Asian Hospital & Healthcare Management - Issue 58

I S S U E 58

2022

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Diversity, Equity & Inclusion NO MORE A GOOD-TO-HAVE

Occupational Hazards of Surgical Smoke in the Operating Room (OR)

The Economics of Behavioural Health www.asianhhm.com

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Foreword Diversity, Equity & Inclusion No more a good-to-have

“Currently, the state of diversity in healthcare still has a long way to go to be representative of the general populations that we serve.”

– Luz Claudio, Professor, Environmental Medicine and Public Health, Icahn School of Medicine

Providing healthcare services means the timely use of health services to achieve the best possible health outcomes. At the end of the day, what matters is patient experience, recovery and quality of life. Diversity, equity and inclusion (DE&I) are the two key factors that highly impact patient health outcomes and are very essential in keeping the staff engaged and improving patient experience.

In healthcare, an individual or group may feel discriminated against when they experience negative actions or lack of consideration. The two main types of discriminatory experience acts are macroaggressions and microaggressions. The former represent radical forms of racism while the latter are short, everyday insults or snubs.

In the modern age, companies need to embrace diversity to remain relevant and thrive in an everchanging marketplace. DE&I helps employees feel respected, valued, and heard; it needs to be an integral part of organisation culture. Companies with a solid commitment to equality, equity, diversity, and inclusion (EEDI) have seen benefits such as improved innovation, enhanced brand reputation, and the ability to attract and retain talent effectively, according to the Workforce Institute D&I Report 2021.

Globally, there is a long way to go for society to become more diverse, equal, and inclusive. However, Asia-Pacific (APAC) countries are evolving in showing progress in DEI compared to other parts of the world.

While in APAC, there is a greater importance to

maintaining archaic and outdated values that can make it challenging to practice inclusivity. Organisations can no longer look at DE&I as a mere initiative as this will to be a core component for healthcare institutions.

Universities, hospitals, and research facilities must implement inclusive frameworks within their systems.

The post-pandemic era has changed our lives in many ways. Advanced technologies and online communication platforms are connecting people widely regardless of physical location. Leveraging technology and digital innovations to drive diversity & inclusion activities can help organisations achieve their goals faster.

The cover story in this issue by Elliott Parris, Co-Founder, Embrace, Elsevier Employee Resource Group highlights the steps that healthcare institutions can take to start prioritising diversity and inclusivity in practice; How technology is driving to bridge inequality gaps. Added comments by our previous contributor Peggy Wu, Vice President, AbbVie, Asia highlight factors to consider for a successful roll-out of diversity and inclusion initiatives.

Prasanthi Sadhu Editor

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CONTENTS HEALTHCARE MANAGEMENT

COVER STORY

Making Healthcare Truly Inclusive by Improving Diversity

06 The Economics of Behavioural Health Gurrit K Sethi, Founder, Miindmymiind

18 Approach to Healthcare and to the Delivery of Services Present and future trends

Elliott Parris, Co-Founder, Embrace, Elsevier Employee Resource Group

Mira Govindarajan, Cardiodiabetologist, Safeguard Family

MEDICAL SCIENCES 24 Precision Medicine in Allergy-Asthma Jaykumar Mehta, Pulmonologist, Zydus Hospitalsi

30 Treatment of Heart Failure in Adults with Congenital Heart Disease (ACHD) The need for international cooperation Christoph Sinning, Department of Cardiology, University Heart and Vascular Centre Hamburg and German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck

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36 Systolic Time Intervals in Clinical Heart Failure Smitha P S, Medical Physiology, Kasturba Medical College Vinutha Shankar, Professor and Head of Dept of Physiology, Sri Devaraj Urs Academy of Higher Education and Research

TECHNOLOGY, EQUIPMENT & DEVICES

40 Every time Hemodialysis is Performed, Air Bubbles are Injected into the Patient

48 Six Reasons to Focus on the Quality of Medtech Devices in India

Kazuhiko Shibata, Researcher, Artisan Lab Co., Ltd. and Yokohama City University school of medicine

Ashok Patel, CEO and Founder, Max Ventilator

SURGICAL SPECIALITY

FACILITIES & OPERATIONS MANAGEMENT

46 Occupational Hazards of Surgical Smoke in the Operating Room (OR) Anil Heroor, Director, Surgical Oncology at the Advanced Onco Surgery Unit, Fortis Hospitals

ExpertTalk

Kaviraja Udupa, Faculty, Dept of Neurophysiology, NIMHANS

50 Enhancing Accessibility to Critical Healthcare Facilities in Asia Pacific's Emerging Markets Massimiliano Colella, CEO, Evercare Group

INFORMATION TECHNOLOGY 52 Balancing Demand and Supply in Mental Health The role of technology Begoña San José, Clinical Psychologist

57 Telemedicine Policy and Practice Recommendations from Saudi Arabia’s journey Rana O Al-Khanbanshi, Pharmacy Quality Coordinator

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Gurrit K Sethi Founder, Miindmymiind

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Pradeep Chowbey Chairman Minimal Access, Metabolic and Bariatric Surgery Centre Sir Ganga Ram Hospital

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HEALTHCARE MANAGEMENT

THE ECONOMICS OF BEHAVIOURAL HEALTH The economics of behavioural health is hardly ever recognised. While this reflects in the outcomes in our life situations (be it professional or personal), we hardly ever own the responsibility of the impact we bring about it. The attitude towards life impacts decision making which impacts the outcomes of the jobs we undertake to do. After all, businesses succeed because of decisions and actions taken by individuals.

Gurrit K Sethi, Founder, Miindmymiind

M

ost of us think of economics as a subject to study or as a study of national performance basis the policies and politics!

We forget that how we conduct ourselves financially is the economics of our daily lives. Of course, this is affected by the larger gambit of policies of taxation, labour laws etc. But our own spending patterns at an individual level, and buying patterns at a group level are the founding basis of behavioural economics, which is today a muchresearched topic. Nevertheless, let’s explore how our own behavioural health affects our economics.

So, what is behavioural health and what is its relation to economics? Our behavioural health is reflected through our ability of reasoning, decision-making skills and how we deal with complex and stressful situations. This affects all areas of our life—personal as well as professional—given the behaviours we display and decisions we finally take. These decisions and behaviours impact the outcomes of relationships at home and at work. When we fare well in our behaviours, outcomes will be good. Generally, good work done derives good financial outcomes. Simply put this is the economics of behavioural health.

What impacts our behavioural health? Three factors: biological, emotional / psychological, and social. The first refers to our physical health.

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HEALTHCARE MANAGEMENT

speak well by way of diction but the motive may not be hidden. The CEO may pass out commands, but cannot push for sensible implementation. These broken loops is where opportunities get lost, opportunities for business, for growth (career or business).

With the staggering statistics that various surveys reveal about the stress, anxiety and depression among people, it is high time organisations recognised the need for positive interventions. Rage, suicides, stress, anxiety are a reflection of the social behaviour however also a critical indicator of the mental health that these behaviours showcase. If we want the economy to really succeed with an all-inclusive growth, these indicators need to be taken serious care of.

Despite these numbers, few individuals or organisation are taking on the initiative to do something about this. These days employee assistance programmes(EAP) is the new fad. In theory, these are the right things to do, however, in the right spirit.. As I progressed in my career, during the economic surge in the country when the IT, telecom, healthcare, insurance and a whole lot of other service industries flourished, the training and development of teams was a very big deal. This development was not limited to tactical skills, but covered the overall personality development of each employee, given that the employees carried the brand of the company on their personas. Today,

AUTHOR BIO

When one is not doing well physically, it affect our psychological health. When not well, we all feel low, we are unable to perform optimally. This only gets worse when one suffers from chronic illnesses. If we are emotionally volatile or weak, it can cause stress headaches, stomach aches etc. Our physical bodies and emotional bodies reflect how we carry ourselves in our social circles. These social circles define the environment we live in, how we interact with and within this environment defines our social health. The better we are able to deal with these, the better our situation.

Let’s look at this in reverse. When do we perform optimally at the workspace?

When we are in robust health, when we are motivated to complete the work.

This a pointer to the fact that physical and mental well-being is a critical factor in performance. In fact, in the longer run, even when afflicted physically, a mentally sound person will deliver good performance. Even in careers where the physical application is required, such as in sports, it is the mental strength which ultimately determines the victory at the finish line – the one who can endure wins. When do we keep healthy, especially in today’s context of an increasingly sedentary lifestyle? When we are disciplined enough to stay well— driven by the mind, the seat of emotions, scientifically speaking.

Success is a sum total of many failures where the hope and trust was kept alive, motivation was fed upon, hard work persisted, smart work was solicited. One might want to do a fact check around this for any successful business or a business person.

Here, I would like to put forth a contentious issue. The persona of the person defines the professional he or she becomes. Any organisation’s output is the sum total of all the people and their individual personas at work together.

No individual can perform optimally if not in a personally sound situation. The receptionist may smile but the smile will lack the warmth. The manager might

unfortunately, that tradition has been lost to the speed we have had to pick up. And during any slump, this was the budget to be trimmed first, limiting things to only basic required skills.

However, all robust organisations went on to thrive because they invested in the development of the most important resource – the human resource. Given today’s volatile, uncertain, complex, ambiguous (VUCA) world, it is imperative that we take a peek inward and start investing in development of people again in a planned manner with a serious commitment to output. The output of this can be clearly measured in terms of productivity metrics. These productivity metrics increase with the investment into not just people skills, but more so with investment into personality building, mindsets, and the most important, people’s health. There are innumerable studies that have proven these. We need to now adopt them in the right manner.

As individual professionals too, we all need to understand a very basic ideology that how we appear or face up to our challenges in the professional world, is no different from how we do that on the personal front. The mind functions in pretty much a similar fashion. We need to drop the fads and address our development as well as behavioural health seriously.

High time to invest in mind training because the mind drives all!

Gurrit K Sethi, Founder, MIINDMYMIIND, contributes to healthcare by bringing to life new concepts which enhance accessibility, helps providers re-engineer businesses, works with Global Challenges Forum (a Swiss Foundation) on sustainable health initiatives. An avid traveller and voracious reader, these attributes provide her with incisive insights about people and systems and what drives them.

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HEALTHCARE MANAGEMENT

Making Healthcare Truly Inclusive by Improving Diversity In this article, Elliott discusses the challenges and complexity in achieving diverse representation and treatment in healthcare in APAC; Steps that healthcare institutions can take to start prioritising diversity and inclusivity in practice; How technology can both be a driver and barrier to bridging inequality gaps; How innovative outcomes are only as good as the data put into the algorithms and importance of implementing inclusivity at the design stage of healthcare practice, from research to treatment.

Elliott Parris, Co-Founder of Embrace, Elsevier Employee Resource Group

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COVER STORY

W

orkplace discrimination remains a fundamental problem in society, and healthcare institutions are no exception.

It not only manifests itself as a barrier to healthcare access, but also impacts the quality of services — even marginalising populations from getting the required assistance.

According to the World Health Organisation (WHO), healthcare should be provided to everyone regardless of race, ethnicity, age, gender, religion, or social status.

In the past few years, awareness of the importance of equal representation has become widespread. According to a 2021 Google survey1, Asia-Pacific in particular has been slower in embracing diversity, equity and inclusivity, as compared to other regions, especially across dimensions such as mental health, LGBTQI+, and race and socioeconomic status, despite being one of the most diverse regions in the world.

To improve our experiences as patients and health outcomes for everyone, it is important to be aware of existing challenges to inclusivity and ways 1 https://www.thinkwithgoogle.com/intl/en-apac/future-ofmarketing/management-and-culture/how-inclusion-andequity-lag-behind-diversity-in-apac/

To make healthcare truly inclusive, tech products within the healthcare field should be truly representative.

They must consider the needs of all patients and support the delivery of empathetic care based on individual patient needs.

healthcare institutions can prioritise diverse representation and cautiously consider technology to eradicate barriers to universal healthcare access.

Challenges to achieving diverse representation in healthcare research and practice

Achieving diverse representation faces hurdles in almost every healthcare institution.

While educators in learning institutions are aware of and can act as proponents of inclusive practices, often the topic of diversity is not implemented within academic curriculums. There is also a lack of confidence and readiness to discuss diversity within lectures and course work. The challenge is not a lack of awareness, but limited funding and diverse representation.

According to a paper published

by Elsevier on COVID-19 research conducted during the first wave of the pandemic, appropriate levels of racial and ethnicity reporting were not factored into the results, despite general awareness of racial disparities and inequity. For example, during the pandemic, vaccine

trials included less than 5 per cent of Asians on average in their samples.

In APAC countries where populations tend to be dominated by a single race or ethnicity, practicing inclusivity can prove to be rather challenging. Due to the lack of exposure to caring for certain populations, ethnic minorities in Vietnam, for example, tend to face communication barriers2 and receive non-specific and non-contextually adjusted health information.

Action for diversity in educational and workplace settings

Raising awareness on the importance of inclusivity through education is a critical step towards equipping future healthcare practitioners in Asia, with the necessary skills to recognise bias and treat patients from diverse groups equally.

Implementing the framework of inclusivity within curriculums, beyond learning about the science of healthcare, can help student doctors and nurses practice care with empathy. Another approach would be to model inclusivity into medical schools at every level; from the board, management and faculty, to the student body.

In APAC, more than 258 million people live with rare diseases, and many still receive limited funding and allocation3. Increased financing and prioritisation in the research field within APAC will help such patients receive adequate care.

Beyond equitable funding, it is also important to ensure that clinical samples are fair and representative of population demographics, which will allow research into the varying responses and risk factors for specific ethnic groups.

Recognising that many efforts to achieve diversity have fallen short due to passivity, it is necessary to set concrete benchmarks. Ideally publicly, 2 https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-017-0687-7 3 https://www.weforum.org/agenda/2021/11/how-toremodel-universal-healthcare-in-the-asia-pacific/

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HEALTHCARE MANAGEMENT

with aggregated data where necessary, to make progress measurable and trackable, for greater accountability.

The role of technology in bridging the gap in healthcare inclusivity

In the digital first world, technology has become closely integrated with our daily lives. Technological solutions have permeated the healthcare industry, driving significant change and impact.

While technology can support

healthcare institutions by streamlining the data collection process, aiding the development of innovative treatments and improving communication across demographics, its Achilles heel remains the fact that technology is dependent on data.

Technological outcomes will only be as good as the data put into them, and depend on how the data is used.

Specifically, algorithms which are derived from a majority pool of Caucasians will

Elliott Parris is the 2020 Co-Founder of Embrace, an Elsevier Employee Resource Group of approximately 200 people, focused on antiracism in research and healthcare, inclusion, diversity and equity for the lives of the racially marginalised. He is also a co-organiser with Tribe Named Athari, London's Black Lives Matter Chapter, a youth-led movement calling for Black liberation and racial justice through healing, direct action and radical education. He has a scientific research background of synthetic biology in Switzerland, following a Bachelors and Masters degree from University College London, in Genetics, Evolution & Environment and Synthetic Organic Chemistry.

not be as accurate when applied to patients from a racially marginalised group4.

To make healthcare truly inclusive, tech products within the healthcare field should be truly representative.

They must consider the needs of all patients and support the delivery of empathetic care based on individual patient needs.

Working with inclusive technology and intelligence platforms, or partnerships with institutions like Elsevier’s Health Research Development programme, can help advise practitioners on the adoption of good practices and global standards: from design, through its undertaking, and until the publication of study results — thus resulting in the collection of representative data.

