HospiMedica International January 2017 by Globetech

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Vol.34 No.8 • 12/2016 - 1/2017

L E A D E R DAILY CLINICAL NEWS

ISSN 0898-7270

Radiation Dose Management Improves Patient Care novel web-based management system uses Microsoft cloud technology to track, analyze, and report practice-level radiation dose data. The GE Healthcare (GE, Little Chalfont, United Kingdom; www. gehealthcare.com) DoseWatch Explore is a cloud-based radiation dose management software suite that

WHO Issues New Guidelines to Reduce Surgical Infections he World Health Organization (WHO; Geneva, Switzerland; www.who.int) has released new global guidelines covering surgical site infections (SSI), with a view to reduce costs and infection-related patient complications. The WHO “Global Guidelines for the Prevention of Surgical Site Infec-

tion” includes a list of 29 concrete recommendations distilled by 20 of the world’s leading experts from 26 reviews of the latest evidence. Included are 13 recommendations for the period before surgery, and 16 for preventing infections during and after surgery. They range from simple precautions, such as ensuring that patients bath or

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Image: Courtesy of GE Healthcare

See article on page 15

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Single-Handed Suturing Advances Vascular Surgery disposable precision instrument enables surgeons to suture tubular and layered structures using just one hand, and at twice the speed of conventional suturing. The Switch Platform is based on a straight needle positioned in a needle holder, which is placed inside a forceps-like device. The needle is passed through the tissue, and is then recovered by a second needle holder on the other jaw of the forceps. The needle is

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Radiation-Free Alternative To Mammograms new, accurate, ultrasonic mammography method could help identify cancerous tumors by blood vessels structure, without radiation, according to a new study. Under development at the Eindhoven University of Technology (TUE; The Netherlands; www.tue.nl), dynamic contrast specific ultrasound tomography (DCS-UST) builds on a patient-friendly prostate cancer detection method called cumulative phase

Conventional

MAGiC

(15:35 minutes)

(5:08 minutes)

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INSIDE

Portable Coagulation Analyzer Enables Point-of-Care Testing

Health IT . . . . . . . . . . . . . . . . 28 Industry News . . . . . . . . . . . . 33 International Calendar . . . . . 34

compact analyzer measures prothrombin time international normalized ratio (PT/INR) on-site for improved management of anticoagulation therapy.

News Update . . . . . . . . . . . . . 6 Product News . . . . . . . . . .6-10

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Inpatient Remote Monitoring Generates Major Savings for Hospitals

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ontact-free continuous monitoring (CFCM) of patients in their hospital beds could save the healthcare sector major funds. These are the latest findings of Frost & Sullivan (Frost; London, United Kingdom; www.frost.com), an international market research firm. The Frost report is based on studies

by researchers at Brigham and Women’s Hospital (BWH; Boston, AM, USA; www.brighamandwomens.org), Chaim Sheba Medical Center (Tel Hashomer, Israel; www.sheba.co.il), and other institutions that evaluated cost savings attributable to the implementation of CFCM in a 33-bed medical-surgical Cont’d on page 3

News Update . . . . . . . . . . . . 14 Product News . . . . . . . . 14-18

News Update . . . . . . . . . . . . 22 Product News . . . . . . . . .22-28

Hospital News . 32 I

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Single-Handed Suturing Advances Vascular Surgery cont’d from cover

then repositioned inside the needle holder and the process is repeated to the reverse direction; the procedure is thus repeated with every suture. This repetitive sequence allows for continuous suturing in a predictable linear path, resulting in less motion friction and damage to the vessel wall. The Switch can be operated by lightly pinching the double-action buttons on the side with the thumb and index finger of one hand; the other hand is free to present the tissue to be sutured. The technique greatly improves the precision and efficiency of the suturing process, as surgeons no longer need to switch the needle between instruments, and can focus on getting control over the tissue instead. It also reduces operational time, as on average 30% of the operation time is spent on suturing. Future developments include Switch devices

with varying geometries; a micro surgery model for coronary artery and arteriovenous fistula procedures; laparoscopic and robotic variants; a reusable electrical model with exchangeable jaws; a 10 cm version; and diversification in suture material, including polydioxanone (PDS) and vicryl. The Switch is a product of Mellon Medical (Nijmegen, The Netherlands; www.mellonmedical.com), and will initially focus on three vascular indications: carotid artery surgery, kidney transplant, and peripheral bypass surgery. “By collaborating with medical specialists, industrial designers, and ergonomic experts in the development of the Switch, Mellon has been able to reinvent suturing, bringing suturing technology into the 21st century,” said vascular surgeon Mark Vrancken Peeters, MD, chief medical officer

Image: The Switch needle is always secured in one of the two jaws (Photo courtesy of Mellon Medical)

of Mellon Medical. “Our mission is to improve medical procedures by providing the best possible tools. We believe our innovative platform suturing technology will improve patient outcome and reduce overall healthcare costs.”

Radiation-Free Alternative To Mammograms cont’d from cover

delay imaging (CPDI) which images and quantifies ultrasound contrast agent (UCA) kinetics. The technology is based on harmless microbubbles injected into the patient’s bloodstream; the microbubbles vibrate in the blood at the same frequency as the ultrasonic echo, as well as at twice that frequency the so-called second harmonic. This second harmonic is delayed by the gas bubbles; the more bubbles are encountered by the sound on its route, the bigger the delay compared to the original sound. By measuring this delay, the researchers can thus localize the air bubbles without any disturbance, since the second harmonic generated by the body tissue is not delayed, and is therefore discernible. This difference, however, can only be seen if the sound is captured on the other side. So the method is perfectly suited to organs that can be approached from two sides, like the breast. An ultrasound scanner can thus be used to precisely track the microbubbles as they flow through the blood vessels. Since cancer growth is associated with the formation of chaotic microvessels, the presence and location of cancer become visible. What also makes the technique different to current mammography is the patient’s position. Instead of standing, the patient lies on a table, with the breast hanging freely in a bowl. The proof-of-concept study was published in the November 2016 issue of Scientific Reports. “For breast imaging, DCS-UST will lead to a more practical, faster, and less operator-dependent imaging procedure compared to standard echo-contrast, while preserving accurate imaging of contrast kinetics,” concluded lead author Libertario Demi, PhD, of the TUE biomedical diagnostics laboratory. “DCS-UST can find clinical applications as a diagnostic method for breast cancer localization, adding important features to multi-parametric ultrasound tomography of the breast.”

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Inpatient Remote Monitoring Generates Major Savings for Hospitals cont’d from cover

unit, and to determine the return on investment associated with its implementation. Each bed was equipped with a monitoring unit, with data collected and compared nine month before and nine months after implementation. The researchers constructed two models: a base case model, in which they estimated the total cost savings of intervention effects; and a conservative model in which they only included the direct variable cost component for the final length of stay and the treatment of pressure ulcers. The results showed that in the 5-year return on investment model, the monitoring system saved between a conservative USD 3,268,000 and USD 9,089,000, given an 80% prospective reimbursement rate. The average net benefit of implementing the system ranged from USD 224 per patient (conservative model) to USD 710 per patient per year. A multiVisit us at way sensitivity analysis was performed using the most and least favorable conditions for all variables, which showed a return on Arab Health investment that ranged from 127.1% to Stand S-AA70 601.7% for the least favorable conditions, and 627.5% to 1,739.7% for the most favorable conditions. By extending the savings to all 750,000 relevant beds in the U.S. Hospital System, Frost estimates that the American Healthcare system could save approximately USD 15 billion annually. “The healthcare industry is constantly working to improve efficiency. These studies show that continuous monitoring presents a unique opportunity to create both top and bottom line benefits, while simultaneously improving quality of care,” said Charlie Whelan, transformational health North America consulting director at Frost & Sullivan. “The economic potential of adopting CFCM is a gamechanger, in terms of changing patient outcomes, shortening hospital stays, and improving economics.” The CFCM technology studied was the EarlySense (Waltham, MA, USA; www. earlysense.com) contact-free motion, heart rate, and respiratory rate monitoring system, which has been shown to assist in the earlier detection of patient deterioration, reduction of patient length of stay, minimizing intensive care unit (ICU) utilization, reduction of falls and pressure ulcers, and avoidance of cardiac and respiratory arrests. “The powerful peer-reviewed data, as well as practical experience gained by clinicians using our technology on hundreds of thousands of patients, is why CFCM solutions are rapidly becoming standard of care in many institutions,” said Avner Halperin, CEO of EarlySense. “We are excited to continue to offer the most advanced CFCM solutions to our customers in the U.S. and abroad, and to expand our reach to new facilities to help achieve positive patient outcomes and improved economics for the healthcare system.” Image: The EarlySense system sensor pad (Photo courtesy of EarlySense).

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Radiation Dose Management Improves Patient Care cont’d from cover

tracks, analyzes, and reports practice-level radiation dose data for GE computed tomography (CT) systems. Using Microsoft (Mountain View, CA, USA; www.microsoft.com) Azure cloud technology and GE’s InSite connection, DoseWatch Explore collects radiation data directly from the CT scanner; no additional hardware integration, infrastructure, or installation is required. The dose management solution helps clinicians quantify the CT systems’ practice-level radiation dose using protocol parameters determined per exam/per device, enabling the development of individual dose management practices, while at the same time improving patient radiation dose levels during diagnostic imaging procedures. The solution this offers clinicians a new level of data analysis, utilizing familiar, browser-based tools and technology with the scale, cost-efficiency, and ease-of-deployment provided by cloud infrastructure. “Patient safety is at the heart of dose management and is a big driver for why we created this solution,” said Agnes Berzsenyi, VP and general manager of product management for global services at

GE Healthcare. “For healthcare clinicians interested in managing radiation dose for CT, DoseWatch Explore is a perfect entry-level dose management solution that harnesses the power of data, analytics, and software to help clinicians achieve optimal dose levels and provide better patient care.” “DoseWatch Explore is a great example of how integrated device, software and cloud platform solutions seamlessly work together to deliver practical, actionable insights to health organizations,” said Neil Jordan, general manager of worldwide health at Microsoft. “Azure provides industry-leading security features and complies with a number of global, regional, and industry-specific standards and regulations, enabling providers using DoseWatch Explore to focus on their primary objective – improving patient health.” New regulatory and accreditation requirements for medical radiation are starting to emerge, but implementing dose management practices and gaining visibility to dose data are still relatively new to clinicians. Healthcare providers are therefore searching for the opportunity to test dose management without compromising image quality.

WHO Issues New Guidelines to Reduce Surgical Infections cont’d from cover

shower (but not shave) before surgery, to instructions for surgical team hand hygiene compliance, what disinfectants to use before incision, and which sutures to use. The guidelines complement the WHO “Surgical Safety Checklist”, which gives a broad range of safety measures. Importantly, the guidelines recomV

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mend that antibiotics be used to prevent infections before and during surgery only, and not after, a crucial measure in stopping the spread of antibiotic resistance, which leads to longer hospital stays, higher medical costs, and increased mortality. The recommendations were published on November 3, 2016, in The Lancet Infectious Diseases. “No one should get sick while seeking or receiving care,” said Marie-Paule Kieny, MD, assistant director-general for health systems and innovation at the WHO. “Preventing surgical infections has never been more important, but it is complex and requires a range of preventive measures. These guidelines are an invaluable tool for protecting patients.” “Sooner or later many of us will need surgery, but none of us wants to pick up an infection on the operating table,” said Ed Kelley, MD, director of the WHO department of service delivery and safety. “By applying these new guidelines surgical teams can reduce harm, improve quality of life, and do their bit to stop the spread of antibiotic resistance. We also recommend that patients preparing for surgery ask their surgeon whether they are following WHO’s advice.” SSI’s are an important contributor, and may even be the most frequent healthcare-associated infection (HAI) after asymptomatic bacteriuria, representing a high burden on patients and hospitals in terms of morbidity, mortality, prolonged length of hospital stay, and additional costs. Researchers have been searching for decades for the optimal bowel preparation, but failed to address biological factors. Today, however, genome sequencing and microbiome studies have open up new areas for study that might give biological insight into what works best and for which patients.

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ISSN 0898-7270 Vol.34 No.8 • Published, under license, by Globetech Media LLC Copyright © 2017. All rights reserved. Reproduction in any form is forbidden without express permission. Teknopress Yayıncılık ve Ticaret Ltd. S¸ti. adına ˙Imtiyaz Sahibi: M. Geren • Yazı is¸leri Müdürü: Ersin Köklü Müs¸ ir Dervis¸ ˙Ibrahim Sok. 5/4, Esentepe, 34394 S ¸ is¸ li, ˙Istanbul P. K. 1, AVPIM, 34001 ˙Istanbul • E-mail: Teknopress@yahoo.com Baskı: Promat Web Ofset Tesisi • Orhangazi Mahallesi 1673. Sokak, No: 34 • 34510 Esenyurt, B. Çekmece • ˙Istanbul Yerel süreli yayındır. Yılda altı kere yayınlanır, ücretsiz dag˘ıtılır.

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DISPOSABLE MASKS

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The HAMILTON-C1 neo combines invasive and NIV modes with the options of nCPAP and high flow oxygen therapy in a small footprint. Developed specifically for neonates, it provides tidal volumes as low as 2 ml for effective, safe, and lungprotective ventilation for the smallest patients.

The Eagle masks are designed for NIV and the administration of oxygen and other breathing gases. Features include three color-coded sizes, built-in 22mm ID port, low deadspace, simple headgear, integrated ports for scope/gases, and four optional swivels for various types of ventilators.

The Everheart is designed to warm and add humidity to gases delivered to patients requiring mechanical ventilation or other positive pressure breathing system. It takes six minutes to heat the plate with its alarm activated when temperatures reach unsafe levels.

