivity with ECG management systems. Moreover, technological advances in sensors now allow recording of electrical impulses from the heart in the absence of conventional ECG machines. Several technologies are now wearable and can monitor and record cardiac impulses for weeks or even months. These devices are increasingly being adopted in out-of-hospital settings such as households and public places. These developments are expected to have a positive impact on the growth of the global ECG market. In 2018, the resting ECG devices segment held a significant share and is expected to continue dominating the global ECG market over the forecast period due to the increasing focus on early diagnosis and disease prevention, rising number of resting ECG procedures and technological advances.

HospiMedica International October-November/2019

International Calendar For a free listing of your event, or a paid advertisement in this section, contact:

International Calendar, HospiMedica International E-mail: info@globetech.net JANUARY 2020 ESOU 2020 – 17th Meeting of the EAU Section of Oncological Urology. Jan 17-19; Dublin, Ireland; Web: esou.uroweb.org ISET 2020 – International Symposium on Endovascular Therapy. Jan 22-25; Hollywood, FL, USA. Web: www.iset.org CACVS 2020 – Controversies & Updates in Vascular Surgery. Jan 23-25; Paris, France; Web: cacvs.org Arab Health 2020. Jan 27-30; Dubai, UAE; Web: www.arabhealthonline.com FEBRUARY 2020 Critical Care Congress 2019 – 48th Annual Meeting of the Society of Critical Care Medicine (SCCM). Feb 16-19; Orlando, FL, USA; Web: www.sccm.org Medical Japan 2020. Feb 26-28; Osaka, Japan; Web: www.medical-jpn.jp MARCH 2020 SAR 2020 – Annual Scientific Meeting of the Society of Abdominal Radiology. Mar 1-6; Maui, HI, USA; www.abdominalradiology.org Hospital Infrastructure Show 2020. Mar 4-7; Kuwait City, Kuwait; Web: www.hospitalinfrastructure show.com Medical Fair India 2020. Mar 5-7; Mumbai, India; Web: www.medicalfair-india.com APSCVIR 2020 – 15th Annual Meeting of the Asia Pacific Society of Cardiovascular and Interventional Radiology. Mar 5-9; Taipei; Web: www.apscvir2020.com Acute Cardiovascular Care 2020. Mar 7-9; Athens, Greece; Web: www.escardio.org HIMSS20 Global Conference & Exhibition – Healthcare Information and Management Systems Society. March 9-13; Orlando, FL, USA; Web: www.himssconference.org ECR 2020 – European Congress of Radiology. Mar 11-15; Vienna, Austria; Web: www.myesr.org ExpoMED Eurasia 2020. Mar 19-21; Istanbul, Turkey; Web: expomedistanbul.com KIMES 2020 – Korea International Medical &

Hospital Equipment Show. Mar 19-22; Seoul, Korea; Web: www.kimes.kr EAU20 – 35th Annual Congress of the European Association of Urology. Mar 20-24; Amsterdam, The Netherlands; Web: eaucongress.uroweb.org 2020 AIUM Annual Convention – American Institute of Ultrasound in Medicine. Mar 21-25; New York, NY, USA; Web: www.aium.org 40th ISICEM – International Symposium on Intensive Care and Emergency Medicine. Mar 2427; Brussels, Belgium; Web: www.intensive.org AAOS 2020 – Annual Meeting of the American Academy of Orthopaedic Surgeons. Mar 24-28; Orlando, FL, USA; Web: www.aaos.org WCN 2020 – World Congress of the International Society of Nephrology (ISN). Mar 26-29; Abu Dhabi, UAE; Web: www.wcn2020.org 13th SIOP ASIA 2020 – International Society of Paediatric Oncology. Mar 27-29; Mumbai, India; Web: www.siopasia2020.com ACC.20 – American College of Cardiology’s 69th Annual Scientific Session & Expo. Mar 28-30; Chicago, IL, USA; Web: www.acc scientificsession.acc.org SIR 2020 – 45th Annual Meeting of the Society of Interventional Radiology. Mar 28 – Apr 2; Seattle, WA, USA; Web: www.sirmeeting.org EHRA 2020 – Annual Congress of the European Heart Rhythm Association. Mar 29-31; Vienna, Austria; Web: www.escardio.org MedtecLIVE 2020. Mar 31 – Apr 2; Nuremburg, Germany; Web: www.medteceurope.com

APRIL 2020 SAGES 2020 – Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons. Apr 1-4; Cleveland, OH, USA; Web: www.sages2020.org WCO-IOF-ESCEO 2020 – World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases. Apr 2-5; Barcelona, Spain: www.wco-iof-esceo.org ISUOG 2020 – 16th International Symposium of International Society of Ultrasound in Obstetrics and Gynecology. Apr 3-5; Cairo, Egypt; Web: isuogsymposium2020.com