AUTHOR BIO

Conclusion

Investing in diversity is critical to ensure that all patients receive the care they need. All healthcare institutions, including universities, hospitals, and research facilities, must intentionally implement inclusive frameworks within their systems.

To this end, it is important to move away from the concept that it is optional. Rather, a minimum requirement and standard should be set and made mandatory.

On an individual level, healthcare professionals can play an active role to advocate for change, be early adopters and change makers, to influence and enact change within their sphere of influence.

Ultimately, the goal is to be able to provide not only robust and comprehensive care to patient populations, but one that is tailored to their diverse needs, aided by the latest, most-inclusive and innovative solutions.

4 https://link.springer.com/article/10.1007/s40273017-0578-1

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COVER STORY

Factors to consider for a successful roll-out of diversity and inclusion initiatives Building a talent pipeline Building an effective diversity and inclusion strategy starts with considering talent management. Building a talent pipeline begins with putting the awareness of EEDI into action.

Hiring managers should learn how to recognise potential unconscious bias that they should avoid when conducting interviews or screening candidates. They need to ensure that they consider the wide range of perspectives and qualities possessed by candidates to attract a diverse and talented workforce.

Secondly, while the competition for talent gets fierce, diversity and inclusion

become critical factors in attracting and retaining talent. According to Forbes Insights, a diverse workforce can attract talent in the market. When companies have good career advancement opportunities, they have a higher chance of securing a diverse workforce. Talent management strategies and development programs can be integral in continuously developing the talent pipeline and helping qualified employees advance their career journeys.

Strengthening of leadership accountability Leaders in organisations must play a

substantial role in cultivating diversity and inclusion in the workplace, as the extent to which companies respond to matters of EEDI is large, if not fully, dependent on leadership. In the Heidrick Asia Pacific Diversity and Inclusion Survey 2019, it was found that business-driven EEDI strategies led by CEOs and other C-suite leaders achieve more success. Additionally, around 70 per cent of employees in the survey believed that it would be helpful for their leaders to learn to manage diverse groups, recognise unconscious bias, and adopt more inclusive behaviour and thinking.

Inclusive leadership should be regarded as a core competency for people leaders. This begins with establishing an inclusive mindset. It is also important for leaders to model behaviours that help nurture a culture that offers the opportunity for employees to achieve their best.

Once an inclusive mindset is adopted, we can move towards putting

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COVER STORY

HEALTHCARE MANAGEMENT

EEDI into practice by promoting flexible ways of working, conscious inclusion of diverse team members, and creating an environment where open communication is encouraged.

Diverse employee communities for the underrepresented can be fostered throughout the organisation by leadership to promote awareness and appreciation of diversity and support people of all backgrounds.

Looking at a long-term holistic approach For diversity and inclusion initiatives to achieve their maximum impact, they should be made integral to the mission of healthcare companies. Companies should have concrete measures to boost diversity and inclusion, such as a roadmap to implement them and a plan to monitor progress over time.

The established strategy should be part of the fabric of the work environment. Leaders should work with their teams to plan a constant stream of

applications of EEDI throughout the year.

We should also measure the performance of diverse and inclusive initiatives by celebrating quick wins, highlighting successes, and managing what should be improved. Realistic goals should also be set to best determine the progress of diversity and inclusion in an organisation. They can take the form of a demographic that the company is looking to increase or perhaps boost overall employee engagement. In both cases, employees, including leaders, need to understand their roles in reaching these objectives and how they can contribute to making impactful change together.

to bring sustainable growth to life. To achieve a favourable outcome, a holistic approach needs to be adopted while prioritising leadership accountability and ensuring the right strategy to weave diversity and inclusion into a company.

When companies can successfully embed a diverse and inclusive way of working into their culture, they can expect highly engaged employees to unleash their potential and ultimately drive business growth.

Peggy Wu Vice President AbbVie, Asia

Steps forward for building diversity and inclusion in healthcare

The adoption of diversity and inclusion in healthcare has proven crucial in driving business impact and success by securing a talent pipeline and enriching a diverse workforce that sparks innovation

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Culture, Diversity and Health in Australia: Towards Culturally Safe Health Care

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Editors: Tinashe Dune, Kim McLeod, Robyn Williams

Date of Publishing: 23 June 2022 No of Pages: 320 Book Description: Social diversity may affect health outcomes in situations when access to health care is limited for certain social groups. Although non-discriminatory access to healthcare service is one of the basic principles of medical ethics and health law, there are still debates regarding the implementation of this concept in practice. Barriers such as inadequate legal entitlements, language, different concepts of health and disease, socio-economic factors or attitudes of healthcare professionals can hinder equity in access to healthcare. The authors of contributions gathered in this volume analyze challenges in access to healthcare for various minority groups and propose possible solutions.

Date of Publishing: 10 May 2022 No. of Pages: 279 Book Description: Developed from the data, experience, and research that emerged from ten years of intentional creation of such an approach at Northwell Health, Reigniting the Human Connection: A Pathway to Diversity, Inclusion, and Health Equity offers readers an adaptable framework on which to build their own response. This carefully constructed framework is centered on a holistic vision of care, one that utilizes approaches that support the emergence of patients as partners in their care in order to meet the demands of twenty-first-century healthcare.

Date of Publishing: 31 May 2021 No of Pages: 300 Book Description: Culture, Diversity and Health in Australia is a sensitive, richly nuanced and comprehensive guide to effective health practice in Australia today and is a key reference text for either undergraduate or postgraduate students studying health care. It will also be of interest to professional health care practitioners and policy administrators.

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Diagnostic Radiation Exposure Dangers to Patients and Healthcare Professionals

“Dose Creep” was ranked 7th out of the Top 10 Health Hazards for 2015. This is an unnoticed variation in diagnostic radiation exposure.1 This is a concern on potential sources of danger to patients and also health care professionals–warrant the greatest attention for the coming years.

We have seen significant advances in radiation emitting technology worldwide over the last 2 decades with reduced radiation dose scanners, iterative reconstruction image techniques and newer technologies that automate radiation dose reduction. However, with all these advances we still have not progressed as much as technology, with significant variation in national diagnostic reference levels 1 Ecri.org. 2022. [online] Available at: https://www.ecri.org/Resources/Whitepapers_and_ reports/Top_Ten_Technology_Hazards_2015.pdf [Accessed 30 August 2022].

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that are above the recommended thresholds set by national and international radiation monitoring bodies.2 At Guerbet we recognise this safety hazard and have added to our solutions portfolio Dose&Care®.

Dose&Care® is also known as DACS (Dose Archiving Communication System) which is designed to collect, control, analyse and optimise doses delivered to patients during medical imaging, interventional radiology, and cardiology examinations.

Dose&Care® is a medical device intended for use by medical professionals responsible and involved in the dose cycle: Radiologists, Interventional Radi2 Awad MF, Karout L, Arnous G, Rawashdeh MA, Hneiny L, Saade C. A systematic review on the current status of adult diagnostic reference levels in head, chest and abdominopelvic Computed Tomography. J Radiol Prot. 2020 Sep;40(3):R71-R98.

ologists and Radiographers, Technologists, Heads of Department, Medical Physicists, Surgeons, Cardiologists, and Interventional Vascular Surgeons.

The application can be connected to the central informatics environment (including, for example: PACS, RIS, HIS), imaging devices, and accessories (CT scanners, X-ray tables, image intensifiers, interventional tables, PET-CT and so on) using DICOM and HL7 communication standards.

Dose&Care® centralises the data to provide a history of the X-ray dose for each patient and displays it graphically and numerically, in the form of effective dose DLP, CTDI, CTDIvol and Size Specific Dose Estimates (SSDE).

It is also generally accepted that in light of recent technological advances, radiographers may lack the relevant knowledge and understanding, leading to radiation dose deskilling.3 With Dose&Care®, the 3 Benfield, S., Hewis, J. D., &Hayre, C. M. (2021). Investigating perceptions of ‘dose creep’amongst student radiographers: A grounded theory study. Radiography, 27(2), 605610

For more information on Dose&Care®, explore this video:

Dose&Care

https://bit.ly/3BzCMqO

About Guerbet At Guerbet, we build lasting relationships so that we enable people to live better. That is our purpose. A world leader in medical imaging, Guerbet is a publicly traded company on the Euronext Paris Stock Exchange, headquartered in France with offices and production facilities in Europe, the Americas and Asia-Pacific. It has a long-standing reputation as a pioneer in the research and development of contrast media for radiology.

software allows you to review – why radiation doses are high due to incorrect patient positioning and protocol exam type. Also, graphical presentation in 2D or 3D of the skin dose and calculation of the Peak Skin Dose (PSD) from any interventional radiology and cardiology procedure.

The main function of Dose&Care® is to record, retrieve, create a radiation dose history for the patient, set benchmarks against national diagnostic reference levels, audit, create quality improvement programs to reduce radiation dose, examination alerts systems for patients and radiology management with user friendly and adjustable digital dashboard matrix that suits the user’s needs.

Dose&Care® is a web application, which can be accessed from any standard browser, either through secured internet or intranet (LAN). There is no limitation on the number of users. Each user has a login and password to access the data. The administration module allows customising the data access rights and functionalities for each user.

AUTHOR BIO CHARBEL SAADE joined Guerbet from a very solid academic and clinical background. He was formerly the Professor and Chair of Radiology at the American University of Beirut and still holds many Adjunct Professor roles worldwide as well as sits on university advisory boards.

He has published more than 120 scientific papers and 120 conference abstracts in international congresses. He served as the APAC Clinical Applications and Education Manager and now taking charge of the APAC Digital Solutions and Technical Service. He is passionate about lifting the clinical and technical practice of Diagnostic Imaging for better patient outcomes.

Email: charbel.saade@guerbet.com

Today, Guerbet contributes to progress made in the diagnosis of major disease areas including cancer, cardiovascular, inflammatory and neurodegenerative diseases. The company’s novel and effective imaging solutions help to improve patient management throughout the world. Guerbet offers a comprehensive range of imaging products, solutions, and services for Diagnostic Imaging –MRI, X Ray, Digital Solutions / AI– and Interventional Imaging, to enhance clinical decision-making, from diagnosis to treatment and follow-up, and improve patients’ quality of life.

For more information, please visit: www.guerbet.com.

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HEALTHCARE MANAGEMENT

Approach to Healthcare and to the Delivery of Services Present and future trends Cutting across clinical disciplines, non-communicable diseases have come to occupy centre stage in our day to day practice of medicine. This phenomenon has considerably changed our outlook towards patients and their families, although an epidemiological disaster the pandemic of COVID-19 has made us more sensitive to co-morbidities and has changed the way we deliver services. This article has cited these trends and has elaborated upon them and their possible causation. This review puts these trends in perspective in order that our peers might prepare themselves for the road ahead.

Mira Govindarajan, Cardiodiabetologist, Safeguard Family

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his is a vast topic which normally cannotbe encompassed. Save for our day-to-day practice which finds its resonance in the current medical literature and in media reports.

By this token, some trends now observed are: 1. A focus on wellness 2. Acceptability and mainstreaming of online practice 3. A cultural shift in the doctor patient interaction 4. A focus on cellular structure and genomics apart from merely tissues or body organs

HEALTHCARE MANAGEMENT

5. A focus on the family and society instead of the individual patient alone 6. A greater understanding and acceptance of interventions related to mental health.

Let us now discuss them one by one.

A focus on wellness:

Everybody intuitively relates to the aphorism ‘an ounce of prevention is better than a pound of cure’.

Nowhere has this been more extensively studied, than in coronary artery disease. Primary prevention here means modifying one’s lifestyle to address modifiable risk factors such as diabetes, smoking, hypertension, dyslipidemia (cholesterol) and obesity.

Secondary prevention means managing risk factors, when an individual patient has one or more of them, so as to prevent effects on the heart and the circulation.

However, in practice, one had to consider the cost of these treatments against the benefit of the events prevented. Namely, the cost-to-benefit ratio.

Until the first decade of the millennium it was held that the costs for prevention and risk factor modification for coronary artery disease could not be justified vis-a vis the benefit of preventing hospitalisation or myocardial infarction (MI).

Subsequent experience and studies proved otherwise. For instance, an article published in Circulation in 2011 Updated under the auspices of the American College of Cardiology and the American Heart association made a strong case for secondary prevention.

It advised that intensive modification of conventional risk factors like diabetes, hypertension, smoking, cholesterol and obesity reduced risk improved outcomes and prevented recurrence in the context of heart disease, stroke and diseases of the blood vessels. It set down recommendations based on levels of evidence for each.

Further, the epidemic of COVID-19 proved to us decisively the hazard posed by co-morbidities.

The implication for cardiovascular care and for healthcare as a whole is that we would need to focus on preserving wellness and not merely managing illness.

That the profession should focus on keeping the patients away from hospitals rather than only treating them therein.

One more benefit of this approach is the prevention of infections acquired by the patient in the hospital setting.

For instance, diabetes gives us a 10 year ‘heads up’ in the form of the pre-diabetic stage where damage to the small blood vessels which forms the basis of future complications starts. Diabetes is about 80 per cent preventable at this stage.

Acceptability and eventual mainstreaming of online practice

In the traditional practice of medicine, regardless of they were Indian, Chinese or Western, the physician used to visit the patient’s home. The chief merit of this practice was an ability to assess the patient, their lifestyle and their support systems as a whole.

For the patient and family, the advantages of such an approach, if it were followed at the present time are obvious —no need to take time off work, no need to make and keep appointments, no need to wait in the queue, expose oneself to crowds, noise, rudeness and infections. All this to obtain a 15 minute or half hour consultation with the doctor!

The obvious demerits from the doctor’s perspective are traffic snarls, time, costs of fuel and the spread of infection.

The Covid-19 epidemic brought online consults to the fore. Now this has become an acceptable way to interact with the patient and their family from the comfort of their home!

Lyrically put: formerly Mahomet used to visit the mountain. Now the mountain moves to Mahomet!

A cultural shift in the doctorpatient interaction

In the past, the relationship between the doctor and the patient was paternalistic. The doctor acted as a father or a mother or even a god-like figure issuing prescriptions and proscriptions.

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HEALTHCARE MANAGEMENT

The internet served to bridge the traditional asymmetry in information between the doctor and the patient.

With regard to chronic disorders such as diabetes which is linked patient education becomes paramount doctors need to encourage their active participation at every turn. Put simply the patient’s role has become more proactive.

Furthermore, with a focus on the wellness of the mind-body patients have become ‘clients’ or ‘beneficiaries’.

The designation ‘customer,’ which is often used in corporate practice is inappropriate because the system has to act to protect and enhance the person’s health. This clearly overrides the end points of ‘customer satisfaction’ or ‘customer delight’.

Strong therapeutic alliances between doctor and patient have become the order of the day.

A focus on cellular structure and genomics apart from merely tissues or body organs

The major scourges of modern times— diabetes, hypertension, cholesterol, cardiac diseases, stroke, deficiencies of Vitamin D and B12, disorders of the thyroid, depression and so forth are complex in nature. There is interplay of multiple genetic and environmental factors in their genesis.

For instance, in hypertension, we need to consider growth retardation in the fetal stage, complex genetic factors, hormonal issues, metabolism of salt and water and its complex regulation, output of nerve impulses which control the blood pressure, stress, salt intake, smoking and alcohol, the level of activity and soon…

This interplay becomes even more complex in psychiatric disorders.