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NPWT Reduces Wound Complication Rates and Length of Stay new study suggests that incisional negative pressure wound therapy (iNPWT) dressings can improve predictability of outcomes following hip and knee replacement surgery. Researcher at the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH; Oswestry, United Kingdom; www.rjah. nhs.uk) conducted a randomized controlled trial of 220 patients undergoing elective primary total hip and knee arthroplasties, in order to explore the potential benefits of a portable, single use, iNPWT dressing

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on wound exudate, length of stay (LOS), wound complications, dressing changes, and cost-effectiveness following surgery. For the final analysis there were 102 cohort patients and 107 controls. For the study, the researchers used the Smith & Nephew (London, UK; www.global.smith-nephew.com) PICO NPWT system, indicated for chronic, acute, and traumatic wounds, subacute and dehisced wounds, partial-thickness burns, ulcers (such as diabetic or pressure), flaps and grafts, and closed surgical incisions. The system uses a one-button pump in order

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to provide discreet, unobtrusive treatment. The disposable device works with a revolutionary dressing technology that manages fluids, eliminating the need for bulky canisters. The results showed an improvement in the iNPWT group compared to control in all areas. Peak post-surgical wound exudate was significantly reduced; overall LOS reduction was not significant, but there was a significant reduction in patients with extreme values of LOS in the iNPWT group. A significantly reduced number of dressing changes and a trend to a significant four-fold reduction in reported postoperative surgical wound complications (2% compared to 8.4% in controls) were observed. The study was published on August 5, 2016, in Bone & Joint Research. “By introducing PICO as a prophylactic measure we have been able to demonstrate predictable wound healing following total hip and knee re-

placement procedures,” said lead author consultant orthopedic surgeon Sudheer Karlakki, MD. “Better wound management offers significant value to our hospital both in terms of reducing associated healthcare costs and by improving each patient’s outcome and experience.” NPWT is a therapeutic technique used to promote healing in acute or chronic wounds and enhance the healing of first and second degree burns. The therapy involves controlled application of sub-atmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump. The continued vacuum draws out fluid exudates from the wound and increases blood flow to the area. NPWT wound management has increased dramatically over the 1990s and 2000s. Image: The PICO NPWT system and dressing (Photo courtesy of Smith & Nephew). HospiMedica International December/2016-January/2017

Implantable Platform Continuously Monitors Tissue Oxygen new system based on implanted biosensors allows the continuous and long-term monitoring of oxygen levels in subcutaneous tissues in the upper extremity, shoulder, or lower extremity. The Lumee Oxygen Platform is an instrument adjunct to the treatment of peripheral artery disease (PAD), which is based on tiny, flexible biosensors 5 mm long and approximately 500 microns in diameter injected into subdermal tissue. Each biosensor is made of a bioengineered hydrogel fiber that forms a porous, tissue-integrating scaffold that induces capillary and cellular ingrowth from surrounding tissue. The smart gel is linked to a fluorescent molecule that signals the presence of oxygen. The platform is comprised of the novel hydrogel biosensors, a specially designed biosensor injector, an optical reader, and a touch screen user interface. Either taped to the skin’s surface or held by hand, the optical reader transmits light through the skin to the embedded biosensor, which emits a corresponding fluorescence that is proportional to oxygen concentration. The data is relayed to the touch-screen tablet computer for an encrypted personal record and historical tracking. The Lumee Oxygen Platform, a product of Profusa (San Francisco, CA, USA; www.profusa.com), has received the European Community CE mark of approval. According to the company, the smart hydrogel biosensors may have many other applications for consumer health and wellness, including management of other chronic diseases such as diabetes and chronic obstructive pulmonary disease (COPD), but should not be used as the sole basis for diagnosis or therapy. “Acquiring the CE Mark is a major milestone our development team and regulatory partners have worked hard to achieve,” said Ben Hwang, PhD, chairman and CEO of Profusa. “Thanks to their dedication and commitment, vascular interventionalists in Europe can now have a revolutionary monitoring device that enables them to better treat their patients and improve their quality of life.” “The muscles and other tissues of the arms and legs need oxygen and nutri-

ents to function properly; in PAD the arteries that feed the extremity are blocked by plaque composed of cholesterol and other calcified substances,” said Miguel Montero, MD, associate professor of surgery at Baylor College of Medicine (Houston, TX, USA; www.bcm.edu). “When low tissue oxygen is detected early, more treatment options can be considered and the need for catastrophic amputation can be avoided.” Decreased tissue oxygen levels in the lower limbs of PAD patients can lead to disabled walking, or in more advanced cases, gangrene and subsequent amputation. By continuously measuring tissue oxygen levels in the ischemic limb before, during, and after treatment, appropriate therapy can be administered in a timely fashion before advanced symptoms appear. Image: The Lumee Oxygen Platform, with the oxygen-sensitive biosensor (4) (Photo courtesy of Profusa).

Portable Coagulation Analyzer Enables Point-of-Care Testing cont’d from cover

The Siemens Healthineers (Erlangen, Germany; www.healthcare. siemens.com) Xprecia Stride coagulation analyzer uses fresh capillary blood collected using fingerstick strips in order to measure coagulation time, especially important for the monitoring oral anticoagulation therapy with warfarin and for measuring blood coagulation before sanguineous procedures such as oral surgery. In order to minimize any potential for variability, the analyzer uses proprietary Dade Innovin reagent to provide performance equivalent to that of a laboratory hemostasis system, but the results are available within minutes, at the point of care (POC), expressed as INR. Feature include intuitive navigation via simple icons and animation on a color display, an integrated barcode scanner to help collect data, and a new eject button that allows the user to easily remove a used test strip and dispose of it without touching it, minimizing potential biohazard exposure. The Xprecia Stride Coagulation Analyzer can be held at virtually any angle and brought directly to the pa-

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tient’s finger for efficient and comfortable blood sample application. “The Xprecia Stride analyzer is designed to be safe, efficient and ergonomically friendly. We now have the ability to cover the full range of hemostasis testing from the hospital lab to the physician’s office,” said Michael Sampson, senior vice president of Siemens Healthineers POC business. “With the Xprecia Stride analyzer, Siemens Healthineers delivers on the promise to bring a safe and lab-accurate test directly to the patient.” Warfarin decreases blood coagulation by inhibiting vitamin K epoxide reductase, an enzyme that recycles oxidized vitamin K to its reduced form after it has participated in the carboxylation of several blood coagulation proteins, mainly prothrombin and factor VII. It was initially introduced in 1948 as a pesticide against rats and mice and is still popular for this purpose. In the early 1950’s warfarin was found to be effective and relatively safe for preventing thrombosis and embolism in many disorders. It is the most widely prescribed oral anticoagulant drug in North America. LINKXPRESS COM

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Controlled Glucose Oscillations May Restore Insulin Production new study suggests that administering controlled pulses of glucose via a microfluidic platform has the potential to reestablish normal insulin production and prevent type 2 diabetes. Developed by researchers at Florida State University (FSU; Tallahassee, FL. USA; www.fsu.edu), the Dual Oscillator Model (DOM) is a mathematical tool that can simulate experiments with the islets of Langerhans, small clusters of pancreatic cells that contain insulin-producing -cells. The DOM predicted that an oscillatory stimulus using pulses of glucose to the bloodstream has the potential to reactivate the insulin clock within -cells that had been halted by exposure to excess glucose. The researchers tested the hypothesis in a non-diabetic islets of Langerhans mice model. Using a specially engineered microfluidic device, they first delivered a high, steady, glucose stream; as expected, the insulin clock within the mouse islets was deactivated. But when controlled pulses of glucose were reapplied to the islets, the insulin clock was restarted. Moreover, when the flow of glucose followed a feedback loop simulating liver activity, the reactivated islets also recruited other islets to restart their insulin clock. The study was published on October 26, 2016, in PLOS Computational Biology. “Microfluidics and mathematical modeling can be used together to gain new insights into the mechanisms for hormone secretion,” concluded senior author Richard Bertram, PhD, of the FSU department of mathematics and programs in neuroscience and molecular biophysics. “Our results have potential implications for enhancing insulin pulsatility, and therefore mitigating the development of type 2 diabetes.”

Pancreatic islets manage elevations in blood glucose level by secreting insulin into the bloodstream, governed by islet oscillations such as bursting electrical activity and periodic Ca2+ entry in -cells. In healthy individuals, -cells release regular pulses of insulin to restrict the amount of glucose released by the liver, as well as impel body tissues to absorb the glucose. However, in hyperglycemia, a hallmark of type 2 diabetes, the excess glucose suppresses the “inner clock” of -cells that controls the rhythm of insulin pulses, reducing insulin production. Image: A controlled microfluidic device used to manage glucose release (Photo courtesy Roper Lab / FSU).

Risk Factors for Hospital Malnutrition Alike Worldwide new study reveals a set of factors associated with full meal intake that is applicable to patients hospitalized in any region of the world. Researchers at the Medical University of Vienna (Austria; www.meduniwien.ac.at), Geneva University Hospital (HUG; Switzerland; www. hug-ge.ch), and other institutions conducted a descriptive analysis of 9 consecutive, annual, and crosssectional nutritionDay samples, involving a total of 91,245 adult patients in 6,668 wards, in 2,584 hospitals, in 56 countries. The objective of the study was to evaluate the main factors associated with reduced meal intake in hospitalized patients, and the differences between geographical regions. The findings revealed that the proportion of patients who ate a full meal varied widely

(24.7–61.5%) across world regions. The factors most strongly associated with malnutrition were reduced intake during the previous week, confinement to bed, female sex, younger (below 49) and older (over 79) years of age, and low body mass index (BMI). The pattern of associated factors was homogenous across world regions with practically equal importance everywhere. The study was published in November 2016 issue of The American Journal of Clinical Nutrition. “The excuse that patients often give that ‘I am ill so I’m not eating,’ or even ‘that’s good, at least I’m losing weight’ are not acceptable and are bad for their prognosis. These risk groups need special attention. Ensuring that patients receive adequate nutrition should therefore be part of an holistic treat-

ment plan,” said lead author nutritional expert Karin Schindler, PhD, of the Medical University of Vienna. “On the other hand, we must bear in mind that 50-60% of patients do not eat all of a meal that is offered, and this reduced food intake is rarely offset by nutritional care.” “Patients’ eating behavior should be systematically evaluated on admission to hospital. The simple questions are quick to ask and easy to answer. It should be explained to patients why it is important to eat,” concluded Dr. Schindler. “It might also be worth considering structural adaptations, such as the possibility of offering smaller portions or highly nutritious snacks between meals or special individual meals. In addition to that, it can be helpful to involve relatives in encouraging them to eat.” HospiMedica International December/2016-January/2017

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Critical Care

One-Third of Hypertension Patients Noncompliant with Therapy ore than 30% of patients with hypertension do not adhere to their antihypertensive drug therapy, according to a new study. Researchers at the University of North Carolina (UNC, Chapel Hill, USA; www.unc.edu) conducted a study among 1,826 participants of the Atherosclerosis Risk in Communities Study, who reported hypertension without prevalent cardiovascular disease (CVD) during their annual follow-up calls in 2006 and 2007. Medication adherence was measured as more than 80% proportion days covered, by using Medicare Part D claims. Study outcomes consisted of a composite of cardiovascular events, Medicare inpatient payments, and inpatient days. The results showed that 31.5% of the participants were noncompliant with their therapy in the three months preceding hypertension re-

ports. Positive predictors included female gender and diabetes; AfricanAmerican race and current smoking were negative predictors. After adjustment, the correlation between noncompliance and a composite end point of cardiovascular outcomes up to 2012 was not statistically significant, as were adjusted associations with Medicare inpatient days or payments. The study was published on November 3, 2016, in the Journal of Evaluation in Clinical Practice. “Despite having medical and prescription coverage, nearly a third of hypertensive participants were not adherent to antihypertensive drug therapy,” concluded lead author Jerome Federspiel, MD, PhD. “Differences in clinical outcomes associated with nonadherence, though not statistically significant, were consistent with results from randomized trials.” The World Health Organization estimates that only 50% of patients

Pretreating Transfused Erythrocytes with Nitric Oxide Prevents Pulmonary Hypertension xposing red blood cells (RBCs) to nitric oxide (NO) can diminish pulmonary hypertension (PH), a dangerous side effect associated with blood transfusions. Researchers at Massachusetts General Hospital (MGH; Boston, USA; www.massgeneral.org), Harvard Medical School (HMS; Boston, MA, USA; www.harvard.edu), and other institutions conducted a trial to see if treating stored packed sheep RBCs with NO before transfusion could prevent PH. To do so, cohort sheep were transfused with autologous RBCs treated with NO and stored for 40 days; control sheep received stored RBCs not exposed to NO. Pulmonary and systemic hemodynamic parameters were monitored before, during, and after transfusion. The researchers found that transfusing RBCs that had not been pretreated with NO nearly doubled the constriction of blood vessels in the lungs, compared to RBCs pretreated with the gas. In addition, treatment with NO increased the survival of stored RBCs after transfusion. Using biotin labeling to measure RBC circulating lifespan, they found that in 40day-old pretreated RBCs, 87% of the cells remained in circulation after one

HospiMedica International December/2016-January/2017

with chronic diseases in developed countries follow treatment recommendations. Low rates of adherence for asthma, diabetes, and hypertension are thought to contribute substantially to the human and economic burden of those conditions. Major barriers to compliance include the cost of prescription medicine, complexity of modern medication regi-

mens, poor health literacy and lack of comprehension of treatment benefits, undiscussed side effects, and poor communication or lack of trust between patient and health-care provider. Image: New research shows onethird of hypertension patients are noncompliant with therapy (Photo courtesy of UNC).

hour, compared with 75% of nontreated RBCs. The study was published in the November 2016 issue of Anesthesiology. “Blood transfusions are one of the top five medical procedures performed by physicians worldwide. Extended storage of RBCs makes them rigid and decreases their ability to change shape, which is necessary as they travel through small blood vessels,” said lead author Warren Zapol, MD, director of the Anesthesia Center for Critical Care Research at MGH. “We found that pretreatment with nitric oxide actually rejuvenates RBCs, making them more flexible so they can more easily travel through blood vessels. This can further reduce the risk of pulmonary hypertension.” The U.S. Food and Drug Administration (FDA) allows transfusion of human RBCs that have been stored for up to 42 days. But recent studies suggest that transfusion of RBCs stored for more than 30 days may lead to elevated PH and reduced survival of the transfused cells, which can cause hypoxia and even heart failure. Each year, approximately 326,000 patients in the United States alone receive one or more RBC units that have been stored for more than 30 days. LINKXPRESS COM

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Critical Care

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Smokers Twice as Likely to Develop Aortic Aneurysms new study suggests that smokers hold almost double the risk of developing an abdominal aortic aneurysm (AAA) than the general population, but they can lower their risk by quitting. Researchers at the University of Minnesota (UMN; Minneapolis, USA; www.umn.edu), Emory University (Atlanta, GA, USA; www. emory.edu), and other institutions conducted a study involving 15,792 participants over the age of 45 recruited in the U.S. national Atherosclerosis Risk in Communities (ARIC) study between 1987 and 1989, and followed up through 2013. The researchers examined lifetime risk of AAA and prospectively assessed the association between midlife cardiovascular risk factors and AAAs. The results showed that after 22 years of follow-up, 590 cases of a ruptured, surgically repaired, or clinically diagnosed asymptomatic AAA were identified. A further 75 cases of asymptomatic AAA were detected by an ultrasound screening. Analysis re-

vealed that lifetime risk of an AAA were 1 in 17 among all study participants; 1 in 9 among current smokers; 1 in 9 among those in the top third of smoking pack-years, whether a current or former smoker; and 1 in 12 among current female smokers. The researchers also found that short-term quitters (3-8 years) still had an approximately 2.6-3.5 fold increased risk for both clinical and asymptomatic AAA in the next 15 years compared to never smokers, representing a lifetime risk 6.6% higher than long-term quitters. Findings also showed that being older, white, or having high levels of lowdensity lipoprotein (LDL) cholesterol also increased the risk of AAA. The study was published on November 10, 2016, in Arteriosclerosis, Thrombosis and Vascular Biology. “Our study quantified the lifetime risk of an AAA and found that it was far from trivial for smokers; and we quantified the benefit of quitting smoking, which turns out to be substantial,” said lead author Weihong

Tang, PhD, MD, of the University of Minnesota. “Women who currently smoke have a similar risk as men who quit smoking; and yet, the task force does not recommend screening these women. This is important data that physicians and health policy makers should be aware of.” AAA is the localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50%, and is the most common form of aortic aneurysm; approximately 90% oc-

cur below the kidneys. The aneurysms can extend to include one or both of the pelvic iliac arteries. The major complication of AAA is rupture, which is life-threatening, as large amounts of blood spill into the abdominal cavity, and can lead to death within minutes. Mortality of rupture repair in the hospital is 6090%. Image: The risk of AAA is twice as high in smokers (Photo courtesy of Medtronic).