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ICJR Middle East 2020 – 8th International Congress for Joint Reconstruction. Apr 4-6; Dubai, UAE; Web: www.icjrmiddleeast.com ESTRO 39 – Annual Congress of the European Society of Radiology & Oncology. Apr 37; Vienna, Austria; Web: www.estro.org ISBI 2020 – International Symposium on Biomedical Imaging. Apr 3-7; Iowa City, IA, USA; Web: 2020.biomedicalimaging.org North Africa Health Expo 2020. Apr 7-9; Cairo, Egypt; Web: www.northafricahealthexpo.com CMEF Spring 2020 – China International Medical Equipment Fair. Apr 9-12; Shanghai, China; Web: www.cmef.com.cn 79th Annual Meeting of the Japan Radiological Society (JRS). Apr 9-12; Yokohama, Japan; Web: www.radiology.jp 140th Annual Meeting of the American Surgical Association (ASA). Apr 16-18; Washington, DC, USA; Web: meeting.americansurgical.org ISMRM 2020 – 28th Annual Meeting of the International Society for Magnetic Resonance in Medicine. Apr 18-23; Sydney, Australia; Web: www.ismrm.org AAEM20 – 26th Annual Scientific Assembly of the American Academy of Emergency Medicine. Apr 19-23; Phoenix, AZ, USA; Web: www.aaem.org SEACare 2020 – 23rd Southeast Asian Healthcare & Pharma Show. Apr 20-23; Kuala Lumpur; Malaysia; Web: abcex.com Charing Cross International Symposium 2020. Apr 21-24; London, UK; Web: www.cxsymposium.com AAN 2020 – 72nd Annual Meeting of the American Academy of Neurology. Apr 25-May 1; Toronto, Canada; Web: www.aan.com ESTES 2020 – 21st European Congress of Trauma & Emergency Surgery. Apr 26-28; Oslo, Norway; Web: www.estesonline.org ECIO 2020 – European Conference on Interventional Oncology. Apr 26-29; Nice, France; Web: www.ecio.org

MAY 2020 ARRS 2020 Annual Meeting – American Roentgen Ray Society. May 3-8; Chicago, IL, USA; Web: www.arrs.org Vietnam Medi-Pharm 2020. May 6-9; Hanoi, Vietnam; Web: vietnammedipharm.vn WCE 2020 – 14th World Congress on Endometriosis. May 8-11; Shanghai, China; Web: endometriosis.ca/world-congress/wce2020 SPR 2020 – Annual Meeting of the Society for Pediatric Radiology. May 9-15; Miami, FL, USA; Web: www.pedrad.org

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ESO-WSO 2020 – Joint Conference of the European Stroke Organisation & World Stroke Organization. May 12-15; Vienna, Austria; Web: eso-wso-conference.org ATS 2020 – International Conference of the American Thoracic Society. May 15-20; Philadelphia, PA, USA; Web: conference.thoracic.org ACR 2020 – Annual Meeting of the American College of Radiology. May 16-20; Washington, DC, USA; Web: www.acr.org ECO-ICO 2020 – European and International Congress on Obesity. May 17-20; Dublin, Ireland; Web: www.ecoico2020.com ESGAR 2019 – 31st Annual Meeting of the European Society of Gastrointestinal and Abdominal Radiology. May 19-22; Amsterdam, The Netherlands; Web: www.esgar.org Hospitalar 2020. May 19-22; Sao Paulo, Brazil; Web: www.hospitalar.com Deutscher Röntgenkongress – 101st Annual Meeting of the German Roentgen Society. May 20-23; Leipzig, Germany; Web: www.drg.de ECE 2020 – 22nd European Congress of Endocrinology. May 23-26; Prague, Czech Republic; Web: www.ese-hormones.org 6th Congress of the European Academy of Neurology (EAN). May 23-26; Paris, France; Web: www.ean.org/paris2020/ Africa Health 2020. May 26-28; Johannesburg, South Africa; Web: www.africahealthexhibition.com EuroAnaesthesia 2020 – European Society of Anaesthesiology. May 30 – Jun 1; Barcelona, Spain; Web: www.esahq.org

JUNE 2020 88th EAS Congress – European Atherosclerosis Society. May 31-Jun 03; Geneva, Switzerland; Web: eas2020.com ASNR 2020 – 58th Annual Meeting of the American Society of Neuroradiology. May 30 – Jun 4; Las Vegas, NV, USA; Web: www.asnr.org ESPR 2020 – 56th Annual Meeting of the European Society of Paediatric Radiology. Jun 1-5; Marseille, France; Web: espr2020.org 57th ERA-EDTA Congress – European Renal Association – European Dialysis and Transplant Association. Jun 6-9; Milan, Italy; Web: www.era-edta.org Asia Health 2020. June 10-12; Bangkok, Thailand; Web: www.medlabasia.com EFORT 2020 – 21st Annual Congress of European Federation of National Associations of Orthopaedics and Traumatology. Jun 1012; Vienna, Austria; Web: congress.efort.org