We need to understand each disorder in terms on individual cells, their internal structure and the genetic makeup of each individual.

lifestyles—erratic habits with respect to food and sleep, lack of family support in many instances, lack of physical activity and above all, stress. For instance diabetes evidently runs in families. This could be passed on from generation to generation. It could be genetic as in a tendency to have a certain gene or set of genes which make one more prone for diabetes. It could be because of shared diet and activities such as exercise in a given family. It could be combination of one or more of these factors.

AUTHOR BIO

Many of the above cited disorders are based on the demerits of modern

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A greater understanding and acceptance of interventions related to mental health

Depression is quite clearly one of the epidemics of modern times. It is part of many chronic disorders. For instance, after a heart attack or in diabetes. It might mimic disorders such as muscular pains or the chronic fatigue syndrome.

Stress is causally linked to hypertension and diabetes. In high blood cholesterol.

Stress induces a specific disorder of the heart muscle. The role of stress in our lives can never be overstated!

Further, as we have discussed, changes in lifestyle pose many challenges.

In the past, there was a stigma attached to mental health as reflected in many colloquialisms such a ‘screw loose’ and ‘mental’ used in our society.

With greater awareness, this stigma is gradually disappearing. Body and mind are being increasingly treated as one unit.

Within their professional span, physicians now have the opportunity to lead and to witness seismic shifts in their profession. Only time will tell if these trends would crystallise for the greater good.

References are available at www.asianhhm.com Mira Govindarajan is a physician with a focus on Non-Interventional cardiology and diabetic care. She obtained her graduate and postgraduate qualifications from a premier national institution, JIPMER, Pondicherry. She is also a qualified clinical administrator having obtained Master’s in Health Administration from Indiana University, USA. She has worked for reputable institutions in India and in the US in both clinical and administrative capacities.

She currently works for Safeguard family, an organisation dedicated to the care of diabetes and other lifestyle disorders.

A focus on the family and society instead of on the individual patient alone.

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It, therefore, becomes mandatory to understand the family, the professional and social background of patients and healthy clients.

The poetic phrase ‘No man is an Island’ (by John Donne) gains meaning!

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Trends Shaping the Future of Healthcare Delivery Stella Ramette, Director, Healthcare Customer Relations & Sales, Southeast Asia for InterSystems

Innovation in digital health is accelerating in the Asia Pacific region. With rising consumer demands, technology advancements, increased life expectancies, and more complex care needs, healthcare organisations are under pressure to deliver digital-first, seamless, and connected healthcare experiences.

But what are the trends shaping the future of healthcare delivery in the Asia Pacific? Which opportunities are ripe for innovation? And how can healthcare leaders help their organisations take advantage of them?

Trend 1 Exploding data drives new solutions Over a decade ago, the world’s total data storage capacity was around 487 exabytes. By 2025, it’s estimated that we’ll be generating the same volume in under two days.

The healthcare sector is one of the most significant contributors to this data explosion, accounting for around 30 per cent of the world’s data volume.

The increased use of MedTech devices, apps, moni-

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toring, and wearable technologies means more data is flowing into healthcare organisations than ever before.

As data volumes continue to rise, so does our difficulty managing it. Healthcare organisations are searching for ways to integrate and harmonise their data to make meaningful connections that lead to actionable insights.

For example, it’s important to ensure that healthcare data is accurate, complete, and accessible in real-time. This is easier said than done and involves sophisticated methods to standardise and transform data so that it is universally understood.

One solution, according to Gartner, is an enterprise data fabric, a way to continuously identify, transform and connect data from different sources to discover relevant and valuable relationships.

Trend 2 AI adoption in healthcare accelerates Artificial Intelligence (AI) has the potential to make care better, faster, and more accessible.

We have seen incredible progress in AI diagnostic applications to aid clinicians in interpreting complex data. This has helped to shorten the time to diagnose and treat cancer patients. Other AI tools, such as early sepsis detection, have helped reduce newborn babies' mortality rate.

However, concerns about patient safety and a lack of quality data have slowed the progress of AI initiatives. For example, it can be difficult for clinicians to be confident in AI algorithms without testing them in their own environments.

With healthcare catching up to other industries in maturity, data will be both a critical success factor and a barrier to the successful application of AI. What do we need to get right before we can realise the full potential of AI technology? An essential prerequisite is for hospitals to build the right foundations at a technology level, like interoperability and data management.

This is already happening. McKinsey’s analysis of The State of AI found that healthcare organisations were leading the way in AI investment, with 44 per cent of organisations surveyed saying they have increased investment in AI in each major business function.

It’s also important to encourage innovation and create a data analytics culture. Clinicians must be willing to adopt digital systems and see the value in capturing and sharing data. Organisations must constantly answer the question,

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“What’s in it for me?” as they roll out their digital transformation strategies.

Trend 3 Interoperability unlocks true power of data According to a Sage Growth Partners report, 51 per cent of healthcare executives say data integration and interoperability are the most significant barriers to achieving their strategic priorities related to data analytics.

This is due to the amount of data being created and the number of sources that data is flowing from.

Medical devices, patient records, hospital databases, and data lakes all house crucial data within the healthcare system.

Accessing real-time data remains an uphill battle without a way to connect these siloed data sources.

Without real-time interoperability, hospitals can only analyse data within one system at a time or after it is out of date. They cannot use all sources of information to get the complete picture when needed.

A persistent hurdle to interoperability is the existence of many healthcare standards such as HL7, DICOM, XML, and more. Systems using different standards are not able to communicate with each other efficiently. Many remote monitoring devices, for example, currently require their own data infrastructure. Because of the cost involved, this is a barrier to hospitals approving business cases.

But there is some good news. New standards such as Fast Healthcare Interoperability Resources (FHIR) and tools such as Application Programming Interfaces are closing the gaps created by the explosion of data and sources in the region.

If medical products include standards-based interoperability, for example, they can leverage existing infrastructure to make them easier and more cost-effective to deploy. Adopting a modern standard like FHIR, which works securely via the Internet, could make a real difference.

These approaches to interoperability make synthesising data from multiple sources much more easily achievable. And by making data more accessible, computable, and usable, you can use analytics to improve healthcare decisions and outcomes or drive digital engagement with patients.

Trend 4 Telehealth delivery moves to virtual care A global pandemic and rising consumer expectations have made telehealth a permanent fixture of the healthcare landscape. And it continues to increase, according to McKinsey, which reported 38 times higher uptake in 2021 compared to the pre-Covid baseline.

Healthcare professionals in the APAC region are embracing this trend, seeing it as a valuable opportunity to improve access to healthcare. The HIMSS 2021 APAC Health CIO Report found that 88 per cent of participants would continue to leverage connected health technologies following the pandemic.

Telehealth is shifting from an isolated mechanism to deliver care outside the hospital to a more holistic, integrated model known as virtual care. Enabled by connected devices, information systems, and data, virtual care enhances the care experience and enables new models of care.

For example, you can significantly reduce the number of trips patients with chronic conditions must make to the hospital. This way, virtual care improves access to care while making better use of resources.

Hospitals can invest in enhanced virtual care capabilities to overcome challenges like finding enough qualified staff or caring for a population living longer with more complex conditions.

The challenge is now how to seamlessly blend remote and in-person care seamlessly. Integrating telehealth into our digital systems and meeting individual care needs while improving patient access and experience is one of the critical challenges facing APAC healthcare leaders.

the IoMT enables more efficient, accurate, and costeffective healthcare delivery.

This opportunity is not lost on Asian health professionals. According to an IDC study of Asia Pacific healthcare providers, nearly 75 per cent have already deployed IoMT solutions, and one-third have firm plans to implement IoMT solutions this year.

The proliferation of devices, while positive, is also causing an explosion of data. As the number of devices grows, so does their associated data and the systems that analyse and communicate that data. Healthcare organisations are now faced with a “data deluge” that may prevent us from unlocking the full value of this technology.

You need the right foundations to take full advantage of IoMT and other digital trends. This includes interoperability and data management capabilities, like those supported by an enterprise data fabric. And you need a culture that rewards data-driven innovation.

By bringing these elements together in their digital transformation strategies, Asian hospitals and other healthcare providers will find new ways to overcome the challenges they face.

To find out more, please download the free InterSystems e-book “5 Trends Shaping the Future of Digital Health in 2022 | Asia Pacific”

AUTHOR BIO

Trend 5 The rise of the Internet of Medical Things

Over the last decade, rapid technological advances have led to the development of an increasing number of connected medical devices that generate, collect, analyse, and transmit data. Commonly referred to as the Internet of Medical Things (IoMT), these devices are revolutionising how healthcare is delivered.

From connected glucose and heart monitors for patients with chronic diseases to ingestible sensors revolutionising disease diagnostics and monitoring,

Stella Ramette is Director, Healthcare Customer Relations & Sales, Southeast Asia for InterSystems, a creative data technology provider dedicated to helping customers solve the most critical scalability, interoperability, and speed problems. Based in Singapore, Stella provides local resources to a growing healthcare customer base and ensures that InterSystems is responsive to their needs.

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MEDICAL SCIENCES

Precision Medicine in Allergy-Asthma Allergy-asthma is an enormous burden on healthcare systems and its health impact is substantial. This article describes scientific information on what allergy is, how allergy responses occur, what are the symptoms, how to diagnose it and a word about medications.

Jaykumar Mehta, Pulmonologist, Zydus Hospitals

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A

ccording to the World Health Organisation (WHO), more than 20 per cent of the world population suffers from IgE (Immunoglobulin E) mediated allergic diseases such as allergic asthma, allergic rhino-sinusitis, allergic conjunctivitis, eczema/atopic dermatitis and anaphylaxis. The recent Global Burden

MEDICAL SCIENCES

of Disease (GBD, 1990-2019) estimated total burden of asthma in India at 34.3 million, accounting for 13.09 per cent of the global burden. The health impact of allergy-asthma is substantial and the burden is increasing owing to climate change and adverse environmental factors.

Asthma is a Greek word meaning “panting”. The Global Initiative for Asthma (GINA) defines it as a heterogeneous disease usually characterised by chronic airway inflammation. Elaborating it, the presenting symptoms as well as treatment responses differ person-to-person and hence it is important not to adopt “one size fits all” or blanket solutions for all asthmatics. These patients require proper understanding of their household as well as work environments and personalised care plans to achieve maximum symptom control. In short, the need of the hour is to practice precision medicine to answer most common questions encountered in clinical scenario: 1. What am I allergic to?

2.Can my allergy be cured?

The following description will help understanding allergy-asthma scientifically. It will also provide information on latest technologies to find out precise culprits and shed lights on hope for allergy cure.

What is allergy?

The term “Allergy” was coined by von Pirquet in the year 1906. With it he wanted to describe a change in reactivity.

In general, allergy occurs when a person reacts to substances known as allergens, which are harmless, non-infectious and in abundance in the surrounding environment. A person’s inherent tendency of being hypersensitive to particular substance is known as atopy.

According to Gell and Coomb, the hypersensitivity reactions are classified into four types based on involvement of different cells and mediators.

Pollen

Peanut

Apple Allergen source

Allergen extract

Allergic reactions are most commonly attributed to Immunoglobulin E (IgE) mediated or Type 1 hypersensitivity reaction. IgE is part of the human body’s immune system. Its level rises in serum on allergen exposure which ultimately is responsible for symptoms of allergy.

SYMPTOMS OF ALLERGY

When a predisposed or atopic individual is exposed to an allergen, the body reacts in a way to eliminate the offending substance out of the body with different behavioural responses like itching, rashes, running nose, sneezing, coughing and watering of eyes. However, in some persons it can lead to inflammation/ swelling and narrowing of airways which causes wheezing and difficulty in breathing — the main attributes of asthma. In some cases it can lead to life threatening anaphylaxis, where the body goes into complete shock.

These symptoms can be seasonal or perennial (year round). Most often it is found that symptoms increase due to triggers. Exposure to smoke, heavy perfumes or pungent smell, air pollution, difference in temperature or humidity as well as emotional stress can trigger allergy-asthma symptoms. As allergic tendencies run in families, positive family history contributes significantly in diagnosis of allergy.

Specific allergen components

Cross-reactive allergen components

Allergic March

Though allergies most commonly manifest as rhinitis/dermatitis, according to a school of thought, it can progress to asthma or life threatening allergies if not addressed in time. The phenomenon is called “allergic march”. It is observed many times that a person first has upper respiratory tract allergies and limited symptoms but it slowly progresses to chest congestion and wheezing with increase in severity and frequency over time. There are no tests yet which can predict development of allergy-asthma or its progression. In that scenario, the best way is to keep regular follow up check up.

Diagnosis

Traditionally, skin prick testing (SPT) was considered as gold standard of allergy diagnosis. In this, a drop of crude allergen extract is placed over the forearm/back and it is pricked with a lancet. The positive response is noted by development of wheel and flare. This roughly hundred years old technique suffers the drawback of purity of allergen extracts as well as issues of cross-reactivity.

Due to poor cooperation this technique is not suitable for diagnosis in children.

The other alternative is called in-vitro tests where the blood is tested for presence of IgE against particular

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MEDICAL SCIENCES

allergen. IgE assays based on ELISA/ EIA are sensitive but not specific. The capture assays are slightly more specific.

However, these in-vitro tests S. IgE against carbohydrate, lipid and protein: all three components of allergen. As only the protein component is responsible to mediate allergenic responses, IgE measured against other two may lead to false positive reports. The issue of crossreactivity still persists and for the same reason, these tests detect ‘sensitivity’ and not true allergy. Hence there is a dire need of precision diagnostic testing to identify the culprit allergens.

Precision diagnosis with CRD allergy profile

Component resolved diagnosis (CRD) allergy profile is an in-vitro method, where the patients’ serum is tested for specific IgE levels against approximately 300 known allergens. In this method, IgE level against only protein moieties of purified and filtered allergenic extract, the specific components responsible for allergic responses, is measured. In addiction, cross-reactive carbohydrate determinant (CCD) inhibitors makes it possible to cancel noise. Presence of IgE in substantial levels against major allergen components is considered a hallmark of allergy diagnosis. The test is reasonably sensitive and specific.

However Indian studies are still awaited as the test is available only in few centres across India.

For example, a person suffering from apple allergy, the reactions can be prevented if the apple is given after peel removal as suggested by CRD allergy profile. Cockroach allergies can be controlled with robust pest control measures. Pollen and Mould allergies can be controlled with appropriate environmental intervention. Most importantly, dust mite sensitisation can potentially be cured.

The recent Global Burden of Disease (GBD, 1990-2019) estimated total burden of asthma in India at 34.3 million, accounting for 13.09 per cent of the global burden.

allergen is administered, mostly via subcutaneous route, to develop immune tolerance, has potential to allow a symptom- and medication-free life.

Known as allergy shots, these can lead to long-term benefits provided the treatment is based on sound knowledge of presence of IgE against major allergen component, mainly dust mites, and administered after thorough evaluation like spirometry and detailed physical examination at an experienced centre and for appropriate duration.

After careful selection, in a person suffering from dust mite allergy,

The goal of an allergy-asthma treatment plan is to reduce the risk and symptoms.

The subset of patients deemed unfit for successful administration of AIT have medications and allergen avoidance as mainstay of treatment plan. The medications can be divided according to their role: preventer/controller medications and reliever medications.

Reliever medications are used after the symptoms have appeared and mainly tame the aggravated symptoms. While preventer/controller medications need to be taken on regular basis, irrespective of symptoms, to be adjusted after re-assessment at scheduled interval, which is usually around 6-12 weeks.