Therapeutic Hypothermia May Reduce Heart Attack Survival new study suggests that use of therapeutic hypothermia (TH) in patients with in-hospital cardiac arrest is associated with a lower likelihood of survival to hospital discharge. Researchers at Duke University (Durham, NC, USA; www.duke.edu), Saint Luke’s Mid America Heart Institute (Kansas City, MO, USA; www. saintlukeshealthsystem.org), and other institutions identified 26,183 patients successfully resuscitated from an in-hospital cardiac arrest at 355 U.S. hospitals between March 1, 2002, and December 31, 2014. The researchers examined induction of TH for all cardiac arrests, as well as separately for nonshockable (asystole and pulseless electrical activity) and shockable (ventricular fibrillation and pulseless ventricular tachycardia) cardiac arrests. The primary outcome of the study was survival to hospital discharge, with a secondary outcome of favorable neurological survival. The results showed that only 6% of the patients were treated with TH; after adjustment, TH was associated with lower in-hospital survival (27.4% versus 29.2%), and this association was similar for both nonshockable and shock-

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able cardiac arrest rhythms. TH was also associated with lower rates of favorable neurological survival for the overall cohort and for both rhythm types. The study was published on October 4, 2016, in JAMA. “When follow-up was extended to one year, there remained no survival advantage with therapeutic hypothermia treatment. Collectively, these findings do not support current use of therapeutic hypothermia for patients with in-hospital cardiac arrest,” concluded lead author Paul Chan, MD, of Saint Luke’s Mid America Heart Institute, and colleagues. Therapeutic cooling is among the most potent interventions for hypoxic-ischemic injury, a broad constellation of conditions ranging from cardiac and respiratory arrest to carbon monoxide (CO) and other poisonous gas exposure, and appears to limit tissue damage by reducing oxygen metabolism and inflammation, while maintaining cell membrane integrity. TH is used for patients following both out-of-hospital and in-hospital cardiac arrest, but trials on its efficacy for the in-hospital setting did not exist, and comparative effectiveness data are therefore limited. HospiMedica International December/2016-January/2017

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Critical Care

First Vaccine Against Toxic Shock Syndrome eveloped by researchers at MedUni Vienna (Austria; www.meduniwien.ac.at) and Biomedizinische Forschungs (Vienna, Austria; www.biomednmr.mpg.de), the recombinant toxic shock syndrome toxin-1 variant (rTSST-1v) vaccine was developed from a detoxified Staphylococcus toxin. To test the vaccine, the researchers conducted a randomized phase I first-in-human trial in 46

Ring-Shaped Pump Supports Weakened Hearts n innovative cardiac support system uses peristaltic motion to help the heart pump and transport blood. Developed by researchers at Ecole Polytechnique Fédérale de Lausanne (EPFL; Switzerland; www.epfl.ch), the miniature pump is made of three tiny rings placed around the aorta at the exact spot where it exits the left ventricle. The rings are made of a dielectric electro active polymer (DEAP) with special electrical properties. Each ring has two electrodes that are drawn together by an electrostatic force whenever the electric pulse, provided by magnetic induction, is activated. Each of the three rings contracts in sequence, in a movement reminiscent of an earthworm. The series of contractions, called peristalsis, creates a wave that moves the blood inside the artery. The double action, both vertical and horizontal, occurs simultaneously and immediately, creating a back-and-forth movement that can be controlled in real time. And since the pump ring does not come into direct contact with the blood, it avoids problems of hemolysis and the subsequent need for regular blood transfusions to replenish the damaged red blood cells (RBCs). “This method does not require us to enter the heart; this means it is significantly less invasive than other cardiac support systems, which work by implanting valves or screw pumps inside the ventricle,” said Yves Perriard, director of the EPFL Integrated Actuators Laboratory (LAI). “The absence of valves and other components used in current methods to provide cardiac support doesn’t just lessen the possibility of hemolysis. It also makes the insertion and removal of the device significantly easier for surgeons. The DEAP peristaltic pump is currently in prototype stage. The researchers plan to improve the device’s performance before testing it on a liquid with similar fluidic properties to those of the blood, such as glycerol. The researchers are also in contact with the University Hospital of Bern (Switzerland), where clinical trials could be conducted.

cause serious diseases such as Toxic Shocks Syndrome,” said senior author Professor Martha Eibl, PhD, director of Biomedizinische Forschungs. “This affects dialysis patients, the chronically sick, people with liver diseases, and people recovering after heart operations.” TSS is a potentially fatal illness caused by a bacterial toxin. The causative bacteria include Staphylococcus aureus, and Streptococcus pyogenes. TSS resulting from infection with the bacterium Staphylococcus aureus typically manifests in otherwise healthy individuals with high fever, accompanied by low blood pressure, malaise and confusion, which can rapidly progress to stupor, coma, and multiple organ failure. TSS was first described in the 1980s, when general symptoms of sepsis or blood poisoning occurred in young women who had used so-called “super tampons” during their periods.

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healthy adults aged 18-64 years. The participants were randomly assigned to receive increasing doses of rTSST-1v or an adjuvant placebo of aluminium hydroxide (Al(OH)3). The per-protocol population received a booster immunization 42 days after the first vaccination, with the primary endpoint being safety and tolerability of rTSST-1v. The results showed that rTSST-1v had a good safety profile, and no vaccination-related severe or serious adverse events occurred. Adverse event rates were similar between participants who received rTSST-1v and those who received placebo, independent of pre-existing TSST-1 immunity. The study was published on June 10, 2016, in Lancet Infectious Diseases. “Staphylococci colonize nearly all of us, especially on our skin and mucous membranes. They are totally harmless to most people. However, for people with weakened immune systems, they can

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The OWL 2.0 features dual-modality vascular imaging technology to facilitate intravascular access for obtaining precision IV placement. Its 7-inch screen displays high-definition RT images and offers an clear and wide FOV, while an articulating arm enables easy and accurate positioning.

The BeneVision N12//N15/N17 models feature large touch screens, rotatable landscape and portrait layouts, ultra-slim main units, as well as plugn-play modules. The user interface offers intuitive patient data and includes multi-window flat menus, alarm indications and online user guide.

The eSeries ventilators comprise the e500, e600 and e700 electronically controlled, pneumatically powered models, which provide a range of ventilation solutions for all types of patients. All models come with a self-contained battery pack and standardized controls for ease of use.

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Injectable Viscous Hydrogel Stops Uncontrolled Bleeding new study describes a novel embolic agent for endovascular embolization procedures that has a hemostatic activity comparable to that of metallic coils, the current gold standard. Developed by researchers at the Massachusetts Institute of Technology (MIT; Cambridge, MA, USA; web.mit.edu), Brigham and Women’s Hospital (Boston, MA, USA; www.brighamandwomens.org), Harvard Medical School (HMS; Boston, MA, USA; https://hms.harvard.edu), and other institutions, the shearthinning biomaterial (STB) is made up of a nanocomposite hydrogel that also contains gelatin and silicate nanoplatelets. The nanocomposite STBs are injected through clinical catheters and needles in a viscous, toothpaste-like consistency. Once in place, the biomaterial expands and hardens, fully occluding the vasculature. It subsequently remains at the site of injection (without fragmentation) until it undergoes natural degradation over time. Advantages include rapid delivery, in vivo stability, and independent occlusion that do not rely on intrinsic thrombosis. The study was published on November 16, 2016, in Science Translational Medicine. “Current therapies that try to occlude blood vessels and stop bleeding in cases of internal bleeding do not work for a major segment of population that are on anticoagulant medication, or have disorders which prevents their blood from clotting,” said Professor Ali Khademhosseini, PhD, of HMS and Brigham and Women’s Hospital. “Our material provides a solution to this issue, and allows for a new standard of care that replaces metallic coils, which are expensive and complicated to use.”

Endovascular embolization of damaged blood vessels can generate better patient outcomes and minimize the need for repeat procedures. However, many embolic materials, such as metallic coils or liquid agents, are associated with limitations and complications such as breakthrough bleeding, coil migration, coil compaction, recanalization, adhesion of the catheter to the embolic agent, or toxicity. Image: An injectable shear-thinning biomaterial aids endovascular embolization (Photo courtesy of Ali Khademhosseini/ HMS).

Global Hypertension Rates Doubled Over 40 Years new study that examined blood pressure in every country in the world between 1975 and 2015 found that the number of people with hypertension has reached 1.13 billion. Researchers at Imperial College London (ICL; United Kingdom; www.imperial.ac.uk), the World Health Organization (WHO; Geneva, Switzerland; www.who.int), and hundreds of other institutions worldwide pooled population-based studies that measured BP in adults aged 18 years and older. They then estimated trends in mean systolic and mean diastolic BP over the study period and the prevalence of elevated BP for 200 countries, taking into account changes in prevalence, population growth, and ageing on the number of adults with raised BP.

The results showed that while BP has dropped sharply in high-income countries, it has risen in many low and middle-income countries, especially those in Africa and South Asia. The United Kingdom was found to be the European country with the lowest proportion of people with high BP in 2015, while South Korea, the USA, and Canada were lowest in the world. Over half of the world’s adults with high BP in 2015 lived in Asia, with around 226 million people in China and 200 million in India. Other findings were that the top five countries with the highest proportion of men with high BP in 2015 were all in Central and Eastern Europe: Croatia, Latvia, Lithuania, Hungary, and Slovenia; nearly two in five men in these countries had high BP. The top five countries with the highest proportion

of women with high BP in 2015 were all in Africa: Niger, Chad, Mali, Burkina Faso, and Somalia; around one in three women in these countries had high BP. The study was published on November 15, 2016, in The Lancet. “We need economic means and regulation to improve access to high quality food, especially fruits and vegetables, and reduce excessive salt in food. We also need a stronger healthcare system, to identify people with high blood pressure earlier, and improve access to treatment and medication,” said senior author Professor Majid Ezzati, PhD, of the ICL school of public health. “Without these measures, the world is unlikely to achieve the World Health Organization’s target of reducing the proportion of people with high blood pressure by 25% by 2025.” HospiMedica International December/2016-January/2017

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The RadPRO OMNERA 400T provides servo tracking to the wall stand and table for precision positioning for easy patient access and transfer. Constructed of aircraft aluminum with a lightweight design, it provides the high throughput needed in high-volume imaging departments.

The FDR Smart f features an ergonomically designed floor-mounted tube stand to provide lighter and smoother movement for faster, more efficient workflow. It offers a choice of a four-way floating tabletop and a six-way elevating table, making it flexible for patients of all shapes and sizes.

The SSI-8000 uses high-density transducer technologies to achieve uniform spatial and contrast resolution and penetration in near/far fields. It is compatible with a full range of transducers, making it ideal for use in superficial diagnosis and emerging medical applications.

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Findings of Zika Virus Effects Detailed in Special Imaging Report esearchers in Brazil have released imaging findings of the effects of the Zika virus on babies and fetuses infected with the virus. The researchers used Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and ultrasound imaging to investigate the wide array of effects on the brain, including microcephaly. The report was published in the August 2016 issue of the journal Radiology. The researchers used imaging and autopsy findings from babies and fetuses affected by the congenital Zika virus infection, and treated at the Northeast Brazilian Instituto de Pesquisa in Campina Grande state Paraiba (IPESQ). The researchers performed a retrospective review

of the CT, MRI, and ultrasound images collected between June 2015 and May 2016. The researchers used images and related data of 17 fetuses or neonates of women who had been scanned at IPESQ, and 28 other fetuses or neonates with brain findings that were suspicious for Zika infections. The researchers found various brain abnormalities in fetuses exposed to the Zika virus, besides microcephaly. These included loss of volume in the gray matter and white matter of the brain, abnormalities of the brainstem, ventriculomegaly, and calcifications. Lead author of the report, Fernanda Tovar-Moll, MD, PhD, said, “Imaging is essential for identifying

the presence and the severity of the structural changes induced by the infection, especially in the central nervous system. Microcephaly is just one of several radiological features. The severity of the cortical malformation and associated tissue changes, and the localization of the calcifications at the greywhite matter junction were the most surprising findings in our research. More than one ultrasound or MRI scan in pregnancy may be needed to assess the growth and development abnormalities of the brain. We are also interested in investigating how congenital Zika virus infection can interfere with not only prenatal, but also postnatal gray and white brain maturation.”