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International Calendar EUROSON 2020 – 32nd Congress of the European Federation of Societies for Ultrasound (EFSUMB). Jun 11-13; Bergen, Norway; Web: www.euroson2020.org EHA25 – 25th Annual Congress of the European Hematology Association (EHA). Jun 11-14; Frankfurt, Germany; Web: ehaweb.org/congress FIME 2020 – Florida International Medical Exhibition. Jun 23-25; Miami Beach, FL, USA; Web: www.fimeshow.com SIIM 2020 – Annual Meeting of the Society for Imaging Informatics in Medicine. Jun 24-26; Austin, TX, USA; Web: siim.org

JULY 2020 ESHRE 2020 – 36th Annual Meeting of the European Society of Human Reproduction and Embryology. Jul 5-8; Copenhagen, Denmark ; Web: www.eshre.eu AOCR 2020 – 18th Asian Oceanian Congress of Radiology. Jul 23-26; Kuala Lumpur, Malaysia; Web: www.aocr2020.com EADV 2020 – 29th Congress of the European Academy of Dermatology and Venereology. Jul 23-27; Vienna, Austria; Web: www.eadv.org 22nd MEDEXPO Africa 2020. Jul 25-27; Nairobi, Kenya; Web: www.expogr.com/kenyamed/ AUGUST 2020 ESC Congress 2020 – European Society of Cardiology. Aug 29-Sep 2; Amsterdam, The Netherlands: Web: www.escardio.org SEPTEMBER 2020 ERS International Congress 2020 – European Respiratory Society. Sep 5-9; Vienna, Austria; Web: www.ersnet.org ITC 2020 – 16th International Thyroid Conference. Sep 8-13; Xi’an; China; Web: www.itc2020.org Medical Fair Asia 2020. Sep 9-11; Singapore; Web: www.medicalfair-asia.com WCES 2020 – 17th World Congress of Endoscopic Surgery. Sep 9-12; Yokohama, Japan; Web: site2.convention.co.jp/wces2020 ESPE 2020 – 59th Annual Meeting of the European Society for Paediatric Endocrinology. Sep 10-12; Liverpool, UK; Web: www.eurospe.org CIRSE 2020 – Annual Congress of the Cardiovascular and Interventional Radiological Society of Europe. Sep 12-16; Munich, Germany; Web: www.cirse.org ESRA 2020 – 39th Annual Congress of the European Society of Regional Anaesthesia V

and Pain Therapy. Sep 16-19; Thessaloniki, Greece; Web: esraeurope.org ESMO 2020 – Annual Congress of the European Society for Medical Oncology. Sep 1822; Madrid, Spain; Web: www.esmo.org EUSEM 2020 – 14th European Emergency Medicine Congress. Sep 19-23; Copenhagen, Denmark; Web: www.eusemcongress.org EASD 2020 – 56th Annual Meeting of the European Association for the Study of Diabetes. Sep 21-25; Vienna, Austria; Web: www.easd.org ESVS 2020 – 34th Annual Meeting of the European Society for Vascular Surgery. Sep 29Oct 2; Krakow, Poland; Web: www.esvs.org

OCTOBER 2020 90th Annual Meeting of the American Thyroid Association (ATA). Sep 29-Oct 3. Scottsdale, AZ, USA; Web: www.thyroid.org ESMRMB 2020 – 37th Annual Meeting of the European Society for Magnetic Resonance in Medicine and Biology. Oct 1-3; Barcelona, Spain; Web: www.esmrmb.org International Congress of Radiology 2020 – International Society of Radiology (ISR). Oct 1-4; Muscat, Oman; Web: www.isradiology.org ICE 2020 – 19th International Congress of Endocrinology. Oct 4-7; Bueons Aires, Argentina; Web: ice-2020.com EuGMS Congress 2020 – 16th International Congress of the European Geriatric Medicine Society. Oct 7-9; Athens, Greece; Web: www.eugms.org ECISM LIVES 2020 – 33nd Annual Congress of European Society of Intensive Care Medicine. Oct 10-14; Madrid, Spain; Web: www.esicm.org UEG Week 2020 – United European Gastroenterology. Oct 10-14; Amsterdam, The Netherlands; Web: www.ueg.eu APSR 2020 – 25th Congress of the Asian Pacific Society of Respirology. Oct 15-18; Kyoto, Japan; Web: www.apsresp.org EANM 2020 – 33rd Annual Congress of the European Association of Nuclear Medicine. Oct 17-21; Vienna, Austria; Web: www.eanm.org 30th ISUOG World Congress – International Society of Ultrasound in Obstetrics & Gynecology. Oct 13-16; Berlin, Germany; Web: www.isuog.org NOVEMBER 2020 Medica 2020. Nov 16-19; Dusseldorf, Germany; Web: www.medica-tradefair.com RSNA 2020 – Annual Meeting of the Radiological Society of North America. Nov 27 – Dec 4; Chicago, IL, USA; Web: www.rsna.org

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