Rapid withdrawal of preventer/controller medications or poor adherence to same are major risk factors for frequent flareups as well as asthma with fixed airway obstruction.

References are available at www.asianhhm.com

Jaykumar Mehta is awarded as “Best interventional Pulmonologist - 2021”. With motto ‘ensuring compassionate care to make people breathe better’, he provides his services full-time at Zydus Hospitals, Ahmedabad, Gujarat.

Allergen immunotherapy (AIT), a scientific method where the offending

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Medications

AUTHOR BIO

Allergy cure: Is it possible?

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AIT administered in build up and maintenance phase can slowly lead to reduction of allergen-specific IgE levels and convert it to an IgG mediated response, which will no longer produce the symptoms. Though it may sounds simple, it is best carried out only under professional guidance and at an experienced centre.

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First Glove’s Manufacturing Providing a High-Quality, Nitrile Exam Glove for Hospitals This article awards a new brand of Nitrile Examination Gloves the Best Glove for Medical Professionals in 2022. Nitrile Gloves are used during medical examinations and procedures to help prevent cross-contamination between caregivers and patients.

When a company stands up for its clients on multiple levels that can only result in becoming a leading manufacturer & distributor in that market. First Glove – the fastest growing glove manufacturer in South East Asia and distributor in North America – has done exactly that. Providing a vertically integrated end to end solution. Resulting in increasing quarterly market share.

Right now their team efforts focus their own Hospital procurement, providing high-quality gloves with additional services that are convincing GPO’s and small hospitals they are the new alternative to the Medline’s & Cardinal Health’s of the world.

Providing a better solution for hospitals means getting right in there with those who use gloves.

Nurses, Doctors and other important staff members finding out the needs that haven’t been met yet in the industry, applying creativity and logistics, and solving 28

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their problems. That intensive groundwork has been proven key to developing better gloves, packaging and ordering systems.

“After speaking with front line healthcare workers we were shocked to hear of the quality of gloves that they were receiving from some of the biggest healthcare suppliers in the world. It seems these companies and their purchasing offices have chosen greater profit margins but forgoing quality for their staff. Staff members often complained about sticky gloves and gloves that easily ripped.” We came in and were able to offer a better glove at a more competitive price and this has led to a significant shift in hospital systems moving away from the large monopolies in the industry and in-trusting First Glove in one of the most important supplies in the Healthcare industry.

First Glove’s Blue Exam glove was the result of building relationships with hundreds of health professionals in hospitals. Their goal was to exceed the performance specs that the medical industry required.

“We started out developing several prototypes with different lengths and thicknesses that might work best. Next came the clinical trials to ensure that our Core Nitrile Exam glove gave Doctors, Nurse Practitioners and other healthcare professionals precision and control yet felt like silk. The final glove design ended up being well-suited for the finest of various range of everyday needs,” Co-Founder, Marlon Browar stated.

• high-efficiency manufacturing production of highquality, reliable gloves • conservation of energy during the glove-making process • consistently solid prices that don’t involve a middle man, thus no mark-ups • focus on building strong customer relationships • distributor partnerships around the world, with 30-60 per cent margins • the creation of personalised gloves according to customers’ needs • adaptation of resources that have minimal impact on the environment

Why Nitrile Gloves? What are the advantages?

Nitrile gloves are ones that offer several different benefits. With these gloves that are comfortable when wearing for long periods of time, you can easily see any type of damage or tear, and easily replace them. This allows you to keep up the protective barrier of a high-quality glove. They can be molded to your hands and are also puncture-resistant and the materials resist degradation by chemicals. Nitrile gloves are also a known barrier for oils, solvents, hydrocarbons, and some acids and bases. And they are a good substitute for those who have known latex glove allergies.

One of the types of FDA-approved medical gloves manufactured by First Glove is the ASTM D6319 glove, a core exam glove that resists chemicals, viruses, and oils. This glove has a length of greater than or equal to 230 mm, fitting nicely over the wrist, a palm thickness of 0.07 mm ± 0.02 mm, and a finger thickness of 0.10 mm ± 0.02 mm. Even after aging of the glove, the tensile strength remains strong and the glove retains its elongation and elasticity properties.

Regulatory compliance followed explicitly First Glove is also developing their own line of biodegradable gloves as well, which will be released soon. And with over 16 different certifications by international governing bodies, First Glove’s quality standards meet regulatory compliance and FDA standards. The details on the standards may be found on their website, https://firstglove.com

Helping hospitals with their bottom line was the next goal For hospitals, their concern isn’t only providing high quality gloves. It’s helping hospitals make positive changes in their processes and purchasing procedures to result in short and long-term cost savings and process improvement.

“The ease in the ordering and reordering process was critical for hospitals. We have an in-house team of web developers, UI/UX designers, which has resulted in additional cost savings for hospitals,” Co-Founder, Dean Segal said.

The success of First Glove’s Core Nitrile Exam Glove is in the process of changing the industry by making several other transformations within their competitive glove procurement industry:

Best Nitrile Exam Glove 2022 Through First Glove’s market research and design development we have awarded their Gloves the Best Nitrile Exam Glove for 2022. We believe that many other healthcare professionals will be switching their glove of choice to First Glove.

A company that cares First Glove is a community-minded company as well.

“With First Glove Cares, our people will give their time and donations locally in ways that are personally meaningful to them – because no one knows a community better than the employees who serve it.”

We have partnered with the Bowery Mission donating 50,000 plus gloves to date.

Find out more at https://firstglove.com

With two master's degrees and over 25 years of experience, Donna Schwontkowski has an Extensive medical background knowledge on stem cells, diabetes, spinal care, disease treatments, mesothelioma, hyperbaric oxygen, PEMF, Permaculture, high blood pressure, and more. Working as the Health & Fitness Magazine Editor-in-Chief since 1996.

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MEDICAL SCIENCES

Treatment of Heart Failure in Adults with Congenital Heart Disease (ACHD) The need for international cooperation The number of adults with congenital heart disease (ACHD) is increasing and heart failure (HF) is often the reason of morbidity and mortality. Heart transplantation is still the gold standard to treat advanced HF and here an international network is needed to collect data on ACHD listed for the heart- or heart and combined organ transplantation to elucidate treatment in this patient cohort.

Christoph Sinning, Department of Cardiology, University Heart and Vascular Centre Hamburg and German Centre of Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck

D

uring the past decades and due to the improvements in cardiology and cardiac surgery, the number of adults with congenital heart disease (ACHD) has increased and so has the need to treat the consequences of palliative or corrective surgery in the youth. In fact, the number of patients with ACHD has increased by about 50 per cent compared with the number of children with congenital heart defects since the beginning of the new millennium, and prevalence of complex lesions is increasing due to a better survival in patients with moderate or complex congenital heart disease. Although ACHD may present with conditions related to general cardiovascular risk factors like coronary artery disease, by far the most common diseases leading to morbidity and mortality encountered by physicians are arrhythmia, heart failure and thromboembolic events. For arrhythmia management, current recommendations

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regarding ablation and device therapy have to be considered including special anatomical considerations as well.

Further, there are implications regarding heart failure treatment in the background of the different anatomical conditions with involvement of the anatomic left or right ventricle as systemic ventricle or with single ventricle physiology.

ACHD with a complex anatomy have a high likelihood of developing heart failure which is related to the underlying congenital heart defect. In this context HF has been reported in 22 per cent of adults with transposition of the great arteries and following atrial switch surgery (Senning or Mustard operation), 32 per cent of ACHD with congenitally corrected transposition of the great arteries, and 40 per cent of ACHD with univentricular circulation and most commonly Fontan surgery previously. Before this background, it is important to point out that HF is responsible for approximately 20 per cent of mortality during early adulthood in ACHD and the current guidelines for therapy of HF cannot be directly applied to these patients as ACHD is often excluded from heart failure trials.

The reason ACHD represents a unique population of patients being prone to develop HF is elucidated with some of the aspects which have to be considered in this cohort of patients. a.Morphology of the systemic ventricle: In some of the ACHD with complex anatomy like transposition of the great arteries and atrial switch operation, hypoplastic left heart syndrome following palliative surgery or congenital corrected transposition of the great arteries the anatomic right ventricle is the systemic ventricle and responsible for the systemic circulation instead of the low pressure lung circulation. Due to a different structure of the muscle layers of the right ventricle, with only two muscle layers, instead of three muscle layers as in the anatomic left ventricle. The anatomic right ventricle is unable to sustain the pressure generation for the duration of

a normal patient’s life and is prone to develop heart failure which is difficult to treat due to the lack of evidence-based treatment recommendations regarding medical therapy. b. Pulmonary arterial hypertension: The development or presence of pulmonary arterial hypertension is a common comorbidity as a result of different underlying types of congenital heart disease. Most often these patients have a diagnosis of shunt of the circulation on the atrial, ventricular or arterial level. Thus, careful evaluation of haemodynamic data, clinical presentation, and laboratory results are needed to evaluate if pulmonary arterial hypertension is complicating the disease in ACHD. In ACHD the disease type is most commonly type 1 according to the World Health Organization (WHO) classification and pulmonary vascular resistance is elevated with ≥3 Wood units. In this context, it is important to point out that some of the patients as well might have an increased pulmonary wedge pressure when the systemic ventricle has an impaired function often present in transposition of the great arteries following atrial switch operation or in patients with congenital corrected transposition of the great arteries.

In fact, the number of patients with ACHD has increased by about 50 per cent compared with the number of children with congenital heart defects since the beginning of the new millennium, and prevalence of complex lesions is increasing due to a better survival in patients with moderate or complex congenital heart disease.

c. Shunts, collateral arteries, buffles following surgery: In patients with complex underlying congenital heart defects, shunts or collaterals of arteries are often present being a residual state following initial corrective or palliative surgery. In this context, localisation of the shunt is of importance as the location of a pre-tricuspid shunt, like in the case of an atrial septal defect, will result in a volume load of the pulmonary circulation whilst post-tricuspid shunt lesions with the most common being a ventricular septal defect, cause volume load of the left ventricle. Baffles the following surgery may be prone to narrow with passing time and might be causing exercise limitation due to limitation of the filling of the ventricle. d.Arrhythmias: The prevalence of arrhythmias is increasing as patients; these arrhythmias might be a consequence of altered anatomy, including the heart conduction tissue, and as well a result of residual or postoperative sequelae. In ACHD the whole spectrum of arrhythmias can be encountered and often several types coexist including disorders of the sinus node, AV-node, His-Purkinje system or intra-atrial propagation. In several types of congenital heart disease, ventricular arrhythmias are the leading cause of sudden cardiac arrest and thus mortality with a 100-fold increased risk in comparison to an age-matched control population. However, the incidence for this often fatal event is only 0.1 per cent and the highest risk is present in patients with Tetralogy of Fallot, univentricular hearts, or patients after Senning or Mustard procedure and transposition of the great arteries. As a consequence, the treatment of ACHD with device therapy including pacemakers or defibrillators is based on few studies although the treatment with devices is an important aspect in HF patients with potential fatal arrhythmias or cardiac resynchronisation therapy, which is often established in HF patients with reduced ejection fraction and left bundle branch block.

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MEDICAL SCIENCES

The pAtientspResenTing with cOngenitalheaRtdIseAseRegister (ARTORIA-R) is an international, observational project collecting retrospective data from 16 countries in the time period 1989 to 2022 and will thereafter include data prospectively (Figure 1)1.

This recently started registry will include data regarding the anatomy of the underlying congenital heart disease, pre- and post-transplant status of the patient, and waiting list details. Study partners are welcome to share their data with the registry and in return are allowed to use the data for scientific projects.

The study is registered at ClinicalTrial.gov (https://www.clinicaltrials.gov/) of the United States Library of Medicine with the identifier: NCT04848844

The suggested register will contribute to the scientific progress regarding treatment of advanced HF in ACHD and in this aspect as well contribute to the improvement of clinical care of ACHD in Europe but as well in the international scope. Thus, with a large cohort of subjects reflecting the current standard of treatment and care of HF in ACHD, implications regarding a certain treatment or intervention can be made which might lead to a consensus regarding future treatment of this patient cohort.

In summary, in the background of increasing numbers of ACHD and thus a challenge to treat heart failure in these often young patients more international networking is needed to address this still unmet worldwide heart care problem.

References are available at www.asianhhm.com

The listed aspects are a selection of the most important reasons why ACHD treatment has to be considered differently as well as decision making regarding advanced heart failure therapies.

Due to the increasing number of ACHD incidences worldwide and an increase of subjects with the development of heart failure, treatment considerations have to be adapted to this population of patients.

Thus, an issue for these patients is that randomised treatment studies are often lacking or are futile to start due to the low number of patients in the context of the overall patient number with heart failure. An option to generate and collect more data in this patient population is analysing data of registry information of ACHD listed for heart or heart and combined organ transplantation and thus a cohort with advanced heart failure.

The study has been reviewed, in individual countries, in line with national

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requirements for ethical approval and followed according to local protocols for data management.

ACHD are included in the register if: a. they are listed as an adult transplant candidate (≥18 years) for heartonly or heart-combined with other organs. b. they have a congenital heart defect c. data is available from the initial evaluation for listing or the first listing on the waiting list. d. data of patients with advanced HF evaluated for listing but being in a too poor condition to be listed are entered as well. e. transferred data is anonymised. f. The institution/organisation agrees to the data management and scientific cooperation plan.

ACHD are excluded if: if they are listed for a second heart transplantation (retransplantation).

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AUTHOR BIO

Figure 1: Current member countries of the ARTORIA-R

Christoph Sinning is senior physician at the Department of Cardiology University Heart and Vascular Center in Hamburg, Germany. He is currently the coordinating physician of the international ARTORIA - R (pAtients pResenting wiTh cOngenital heaRt dIseAse -Register) which has the focus on adults with congenital heart disease listed or evaluated for heart or heart and combined organ transplantation. He is the head of the echocardiography laboratory at the University Hamburg with research focusing on heart failure, adults with congenital heart disease, atrial fibrillation and cardiovascular imaging.

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Stiegelmeyer China starts bed production in Foshan

The German manufacturer celebrated the official opening of its Chinese facilities

More than 120 years of innovations in health and long-term care, German brand quality and international experience: the Stiegelmeyer Group is one of the world's most successful manufacturers of medical beds. With the launch of Stiegelmeyer China, the German family-owned company is now dedicating itself to the Asian market even more than before.

The new subsidiary is based in Foshan, an up-andcoming city of millions northwest of Hong Kong. In 2021, Managing Director Jochen Zhu-Schleiss and his team moved into a modern office space on the 30th floor of a high-rise building and began preparing for production and distribution and finding regional suppliers. They are now setting out with high goals – in the truest sense of the word. Because the new factory with 5,000 square metres of space is also located in a skyscraper and occupies the 6th and 7th floors there. Factories in skyscrapers are common in Chinese megacities to save space.

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The Dali from the Burmeier brand is the best-selling care bed in Germany.

The new production site comprises three areas: the innovation centre, the assembly plant and the warehouse for the dispatch of the beds. In the impressive innovation centre, there are 16 workplaces for employees from the areas of product planning, engineering and development. There are also inviting lounge areas for discussions and a large training room: "Here we can train nursing staff and technicians from our customers as well as our own employees," explains Mr Zhu-Schleiss.

During the opening ceremony the guests were able to take a first glance at the beds for the Asian market.