Uncertain Benefit for Imaging After Thyroid Cancer Treatment

esearchers at the University of Michigan (Ann Arbor, USA; www.umich.edu) con-

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tween 1998 and 2011. The study cohort was followed up to 2013, with a median follow-up of 69 months. Following treatment, 56.7% of the patients had at least one ultrasound, 23.9% had a radioiodine scan, and 14.9% had a positron emission tomography (PET) scan to monitor for signs of cancer recurrence. The main outcome measures were treatment for recurrence of differentiated thyroid cancer and death. The results showed that patients who underwent imaging were more likely to undergo further treatment, such as additional neck surgery, additional radioactive iodine treatment, or radiotherapy. The researchers also found that while the use of neck ultrasounds or PET scans did not significantly affect disease-specific survival, radioiodine scans were associated with an improved disease-specific survival. The study was published on July 20, 2016, in BMJ. “Over time, we have seen this marked increase in the use of imaging

after primary treatment of thyroid cancer, despite the fact that the majority of our patients have low-risk cancer. For the most part, this imaging isn’t affecting survival,” concluded senior author assistant professor of medicine Megan Haymart, MD, and colleagues. “With the exception of radioiodine scans in presumed iodine avid disease, this association has shown no clear improvement in disease specific survival. These findings emphasize the importance of curbing unnecessary imaging and tailoring imaging after primary treatment to patient risk.” Differentiated thyroid cancer has been increasing in incidence for several decades, and is expected to be the fourth leading cancer diagnosis by the year 2030; most of this rise is explained by diagnoses of small, low risk cancers, which are associated with an excellent long-term survival. Despite this, imaging tests after primary treatment of thyroid cancer is also rising, for reasons as yet unknown. HospiMedica International December/2016-January/2017

Portable Ultrasound System Monitors Brain Blood Flow fully portable, transcranial Doppler (TCD) diagnostic ultrasound system assesses blood vessels in the brain in order to facilitate rapid triaging and monitoring of patients with brain disorders. The Lucid M1 TCD ultrasound system is a battery-operated, medical-grade tablet device designed to non-invasively measure and display cerebral blood flow velocity over the head and neck using a reusable, non-sterile 2-MHz handheld probe. It can also be used to perform bilateral cephalic monitoring by monitoring blood flow velocity in the temporal window, using a headset equipped with a pair of monitoring transducers. Clinical measurements include maximum velocity, mean velocity, minimum velocity, pulsatility index, cerebrovascular reactivity, and emboli count. The system can be moved easily throughout a medical facility in a range of settings that require the rapid assessment of blood flow in the brain to expedite treatment. Many significant cerebral disorders, such as severe traumatic brain injury (TBI), are caused by blood flow disruption. A unique feature of the Lucid M1 system is a modified M-mode display, which is a presentation of standard M-mode display information in a signal “strength versus depth” format. Using the modified M-mode display, the operator can quickly acquire the spectrogram signal and therefore perform a faster exam. Using this feature, the M-mode signal strength can be visualized along the horizontal axis, allowing depth of the sample gate to be set. The Lucid M1 TCD ultrasound system is a product of Neural Analytics (Los Angeles, CA, USA; www.neuralanalytics.com), and has been approved by the U.S. Food and Drug Administration (FDA). “The Lucid system is the first truly portable ultrasound system to assess brain blood flow, and is the first product we will commercialize in the United States,” said Leo Petrossian, CEO of Neural Analytics. “This is a significant milestone for our organization, and more importantly, represents a step forward in improving the care of all patients suffering from blood flow disorders.” “The Lucid system offers the ability to accurately measure the flow of blood

Multi-Contrast MRI Technique Reduces Scan Times n innovative multi-contrast magnetic resonance imaging (MRI) technique can manipulate scans retrospectively, leading to significant timesaving and fewer rescans. The MAGnetic resonance image Compilation (MAGiC) acquisition technique allows clinicians to modify image contrast after scanning has been completed, which is not possible with conventional imaging. While with conventional MR imaging, a radiologist may need to order a rescan if the proper contrast was not acquired, MAGiC allows the radiologist to view multiple different contrasts acquired from just a single scan, enhance differential diagnosis at a fraction of the scan time, improving patient throughput and comfort. Clinicians will be able to generate multiple image contrasts in T1, T2, STIR, T1 FLAIR, T2 FLAIR, Dual IR, Phase Sensitive IR, and Proton Density weighted images of the brain, all in a single acquisition. To change contrast, users simply move a cursor on the interface to change parameters, such as repetition time (TR), echo time (TE), and inversion time (TI). MAGiC can also generate parametric maps for further analysis of patient-specific tissue

HospiMedica International December/2016-January/2017

values like T1, T2, and proton density (PD). MAGiC was developed by GE Healthcare (Waukesha, WI, USA; www.gehealthcare.com), in collaboration with SyntheticMR (Linköping, Sweden; www.syntheticmr.com). “MAGiC is a terrific clinical innovation…this technique can improve the way clinicians conduct neuro scans and diagnose their patients,” said Eric Stahre, president and CEO of MRI at GE Healthcare. “Neuro scans are approximately 30% of all MR scans; therefore MAGiC could have a tremendous impact on the MR community. GE Healthcare is committed to delivering industry-leading MR innovations that advance clinical care.” “MAGIC simultaneously provides a new level of protocol efficiency and tissue characterization,” said professor of radiology, neurology, and neurosurgery Howard Rowley, MD, of the University of Wisconsin (Madison, USA). “The flexibility to postprocess a wide variety of key image families with different tissue contrasts from a single acquisition is groundbreaking. This will be a major advance for fast brain protocols and patient comfort due to the reduced scan time.”

in the brain, which is critical to assess and monitor patients suspected of severe brain conditions,” said Neil Martin, chief medical officer of Neural Analytics, and chief of neurosurgery at the University of California Los Angeles (UCLA; USA). “Thanks to the portability of the product, for the first time, clinicians will be able to bring this level of care directly to the patient prior to the need for more complex and invasive tests.” Image: The Lucid M1 transcranial doppler ultrasound system (Photo courtesy of Neural Analytics).

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The SOMATOM Confidence RT Pro generates personalized images for all patients that are optimized for both contouring and dose calculation. It reduces unnecessary workflow steps and potential sources of errors, and features advanced technology for improved visualization.

The ChromaPaxx 17C2D4G160HD integrates a 17-inch display and digital recorder to capture video/images via S-Video or Composite and record in three formats. It is suitable for recording/displaying videos and images for endoscopy, surgical applications, and X-ray procedures.

The EVO series is equipped with an easy-open, lever-style handle to facilitate access into and out of the MRI suite. It features a low-friction design, aided by a reduced contact surface, to make it easy to open for MR technicians, and an architectural style suited for all environments.

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BOLD MRI Can Detect Coronary Stenosis at Rest new study suggests that blood oxygen-level dependent (BOLD) magnetic resonance imaging (MRI) can detect myocardial ischemia without inducing cardiac physiological or pharmacological stress. Researchers at John Radcliffe Hospital (Oxford, United Kingdom; www.ouh.nhs.uk/hospitals/jr) conducted a study to reevaluate data published in 2012 that focused more on segment-based analysis of BOLD, whereas the new analysis focused on whole-slice analysis. In the first study, which included 25 coronary artery disease (CAD) patients and 20 healthy volunteers, the researchers determined the diagnostic performance of stress BOLD imaging in identifying significant CAD. For the present analysis, resting BOLD signal intensity was first evaluated in the derivation group, and then tested in a separate validation group of 57 patients with suspected CAD referred for diagnostic coronary angiography. The range of BOLD signals at rest for each patient was indexed to create a score that correlated with presence of CAD, with an average index of 22.6% in those with versus 15.4%

for those without ischemia. The researchers therefore defined a 16.1% cutoff score that identified ischemia-causing blockages. Upon validation, the researchers found that the BOLD model could identify blockages with 88% sensitivity, 58% specificity, and 75% overall diagnostic accuracy. It performed similarly for diagnosing anatomically-significant CAD – defined as 50% or greater stenosis – at 82% sensitivity, 61% specificity, and 75% overall diagnostic accuracy. The researchers also concluded that BOLD MRI could perform equally well at stress as at rest. The study was published in the July 2016 issue of JACC: Cardiovascular Imaging. “Our findings are pertinent to alternative imaging modalities with the potential to identify microvascular heterogeneity, and advance the concept of a functional assessment of CAD being performed at rest,” concluded lead author Jayant Ranjit Arnold, BMBCh, MA, and colleagues. “The inability of resting myocardial blood flow to discriminate the presence of CAD indicates that the favorable diagnostic performance of resting BOLD assessment

is not dependent on changes in resting myocardial blood flow.” BOLD MRI measures the blood oxygen level dependent signal that is associated with changes in blood flow and oxygenation following neural activity. The technique is particularly helpful in neurology for patients with premotor symptoms of Parkinson’s disease (PD) such as frontal executive dysfunction. The neuroimaging provides excellent resolution and diagnostic sensitivity, and can facilitate the diagnosis of other neurodegenerative conditions, including multiple system atrophy, corticobasal degeneration, and progressive supranuclear palsy. Image: A patient about to undergo an MRI scan (Photo courtesy of MNT).

CT Attenuation Measurements Can Differentiate Bone Tumors new study suggests that computerized tomography (CT) attenuation measurements can be used to distinguish untreated osteoblastic metastases from benign bone lesions. Researchers at Massachusetts General Hospital (MGH; Boston, USA; www.massgeneral.org) conducted a study in 62 patients with 279 sclerotic bone lesions found at CT. The cause of the sclerotic lesions was then assessed histologically, determining there were 126 benign enostoses (bone islands) in 37 patients, and 153 osteoblastic metastases in 25 patients. The researchers then performed an analysis of the CT images to determine sensitivity, specificity, AUC, 95% confidence intervals, and cutoff values of CT attenuation to help differentiate metastases from enostoses.

The researchers concluded that CT attenuation measurements can be used to distinguish untreated osteoblastic metastases from enostoses, and that a mean attenuation of 885 Hounsfield units (HU) and a maximum attenuation of 1,060 HU provide reliable thresholds below which a metastatic lesion is the favored diagnosis. According to the researchers, the detection of metastatic disease is crucial because it allows accurate diagnosing and determination of prognosis and can drastically change treatment. The study was published in the August 2016 issue of the American Journal of Roentgenology. “While imaging has become an integral part of diagnosing patients presenting with malignancy, it can be confusing when an osteoblastic lesion is

identified in the presence and absence of a primary malignancy,” concluded lead author Connie Chang, MD, of the MGH department of radiology, and colleagues. “As CT use has increased, the frequency of incidentally detected lesions has also increased.” The Hounsfield scale is a quantitative scale for describing radiodensity, in which distilled water at standard pressure and temperature is defined as zero HU, while the radiodensity of air under the same conditions is defined as -1000 HU; one HU represents a change of 0.1% of the attenuation coefficient of water. A practical application of this is in evaluation of tumors, wherein an adrenal tumor with a radiodensity of less than 10 HU is rather fatty in composition and almost certainly benign. HospiMedica International December/2016-January/2017

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Medical Imaging

Multi-Parametric MRI and PET Imaging Improve Accuracy of Prostate Cancer Biopsies esearchers have demonstrated that a combination of PET and multi-parametric MR imaging can improve targeted prostate cancer biopsies.

Compact Proton Therapy System Provides Advanced Beam Modes new intensity modulated proton therapy (IMPT) system allows clinicians to operate with sub-millimetric precision treatment. The IBA Proteus ONE is a single-room configuration consisting of an accelerator, a direct beam line, and a compact gantry. The smaller footprint of the Proteus ONE allows for correspondingly smaller facilities, reducing construction and maintenance costs, which helps make the technology available to more cancer care providers. It also reduces the amount of time staff members need to position patients for optimal treatment, which helps reduce treatment times and patient stress. The Proteus ONE is equipped with pencil beam scanning (PBS) which allows delivery of very high levels of conformity and dose uniformity, even in complex-shaped tumors, whilst at the same time sparing the surrounding healthy tissue. Advanced imaging techniques include cone beam computed tomography (CBCT) and stereoscopic imaging, which allow the treatment of a diverse range of ocular tumors, central nervous system (CNS) tumors, head and neck malignancies, thoracic malignancies, and abdominal and pelvic malignancies. The compact gantry offers a rolling floor design for 360° of treatment access. This is achieved due to the 220° rotating structure and a robotic patient positioner with the six degrees of freedom of movement. And since the system is allocated with a dedicated accelerator, the need for a control space and the accompanying operational requisites are eliminated. The Proteus ONE IMPT system is a product of Ion Beam Applications (IBA; Louvain-La-Neuve, Belgium; https://iba-protontherapy.com), and has been approved by the U.S. Food and Drug Administration (FDA). “The Proteus ONE aligns with the US healthcare trend of providing the highest quality of cancer treatment possible at the best possible price,” said Olivier Legrain, CEO of IBA commented: “We are confident that Proteus ONE will drive greater momentum in the adoption of this next generation targeted cancer treatment internationally. The approval reaffirms our world leading position in the delivery of highly targeted, safer cancer treatment solutions.” Proton therapy is a precise form of radiotherapy (RT) that uses charged particles instead of x-rays. It can be a more effective form of treatment than conventional RT as it directs the therapeutical radiation beam more precisely, with minimal damage to surrounding tissue. Evidence is growing that protons can be effective in treating a number of cancers, in particular children and young people with brain tumors, for whom it appears to produce fewer side effects such as secondary cancers, growth deformity, hearing loss, and learning difficulties.

HospiMedica International December/2016-January/2017

The study was published in the July 2016 issue of The Journal of Nuclear Medicine and found that adding F-18-choline Positron Emission Tomography (PET) molecular imaging to multiparametric Magnetic Resonance Imaging (mpMRI) improves the chance of recognizing significant prostate cancer during targeted trans-rectal prostate biopsies. The study, part of an ongoing prospective clinical trial was carried out by researchers at the University of Michigan (UMS; Ann Arbor, MI, USA; www.umich.edu) and included 36 subjects of which 15 were eventually identified with significant prostate cancer. The researchers concluded that image registration using fusion PET imaging together with MRI real-time Trans-Rectal Ultrasound (TRUS) during targeted prostate biopsies was accurate and clinically feasible. The addition of F-18-choline PET, to the mpMRI procedure re-

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sulted in improved identification of significant prostate cancer. Morand Piert, MD, radiology professor, Division of Nuclear Medicine, University of Michigan, said, “Our positive results suggest that in the future, PET/MRI may become a one-stop imaging test for men with suspected but undetected prostate cancer or for patients undergoing surveillance for known low-risk prostate cancer. Since prostate cancer is often multi-focal and presents with multiple lesions of varying risk, it is important to identify the lesions that harbor the greatest malignant potential. Accurate identification of clinically significant cancer and avoidance of clinically insignificant cancer is the centerpiece of modern prostate cancer diagnosis. The use of advanced imaging to inform placement of biopsy needles promises to greatly minimize the uncertainty associated with prostate cancer care.”