Jochen Zhu-Schleiss, Managing Director of Stiegelmeyer China, has prepared the start of the new subsidiary with passion and commitment

The heart of the production facility is an assembly line over 20 metres long. The production of the care beds Libra, variant bodenfrei Plus, and Libra partner

by Stiegelmeyer as well as the models Dali and Dali low-entry by Burmeier is currently being tested here.

Within the Stiegelmeyer Group, the Stiegelmeyer brand stands for hospitals and nursing homes, while Burmeier is responsible for homecare.

The selected beds are particularly well suited for the entry into the Chinese market. For the Libra care bed, for example, he chose the variant bodenfrei Plus because the laminate or plastic floors in the local nursing rooms are often thoroughly cleaned with a mop, explains Mr Zhu-Schleiss. In the process, the bed's chassis cannot be in the way.

The Dali is Germany's best-selling care bed and is recognised throughout Europe for providing safe, comfortable care for residents in homecare. This model is tailor-made to support the rapid development and professionalisation of geriatric care in Asia. The low-height variant Dali low-entry protects users from fall injuries without restricting their freedom of movement. In addition to these care beds, Stiegelmeyer China is also planning to start manufacturing hospital beds in 2023.

The first deliveries are planned for this autumn. The principle of "China for China" applies to assembly and distribution: several regional suppliers produce the required wood and metal components, and the beds made in China are sold exclusively in Asia. It is helpful that important European partners of the Stiegelmeyer Group are also represented in China and can deliver from there. For example, the location of the Danish bed control manufacturer LINAK is only a 90-minute drive from Foshan. LINAK contributes the modern energysaving drives and the ergonomic handset for the beds.

To ensure that the assembly of the first beds can proceed smoothly, "back-up containers" with compo-

nents from the European Stiegelmeyer plants have arrived in Foshan for the coming weeks. Sales of 500 beds are planned for 2022, and this number is to increase rapidly in 2023. At the end of August, Stiegelmeyer China employed ten people, according to Mr. Zhu-Schleiss, and by the end of the year this number is expected to rise to 40. Right from the start, Stiegelmeyer China has presented itself locally as an attractive employer.

The official opening of the production facility at the beginning of September was appropriately glamorous.

Mr. Zhu-Schleiss hosted a social event with speeches, a buffet and a spectacular dragon performance. In the light-flooded halls, the guests were able to explore all the beds at length. In China, the dragon stands for luck, kindness, wisdom and success – qualities that Stiegelmeyer China has made its own.

The dragon dance promised luck and success to Stiegelmeyer China.

The team is also looking beyond China. In the longer term, many Asian countries are to be supplied with customised products. In doing so, the new subsidiary can always rely on support from Europe.

A strong export department and a modern engineering and development team in Germany are looking forward to promoting the global growth of the Stiegelmeyer Group. In addition to beds, the company also offers bedside cabinets, mattresses, furniture and digital solutions. The latter are developed in the Connectivity Lab at the German headquarters in Herford in close exchange with customers.

The launch of Stiegelmeyer China is a signal full of optimism in these challenging times. And it is an important building block in the company's goal of offering support and a new quality of life to people in health and long-term care worldwide.

STIEGELMEYER CHINA CO., LTD. Rm 3007, Block 1, Poly Center, No. 8 South Wenhua South Road, New Town, Lecong Shunde District, Foshan 528300, Guangdong, P.R. China Phone : +86 757 298787100 Fax : +86 757 28790210 Email : inquiry@stiegelmeyer.cn

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MEDICAL SCIENCES

Systolic Time Intervals in Clinical Heart Failure Left ventricular (LV) systolic function evaluation is based on ejection fraction assessment. Due to the great sensitivity of the examination, systolic time intervals (STI) are ideally suited to studying the effects of pharmacologic agents on the heart. By knowing the values of STI in ischemic heart disease (IHD) LV systolic dysfunction can be identified. Additionally, this method could have impending applications in the management of IHD. Smitha P S, PhD Scholar, Dept of Physiology, Sri Devaraj Urs Academ of Higher Education and Research Kaviraja Udupa, Faculty, Dept of Neurophysiology, NIMHANS Vinutha Shankar, Professor and Head of Dept of Physiology, Sri Devaraj Urs Academy of Higher Education and Research

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urrently, cardiovascular diseases (CVD) is the leading cause of mortality in India. Ischemic heart disease (IHD) and stroke are the predominant causes and are liable for >80 per cent of CVD deaths. The quality of cardiovascular care in timely detection and variation in CVD treatment to halt the progression of the disease is of paramount importance. Systolic time intervals (STI) measurement provides a temporal representation of the stages of the cardiac cycle that occur sequentially and are physiologically impacted by factors such as heart rate, preload, afterload, and myocardial inotropic condition.

Hence, the addition of easily available techniques like STI measurements in primary and secondary healthcare settings in India along with routine standard investigations is the need of the hour.

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Figure 1: Study flow IHD: Ischemic heart disease; MI: Myocardial infarction; ACS: Acute coronary syndrome; STEMI: ST-elevation MI; NSTEMI: Non-STEMI; PCI: Percutaneous coronary intervention; STI: Systolic time intervals; PEP: Pre-ejection period; LVET: Left ventricular ejection time; QS2: Total electro-mechanical systole.

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Additionally, it became clear from the literature review that there haven't been many studies in India that have used pulsed-Doppler echocardiography to assess STI in patients with IHD. As a result, our study aimed to assess STI in IHD patients and compare the results with those of healthy controls based on LV ejection fraction. (Fig 1).

Our study results revealed a significant difference in STI between cases (n=33) and controls (n=32) (Table and Fig 2). Similar results were observed in a study conducted in France, in which PEP was found to be significantly prolonged; LVET was significantly reduced, with the subsequent significant rise in PEP/ LVET among heart failure (HF) patients using pulsed-Doppler echocardiography. In addition, they observed a correlation between LVEF and PEP/LVET (r = -0.55; P <0.001).

Similar results were found in the current study (r = -0.368, P = 0.196) between LVEF ≤40per cent and PEP/ LVET about IHD patients.

STI fluctuates inversely with heart rate (HR), thus corrections must be made, resulting in PEP index (PEPI), LVET index (LVETI), and QS2 index (QS2I). Even though these modifications are minor, they are substantial, and correcting the PEP for HR improves the method's sensitivity, particularly in clinical pharmacology.

In this study, LVET and HR showed a rather strong association in the case of IHD patients (r=-0.432, P=0.012).

A prospective observational study by Sorrenson et al. included 1980 African-Americans of the Atherosclerosis Risk in Communities.

Subjects underwent echocardiography and LVET was measured using pulsedwave Doppler. On multivariable adjustment for confounding variables, LVET continued to be an independent interpreter of incident HF. LVET additionally offered incremental prognostic data on the likelihood of future HF and death but not MI.

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Table: Comparison of PEP, LVET, QS2, and PEP/LVET between Cases and Controls using independent t-test.

Cases (n=33)

Controls (n=32) t-value

p-value

PEP (ms)

145.23±23.20

82.99±8.63

10.086

<0.00001**

LVET (ms)

231.34±40.89

265.39±31.98

-3.469

0.000947**

QS2 (ms)

376.6±47.8

348.4±29.9

1.244

0.218NS

PEP/LVET

0.63±0.15

0.31±0.08

8.633

<0.00001**

Values expressed as mean±SD. ** Highly significant p ≤0.001; NS: Not significant; PEP=Pre-ejection period; LVET=Left ventricular ejection time; QS2=Total electro-mechanical systole.

Besides, a normal STI among 32 IHD patients with mild to moderate mitral regurgitation was observed in the present study, which was in line with the literature.

Early acute myocardial infarction causes PEP, LVETI, and QS2I to shorten; late acute myocardial infarction causes prolonged PEP and short LVETI. Succeeding acute MI

there will be a reduction in QS2I and ejection time (ET). Additionally, changes in PEP/LVET could be noticeable between the first and fourth days. Instead, the PEP will either be normal or lengthened. Twenty-seven acute MI patients were included in the current investigation (10 early and 17 late), and the STI also demonstrated comparable changes. It's

possible that a longer isovolumetric contraction time contributed to the extended PEP. Known factors which reduce ET are tachycardia, reduced cardiac contractility, reduced stroke volume, catecholamines, digitalis, and isoprenaline administrations. The short-term effects of altered preload on STI were investigated in a different investigation by Khanna et al. in 17 AMI patients and 7 people without AMI. The effects of changing preload on STI were found to have the potential to give a more precise indicator of LV function in patients with AMI than the STI when assessed alone.

Excellent relationships between contractility markers and EF were found in a study by Parker et al. involving 36 male patients with electrocardiographically and angiographically apparent coronary artery disease (CAD). However, it was discovered that STIs were unreliable markers of ventricular function.

Therefore, it is questionable whether or not STIs are useful in the clinical evaluation of CAD. The median LV systolic ejection time (SET) was found to be shorter in heart failure patients with reduced

Systolic time intervals (STI) measurement provides a temporal representation of the stages of the cardiac cycle that occur sequentially and are physiologically impacted by factors such as heart rate, preload, afterload, and myocardial inotropic condition.

Figure 2: Pearson’s correlations and linear regression analysis between left ventricular ejection time (LVET) and heart rate (HR)

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applied, which was not addressed in our study. Patients with congestive heart failure (NYHA class IV) or pulmonary edema will be in respiratory distress or are ventilated mechanically and thus the STIs cannot be obtained properly from them; accordingly, they were excluded from our study. Future prospective studies with large sample sizes need to be done to replicate and confirm our findings and the utility of this technique as routine investigation as a prognostic measure in IHD patients.

Declaration of patient consent: Written informed consent was obtained from all the study participants. ejection fraction (HFrEF) compared to those with preserved ejection fraction (HFpEF) (280 vs. 315 ms, P<0.001), the median PEP obtained was longer (114 vs. 89 ms, P<0.001), and the median relaxation time was shorter (78.7 vs. 93.3 ms In cases where there was a death or hospitalisation for HF, 11.8 per cent (n = 44) and 26.9 per cent (n = 46) of HFrEF patients respectively. Longer SET was independently linked with improved outcomes among HFrEF patients but not HFpEF patients, according to multivariate testing, indicating a potential role for stabilising SET as a beneficial strategy in patients with systolic dysfunction.

Therefore, utilising pulsedDoppler echocardiography, our study was able to precisely assess systolic time intervals as an indication of LV systolic function in patients with IHD. STIs, particularly PEP/LVET, had strong correlations with traditional LV systolic performance indices such LVEF. Therefore, this approach may be particularly helpful for IHD patients with LVEF lower than 40 per cent.

STI is a non-invasive, low-cost, and straightforward procedure that may be clinically effective for identifying individuals who have early LV

dysfunction as well as for the treatment of IHD. Pre-ejection period and PEP/LVET are linked to QRS width; henceforth corrections as described must be

Funding: Self-funding.

Conflicts of interests: None declared.

References are available at www.asianhhm.com

AUTHOR BIO Miss Smitha P.S., completed M.Sc. in Medical Physiology from KMC Manipal, India. Currently pursuing Ph.D.in the field of Cardiovascular Physiology under the guidance of Dr. Vinutha Shankar MS at Dept of Physiology, SDUMC, SDUAHER, Kolar. Holds 10 years of teaching experience.

Published several research articles in national and international journals. Reviewer of JCDR and so on

Kaviraja Udupa, currently faculty at Dept of Neurophysiology, NIMHANS, Bangalore after his MBBS (Mysore Medical College), MD (Physiology, JIPMER), Ph.D. (Neurophysiology, NIMHANS), and Post-doctoral fellowship in Clinical Neurophysiology from the University of Toronto. His expertise and interest are cardiac autonomic functions, clinical neurophysiology, and noninvasive brain stimulation in neuropsychiatric disorders Vinutha Shankar M.S currently the Professor and Head of Dept of Physiology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka. Completed her MBBS (Mysore Medical College), MD (Physiology, Bangalore Medical College), and a fellow of FAIMER. She is the Director of University Centre for Health Professions Education and has more than 20 years of teaching experience. Her expertise and research interests are Cardiovascular physiology and Neurophysiology

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Every time Hemodialysis is Performed, Air Bubbles are Injected into the Patient During haemodialysis treatment, air bubbles may enter the patient’s blood circulation from the haemodialysis circuit, resulting in air embolies in many organs. Our novel capped needle has been shown to reduce the residual volume of air bubbles entering the blood circulation. At the moment, we are seeking manufacturers for this invention.

Kazuhiko Shibata, Researcher, Artisan Lab Co., Ltd. and Yokohama City University school of medicine

A

t the start of haemodialysis, we often find air bubbles remaining in the blood circuit.

Nevertheless, these air bubbles flow into the patient's body soon after haemodialysis is started.

This is a common occurrence, and even though the medical staff would like to eliminate all air bubbles, they cannot solve the problem through effort alone.

You might think that such a thing would only be bad for dialysis patients. That is true. The bad news is that some reports have indicated that air bubbles in the blood circuit are broken up into smaller bubbles by turbulence in the vascular access after the start of the haemodialysis. Some of these broken bubbles become air emboli in the lungs resulting in ischemic damage and pulmonary hypertension. To make matters worse, some air bubbles pass through the pulmonary vascular bed and migrate into the systemic circulation. In more serious cases, when there is the presence of an intracardiac shunt, most frequently caused by a patent foramen ovale, this may allow air bubbles to enter the body’s circulation directly. A patent foramen ovale is present in more than 20 per cent of haemodialysis patients. The most shocking and important study to date was published by Forsberg and colleagues in 2019.The findings of autopsy on five patients who

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passed away during or shortly after haemodialysis. In all five autopsy cases had evidence of air embolism before their death in several organs, including the brain. It is no surprise that haemodialysis has been reported to be associated with air emboli in the brain.

It is well known that the number of microbubbles rises at the start of dialysis and subsequently falls over the course of the therapy. These reports suggest that all visible air bubbles should be removed before haemodialysis. The problem arises due to the fact that the air-filled needle must be connected to a blood circuit filled with fluid. In order for the medical staff to remove the air from the needle and needle connecting tube, they have to resort to operating the dialysis machine to blow the dialysate out of the needle tip. Another method is to puncture a vessel with a needle first and wait for the blood to flow back, but blood is precious and cannot be flooded in large quantities. Fewer air bubbles remain in the circuit when blowing out dialysate in comparison to wasting a small amount of blood.

The idea of auto priming using a set of two connected needles with a whole blood circuit has been proposed for some time. However, this method has the fatal problem of not being able to select the appropriate needle for each puncture site freely. For this reason, it is not commercially available. To solve this problem, we developed a separated capped needle with a watertight structure to connect to the blood circuit.

The photo shows a needle with a novel cap and a standard connector to close the blood circuit. With this method, the optimal needle for each puncture site can be selected, or only one of the needles can be used. These new capped needles can be connected to a blood circuit, and the auto priming process would be able to eliminate the air not only in the circuit but also in the needle.

Due to the fact that automated priming process applies intense negative pressure to the dialysate, the cap and

needle needed to be glued together. The cap's base was given a groove so that it could be readily removed with a small twist. The cap was open on one end, and a screw was equipped to firmly fasten it to the extracorporeal circuit(Figure 1).The two capped needles can then be connected by an ordinary connector to form a closed circuit. Automatic priming of the haemodialysis machine eliminates air from the needle and the circuit all together. The cap is removed with a slight twist and is ready for puncture. We investigated in the field whether this new capped needle could reduce air bubbles compared to conventional methods.

The conventional method

Before automated priming can be carried out using the majority of haemodialysis machines, the arterial and venous sides of the blood circuit must be connected to establish a closed circuit.

The extracorporeal circuit was primed using a DCS100NX (Nikkiso Co., Ltd., Tokyo, Japan). This common technique for automatic priming is now used by Nikkiso and other manufacturers. Then, our expert nurses unplugged the arterial and venous sides of the extracorporeal circuit and attached both ends to the needles after the automatic priming procedure. They then turned on the

dialysis machine to pump dialysate into the circuit while making an effort to blast air bubbles out of the needle. We next carefully checked the extracorporeal circuit and needle-connecting tubing to see if there were any air bubbles after this procedure. Only bubbles from the chamber outflow on the venous side of the needle were measured because bubbles on the artery side of the extracorporeal circuit are likely to be eliminated by the air trap chamber. The following is an explanation of The Novel CappedNeedle Method: The extracorporeal circuit and the capped needles were closed. The circuit and capped needle were then both automatically primed.

There were ten consecutive trials run.

The air bubbles in the extracorporeal circuit and needle connecting tube were carefully inspected and measured.

In addition to the conventional and novel-capped needle method, the experiments using a microparticle counter were also performed: we expected that a tiny number of bubbles would remain in the circuit after the capped needle method. Due to this, a microparticle counter had to be used to measure the size and number of the bubbles. Twenty-five automatic primings were carried out using the brand-new capped needle technique.

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MEDICAL SCIENCES

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Careful exploration of every inch of the circuit revealed no visible bubbles on the venous or arterial side of the circuit in any of the cases. Furthermore, we also obtained results from additional experiments using a microparticle Counter. The capped-needle method using a particulate counter was evaluated in 25 consecutive automated priming sessions. The dialysate collected from the extracorporeal circulatory tract contained a total of 361 particles.

Using the capped-needle method, the average amount of air still present in

References

1. Shibata, K., et al., Novel CappedNeedle Device: A Novel Safety Feature to Eliminate Air Bubbles in Hemodialysis.

Blood Purif, 2022: p. 1-6.

Kazuhiko Shibata is a researcher at Artisan Lab Co., Ltd. and Yokohama City University school of medicine. His major inventions are a new hemostatic agent using cationic cellulose launched last year with Nipro Corporation, which rducetha average of hemostatic time to an average of 3 minutes in haemodialysis patients at puncture site. And a slimming substance derived from euglena with the National Institute of Advanced Industrial Science and Technology (AIST) which could prevent obesity and diabetes mellitus.

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AUTHOR BIO

We then collected 3 mL of dialysate samples to determine the number and size of the residual bubbles. Measurements were made in this experiment using the RION particle counter KL-04A. (RION Co.,Ltd.).

We obtained the following results from the Conventional Method. In 29 out of 50 cases, we detected bubbles.

We counted the leftover bubbles and discovered that they were all contained in the connecting tube of the needle, not in the dialysis circuit. The circuit had a 3.5 mm diameter. The minimum volume of the bubbles reaching the tube wall was determined to be 22.43 L, taking into account that huge bubbles would at least reach this diameter. Since the tiny bubbles were different sizes, it was impossible to quantify their volumes properly. In 50 tests, the average air volume was 11.67 ±17.28 L. The real volume of the bubbles was likely several times more than this value because the majority of the huge bubbles were elongated rather than spherical.

The following results were obtained from the Novel Capped-Needle Method.

For this procedure, ten consecutive automated priming trials were carried out using the novel capped needle.

the extracorporeal circuit was 0.0999± 0.2438 nL. This clearly indicates that considerably more air bubbles are remained by the conventional method than by the capped needle method. The capped needle also reduced the number of bubbles to 1/100,000.

Dialysis staffs must repeatedly put on air-filled needles and then operate the dialysis machine to flush dialysate from the circuit and needle to remove air. Their efforts are as futile as Sisyphus' effort to roll a heavy stone up a hill.

Moreover, the workload is enormous because two needles are attached to each circuit. Furthermore, this method decreases the amount of air entering the patient’s blood circulation by 100,000 times. [1] In conclusion, the new capped needles reduce air bubbles from entering into the patient’s blood circulation.

First, and most importantly, there is a high possibility that this can positively affect the prognosis of the haemodialysis patient. In addition, it may also reduce the workload of dialysis staff who are already overworked. Further information is provided in my paper.

RESEARCH INSIGHTS

The rapidly evolving monkeypox epidemic: A call to action to leave no one behind WHAT ARE THE KNOWN KNOWNS? • Steffanie A. Strathdee, Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, United States of America • Davey M. Smith, Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, United States of America • Megan Halbrook, Fielding School of Public Health, University of California—Los Angeles, Los Angeles, California, United States of America • Placide Mbala-Kingebeni, Institut National de Recherche Biomédicale (INRB), Kinshasa, Democratic Republic of Congo, University of Kinshasa, Kinshasa, Democratic Republic of Congo • Shira Abeles, Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, United States of America • Francesca Torriani, Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, United States of America • Anne Rimoin, Fielding School of Public Health, University of California—Los Angeles, Los Angeles, California, United States of America Published: October 31, 2022

Monkeypox virus (MPXV) is characterized by painful skin lesions and fever, sometimes with lymphadenopathy, pharyngitis and myalgia, and a prodromal period.

Although infections are self-limiting, severe complications can occur. In a multicountry case series, 13% were hospitalized, mostly for pain, but no one died. Unlike previous MPXV outbreaks that were zoonotic and primarily confined to Africa, this pandemic had multiple introductions of a seemingly more transmissible Clade 3 B.1 variant in Western Europe and North America and is characterized by human-to-human transmission, mostly among men having sex with men (MSM). Although direct contact with infected lesions and fomites appear to be the most important risk factors (Fig 1), respiratory secretions can transmit MPXV and it can cross the placenta. We can expect ongoing transmission since global population immunity waned following cessation of routine smallpox vaccination.

Vaccines exist. Single-dose and dual-dose smallpox vaccines seem efficacious against MPXV. Both remain in short supply due to shortcomings in global manufacturing and distribution.

Roll-out has been further complicated by lack of testing to inform decisions about which populations should be prioritized, which has contributed to vaccine inequities. www.asianhhm.com

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RESEARCH INSIGHTS WHAT ARE THE KNOWN UNKNOWNS?

We can predict spread. MPXV DNA has been detected in feces, nasopharyngeal swabs, urine, saliva, blood, and semen. If it persists and is viable in sexual fluids, other at-risk populations include those engaging in sex work and sexual entertainment. If it persists in blood, it could be transmitted by contaminated paraphernalia of injection drug use. An outbreak has been associated with a piercing and tattoo parlor in Spain. New animal reservoirs could include pets and other domesticated animals.

Spillover to other vulnerable populations should be anticipated due to close associations between MPXV and rodents, oral–fecal contamination, and transmission between close contacts. This includes people experiencing homelessness, incarceration, addiction, and forced migration due to intersecting risks such as poverty, stigma, discrimination, mobility, and low health literacy, which can foster medical mistrust and vaccine hesitancy. Minority groups who face systemic prejudices in healthcare settings are being disproportionately affected. Congregate settings such as homeless encampments, prisons/jails, nursing homes, daycares, and refugee/migrant camps are also at risk. Mathematical modeling scenarios can be used to predict trends in transmission, morbidity, and mortality to inform prevention efforts, as was done for HIV and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

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Potential treatment exists. Smallpox antivirals (tecovirimat and brincidofovir) may reduce disease severity and duration, but safety and efficacy data await results from clinical trials.

WE KNOW ENOUGH TO ACT

Learn from past successes. Smallpox was eradicated in 1980 following a globally coordinated plan involving testing, contact tracing, and ring vaccination. Similar approaches should be undertaken for MPXV, using sero-surveillance, molecular testing of high-risk populations, and wastewater surveillance.

Learn from past mistakes. Although MPXV is very different from SARS-CoV-2 and HIV, the Coronavirus Disease 2019 (COVID-19) and HIV/ AIDS pandemics offer lessons. Testing, vaccination, and treatment should be immediately scaled up and offered free to high-risk populations globally, through coordinated strategies that minimize bureaucracy (e.g., strict eligibility requirements for testing) and includes timely contact tracing.

Affordable health care, paid sick leave, and telehealth should be expanded. Health communication requires mandated reporting, consistent messaging and transparency, being clear about what we know and what we don’t. Concerted efforts should be made to quell stigma, misinformation, and disinformation through meaningful consultation with affected populations.

Address global health inequities. International multiagency coordination is needed so high-income countries do not hoard vaccines, treatments, or protect patents at the expense of lower and middle-income countries where MPXV is endemic. Global cooperation and political will is needed to assist lower income countries with access and last-mile delivery of testing, treatment, and vaccines. Affected populations need to be consulted at all stages to ensure that interventions are regionally and culturally appropriate.

Take action. Decriminalizing substance use, sex work, homosexuality, and homelessness would decrease stigma and encourage vulnerable populations to seek testing, improving case-finding, and treatment.

During the COVID-19 pandemic, some regions depopulated prisons or included sex workers in government subsidies. Regions facing armed conflict and other complex emergencies cannot be overlooked in prevention and treatment efforts. Testing and vaccination programs should leverage social media and engage nongovernmental organizations in mobile outreach.

Invest in research. Studies to characterize the epidemiology, social networks, clinical presentation, morbidity, and mortality associated with MPXV infection are critically needed to inform primary and secondary prevention. Sero-surveillance should extend to animals, including pets and wildlife that could serve as reservoirs. Treatments found safe and effective should be evaluated as prophylaxis in highrisk populations. Research and implementation studies could leverage existing networks including but not limited to those established for HIV/AIDS (e.g., AIDS Clinical Treatment Group, Centers for AIDS Research, HIV Prevention Trials Network, HIV Vaccine Trials Network) and COVID-19 (e.g., ACTIV, RADx, RADxUP).

WHAT ABOUT THE UNKNOWN UNKNOWNS?

MPXV isn’t the first pandemic of the 21st century, but it has already shown how unprepared we continue to be.

Declaring a public health emergency of international concern (PHEIC) has limited impact if not met with action, building upon COVID-19 mitigation approaches, with an eye towards other threats (e.g., enteroviruses, avian influenza, new coronaviruses and antimicrobial resistance). Addressing root causes of syndemics that disproportionately affect socially disadvantaged populations could significantly reduce health disparities associated with multiple disease

outcomes and would ultimately be cost saving.

Ensuring that we leave no one behind requires global cooperation to strengthen infrastructures for public health surveillance and capacities of health care systems and their workers. Without addressing global health inequities, we will continue to be unprepared for future pandemics.

References are available at https://doi.org/10.1371/journal. pmed.1004128

CITATION: Strathdee SA, Smith DM, Halbrook M, Mbala-Kingebeni P, Abeles S, Torriani F, et al. (2022) The rapidly evolving monkeypox epidemic: A call to action to leave no one behind. PLoS Med 19(10): e1004128. https://doi.org/10.1371/journal. pmed.1004128 PUBLISHED: October 31, 2022 COPYRIGHT: © 2022 Strathdee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

FUNDING: SAS was supported by the National Institute on Drug Abuse (NIDA) (3R01DA049644-03S3). DMS was supported by the National Institute of Allergy and Infectious Diseases (NIAID) (P30AI036214) and the John and Mary Tu Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

COMPETING INTERESTS: I have read the journal’s policy and the authors of this manuscript have the following competing interests: DMS has serves as consultant for FluxErgy Inc, Brio Clinical, Bayer HealthCare, Model Medicines, Linear Therapies, Pharma Holdings, VxBiosciences, and Signant Health.

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SURGICAL SPECIALITY

Occupational Hazards of Surgical Smoke in the Operating Room (OR) Surgeons and medical personnel face growing health risks in the operating room (OR) from prolonged exposure to surgical smoke which can cause acute and chronic health effects. To address this, for the first time in Asia, a consensus statement based on the expert opinions of 10 leading surgeons from Singapore, Hong Kong, and India; and one leading surgeon from the United States, was developed. The purpose of this consensus statement is to discuss the key issues regarding surgical smoke and share recommendations based on the current scientific evidence.

Anil Heroor, Director, Surgical Oncology at the Advanced Onco Surgery Unit, Fortis Hospitals

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1. What are the potential risks of surgical smoke exposure?

Energy devices used during surgeries, regardless of open or laparoscopic procedures, can generate surgical smoke.

The presence of over 80 potentially hazardous chemicals, blood and tissue particles, bacteria, and virus particles, as well as carcinogenic compounds that can be found in surgical plume has made this a growing concern.

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A recent study which investigates the results of exposure to surgical smoke revealed that OR personnel experienced headaches, dizziness, watery eyes, coughs, and several other complications. During the expert panel discussion, there was also a consensus that the compounds found in surgical smoke are above recommended levels of acute exposure limits that have been set by national health organisations.

SURGICAL S PECIALITY

Healthcare professionals need to be aware of such risks and ensure they take the necessary precautions to avoid longterm complications.

2. How are current guidelines and recommendations in the region addressing this?

3. What are the key factors that surgeons and OR personnel need to consider with regards to surgical smoke?

During the panel discussion, we concluded that there are several factors that need to be considered to determine the right mitigation approach. Firstly, the type of surgical approach—Open, Laparoscopic or Robotic—can have an impact on the amount of surgical smoke exposure. Secondly, the duration of exposure is an absolute factor that can have a hazardous effect on OR Personnel. Lastly, it is critical to measure air quality in the OR as an important safety measure. Surgeons and OR personnel should keep these factors in mind and adjust techniques accordingly.

4. What are the recommendations around achieving a smoke-free OR environment?

The panel came to a consensus that a multidisciplinary approach involving engineering, work-practice and administrative controls is key to achieving a smoke-free OR. Engineering controls are important to ensure ORs are adequately ventilated and maintain air quality at safe levels.

This includes the use of local exhaust ventilation, which has shown to be effective in mitigating smoke exposure by reducing airborne particles and volatile organic compounds .

The panel also recommends implementing adequate work practice controls and a reasonable smoke Anil Heroor is the Director, Surgical Oncology at the Advanced Oncology Surgery Unit at Fortis Hospitals, Mumbai. He is also a Consultant Oncosurgeon as part of his independent practice in the city suburbs. At Fortis Hospital – Mulund in Mumbai, he trains junior residents in the field of Laparoscopic Minimal Access Oncosurgery. He also serves as a faculty member at Johnson and Johnson Institute India. His experience includes working with international hospitals in Japan and the USA. Performing an average of 600 supramajor procedures a year, Dr Heroor has been involved in over 25 publications across several surgical fields including thoracoscopy and oncology

management system to minimise the exposure. Such measures include policies around surgical attire, implementing scheduled breaks and the use of smoke evacuator systems specially designed to remove smoke near the source. Smoke evacuator devices also offer options to adjust the run time and flow rate based on the type of surgery being performed to effectively mitigate the risk.

With varied approaches required across hospitals and regions, setting in place stringent administrative measures and national policies is the need of the hour for OR safety. During the discussion we agreed that enhancing the safety of OR personnel is a shared responsibility between hospital administrators, nursing staff, operating surgeons and others.

AUTHOR BIO

Despite increasing awareness and a mounting body of evidence around risks associated with long-term exposure to surgical smoke for OR personnel, there are still limited standards on addressing these hazards in Asia. This could be due to the lack of studies that investigate the long-term effects of surgical smoke exposure, preventive measures and associated adverse events.