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New PET Tracer Images Epigenetics of Human Brain novel positron emission tomography (PET) radiotracer can help reveal epigenetic activity within the human brain, claims a new study. Developed by researchers at the Martinos Center for Biomedical Imaging (NMR; Charlestown, MA, USA; www.nmr.mgh.harvard.edu), part of Massachusetts General Hospital (MGH; Boston, USA; www. massgeneral.org), Martinostat is patterned after histone deacetylase (HDAC) inhibitors in order to tightly bind to HDAC molecules in the brain. PET scans of the brains of eight healthy human volunteers who received Martinostat revealed charac-

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teristic patterns of uptake – reflecting HDAC expression levels – that were consistent among all participants. The results revealed that HDAC expression was almost twice as high in gray matter as in white matter; and within gray matter structures, uptake was highest in the hippocampus and amygdala, and lowest in the putamen and cerebellum. Experiments with brain tissues from humans and baboons confirmed Martinostat’s binding to HDAC, and studies with neural progenitor stem cells revealed specific genes regulated by this group of HDACs, many of which are known to be important in brain health and disease. The study was published on

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August 10, 2016, in Science Translational Medicine. “HDAC dysregulation has been implicated in a growing number of brain diseases, so being able to study HDAC regulation both in the normal brain and through the progression of disease should help us better understand disease processes,” said senior author associate professor of radiology Jacob Hooker, PhD. “We’ve now started studies of patients with several neurologic or psychiatric disorders, and I believe Martinostat will help us understand the different ways these conditions are manifested and provide new insights into potential therapies.” “The ability to image the epigenetic machinery in the human brain can provide a way to begin understanding interactions between genes and the environment,” added Dr. Hooker. “This could allow us to investigate questions such as why some people genetically predisposed to a disease are protected from it? Why events

during early life and adolescence have such a lasting impact on brain health? Is it possible to ‘reset’ gene expression in the human brain?” Epigenetics is the study of heritable changes in gene expression that does not involve changes to the underlying DNA sequence – i.e. a change in phenotype without a change in genotype – which in turn affects how cells read the genes. Epigenetic change is a regular and natural occurrence, but can also be influenced by several factors including age, the environment/lifestyle, and disease state. Epigenetic modifications can manifest as commonly as the manner in which cells terminally differentiate to end up as skin cells, liver cells, brain cells, etc. Epigenetic change can also have more damaging effects that can result in diseases like cancer. Image: A human brain MR-PET image using Martinostat (Photo courtesy of NMR). HospiMedica International December/2016-January/2017

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Digital Radiography Table Advances Clinical Diagnostics new digital radiographic table system offers high-performance digital projection radiography with features that supports productivity, user-operability, patient comfort, and safety. The RADspeed Pro Edge Digital Radiography package of advanced applications includes tomosynthesis, which allows the user to obtain multiple digital cross section images from a single linear tomography scan. The raw scan data can then be used to reconstruct cross sectional images from any height, as many times as desired. Furthermore, it offers the flexibility of scanning patients while applying loads in the standing position, in the supine position on the table, or with elbows or knees bent. A metal artifact inhibition feature helps evaluate bones near metal objects, such as used for checking bone union status after orthopedic surgery. Another innovative feature is dual energy subtraction, which utilizes the difference in X-ray absorption levels of bones and soft tissues to generate separate images of each, in addition to plain radiographic images, by successively applying high- and low-voltage exposures and then using an algorithmic process to separate them. This enables rendering of nodes obscured behind ribs in soft-tissue images of the chest area or calcifications in bone images, which are especially useful for diagnoses of the chest area, such as with lung cancer. The newly developed Bucky table is able to obtain 120 cm long view images in the supine position and 160 cm standing long view images, helping to visualize the entire spine or entire lower extremities, even for large patients or patients with difficulty in standing. Automatic linking of the settings made on the X-ray tube with the Bucky table or Bucky stand allows the system to perform subsequent automatic stitching of the radiographs to generate an anatomically coherent image. Innovative flat panel detectors (FPD) in various cassette formats offer maximum efficiency in clinical practice; large format, 43x43 cm and 34x43 cm detectors for general radiographic examinations are available, equipped with a Cesium Iodide (CsI) or Gadolinium oxysulfide (GOS) scintillator. Additionally, a smaller sized FPD with an imaging area of 24x30 cm allows free positioning on the X-ray table, such as for dedicated orthopedic examinations. The RADspeed Pro Edge Digital Radiography package is a product of Shimadzu (Kyoto, Japan; www.shimadzu.com).

Image: The RADspeed Pro Edge digital radiography system (Photo courtesy of Shimadzu).

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Medical Imaging

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Cone Beam CT Imaging Could Help Detect Joint Osteoarthritis Earlier ombining cone beam computed tomography (CBCT) with complementary metaloxide semiconductor (CMOS) sensors could detect early stage osteoarthritis (OA). Developed by researchers at Johns Hopkins University (JHU, Baltimore, MD, USA; www.jhu.edu), the portable CBCT/CMOS system could be used in doctors’ offices, helping to detect OA with a radiation dose lower than that of standard computed tomography (CT). And since the CMOS sensor provides very high spatial resolution, it allows detection of finer details than standard CT, greatly enhancing doc-

tors’ ability to assess trabecular bone. According to the researchers, the imaging system also could help with early identification of osteoporosis. The researchers used the CBCT/CMOS system to image the hand of a human cadaver, as well as pelvic bone biopsy samples from 25 living women. They determined that the system provided results that correlate with micro-CT with an amorphous silicon (aSi) flat-panel detector (FPD), which is the gold standard for assessing trabecular bone. The preliminary results were presented at the 58th annual meeting of the American Association of Physicists in Medicine

(AAPM), held during July-August 2016 in Washington (DC, USA). “The technology we are developing allows us to see very fine detail in the mesh-like microstructure of bone – known as trabecular bone – which currently can’t be assessed in patients,” said senior author medical physicist Wojciech Zbijewski, PhD, of the JHU department of biomedical engineering. “There is growing evidence that early stages of osteoarthritis involve changes in trabecular bone, so if we can detect such change, a patient could potentially avoid painful knee replacement surgery by getting treatment before the cartilage was irreversibly damaged.” Currently, joints are usually assessed by x-ray or magnetic reso-

nance imaging (MRI), which show if the cartilage lining the joint has been damaged. In most cases, by the time a patient has pain, the damage to the joint is irreversible, and the only solution is to surgically replace that joint. Joint replacement is therefore a common procedure, with 719,000 knee replacements and 332,000 hip replacements performed every year in the United States alone, according to the Centers for Disease and Prevention (CDC; Atlanta, GA, USA). Image: Imaging reconstruction of a joint using CBCT/CMOS (Photo courtesy of JHU).

Photoacoustic Imaging Could Monitor Prostate Cancer new study suggests that photoacoustic imaging (PAI) may be an effective tool for non-invasive monitoring of prostate cancer (PC). Researchers at Roswell Park Cancer Institute (RPCI; Buffalo, NY, USA; www.roswellpark.org), the University of Rochester (NY, USA; www. rochester.edu), and the Rochester Institute of Technology (RIT; NY, USA; www.rit.edu) conducted a study that focused laser light on phantoms containing PC cells, and then used ultrasound technology to see how molecular imaging agents that target the prostate-specific membrane antigen (PSMA) expressed under PAI. The two PSMA-targeting agents, ribonucleic acid aptamer (A10-3.2), and a urea-based peptidomimetic inhibitor (YC-27), were linked to the near-infrared (NIR) dye IRDye800CW. The researchers found that the PAI with an acoustic lens enabled good discrimination between cells with and without the PSMA-targeting agent attached with both imaging agents. They found however, that YC-27 fluoresced much brighter and that conjugation of the modified chromophores was more tractable. They concluded therefore that the urea-targeting agent represents a better approach to developing “louder” signals necessary to overcome the

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challenges of detecting PC by PAI in vivo. The study was published in the June 2016 issue of the Journal of Biomedical Optics. “This proof-of-concept study demonstrates that this technology may allow for real-time monitoring of prostate cancer in patients during the course of active surveillance. For patients with more aggressive disease, the technology could offer more precise targeting of biopsies to confirm the need for definitive therapy,” said senior author Kent Nastiuk, PhD, assistant professor of cancer genetics and genitourinary cancers at RPCI. “This technology offers the potential to confirm the initial prostate cancer diagnosis, guide biopsies and monitor tumor volume – which is currently not measureable – for improved case management and treatment decision-making.” PAI uses non-ionizing laser pulses delivered into biological tissues. Some of the delivered energy is absorbed and converted into heat, leading to transient thermoelastic expansion, and thus wideband ultrasonic emission, which can be detected by ultrasonic transducers and analyzed to produce images. The magnitude of the photoacoustic signal is proportional to the local energy deposition, which can be demonstrated by optical absorption contrast on the images of the targeted areas. HospiMedica International December/2016-January/2017

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Medical Imaging

Intelligent Imaging System Assists Mammography Procedures novel mammography system with intelligent image processing supports healthcare professionals in the early detection and diagnosis of breast cancer. The Aspire Cristalle is an advanced digital mammography system that optimizes image contrast and dose across all breast types, thanks to a combination of hexagonal close pattern (HCP) capture technology and intelligent image processing, resulting in a reduced acquisition time of 15 seconds. Images are enhanced by intelligent automatic exposure control (iAEC) and image based spectrum conversion (ISC), which analyze the breast for glandular tissue characteristics, detect implants to optimize dose and processing, and precisely tune contrast to adapt for every breast type and to image implants. Simplicity of operation allows reliable exams quickly and easily, starting from a simple one-button startup to a patented comfort paddle equipped with soft edges, a flexible composition, and a four-way pivot that contours to the individual shape of the breast, in order to apply a gentle, even compression that results in optimal tissue separation. The Aspire Cristalle system is a product of Fujifilm Medical Systems (Tokyo, Japan; www.fujifilm.com/products/medical), and was designed to provide an upgrade path to future technologies. “Fujifilm is constantly innovating to develop the most advanced digital mammography systems to as-

sist in the early detection of breast cancer,” commented Timothy Gustafson, RT, director of the imaging service at White Memorial Medical Center (Los Angeles, CA, USA). “Aspire Cristalle brings together Fujifilm’s extensive research, expertise, and experience. The technology allows us to continue our mission, providing comprehensive cancer care for our community, combining sophisticated technology with a warm, caring touch.” HCP is based on hexagonal pixels distributed in

the electrical field, which are more efficient than traditional, square pixels; this results in a strong, homogenous signal that provides images with high detective quantum efficiency (DQE) and modulation transfer function (MTF), which delivers exceptionally sharp images, even at low dose, with a small (50 micrometer) pixel size. Image: The Aspire Cristalle digital mammography system (Photo courtesy of Fujifilm).

Image-Guided PET-CT Surveillance As Effective as Neck Dissection for Advanced Head and Neck Cancer he results of a recent study show that the survival rates of patients with advanced head and neck squamous-cell carcinoma, was similar for those diagnosed using PET-CT guided surveillance, and those who underwent a planned neck dissection. The use of the different techniques for the treatment of patients with advanced head and neck squamous-cell carcinoma nodal disease (stage N2 or N3) who have undergone chemoradiotherapy for primary treatment, is unclear and under debate. The primary end point of the prospective, randomized, controlled trial was to assess overall survival rates, and the non-inferiority of Positron-Emission Tomography-Computed Tomography (PET-CT) guided surveillance when compared with planned neck dissection for patients with stage N2 or N3 carcinoma nodal disease. The researchers used data gathered by the UK Warwick Clinical Trials Unit. Tissue samples were collected and stained for the p16 protein at the University of Birmingham (Birming-

HospiMedica International December/2016-January/2017

ham, UK; www.birmingham.ac.uk). The study lasted from 2007 to 2012, and included 564 patients from 37 centers in the UK. Seventeen percent of the patients had nodal stage N2a disease, while 61% had stage N2b disease. The results showed that the use of PET-CT guided surveillance resulted in significantly less neck dissections (54) compared to planned dissection surgery (221). Surgical complications were similar in both groups. The 2year overall survival rate was 84.9% for those patients undergoing PET-CT surveillance, and 81.5% for those that underwent planned-surgery. In addition, savings of UKP 1,492 per patient were realized per patient, for the duration of the trial, when PETCT guided surveillance was used instead of neck dissection. The researchers concluded that survival rates for patients who underwent planned neck dissection were similar to those that underwent PETCT guided surveillance, and that imaging surveillance resulted in significantly less operations than neck dissection, and was more cost-effective. LINKXPRESS COM

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Network Dynamics Help Devise Strategies for Epilepsy Surgery

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new study describes a mathematical model that can help distinguish ictogenic brain networks that act as the source of epileptic seizure activity. Researchers at the University of Exeter (United Kingdom; www. exeter.ac.uk) have devised a predictive, network dynamics paradigm that allows the study of the relationship between brain network structure, node dynamics, and the generation of epileptic discharges. As part of the mathematical framework, the researchers quantified the ability of a brain network to generate emergent pathological dynamics, such as electrical discharges or seizures. They termed this ability as Brain Network Ictogenicity (BNI). The specific model they developed for epilepsy surgery used spiking as a proxy for discharges. They claim that quantifying the ictogenicity of networks in this way allows them to determine the effect of perturbations to specific nodes of the network, thus uncovering the mechanistic contribution of each node to the emergent ictogenicity. Under this model, factors conventionally used to determine the region of tissue to resect, such as location of focal brain lesions or the presence of epileptiform rhythms, do not necessarily predict the best resection strategy. The researchers then validated the paradigm framework by analyzing electrocorticogram (ECoG) recordings from 16 patients who had undergone epilepsy surgery. They found that when post-operative out-

come was good, model predictions for optimal strategies aligned better with the actual surgery undertaken than when the post-operative outcome was poor. The model thus allows the prediction of optimal surgical strategies and the provision of quantitative prognoses for patients undergoing epilepsy surgery. The study was published on July 7, 2016, in Scientific Reports. “Imagine someone was in a theatre and sending text messages to random audience members, making their phones ring. Current techniques are in essence akin to removing those people who receive the messages; they are contributing to the disruption and so removing them could make a difference,” said senior author Professor John Terry, PhD. “But clearly it would be better to identify and remove the individual sending out the messages – the original source. That is what our methods achieve – identifying the original source.” “We were able to compare, for the first time, predictions made by a computer model applied to pre-surgical brain recordings with the post-surgical outcomes from a group of people with epilepsy,” said lead author Marc Goodfellow, PhD. “The potential for future treatment is clear - we are looking at a more accurate way of identifying exactly where to operate to give the best results for an individual, and so improve the lives of so many people who would otherwise have to live with the constant threat of seizures.” HospiMedica International December/2016-January/2017

Robotic Assistant Helps Position Interventional Needles n innovative robotic arm can help clinicians precisely position interventional needles at the optimal insertion point. The robotic arm, developed jointly by researchers at the Fraunhofer Institute for Manufacturing Engineering (IPA; Stuttgart, Germany; www.ipa.fraunhofer.de) and the Fraunhofer Institute for Medical Image Computing (MEVIS; Bremen, Germany; www.mevis.fraunhofer.de) traces the initial interrogatory computerized tomography (CT) scan, using a calibration tool to determine the ideal position to target a specific point in the image. Software developed at MEVIS then analyzes the image and supports the doctor in placing the virtual needle, displaying it in the image. If, instead of a biopsy, the aim of the treatment is direct heating, cooling, or high-energy beams into a tumor, the software also simulates energy propagation throughout the tissue. The last step is to determine the number of needles required and their relative positions so as to destroy the entire tumor. Once a treatment plan is complete, the robotic arms calibration tool is replaced with a needle guide. The robot then transports the guide to the calculated position and angle on the skin; the doctor then inserts the needle into the tissue through the guide, held in place by the robot. The robotic assistance requires just five minutes to accurately position the needle, as opposed to 30 minutes with conventional techniques. In addition, the robotic arm reduces radiation exposure for both the doctor and patient; in conventional needle insertion, the needle is held in place manually, obscuring part of the X-ray and exposing doctors’ hands to radiation. With the robotic arm, which is impervious to radiation, the needle is held in place with its needle guide. There is also a significant reduction in the patient’s radiation exposure. As a result, the number of monitoring Xrays is greatly reduced. “Whereas humans struggle to position this sort of needle, it’s hard to beat a robot designed for the purpose. Our system removes burdens for doctors while leaving them in control,” said Andreas Rothfuss, of the IPA Project group for Automation in Medicine and Biotechnology (PAMB). “A human needs 30 minutes to position the needle, but with robot assistance this is cut down to five minutes at most.”