There are guidelines such as the Occupational Safety and Health Act and the Center for Disease Control and Prevention-National Institute for Occupational Safety and Health (CDC-NIOSH) that speak to recommendations and preventive measures. However, there are still no specific guidelines from Asia including the National Accreditation Board for Hospitals and Healthcare Providers from India.

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TECHNOLOGY, EQUIPMENT & DEVICES

Six Reasons to Focus on the Quality of Medtech Devices in India Quality of medical equipment, whether simple or sophisticated, has a direct impact on the quality of care. This especially applies to cases where a patient uses the medical device by themselves, such as a hearing aid, or they are placed on a ventilator under expert supervision, or have a some device installed internally such as a stent by an expert. This could also apply to equipment used in diagnostics and monitoring including in vitro diagnostics, or consumables such as a syringe or a needle that is used by a doctor. For best results, there is no doubt that the quality of the device would remain indispensable to over-all outcome.

In fact, given the very nature of a medical device and its immense value to a patient, in somewhat metaphorical terms, quality and medical device must be inseparable from each other.

Ashok Patel, CEO and Founder, Max Ventilator

Why is quality so important?

Quality is a function of intent and thought First of all, quality begins in the mind. For a manufacturer to produce quality product, their natural thought process should steer towards wanting to make quality medical devices. For this, they must envisage a long shelf life for the product, prompting the use of quality inputs and components.

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TECHNOLOGY, EQUIPMENT & DEVICES

Best for patient’s health outcome

Second, from a patient’s perspective, the best available device at a given point in time would be ideal for their health outcome. While the expert doctor’s proficiency and ability is important enough, the quality and features of the tool that they use is equally critical.

Quality innately linked with patient safety

Third, quality has an innate linkage to patient safety. If the quality of a medical device is not above par, there is a risk of endangering or even aggravating a patient’s health condition, or, in extreme cases, endangering the patient’s life. There have been several instances reported in the media on how faulty devices have played havoc with the health and lives of Indians. Some years ago, the coronary stents of a top medical equipment maker were found to be responsible for more that 50 per cent of adverse events. In another instance, a leading healthcare and medical device manufacturer had to be hauled up before courts for supplying faulty hip transplants to patients, resulting in compensation being paid to the aggrieved patients. Recently, it has been reported that nearly 100 heart patients, who had got heart stent implants at a Delhi-government-run super specialty hospital died in the last two years allegedly due to poor quality of the stents. During the COVID fight back, there were reports of how poor quality ventilators were being churned out in the rush for ramping up the quantity of these lifesaving devices.

Quality critical to India’s commercial interests

Fourth, from a commercial pointof-view, turning out quality medical devices is also critical to India’s global business interests as well as to meet India’s cherished goal of becoming Atmanirbhar(self-reliant). Given the exceptionally demanding and rigorous quality benchmarks and standards

set by Western regulatory authorities, only a high-quality products would pass muster with them and compete in international markets. Moreover, with Chinese products being widely reported to be of substandard quality, and failing to live up to industry and consumer expectations, upgrading quality of Indian medical device products can also help Indian manufacturers take China’s place in the global market.

Quality of a product equivalent to the quality of components

Fifth, quality of a finished and end-use medical device would be as good as the quality of its components. The pursuit of manufacturing quality product would necessitate sourcing quality inputs and materials. This could lead to setting up the base for a value chain of quality medical devices within the country. It would also entail incorporation of good manufacturing practices and putting in

AUTHOR BIO The visionary founder and the brain behind Max Ventilator, Ashok Patel has been a prominent face in the health technology sector for over four decades now. Patel initially established A B industries focused on power management and control systems and equipment at Vadodra, Gujarat. However in 1992, in view of the surging demand from the medical fraternity and the domination of the existing ventilator market by foreign players supplying the critical care equipment at exorbitant rates, the company diversified into making medical ventilators. Under Patel’s able leadership, over these nearly three decades, the company has come a long way registering impressive growth and carving a name for itself as a specialist ventilator maker in the domestic as well as foreign market.

place credible and time-tested quality management systems backed by a quality manual, proper documentation and recording etc.

Quality rules out unnecessary and recurrent expenditure

Sixth, making use of quality equipment also obviates the need for unnecessary and extra expenditure for patients. If a certain medical equipment is prone to malfunctioning or breaking down, besides posing risks to a patient’s health, it adds to the patient and their family’s monetary burden by way of repair or replacement costs. Similarly, in government-run, or government-backed health facilities, poor and malfunctioning equipment and machines would escalate the cost burden of the government.

Therefore, producing quality medical devices must become the overriding goal of policymakers and manufacturers.

While quantity production remains important for a huge country with an imposing health burden, quality cannot be glossed over. And the authorities have already taken several measures in that respect in recent years. From laying out a four-fold risk-based classification system to setting a separate regulatory framework for medical devices, making manufacturers and importers more accountable through registration, mandating the acquisition of ISO 13485 certification to reexamining and implementing Schedule MIII vis-à-vis quality management system for medical devices (a draft guidance on good manufacturing practices and facility requirements), there has been clear intent on the part of the government to make quality a priority. Last year in June, the Quality Council of India (QCI) and the Association of Indian Manufacturers of Medical Devices (AiMeD) launched the Indian Certification of Medical Devices (ICMED) 13485 Plus scheme to undertake verification of the quality, safety and efficacy of medical devices.

This demonstrates that we are on right track.

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FACILITIES & OPERATIONS MANAGEMENT

Enhancing Accessibility to Critical Healthcare Facilities in Asia Pacific's Emerging Markets After facing the second waves of covid-19 and with global recession, the APAC market is under faster recovery process. To quicken the process further, every healthcare provider should aim to build a sustainable future providing world-class healthcare facilities in emerging markets. One of the region’s key missions should be to invest in local resources to develop local talent to add to the medical and clinical skillsets required to help communities with their healthcare needs.

Massimiliano Colella, CEO, Evercare Group

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1. What is your assessment of healthcare accessibility across the APAC region today?

the patients and provides a sustainable ecosystem.

The Covid–19 pandemic highlighted many inequalities in healthcare around the world. After facing multiple waves of the pandemic, the Asia-Pacific (APAC) market is undergoing a steady recovery process. The pandemic has also given rise to a rapid reinvention of healthcare delivery across the APAC region. Certain healthcare providers are disrupting the traditional healthcare model by providing an impact-driven model aimed at increasing accessibility to quality healthcare for underserved populations across the low and middleincome sectors.

Today, healthcare providers are increasingly focused in their approach to provide an integrated, impact-driven healthcare model that meets the needs of

2. What are the current gaps in access to safe and quality healthcare in the region?

A SI A N H O S P I T A L & H EA LT HCA R E M A N AGE M E N T

Health disparities exist in the quality of health and provision of healthcare across different geographies and different socio-economic conditions. Many low and middle-income countries continue to suffer from insufficient investment in healthcare, leading to often highly strained and burdened systems that are unable to keep up with demands of patients. According to the World Bank, if current trends continue, up to five billion people will be unable to access quality healthcare by 2030 with 56 per cent of the population lacking sufficient healthcare coverage, especially in rural areas.

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A key learning is to continue to invest in medical technology along with building energy-efficient infrastructures and developing a competent and compassionate workforce. Technology has been our biggest contributor to date and going forward tech-enabled healthcare solutions will reshape the dynamics of and access to quality healthcare services. Many healthcare providers are determined to create a positive change by ensuring that more and more underserved populations have access to quality healthcare.

3. What are some strategies to ensure greater accessibility in APAC’s emerging markets?

Many healthcare providers are delivering high-end health solutions and services that complement their core health offerings and meet the delivery of

ExpertTalk

FACILITIES & OPERATIONS MANAGEMENT

AUTHOR BIO

end-to-end patient care. However, there has been limited awareness and funding of these services. With an ageing population and the increasing prevalence of non-communicable diseases along with the high demand for quality care in an evolving middle class, it has become more difficult to provide the right quality care to those in need. In such a situation, it is imperative for both government and private healthcare providers to collaborate to provide and support the increased and diversified access to quality healthcare in the underserved regions. Many healthcare providers are missioned to unite to improve the standard of care for all patients and strengthen healthcare ecosystems across APAC through greater innovation and regulatory harmonisation.

4. How are sustainable healthcare systems built and maintained?

There is a basic connection between healthy patients and a sustainable eco-environment.

Healthcare providers should incorporate a corporate social responsibility commitment in their business practices. To build a sustainable healthcare system, one should be aware and focus on improving greater resource efficiencies across their ecosystems.

By collaborating with external partners and NGO’s, not only can this be beneficial for the sustainability, but this can be financially rewarding too. Equally, setting up KPIs for minimisation of waste, water, energy utilisation and regular monitoring and analysis can help maintain sustainable healthcare systems. Also, healthcare providers must put in place the best ethical practices within their facilities encouraging their employees to be the champions of sustainable growth, so that at every level there is better conservation of resources, and judicious utilisation of available resources.

Massimiliano Colella is the Chief Executive Officer of the Evercare Group, the leading impact driven healthcare network in emerging markets across Africa and South Asia. He is widely recognised as an expert in leading healthcare companies to success globally with almost three decades of experience in large multinationals such as Johnson & Johnson and Smith & Nephew. He has served as a Board Member with Industry Associations and Chambers of Commerce such as Asia-Pacific Med-tech, Europe MedTech Association, the American Chamber of Commerce in Czech Republic, and the British Chamber of Commerce in Singapore.

References – Universal Health Coverage Overview (worldbank.org) Tackling the Pandemic of Inequality in Asia and the Pacific – The Diplomat

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INFORMATION TECHNOLOGY

Balancing Demand and Supply in Mental Health The Role of Technology There is a demand-–supply imbalance in mental healthcare.

The rapidly growing demand for mental healthcare services has met the undersupply and overstretched provision of healthcare services. Balance can be achieved by increasing technology to increase supply and decreasing technology to decrease demand.

Begoña San José, Clinical Psychologist

T

he demand for mental health support is rapidly growing.

The COVID-19 pandemic, looming financial uncertainty, the energy crisis, and armed conflicts, among others, have triggered significant worsening of the mental health of populations across the globe.

This is reflected in sleeping difficulties, increases in alcohol consumption or substance use, symptoms of trauma, and suicidal thoughts. The prevalence of anxiety and depression has increased, and with it, the consumption of antidepressants and anxiolytics.

Simultaneously, and partly as a result of the measures to contain and limit the spread of COVID-19, mental health protective factors such as social connections with colleagues and friends and family, physical exercise, natural light exposure, daily routines, access

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to health services fell dramatically.

Plus, mentally unhealthy lifestyles characterised by sedentarism, poor diets, high social media consumption, substance use and abuse, poor quality interpersonal relationships, isolation, sleep deprivation, lack of work-life balance exacerbated by teleworking and blurred boundaries between work and home, overweighted mentally healthier ones.

This dangerous cocktail affects larger and larger segments of the population but takes an especially high toll on the most vulnerable. Women, more likely than men to report mental health disorders, are experiencing burnout, especially those juggling increasingly demanding jobs, homeoffice and childbearing responsibilities.

People suffering from chronic illness, and older adults, already at higher risk

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of having a concurrent mental health issue, experience an exacerbation of their vulnerability, both to a mental and a physical worsening of their condition. Children and young adults are experiencing mental distress due to disruption in routines, loss of social contact. Stress in the households is leading many to turning to social media and substance use as coping mechanisms. For those with disruptive family structures or exposed to abuse, the situation is even worse, and sadly, too many young adults are experiencing suicidal ideation. Healthcare providers and educators, often buffering thanks to their training and the social nature of their professions, are increasingly threatened by burnout. Last but certainly not the least, the situation for those already experiencing mental health disorders, is especially delicate

INFORMATION TECHNOLOGY

Figure 1: Unbalanced demand-supply in mental health

since the increasing demand for mental health support of other segments, affect negatively their own ability to access services.

As illustrated above, there is an increased demand for mental health services. What is the situation like at the supply level? There is an undersupply of mental health support. The situation is not promising. There is a quantitative and qualitative shortage of mental health professionals, especially psychiatrists, who are working beyond capacity, who feel unable to meet the growing demand for support and who feel burned out. Waiting lists are growing and this increased workload is resulting in a reduction of time available per patient and are likely to impact outcomes negatively. To add on to the situation, the fragmentation in mental healthcare makes it difficult

Technology enables bridging physical healthcare with mental healthcare, breaking a historical barrier between the two and providing opportunities to better integration of behavioural and physical healthcare.

and inefficient to get supported while transitioning to the different levels of care. Figure 1.

In the current context, there is, therefore, an imbalance between a high demand for mental health services and a shortage in the supply of these needed services.

Increase technology to increase supply

Technology can boost the supply of mental health support by improving access, quality, and efficiency.

Since the onset of the coronavirus pandemic, telehealth has rapidly evolved from a nice-to-have to a necessity. Psychiatry has become the medical specialty with the highest rate of tele-consultations at primary-care level, granting access to those for which stigma had long undermined access to

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INFORMATION TECHNOLOGY

Figure 2: Increase technology to increase supply

mental health support in a variety of ways. Technology facilitates access and updates on patients’ records, allowing care teams providing care for the same patients at a given moment or through time, to react more quickly to changes in a patient’s status.

Technology enables assessing the patient's needs and goals, developing a care plan, monitoring and follow-up care, supporting patients' selfmanagement goals, communication and coordination across multiple providers, facilitating transitions of care through levels of care and across providers, aligning and accessing resources to best meet patient’s needs, all of which result in improvements in quality of care.Figure 2.

Technology enables bridging physical healthcare with mental

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healthcare, breaking a historical barrier between the two and providing opportunities to better integration of behavioural and physical healthcare, especially relevant for the most vulnerable populations affected by both.

Technology enables behavioural health providers, psychologists, health coaches, health educators and others, to take on their respective roles and actively contribute to mitigating the effects of the shortage of mental health specialists and releasing them from cases that are more appropriately managed at lower levels of care.

Technology improves the efficiency of mental health practices by allowing collection and measurement of outcomes and progress, by facilitating access to resources and treatment

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options (including the prescription of lifestyle interventions or accessing selfmanagement tool and app libraries) and by facilitating unavoidable and time-consuming administrative tasks such as appointment booking and rescheduling, or billing, freeing up time for core activities directly impacting patient’s care. Technology leads to decreased healthcare costs, reduction in fragmented care, and improvement in the patient experience of care.

Technology works best in an integrated, connected system, supporting patients when they need care because they’re sick or helping them stay healthy. Self-management tools, designed based on the principle that people know what works best for them, should be easily accessible to patients and caregivers throughout the mental health continuum. These tools support patients in recognising what triggers a relapse and spotting its early warning signs, identify what, if anything, can prevent these relapses, tap into other sources of support, make an action plan. Technologically enables

Psychiatry has become the medical specialty with the highest rate of teleconsultations at primary-care level, granting access to those for which stigma had long undermined access to mental health support in a variety of ways.

INFORMATION TECHNOLOGY

Figure 3: Decrease technology to decrease demand

patients’ access to self-management tools timely, contributing to giving them the confidence they need to take active steps in managing their own problems at every stage.

Reducing technology to reduce demand

When looking at the balance between demand and supply, one cannot look only at one side of the scale.

The World Health Organization (WHO) defines mental health as a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community.