Image: A robotic assistant helps position interventional needles (Photo courtesy of V

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Surgical Techniques

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New OR Monitors Introduced wo new industry-first 55-inch and 31-inch high-definition 4K and 3D medical monitors intended for use by surgical teams have been launched. The monitors combine 4K, and 3D imaging technologies, and provide enhanced resolution, increased depth of field, and high brightness. The Sony (Tokyo, Japan; www.pro.sony.eu/ medical) 55-inch LMD-X550MT and 31-inch LMDX310MT surgical monitors are designed for use in operating rooms and for training, with surgical microscopes and with new 4K or 3D endoscopes that being launched. Two dimensional and 3D images are displayed as 4K or High Definition (HD) resolution images for improved contrast, enhanced clarity, and accurate color reproduction. The monitors are designed with a narrow bezel and a slender chassis and offer the same features as other Sony medical monitors. The monitors can combine, and reproduce full

HD resolution of both left and right channels of the dual-channel 3D HD video format used by many 3D endoscopes. Conventional 3D monitors discard half of the vertical resolution because they use an HD panel. The new monitors comply with the European Medical Device Directive 93/42/EEC as amended by 2007/47/EC. John Herman, European product marketing manager, Sony Professional Solutions Europe, said, “With the introduction of these monitors, Sony has combined the best of both 4K and 3D worlds, namely - improved surgical vision through higher reso- Image: The 31-inch, 4K surgical monitor (Photo courtesy of Sony). lution, enhanced identification of tisaccuracy with increased depth perception from 3D sue surface structure from increased brightness and visualization.” color reproduction and improvements in surgical

FFR Guidewire Improves Percutaneous Coronary Interventions n improved guidewire provides physicians with fractional flow reserve (FFR) measurements in order to gauge narrowed coronary arteries. The St. Jude Medical (SJM; St. Paul, MN, USA; www.sjm.com) PressureWire X Guidewire Measurement System has been redesigned to adapt to unique, complex anatomies in order to support more accurate lesion assessment during percutaneous coronary intervention (PCI). The tip of the guidewire can be shaped and re-shaped throughout the PCI procedure, enabling access to multiple lesions. The guidewire also provides enhanced durability and improved handling, in either a cabled or wireless configuration. Concomitant to the launching the latest PressureWire X Guidewire iteration, SJM has also launched the PRESSUREwire multicenter clinical trial in order to determine the routine use of FFR measurement and clinical outcomes of FFR-guided

PCI in patients with acute coronary syndrome (ACS), a major cause of global morbidity and mortality. The PRESSUREwire REGISTRY will build upon clinical trials designed to assess the positive outcomes associated with FFR technology. “St. Jude Medical strives to provide physicians with fractional flow reserve pressure guidewire technology that is backed by ample clinical data, and that matches the handling performance of conventional PCI guidewires,” said Mark Carlson, MD, chief medical officer and vice president of global medical affairs at St. Jude Medical. “The new PressureWire X Guidewire shows our dedication to providing physicians with

cost-effective, easy-to-use technologies that aid them in making the best treatment decisions for their patients.” “Clinical research has confirmed that fractional flow reserve is one of the most important tools available when assessing coronary lesions and making informed treatment decisions during percutaneous coronary intervention,” said Annapoorna Kini, MD, director of the cardiac catheterization lab at Mount Sinai Medical Center (New York, NY, USA). “The improved design and shape retention of the new PressureWire X Guidewire tip allows us to perform FFR measurements in more tortuous anatomies.” FFR is a physiological index used to determine the hemodynamic severity of atherosclerotic narrowing of the coronary arteries. It specifically identifies which coronary narrowing is responsible for the ischemic obstruction of the flow of blood to a patient’s heart muscle, and helps guide interventional cardiologists in determining which lesions warrant stenting, resulting in improved patient outcomes and reduced health care costs. Image: The PressureWire X Guidewire for FFR measurement (Photo courtesy of St. Jude Medical).

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Surgical Techniques

Ultrasonic Technology Augments Soft Tissue Fixation new bioresorbable implant utilizes ultrasonic energy to liquefy and flow into cancellous bone to provide stable soft tissue to bone fixation. The Stryker (Kalamazoo, MI, USA; www.stryker.com) SonicAnchor is a bioresorbable implant made of poly-L-DL-lactic acid (PLDLLA), which is placed into a hole drilled into the cancellous bone. Once high frequency, low amplitude ultrasonic energy is applied to liquefy the tip of the implant, PLDLLA flows into the bone cavities. Following cessation of the ultrasound pulse, the material resolidifies and hardens, providing stable three-dimensional (3D) anchoring within five seconds. The SonicAnchor is intended for suture or tissue fixation in foot, ankle, knee, hand, wrist, elbow, and shoulder open procedures. Examples include Achilles tendon repair, lateral and medial stabilization, hallux valgus reconstruction, midfoot reconstruction, metatarsal ligament repair, and digital tendon transfer. Even with

its small, 2.5 mm diameter footprint, the SonicAnchor demonstrates significant enhancement in dynamic load stability, lower risk of breakage during insertion, and high pull out strength and reliability. “Stryker is helping drive innovation in the industry with SonicAnchor and its unique fixation technology,” said orthopedic surgeon Adam Schiff, MD, of Loyola University Medical Center (Maywood, IL, USA), who has performed several procedures using the product. “Every time I place one, I am truly impressed by the strength and performance of this small implant.” “SonicAnchor is transforming the soft tissue experience, and we are excited Stryker is leading the way in providing this innovative solution to orthopedic surgeons,” said Tom Popeck, vice president and general manager of Stryker’s Foot and Ankle business unit. “SonicFusion technology is unlike any other on the market.” Polylactide is biodegradable ther-

Image: The SonicAnchor bioresorbable implant (Photo courtesy of Stryker).

moplastic aliphatic polyester derived from renewable resources, such as cornstarch, tapioca roots, or sugarcane. It can be processed by extrusion, 3D printing, injection molding, film and sheet casting, and spinning, providing access to a wide range of

products. Since it degrades into innocuous lactic acid, it is often used in surgery in the form of anchors, screws, plates, pins, rods, and as a mesh. Depending on the exact type used, it breaks down inside the body within 6 months to 2 years.

Arterial Revascularization Superior in Bypass Surgery new study concludes that diabetic patients who undergo coronary artery bypass surgery (CABG) have better long-term outcomes when arteries are used rather than veins. Researchers at Royal Melbourne Hospital (RMH; Australia; www. thermh.org.au) and the University of Melbourne (Australia; www.unimelb. edu.au) reviewed 63,592 cases from the Australian and New Zealand Society of Cardiothoracic Surgeons (ANZSCTS) database, identifying 34,181 patients (34.1% diabetics), who underwent isolated CABG between 2001and 2012; total arterial revascularization (TAR) was performed in 35.9% of the patients. The researchers then matched 6,232 diabetic and non-diabetic pairs. The results showed that more diabetic patients survive when only arteries are used for bypasses during CABG surgery. Diabetic patients also experience fewer long-term complications from TAR/CABG than from conventional CABG. The researchers also found that TAR/CABG can be performed on diabetic patients without increasing the rate of complications, such as angina (chest pain),

HospiMedica International December/2016-January/2017

heart attacks, heart failure, and hospital readmissions. The study was published on July 14, 2016, in The Annals of Thoracic Surgery. “Average conventional CABG surgery involves three to four grafts: one artery is usually used, along with vein grafts from the leg or thigh for the remaining new bypasses. In TAR/ CABG surgery, only arteries are used,” said lead author James Tatoulis, MD, of RMH and the University of Melbourne. “For every 100 diabetic patients undergoing CABG surgery, four more will be alive at 10 years when arteries are used for the bypasses, rather than just one arterial graft together with veins.” For patients with coronary artery disease (CAD), a coronary artery surgical bypass can be placed to reroute blood around blocked arteries to restore and improve blood flow and oxygen to the heart. To create the bypass graft, a surgeon harvests healthy blood vessels from another part of the body, often from the patient’s leg or arm. This vessel becomes a graft, with one end attaching to a blood source above and the other end below the blocked area, creating a new conduit channel. LINKXPRESS COM

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PRODUCT NEWS ELECTROSURGERY SYSTEM

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OPERATING TABLE

SURGICAL LIGHT

Eschmann

Mediland

The E50 features Bipolar Vessel Sealing, which allows the sealing of vessels and tissues up to 7mm in diameter. It also features Argon Beam monopolar technology that delivers ionized argon gas for creating a wide area of coagulation with a limited penetration depth of 3mm.

The TX200 features a full-length radiolucent top with integral X-ray cassette tunnel and a maximum patient weight of 450 kg. Other features include covers made of impact-resistant acrylic capped ABS, and a 3-inch LCD screen on the handset for positioning information.

The MediLED Symphony features a focus adjustment system that can focus light on one spot to form a clear, even field of brilliance on the surgical area. It can maintain a consistent light intensity at distances of 70 cm to 150 cm, and allows the light pattern to be adjusted using a motorized control.

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Sterile Gloves Hold No Advantage Against Surgical Site Infections esearchers at the Mayo Clinic (Rochester, MN, USA; www.mayoclinic.org) conducted a systematic review and meta-analysis of studies to explore surgical site infections (SSI) rates and determine whether the use of sterile versus nonsterile gloves in outpatient cutaneous procedures affects the rate of postoperative wound infection. Patients in the studies underwent outpatient cutaneous or mucosal surgical procedures, including Mohs micrographic surgery (MMS), repair of a laceration, standard excisions, and tooth extractions. Overall, 14 studies met eligibility and inclusion criteria, with a total of 12,275 patients who underwent outpatient procedures with sterile or nonsterile gloves, and had follow-up regarding SSI. In all, 228 patients (2.1%) were documented as having postoperative SSI, including 107 of 5,031 patients in the nonsterile glove group (2.1%) and 121 of 6,040 patients in the sterile glove group (2.0%). The study was published on August 3, 2016, in JAMA Dermatology. “When considering surgical practices and guidelines, multiple factors should be considered, including the potential consequences of deviating from accepted sterile glove use and the potential challenges this could cause from a medico-legal stand-

point,” concluded lead author Jerry Brewer, MD, and colleagues. “Patient perception of the sterile technique used should also be considered, in addition to the dexterity that comes from wearing a surgical glove that fits snugly, as opposed to a clean glove that gives the surgeon a different feel.” “Although the broad use of nonsterile clean gloves may be justified, caution is advised in generalizing this justification to more advanced outpatient surgical procedures that may not pertain to the information summarized in this review and meta-analysis,” advised the authors. “Future study could include whether duration of surgery and complexity of the repair influence postoperative SSI development in the setting of sterile versus nonsterile gloves.” Gloves were first introduced to surgical practice more than a century ago, mostly for hygiene purposes. After that, gloves were mainly used for other reasons, including the prevention of hand dermatitis. During the past few decades, the use of surgical

gloves has become standard practice to prevent postoperative wound infections or SSI. But while nonsterile gloves are cheap, coming in boxes of 100 gloves each, sterile gloves are of higher quality, individually packed, and are more expensive. Image: A new study shows no difference in the rate of postoperative surgical site infection outpatient surgical procedures between sterile and nonsterile gloves (Photo courtesy of the Mayo Clinic).

New Closure Device for Large Bore Access Procedures novel vascular closure device address the complexities of closing the large access punctures required in many advanced cardiovascular interventions. The MANTA Large Bore Vascular Closure Device is designed to close punctures ranging from 10F to 24F at femoral arterial access sites used during transcatheter aortic valve replacement (TAVR), endovascular treatment of abdominal aortic aneurysms (EVAR), implantation of a ventricular assist device (VAD), and balloon aortic valvuloplasty (BAV). The vascular closure device can be deployed in less than 60 seconds and utilizes an absorbable biomaterial sealing components to plug the access puncture. Features of the closure device include a rapid

fail-safe deployment with immediate hemostasis in order to reduce complications associated with large bore closure, x-ray visibility, and improved control during the deployment procedure. The MANTA Large Bore Vascular Closure Device is a product of Essential Medical (Malvern, PA, USA; www. essmedclosure.com), and has received the European Community CE mark of approval. “The MANTA vascular closure device revolutionizes any catheter based transfemoral procedure that requires large-bore arterial access. Access management becomes faster, safer, and reproducible in the hands of many more operators,” said Nicolas Van Mieghem, MD, PhD, medical director of the department of interventional cardiology at the Eras-

mus Medical Center (EMC; Rotterdam; The Netherlands) Thoraxcenter. “MANTA should become a mantra when performing TAVI,” said Jan van der Heyden, MD, PhD, of St. Antonius Ziekenhuis (Niewegein, The Netherlands). The Manta is very intuitive to use and provides instant hemostasis. It’s a great asset in the lab and will make TAVR cases even more successful going forward.” Closure of large bore femoral access sites has been associated with significant morbidity, including longer hemostasis times, extended procedure time, the need for a vascular surgeon in the catheterization lab, delayed ambulation, a higher rate of complications, and a higher total cost of care. HospiMedica International December/2016-January/2017

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Surgical Techniques

Implant Envelope Forms Vascularized Tissue Pocket novel extracellular matrix (ECM) pouch creates a stable environment for cardiac implantable electronic devices (CIEDs). The CorMatrix CanGaroo ECM envelope is constructed from a multi-laminate sheet of decellularized, lyophilized ECM derived from porcine small intestinal submucosa. The ECM serves as a bioscaffold for vascular ingrowth from adjacent tissues that deliver progenitor cells and nutrients, which then differentiate into tissue-specific cells and structures. The ECM material is then naturally degraded and resorbed, gradually replaced by the patient’s own cells, leaving behind remodeled functional tissue that may ease CIED removal during exchanges or revisions. The ECM envelope, which is provided in four different sizes, is intended to hold an array of different CIEDs, including pacemakers, cardiac resynchronization therapy (CRT) devices, and implantable cardioverter defibrillators (ICDs). It is positioned after the cardiac surgical procedure has been completed

to provide stabilization, support, and reinforcement of the pocket, reducing the risk of device migration and erosion. The CorMatrix CanGaroo ECM Envelope is a product of CorMatrix (Rosewell, GA, USA; www. cormatrix.com), and has received the European Community CE mark of approval. ECM is a collection of extracellular molecules that provides structural and biochemical support to the surrounding cells. It includes the interstitial matrix, composed of polysaccharide gels and fibrous proteins, and the basement membrane, which are sheetlike depositions on which various epithelial cells rest. Each type of connective tissue has a different ECM; collagen fibers and bone mineral comprise the ECM of bone tissue; reticular fibers and ground substance comprise the ECM of loose connective tissue; and blood plasma is the ECM of blood. Image: The CorMatrix CanGaroo ECM envelope (Photo courtesy of CorMatrix).

IVF Does Not Elevate Long-Term Breast Cancer Risk omen undergoing ovarian stimulation for in vitro fertilization (IVF) treatment do not have an increased risk of breast cancer (BC), according to a new study. Researchers at the Netherlands Cancer Institute (NKI; Amsterdam, The Netherlands; www.nki.nl), Catharina Hospital (Eindhoven, The Netherlands; www.catharinaziekenhuis. nl), and other Dutch institutions conducted a study among 19,158 women who started IVF treatment between 1983 and 1995 and 5,950 women who started other fertility treatments between 1980 and 1995 from all 12 Dutch IVF clinics. Information on ovarian stimulation for IVF, other fertility treatments, and potential confounders was collected from medical records and through mailed questionnaires. The main outcome was incidence of invasive and in situ BC. The results showed that after a median follow-up of more than two decades, BCincidence among IVF patients was relatively comparable with the non-IVF comparison group. The cumulative incidence of BC at age 55 was also nonsignificant when comparing the two groups (3% for IVF group and 2.9% for non-IVF group). The researchers noted that women

HospiMedica International December/2016-January/2017

who had seven or more IVF cycles had a significantly lower risk of BC than women who underwent just one or two cycles. The study was published on July 19, 2016, in the Journal of the American Medical Association (JAMA). “The risk did not differ by type of fertility drugs or subfertility diagnosis, and was not increased at 20 or more years after IVF treatment. Poor response to the first IVF cycle was also associated with decreased breast cancer risk,” concluded lead author Alexandria W. van den Belt-Dusebout, PhD, of the NKI, and colleagues. “These findings are consistent with the absence of a significant increase in the long-term risk of breast cancer among women treated with these IVF regimens.” IVF is the process of fertilization by manually combining an egg and sperm in a laboratory dish, and then transferring the embryo to the uterus. To increase success rates, various ovarian stimulation protocols are used to induce the ovaries to make more follicles and eggs. The most commonly used stimulation regimens include injections of follicle stimulating hormone (FSH), with the goal of getting approximately 8 to 15 quality eggs at the egg retrieval procedure. LINKXPRESS COM

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PRODUCT NEWS IMAGE SHARING PLATFORM

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DIGITAL ROOM UPGRADE KIT

DR CONVERSION SYSTEM

lifeIMAGE

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The lifeIMAGE 5.0 platform allows clinicians to quickly gain access and compare data from a number of locations internal and external to the hospital. It allows physicians in multiple locations to simultaneously review and annotate diagnosticquality images.

The Digital Room Upgrade Kit for is meant for upgrading existing rooms with compatible X-ray systems from CR to DR without having to upgrade the entire room. It offers a choice of wireless, tethered, or fixed Canon CXDI DR system to suit different budgets.

The AeroDR Portable Retrofit turns existing portable X-ray unit into a digital wireless solutions. It has a very small footprint, which allows for installation and storage inside the cassette storage bin, and is completely self-contained and includes two long-life batteries.

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Wearable Tattoo Detects Alcohol Levels in Human Sweat new study describes a novel biosensing patch that can detect alcohol in induced perspiration and send the information to a smartphone in just 8 minutes. Researchers at the University of California, San Diego (UCSD, USA; www.ucsd.edu), in collaboration with the U.S. National Institute of Biomedical Imaging and Bioengineering (NIBIB; Bethesda, MD, USA; www.nibib.nih.gov) developed the prototype noninvasive alcohol-monitoring platform, which integrates an iontophoretic-biosensing temporary tattoo with flexible wireless electronics. The device is based on the transdermal delivery of pilocarpine, a drug that induces sweat via iontophoresis. Ethanol can then be detected using an alcoholoxidase enzyme and a Prussian Blue electrode transducer. The new skin-compliant biosensor displays a highly selective and sensitive amperometric response to ethanol. On-body results with human subjects show distinct differences in current re-

sponse before and after alcohol consumption, reflecting the increase of ethanol levels. The skin-worn sensor is coupled with a flexible electronics board that controls the iontophoresis an amperometry operation and data transmission in real time via Bluetooth communication to a smartphone app. The study was published in the July 2016 issue of the ACS Sensors. “Measuring alcohol in sweat has been attempted before, but those technologies took 2-3 hours to measure alcohol levels,” said senior author Patrick Mercier, PhD, of the UCSD Jacobs School of Engineering. “Our patch sends alcohol levels to your smartphone in just eight minutes, making real-time alcohol monitoring possible, practical, and personal.” “It resembles a temporary tattoo, but is actually a biosensor patch that is embedded with several flexible wireless components,” commented Seila Selimovic, PhD, director of the NIBIB Program in Tissue Chips. “One component releases a chemical

that stimulates perspiration on the skin below the patch. Another component senses changes in the electrical current flowing through the generated sweat, which measures alcohol levels and sends them to the user’s cell phone.” According to the researchers, the new wearable monitor has the advantage of being non-invasive and unobtrusive, which makes it ideal, for example, in a bar, where it could potentially aid people to self-monitor their alcohol intake and avoid driving if they have had too much to drink. Image: A wearable alcohol detection patch can prevent dangerous drunk driving (Photo courtesy of NIBIB).

Medical-Grade Mobile App Manages Stroke Risk Factors novel Smartphone app combines electrocardiogram (ECG), body weight, and blood pressure data to improve overall heart health and lower the risk of cardiovascular disease (CVD). The result of a collaboration between AliveCor (San Francisco, CA, USA; www.alivecor.com) and the Mayo Clinic (Rochester, MN, USA; www. mayoclinic.org), the new app, which is available for both Apple iOS and Android platforms, enables users to capture five of the most important factors for evaluating CVD risk: heart rhythm, blood pressure, weight, physical activity, and resting heart rate. Enabling users to view the results provides them with an overall picture of their own health and helps them share readings with loved ones. The app combines AliveCor’s Kardia app measurements with manually entered weight, together

with other data collected by various activity apps. In the case of IOS, users can access Apple Health or Google Fit; Android users can manually enter their blood pressure results and access their readings from Google Fit. In both cases, the indicators have the potential to not only improve heart health but also overall health care for a variety of conditions. “Mayo Clinic has pioneered new approaches that may uncover significant measures of physiology that have been hidden in individuals’ ECGs,” said Vic Gundotra, CEO of AliveCor. “With these new integrations, AliveCor is expanding beyond just atrial fibrillation detection and giving patients more control over their own care. This combination of vital stats gives patients an unprecedented view of their heart disease risk factors, making them more engaged in their heart health care.” By using AliveCor’s deep machine learning capa-

bilities, as applied to over 10 million user ECG recordings of patients at the Mayo Clinic, the two companies will work together to uncover hidden physiological signals to improve heart and overall human health. For example, the health indicators that are uncovered may have implications for patients who are at risk from marked changes in blood potassium levels, such as those with kidney failure. “Dangerously abnormal potassium levels can impact the morphology of an ECG. The ECG can be used to quantify serum potassium as a significant enhancement to traditional morphology analysis,” said Paul Friedman, MD, a Mayo clinic cardiologist who helped develop the intellectual property that went into the technology. “It is exciting to see the application of machine learning algorithms in ECG and its potential to quickly detect rhythm abnormalities in patients.” HospiMedica International December/2016-January/2017

Human Physicians Outperform Diagnostic Apps by Wide Margin

Health IT I

octor’s diagnoses remain vastly superior to those of 23 commonly used symptom-checker apps, according to a new study. Researchers at Harvard Medical School (HMS; Boston, MA, USA; www. harvard.edu), the Human Diagnosis Project (Washington, DC, USA; www. humandx.org), and other institutions conducted a study in which 234 internal medicine physicians evaluated 45 clinical cases of both common and uncommon conditions, with varying degrees of severity. For each scenario, the physicians had to identify the most likely diagnosis along with two additional possible diagnoses. Each clinical vignette was solved by at least 20 physicians. The researchers then compared the diagnostic accuracy of the physicians with computer algorithm symptom checker applications. The results showed that the physicians outperformed the symptom-checker apps, listing the correct diagnosis first 72% of the time, compared with 34% of the time for the digital platforms. In addition, 84% of clinicians listed the correct diagnosis in the top three possibilities, compared with 51% for the digital symptom-checkers. The difference between physician and computer app performance was most dramatic in more severe and less common conditions; it was smaller for less acute and more common illnesses. But despite outperforming the apps by a wide margin, physicians still made errors in about 15% of WORLD’S MEDICAL cases. According to the researchers, developing computer-based algorithms to be used in conjunction with human decisionmaking may help further reduce diagnostic errors. The study was published on October 10, 2016, in JAMA Internal Medicine. “While the computer programs were clearly inferior to physicians in terms of diagnostic accuracy, it will be critical to study future generations of computer programs that may be more accurate,” said senior author associate professor of health care policy Ateev Mehrotra, PhD, of HMS. “Clinical diagnosis is currently as much art as it is science, but there is great promise for technology to help augment clinical diagnoses. That is the true value proposition of these tools.”

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MEDICAL REVIEW MONITOR

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EIZO

Dell

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The RadiForce RX660 allows an image to be displayed that is true to the original source data, even at high brightness levels. Its wide viewing angles allow the user to view the screen from the side with minimal color shift, as well as view a variety of medical images at the same time.

The MR2416 offers superior grayscale viewing with DICOM-ready images for precise clinical review. It features anti-reflective, edge-to-edge glass and a smooth, fully sealed enclosure that is IP-32 rated, and stands up to ethyl alcohol cleanings.

The Anesthesia Touch automated record-keeping system streamlines the capture of RT anesthesia data throughout the pre-operative process. The system was designed for anesthesia providers, physician groups, ambulatory surgery centers, hospitals and office-based surgery settings.

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Surgical Microscope Imaging System Incorporates Virtual Reality n innovative image injection system overlays virtual reality (VR) images directly onto the operating field when viewed through a surgical microscope. The Leica Microsystems (Wetzlar, Germany; www.leicamicrosystems. com) CaptiView microscope image injection system allows images of chosen objects, including original computerized tomography (CT), magnetic resonance imaging (MRI), and angiogram datasets to be superimposed directly into the neurosurgeon’s eyepiece during microscopic surgery. The CaptiView is intended for use with the Brainlab (Munich, Germany; www.brainlab.com) Cranial 3.1 Navigation Software, in conjunction with a Leica M530 OH6 microscope. The heads-up display provides neurovascular and fiber-track information

in two-dimensional (2D) or three-dimensional (3D) projections, as well as on-screen video overlays visible through the ocular. The microscope integration also allows the surgeon to switch views in the eyepiece, toggling between live and pre-operative anatomical images using handle control buttons or footswitch for ease of use and uninterrupted workflow. Markers attached to the microscope enable positional tracking and autofocus. “This next-generation augmented virtual reality tool provides real-time information in ways never before realized,” said Professor Joshua Bederson, MD, chair of the department of neurosurgery at Mount Sinai Health System (New York, NY, USA), who worked closely with Leica Microsystems and Brainlab to develop the surgical navigation tool. “We are driving and advancing the development of

next-generation simulation and virtual reality technology, which can help improve patient outcomes and solve neurosurgical challenges.” The new technology will also be utilized alongside the Surgical Navigation Advanced Platform (SNAP), developed by Surgical Theater (Mayfield, OH, USA; www.surgical theater.net), which is now a standard

feature in the operating room (OR). SNAP provides advanced 3D visualization technology that gives surgeons an intraoperative and patient-specific 3D environment to plan and understand surgical approaches. Image: A screenshot of CaptiView image injection on Brainlab software (Photo courtesy of Leica Microsystems).