Mental health is not defined by the absence of a mental illness or of life’s challenges. On the contrary, it is often

adversity that shapes our mental health and well-being each time we face and we deal with difficulties. In simple words, mental well-being is the ability to respond to life’s ups and downs. It includes self-acceptance, sense of self as part of something greater, sense of self as independent -rather than dependent on others for identity or happiness-, knowing and using our unique character strengths, having an accurate perception of reality, knowing that our thoughts aren’t always true, having a desire for continued growth, thriving in the face of adversity (emotional resilience), having and pursuing interests, knowing and remaining true to our values, building and maintaining emotionally healthy relationships, being hopeful and having a mindset that supports the believe that things can

improve, understanding that happiness comes from within rather than being dependent on external conditions and taking an active role in life, rather than waiting for things to happen.

But we live in a digital-first world where from the start to the end of the day we are looking at a screen. With our mobile phones and computers we access the Internet e-mails, social media, at any time, anywhere, 24x7.

This overexposure to technology, is not only affecting our sleeping habits, our ability to focus, as we are constantly distracted by incoming messages and notifications and exposed to a constant flow of information, but it affects also our ability to build social skills, and furthermore, an increasing number of people is addicted to technology.

How does our current lifestyle affect the demand in mental health? How can this overexposure to technology contribute to our mental health?

How can social media consumption contribute to building and maintaining emotionally healthy relationships? How does our limited focus capability affect our desire for continued growth? To taking an active role in life? How does our work-life and our lack of spare time affect the use of our unique character strengths? Figure 3.

Just as lifestyle interventions such as diet, physical activity, or smoking cessation contribute to the reduction of risk factors associated with physical ill health, similarly, lifestyle interventions contribute to reducing the demand of mental healthcare services, reversing the trend. Which are these lifestyle interventions in mental health?

Connecting with other people faceto-face provides a sense of belonging and opportunities to share positive experiences. Despite the fact that technology facilitates connecting with people, it is easy to get into the habit of only ever texting, messaging or emailing people, leaving us with a feeling of isolation. Therefore, it is important to not rely solely on

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INFORMATION TECHNOLOGY

are infinite possibilities and many of them act upon several dimensions.

Practicing relaxation, meditation, yoga, praying, caring for pets or other animals, outdoor activities which increase exposure to light, spending time in nature, consuming or participating into artistic or creative activities, consuming or participating in music events, and practicing own hobbies are also activities that facilitate social cohesion and technological disconnection.

Putting all together, the balance between demand and supply in mental health can be achieved by increasing technology to increase supply and decreasing technology to decrease demand. Figure 4.

References are available at www.asianhhm.com

Figure 4: Balance demand-supply in mental health

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it also improves mood, self-esteem, goal setting and achievement. Some forms of physical activity, like dancing, have a multiplier effect by being a physical activity, an opportunity for positive social interaction, learning a new skill or practicing a hobby. Hiking is also a physical activity, often social and in contact with nature. There

AUTHOR BIO

technology or social media to build relationships but to engage into in person contacts.

Contributing to a community and ‘giving’ creates a sense of self-worth, give a feeling of purpose, and provokes positive feelings. Learning new skills boosts self-confidence and self-esteem, help build a sense of purpose and often present opportunities to connect with others. Learning new skills, which can be achieved through learning to cook something new, engaging into crafts, trying new hobbies or playing an instrument, or reading on new topics, whatever resonates to the person most, helps getting new perspectives, gain new experiences, and trains the brain to handle a wide range of challenges, thus contributing to mental health and wellbeing.

Being physically active besides its well-known effects on physical health,

Begoña San José is an author and a public speaker. She is a Clinical Psychologist and has a PhD degree in Health Services Research. She is the founder of beandgo, a consultancy firm dedicated to people and health. She thrives when she inspires. She advocates through her work for better mental health for all.

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Telemedicine Policy and Practice Recommendations from Saudi Arabia’s Journey

The COVID-19 pandemic has positively influenced the uptake of telemedicine service provision, due to lockdowns, social distancing mandates and concern surrounding infection risks to healthcare practitioners (HCPs) and patients. Although the benefits of telemedicine have been proven in the recent shift to the ‘new normal’ post-COVID, there are significant barriers to adoption and successful implementation, such as HCP knowledge, skills, and attitudes, and health organisation administration clarity and communication of policy and procedures for telemedicine.

We discuss some of these key issues in our article below.

Rana O Al-Khanbanshi, Pharmacy Quality Coordinator

I

nformation and Communication Technology (ICT) has had a significant impact on the quality and safety of patient-centred healthcare delivery in diagnosis, management, and monitoring of communicable and non-communicable diseases. Modern technology has enabled HCPs to remotely monitor and record patient medical information, such as physiological vital signs, lab results, radiology images, and medication regimens. ICT plays a key role in re-engineering healthcare costs as well as reducing medical errors and patient complaints.

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Patient-centred telemedicine platforms area potentially costeffective tool reducing travel expenses among both HCPs and patients, improving access to healthcare, and reducing disparities, particularly in resource-constrained medical departments and for rural and remote areas.

Telemedicine technology increases service efficiency and patient satisfaction by reducing waiting times and ensuring HCPs are consulting with the right patient. Telemedicine has a remarkable impact on reductions of morbidity and mortality rates related to non-communicable diseases and improving health-related quality of life. Telemedicine technology helps to expand the scope of healthcare services in society from where it was previously treatment-focused to now increasingly incorporating elements of preventive healthcare, health education and promotion, and increasing opportunities for patients to take ownership of and collaborate with their providers in making their healthcare choices.

Several major regulatory, organisational, and technical barriers negatively impact the adoption of telemedicine technology. There is a lack of comprehensive policies and integrated regulatory frameworks to ensure the security, privacy, and confidentiality of electronically transmitted patient data. It is imperative to provide HCPs and patients with reassurance of the safety of their data. From that, even with some growing interest by HCPs in using the technology, there are concerns about using it appropriately and ethically, and a lack of visibility, clarity and understanding as to any existing policies and procedures for telemedicine implementation and use.

Another issue is the lack of robust information technology infrastructure, the quality and capacity of the internet, or intermittent coverage of wireless local area networks (WLANs) in rural

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and remote areas, along with electrical capabilities in healthcare facilities and the availability of necessary technical infrastructure. Furthermore, there is a shortage of experienced IT technicians and specialist health informaticians who can inform policy and decisionmakers, as well challenges in setting standards for quality in telemedicine practices, limited training opportunities, dedicated conferences, and symposia about advancesin telemedicine technology and how it impacts the HCP, care provision and the patient experience that can support the required upskilling and confidencebuilding of these capacities.

As it stands, HCPs may be reluctant to take up telemedicine, concerned with their lack of knowledge, experience and skills that would enable them to use the technology seamlessly and comfortably. Finally, consideration and respect must be incorporated for cultural and social factors that may affect successful telemedicine implementation, such as the social norms and expectations for doctor-patient interactions and the communication styles that are used during virtual consultations and in digital communications to avoid any confusion or misunderstanding.

These are all issues that enable a better understanding of the reasons for the as yet limited use of telemedicine technology and potentially areas we can work to more positively influence HCPs’ interest, attitudes and willingness to use telemedicine to provide care for patients and achieve the goals we have set out to achieve.

In Saudi Arabia (SA), rapid technological advances, and the ambitious National Health Transformation Program (NTP) are driving sweeping healthcare reforms towards the achievement of the Saudi Vision 2030. Several key initiatives, coupled with the imperatives imposed by the realities of operating a resilient healthcare system throughout

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the pandemic have facilitated the proliferation of telemedicine services throughout the country in recent years.

The earliest telemedicine system in SA was initiated in 1990 in collaboration with the Yale Telemedicine Center as a major source of consultations with physicians and follow-up with patients after face-to-face visits. In 2011, the first project for telemedicine, the Saudi Telemedicine Network (STN) was issued under the Ministry of Health (MOH) collaborated with Canada Health Infoway and the Ontario Telemedicine Network. The project aimed to provide recommendations for the development of a national telemedicine system.

In 2013, the STN launched a list of standards in cooperation with King Faisal Specialist Hospital (KFSH) to provide exclusive, high-quality, tertiary telemedicine care services.

The National Health Information Center (NHIC) was established in 2016 as a national center for assessment and monitoring of healthcare technologies. The NHIC is using ICT to build and provide a network of health information to facilitate clinical care remotely, safely, and efficiently. The provision of telemedicine in the country is now expanding beyond merely data sharing and transferring information through video consultations, audio, picture, or text to support remote health service provision, it is now facilitating surveillance, education, and research as well. The NHIC published the Saudi Health Information Exchange (SeHE) policy in 2016 to monitor and evaluate the privacy and security of telemedicine

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applications that deliver high quality accessible healthcare services all over the country, such as Tawwakalna, Tabaud, Mawid, Sehhaty and many others that have achieved widespread international acclaim.

In 2022, the MOH launched the Seha Virtual Hospital, the first of its kind in the Middle East. A specialised hospital that utilizes the latest innovative technologies to provide 30 specialised services and support 130 hospitals nationally. The hospital employs the latest treatment technologies, such as virtual services for electroencephalogram (EEG) patients, virtual specialised clinics and medical support services for stroke patients, as well as critical care patients.

The COVID-19 pandemic has had a positive influence on the uptake of telemedicine service provision, due to lockdowns, social distancing mandates and concern surrounding infection risks to healthcare practitioners (HCPs) and patients. Although the benefits of telemedicine have

AUTHOR BIO

services and their adherence to HIPAA regulations and guide the development of interoperability frameworks.

In 2017, King Fahd Medical City (KFMC) was launching diverse telemedicine services that met the STN standards, which resulted a key player in a high turnout telemedicine healthcare services for patients in all regions.

Another significant initiative was the launch of the Saudi Patient Safety Center (SPSC) in 2017, which works to align healthcare regulators, payers, providers, patients, and communities to focus on patient safety with the goal of providing healthcare services that are free from harm, promoting a national culture of patient safety reporting, and awareness of safety issues. The Saudi Communications and Information Technology Commission (CITC) established a Cybersecurity Regulatory Framework (CRF) in 2019 to provide comprehensive cybersecurity regulations and privacy laws to safeguard patient data using ICT. CRF also maintains communications, information security, and confidentiality in compliance with the highest quality and security requirements, increasing the level of cybersecurity awareness in Saudi society.

Among the more recent initiatives is the National E-Health Strategy, with its strategic objectives to increase accessibility to healthcare services, improve service quality and promote preventive care of health risks via e-health technology.

In 2019, the MOH established the National Healthcare Command Center (NHCC) as a central hub, to collect, visualise data and generate insights to drive the sustainability of health system operations using data-analytics, generating predictions and recommendations using a combination of artificial intelligence and human actions. Most recently in 2020, in response to the pressures of the COVID-19 pandemic, the MOH collaborated with NHIC to activate several transformative mobile

been proven in the recent shift to the ‘new normal’ post-covid, there are significant barriers to adoption and successful implementation of telemedicine in practice, such as HCP knowledge, skills, and attitudes, and health organisation administration clarity and communication of policy and procedures for telemedicine.

The rapid developments in health technologies and implementation of telemedicine services must be underpinned with robust HCP capabilities to sustain them, encourage their uptake, and realise the improvements to outcomes for patients and providers according to our aspirations. Intense efforts must be put forward to orient and train HCPs on policies and procedures for telemedicine technology and its applications in practice. This training must be well-designed and developed in line with the advancements in the knowledge, science and evidence-base for telemedicine, and in alignment with HCP educational and professional competencies, as well as technological literacy and device access. The evaluation of training programme outcomes needs to be built-in and reviewed frequently to keep pace with the developments. Telemedicine policies must be updated regularly and be readily available on hospital intranet systems, and should ensure to address HCP concerns on security, privacy and other legal and ethical aspects.

References are available at www.asianhhm.com Rana O Alkhanbashi (Pharm.D, MHA) is an experienced Pharmacy Quality Coordinator, Certified Professional in Healthcare Quality (CPHQ), Lean Six Sigma practitioner and patient safety leader. She leads a Pharmacy Quality of Care and Patient Safety team that works to develop policies and implement plans to achieve the goals of the healthcare organisation in alignment with the Saudi Vision 2030.

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COMPANY. . ............................................. PAGE NO.

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Blackmagic Design................................................................................ 05 Fotona d.d..............................................................................................03 First Glove.........................................................................................28-29 Guerbet Asia Pacific Ltd............................................................ IBC, 16-17 K J Somaiya Institute of Management.................................................... IFC Stiegelmeyer...............................................................................14, 34-35

MEDICAL SCIENCES

Guerbet Asia Pacific Ltd............................................................ IBC, 16-17 K J Somaiya Institute of Management.................................................... IFC

First Glove.........................................................................................28-29 https://firstglove.com Fotona d.d..............................................................................................03 www.fotona.com

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Fotona d. d.............................................................................................03 Greiner Bio-One................................................................................08-09 K J Somaiya Institute of Management.................................................... IFC

TECHNOLOGY, EQUIPMENT & DEVICES

Fotona d.d..............................................................................................03 First Glove.........................................................................................28-29 Greiner Bio-One................................................................................08-09 Guerbet Asia Pacific Ltd............................................................ IBC, 16-17 K J Somaiya Institute of Management.................................................... IFC Stiegelmeyer...............................................................................14, 34-35

Greiner Bio-One................................................................................08-09 www.gbo.com Guerbet Asia Pacific Ltd............................................................ IBC, 16-17 www.guerbet.com InterSystems.....................................................................................21-23 www.intersystems.com

FACILITIES & OPERATIONS MANAGEMENT

Greiner Bio-One.................................................................................. OBC K J Somaiya Institute of Management.................................................... IFC Stiegelmeyer...............................................................................14, 34-35

K J Somaiya Institute of Management.................................................... IFC https://simsr.somaiya.edu/

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Blackmagic Design................................................................................ 05 InterSystems.....................................................................................21-23 K J Somaiya Institute of Management.................................................... IFC

Stiegelmeyer...............................................................................14, 34-35 www.stiegelmeyer.com

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PATIENT X-RAY DOSE MANAGEMENT SOLUTION

LOOKING FOR PATIENT SAFETY

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with real-time monitoring?

on data retrieval and regulatory compliance?

patient dose data that can easily export and share ?

Comparisons

Statistics A

B

Benchmarks

VISIBILITY

TIME SAVING

RELIABILITY

• Collect and retrieve patient dose data from all ionizing machines • Real-time monitoring of examinations with advanced alert systems • Access to the patient’s dose history • Detect high-risk patients

• Quickly create lists and identify your best practices • Satisfy the requirements of the Euratom 2013/59 Directive • Automatic transmission to the national authorities

• Compare and easily export dose data to share and respond to authorities requirements • Set up and receive automated reports • Receive alerts in case of abnormal exposure and notify authorities as required

PRE-EXAM WARNINGS

AUTOMATES REPORTS

ORGAN DOSE

PEAK SKIN DOSE

ADVANCED STATISTICS

Based on patient history and characteristics

Easily track user-defined metrics for reporting and analysis

For use in computed tomography, and interventional and nuclear medecine

To evaluate the need for secondary therapy

For detailed analysis

Dose&Care® is a medical device intended for use by healthcare professionals. It allows storage and survey of Patient’s dosimetric information. It collects dose reports created by modalities (Scanner, conventional and interventional radiology, mammography, etc.)

Dose&Care® enables real time monitoring of Patient’s dose and includes a user management system. It also provides tools to associate procedure descriptions.

For complete information about precautions and optimal usage conditions, we recommend consulting the instruction for use supplied with the device or by your local Guerbet representative(s). For use only in countries with applicable health authority registrations.

Class I/CE

Manufacturer: Mptronic

www.dosencare.com

P22001655 - Asia Pacific

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