Remote-Controlled Micro-Robots Advance Medical Procedures iniature robots that enter the human body could eventually replace invasive, often complicated surgery, optimizing the treatment of a variety of diseases. Under development at Ecole Polytechnique Fédérale de Lausanne (EPFL; Switzerland; www.epfl.ch) and ETH Zurich (Switzerland; www.ethz.ch), the biologically inspired microrobots were designed to mimic the parasitic protozoan trypanosomes, which causes African trypanosomiasis, also known as sleeping sickness. Trypanosomes uses a flagellum for propulsion, but hides it away once inside a person’s bloodstream as a survival mechanism. The prototype microrobot robot also has a bacterium-like flagellum that enables it to swim. Unlike conventional robots, the microrobots are soft, flexible, and motor-less, made of a biocompat-

ible hydrogel and magnetic nanoparticles. They are controlled via an integrated manipulation platform that can remotely control their mobility with electromagnetic fields, and can cause them to shapeshift when heat is applied, unfolding to their pre-determined shape. Once the final shape is achieved, the magnetic nanoparticles make them move and swim when an electromagnetic field is applied. The microrobots can then complete their mission, delivering drugs or performing precision tasks such as clearing clogged-up arteries. Once the mission is completed, they can be heated with a laser, resulting in the flagellum wrapping around the body. To build a microrobot, the nanoparticles are placed inside layers of a biocompatible hydrogel. An electromagnetic field is then

applied to orientate the nanoparticles in different parts of the construct, followed by a polymerization step to solidify the hydrogel. It is then placed in water, folding in specific ways depending on the orientation of the nanoparticles inside the gel to form the final overall 3D form. The study was published on July 22, 2016, in Nature Communications. “Both a bacterium’s body and its flagellum play an important role in its movement. Our new production method lets us test an array of shapes and combinations to obtain the best motion capability for a given task,” said study co-author Mahmut Selman Sakar, PhD, of EPFL. “Our research also provides valuable insight into how bacteria move inside the human body and adapt to changes in their microenvironment.” HospiMedica International December/2016-January/2017

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Health IT

CPAP Tracker App Increases Treatment Compliance Rates new, easy-to-use online app for sleep apnea patients helps them achieve optimum continuous positive airway pressure (CPAP) therapy. The ResMed (San Diego, CA, USA; www.resmed.com) myAir application delivers a daily “myAir score” to users every morning, showing how long they slept on CPAP, how many apneas they had per hour, and how well their CPAP mask fit. The app also provides personalized tips for greater comfort and sleep, and badges when users reach milestones in their therapy. The data can also help doctors and care providers sort and prioritize support concerns, and also know who is doing well with their CPAP compliance. Compliant CPAP is key for patients to effectively treat their obstructive sleep apnea (OSA), and according to a company statement, 84% of myAir users are compliant on CPAP within 90 days, compared to an average 50% compliant rate achieved by CPAP users without the app. The myAir web application, which is compatible with the ResMed Air10, AirSense, and AirCurve machines, is currently available only for iPhone or other Apple devices users. Roughly 900 patients a day are signing up for the service. “We have seen increased rates of patient engagement and satisfaction by integrating myAir into their treatment plans,” said Raj Sodhi, president of health-

care informatics at ResMed. “Now it’s even easier for patients to engage with their therapy, thanks to the added convenience of an iPhone app.” “MyAir helps my patients be more engaged with their therapy and achieve better health outcomes,” said Jennifer Wilkymacky-Wormald, clinical and marketing manager for ATI CPAP Solutions (Crestview Hills, KY, USA). “Plus, it helps our office run more efficiently. The more patients who achieve CPAP compliance, the more time we have to focus on patients who still need extra support.” Sleep apnea is a condition of chronic airway obstruction during sleep, potentially leading to high blood pressure, cardiovascular disease, memory

problems, weight gain, impotency, and headaches. Major include obstructive sleep apnea (OSA), frequently found in obese and aged individuals with low muscle tone and excessive soft tissue around the airway; central apnea, an imbalance in the brain’s respiratory control center that leads to a delayed neurological response to carbon dioxide (CO2) blood levels; and mixed apnea, a combination of both. CPAP is the most commonly prescribed treatment, involving a mask worn during sleep that pumps air to help prevent the airway from closing. Image: Screenshots of the myAir application (Photo courtesy of ResMed).

Computer-Based Detection of Esophageal Cancer On Par with Specialists esearchers in the Netherlands have demonstrated a computer algorithm that can scan esophagus images and recognize signs of esophageal cancer nearly as accurately as gastroenterologist specialists can. The research was published in the July issue of the journal Endoscopy. Patients with gastric irritation in the esophagus from prolonged reflux are at risk of developing abnormal tissue, a condition called Barrett’s esophagus. The condition is one of the main risk factors for esophageal cancer, and requires patients to undergo regular endoscopic check-ups in hospital. The software was developed by researchers at the Technical University of Eindhoven (TU/e; Eindhoven, Netherlands; www.tue.nl/en) and was tested at the Catharina Hospital (Eindoven, Netherlands; www. catharinaziekenhuis.nl). Only a handful of specialists in the Netherlands are able to detect the early stages of the disease when it can still be treated effectively. There are approximately 2,500 new esophageal cancer pa-

HospiMedica International December/2016-January/2017

tients in the Netherlands every year, and this increases every year because of the rise in the number of overweight people that are more susceptible to the disease. The new computer analysis technique could save patients unnecessary and costly surgery by enabling earlier detection of the disease. Barrett’s esophagus specialist Dr. Erik Schoon, gastroenterologist, Catharina Hospital, said about the results, “To recognize early forms of cancer in a Barrett’s esophagus is one of the most difficult things to do in our field.”

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Hospital News I

US Government HMO to Launch Effort for Reducing Hospital-Acquired Conditions he U.S. Centers for Medicare & Medicaid Service (CMS, Baltimore, MD, USA; www.cms.gov) is launching a second nationwide effort to reduce patient harm and decrease hospital readmissions. The CMS Hospital Innovation and Improvement Network will award USD 347 million to 16 different groups, including hospital associations, quality improvement organizations, and health systems, with the goal of achieving a 20% decrease in overall patient harm and a 12% reduction in 30-day hospital readmissions by 2019, based on a 2014 baseline. The new project follows the success of the Partnership for Patients initiative launched in 2010, which set a goal of 40% reduction in preventable harm, with a 17% reduction in all-cause harm.

The hospitals in the network will be required to work on reducing both readmissions and a range of hospitalacquired conditions, including adverse drug events involving anticoagulants, opioids, and hypoglycemic agents; central line-associated blood stream infections; catheter-associated urinary tract infection (CAUTI); Clostridium difficile infection; injury from falls and immobility; pressure ulcers; sepsis and septic shock; surgical site infections (SSIs); venous thromboembolism (VT); and ventilator-associated events. “We have made significant progress in keeping patients safe; an estimated 2.1 million fewer patients harmed, 87,000 lives saved, and nearly USD 20 billion in cost-savings from 2010 to 2014, and we are focused on accelerating improvement efforts,” said Patrick Conway, MD,

MSc, acting principal deputy administrator and chief medical officer of the CMS. “The work of the Hospital Improvement and Innovation Networks will allow us to continue to improve health care safety across the nation and reduce readmissions at a national scale, keeping people as safe and healthy as possible.” “In just four years, the Partnership for Patients made an important difference. The fact that we have done this in collaboration with patients and families as genuine partners, from the point of conception to design and development and implementation of

this work, has been a key ingredient in its success,” said Debra Ness, president of the National Partnership for Women and Families (Washington, DC, USA; www.nationalpartnership. org). “We will do our best to educate patients and family members to help them be full contributors in this process.” Image: The CMS awarded $347 million to 16 healthcare organizations to serve as Hospital Improvement Innovation Networks (HIINs), and continue efforts in reducing hospital-acquired conditions and readmissions (Photo courtesy of Shutterstock).

Indian Hospital Chain to Expand Across Country rathima Hospitals (Hyderbad, India; www. prathimahospitals.com) has announced an expansion project to establish several new hospitals across the Indian states of Telangana and Andhra Pradesh. Prathima currently operates three hospitals in Kachiguda, Kukatpally, and Karimnagar (with a total of 1,500 beds) with centers of excellence in cardiology, critical care, gastroenterology, mother & childcare, neonatology, and orthopedics. The company will invest RS 3.5 billion (USD 52.46 million) in the project, which will include a fully integrated cancer care facility in Warangal and a new hospital in Hyderbad. The investment is in addition to the

RS 2 billion (USD 29.9 million) invested in current projects, which included the purchase of Mamatha Hospital in Hyderabad. “We are planning to set up hospital in every district headquarters in the State. The idea is to ensure people get best healthcare within their district without having to travel to Hyderabad. Typically, each hospital will have about 50-100 beds initially and may be ramped up later,” said Harini Boinipally, MD, managing director of Prathima Hospitals. “At every location a hospital is set up, we will make local doctors partners in the project, offering them 30% equity in that project.” “This is the first time I am featuring as a brand ambassador with Saif. We decided to be part of the

hospital chain, as this is for a noble cause,” said Bollywood film star Karina Kapoor, who was enlisted as along with her partner Saif Ali Khan to promote the expansion drive. According to the World Health Organization (WHO, Geneva, Switzerland; www.who.int), India’s hospital bed strength should ideally be 2.6 beds for every 1,000 people in the population, but the country has a shortfall, with just 0.7 hospital beds per 1,000 people. Healthcare players see this as an opportunity, due to the upsurge in chronic diseases in India, new initiatives in the health insurance sector, corporate medical benefits programs, and government schemes which are creating high density traffic into hospitals.

Reducing Low-Value Health Services Encourages Savings new study concludes that reducing spending on a wide array of low-value health services among insured adults holds considerable potential for cost savings. Researchers at RAND Corporation (Pittsburgh, PA, USA; www.rand.org) and the University of Southern California (USC; Los Angeles, USA; www.usc.edu) examined spending on 28 low-value healthcare services and procedures among U.S. adults (18 to 64 years of age) by reviewing more than 1.46 million commercial claims lodged at United Healthcare (UHC; Minnetonka, MN, USA; www.uhc.com) between 2011 and 2013. In all, 7.8% of the patients who put in claims received lowvalue services in 2013, with the total amount spent being USD 32.8 million, which accounted for 0.5% of total spending, or USD 22 per person annually. The most commonly received low-value services included hormone tests for thyroid problems and

imaging for low-back pain and uncomplicated headache. The greatest proportion of spending was for spinal injection for lower-back pain at USD 12.1 million, imaging for uncomplicated headache at USD 3.6 million, and imaging for nonspecific lowback pain at USD 3.1 million. Demographically, low-value spending was lower among patients who were older, male, black or Asian, lower-income, or enrolled on consumer-directed health plans, which have high member cost-sharing. The study was published as a research letter on August 29, 2016, in JAMA Internal Medicine. “The services in this study reflect many clinical areas and types of care, but still are a small portion of all the low-value care patients receive. Our findings add evidence to the notion that reducing overuse of medical procedures could improve quality while reducing spending,” said lead author Rachel Reid, MD, of RAND. “The potential savings from reducing

these low-value services and others are substantial.” “Areas with high Medicare spending also seem to have greater use of low-value services among those with commercial insurance. This confirms that there are opportunities for cost savings, and that both private insurers and Medicare can benefit from efforts to reduce use of low-value care,” added senior author Professor Neeraj Sood, PhD, of USC. According to a 2012 report by the U.S. Institute of Medicine (IOM, Washington, DC, USA; www.iom.edu), more than USD 750 billion of health care spending annually represents waste, including approximately USD 200 billion in overtreatment. In order to reduce that amount, the American Board of Internal Medicine Foundation and consumer groups launched an initiative called ‘Choosing Wisely’ in order to encourage physicians and patients to engage in conversations about evidence-based medical practices. HospiMedica International December/2016-January/2017

Industry News

Taiwanese Medical Software Leader Acquires Korean Medical Display Company dvantech (Taipei, Taiwan; w w w. a d v a n t e c h . c o m ) , which provides computing systems for the medical market, has announced that it has acquired a 60% stake in Kostec (Gangwon-do, South Korea; www.n-kostec.co.kr), a medical display company. Advantech offers comprehensive system integration, hardware, software, customer-centric design services, embedded systems, automation products, with its solutions finding a wide range of applications in diverse industries. Its digital healthcare portfolio includes medical grade PoE information terminals, medical computers for the operating room, mobile medical carts, and telemedicine solutions. Kostec offers medical grade LCD monitors and industrial LCD monitors with specialized capabilities in diagnostic, surgical, X-ray modality, clinical review, medical information consulting systems and ultrasound monitors. Advantech expects Kostec’s medical display expertise and business ex-

posure in South Korea, Southeast Asia, and the North American markets, combined with its own global brand and sales, marketing, and services network in Europe, Greater China, the Middle East, and Australia, to further aid its growth in the smart medical field. In addition to extending global cooperation in medical displays, Kostec will also adopt and sell Advantech’s digital healthcare products in the South Korean market. “Though Advantech has product development capabilities and sales teams in medical nursing carts, medical tablets, and medical computing areas, we are still learning about professional-grade medical display product lines for the operating room,” said Advantech CEO KC Liu. “We expect to rely on Kostec’s industrial experience and professional techniques and expertise, in combination with Advantech’s existing global marketing and sales teams, to expand Advantech’s position in the intelligent hospital field.”

Arab Health Spins Off MEDLAB as Separate Event rab Health Exhibition & Congress (Dubai, UAE; www. arabhealthonline.com) and MEDLAB Exhibition & Congress (Dubai, UAE; www.medlabme.com), the largest healthcare shows in MENA, will be launched as standalone events next year, due to a significant increase in healthcare investment across the region. Arab Health Exhibition & Congress, the largest healthcare event in the Middle East, is organized by Informa Life Sciences Exhibitions (Dubai, UAE; www.informalifesciences.com) and provides a platform for the world’s leading manufacturers, wholesalers and distributors to meet the medical and scientific community in the Middle East and subcontinent. The Arab Health Congress features Continuing Medical Education (CME) accredited conferences, which are attended by more than 8,000 delegates from around the world, with international speakers covering a broad spectrum of medical specialties and disciplines. Similarly, MEDLAB Exhibition & Congress is the world’s largest medical laboratory exhibition and congress, and provides a platform for laboratory industry leaders, including manufacturers, dealers and distributors, to share best practices, showcase new in-

HospiMedica International December/2016-January/2017

novations, collaborate and network. MEDLAB also features 11 CME-accredited multi-disciplinary conference tracks covering topics such as laboratory management, molecular diagnostics and clinical chemistry. In 2016, Arab Health featured 4,187 exhibiting companies, while MEDLAB hosted 589 leading exhibitors. The 42nd edition of the Arab Health Exhibition & Congress will now be held between January 30February 2, 2017, showcasing more than 4,400 companies and attended by over 120,000 healthcare and trade professionals from 70 countries. The Congress will also feature 14 CME-accredited conferences with international speakers on topics such as emergency medicine, oncology and workforce empowerment, and will be attended by more than 8,000 delegates from around the globe. Meanwhile, the 16th edition of MEDLAB will be held February 6-9, 2017, and attended by over 30,000 laboratory and trade professionals from across different continents. MEDLAB 2017 will features 11 multi-disciplinary conferences offering up to 28 CME credits that will be led by globally recognized speakers on various topics such as laboratory management, microbiology, immunology and clinical chemistry.

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JANUARY 2017 2017 Gastrointestinal Cancers Symposium. Jan-19-21; San Francisco, CA, USA; Web: http://gicasym.asco.org Controversies & Updates in Vascular Surgery (CACVS 2017). Jan 19-21; Paris, France; Web: www.cacvs.org/en Arab Health 2017. Jan 30-Feb 2; Dubai, UAE; Web: www.arabhealth online.com 46th Annual Meeting of the Society for Critical Care Medicine (SCCM). Jan 21-25; Honolulu, HI, USA; Web: www.sccm.org

FEBRUARY 2017 ISET 2017 – International Symposium on Endovascular Therapy. Feb 4-8; Hollywood, FL, USA; Web: http://iset.org HIMSS Annual Meeting 2017 - Health IT Conference and Exhibition. Feb 923; Orlando, FL, USA; Web: www. himssconference.org MEDICAL JAPAN 2017. Feb 15-17; Osaka, Japan; Web www.medical-jpn.jp MARCH 2017 ECR 2017 – European Congress of Radiology. Mar 1-5; Vienna, Austria; Web: www.myesr.org KIMES 2017. Mar 16-19; Seoul, Korea; Web: www.kimes.kr ISICEM 2017 – The International Symposium on Intensive Care and Emer-

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