HospiMedica International September 2017 by Globetech

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CLINICAL NEWS

Vol.35 No.4 • 8-9/2017

LEADER DAILY CLINICAL NEWS

ISSN 0898-7270

Robotic System Improves Colorectal Procedures novel robotic surgical platform provides access to hard-to-reach anatomy in colorectal procedures, offering treatment options that may not be possible with straight, rigid instruments. The Medrobotics Flex System is a highly articulated, multi-linked endoscope that enables minimally-invasive

Hospital-Acquired Anemia Affects One-Third of Patients ne in three patients hospitalized for medical problems experience hospital-acquired anemia (HAA), a drop in hematocrit due to the hospitalization, claims a new study. Conducted by researchers at the University of Texas Southwestern Medical Center (UT Southwestern; Dallas, TX, USA; www.utsouthwestern.

edu) and the Parkland Health and Hospital System (Dallas, TX, USA; www.parklandhospital.com), the observational cohort study reviewed 11,309 patients discharged between November 1, 2009 and October 30, 2010 from six Texas hospitals, examining the incidence, predictors, and post-discharge outcomes associated Cont’d on page 2

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Integrated System Advances Liver Disease Management

Molecular Test Rapidly Diagnoses Sepsis apid diagnosis of sepsis in hospitalized patients is crucial because in severe cases, there is an average 7.6% decrease in survival rate per hour from the onset of low blood pressure without effective antimicrobial treatment. Early identification of a pathogen increases the chance of targeting the correct agent and may avoid misuse of antibiotics. A molecular test has been developed that can rapidly and

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Blood Group May Affect Heart Attack Risk

new integrated system that combines liver tisA sue quantification with ul-

Image: Courtesy of GE Healthcare

ealthcare professionals should consider a person’s blood group when assessing their cardiovascular risk as people with A, B, and AB blood types may be at greater risk of cardiovascular events, particularly heart attacks, than individuals with O blood types. There are some risk factors for heart attack that can be addressed, such as a poor diet, lack of exercise, and smoking. However, some heart

trasound imaging, can visualize and quantify liver disease in a single exam. The system is based on GE's LOGIQ S8 XDclear 2.0 premium ultrasound in combination with the Echosens FibroScan liver tissue quantification tool. See article on page 13

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leek design and an engaging smartphone app revolutionize the continuous positive airway pressure (CPAP) experience for obstructive sleep apnea (OSA) sufferers. The ResMed pocketsized AirMini CPAP device weighs

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

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Cost-Effective Da Vinci Surgical Option Introduced

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Smallest CPAP Redefines Sleep Apnea Therapy

he new da Vinci X System offers surgeons and hospitals access to a wide portfolio of advanced, innovative robotic-assisted surgical technologies and a full ecosystem of programs, support, services, and solutions. The system features flexible port placement, advanced three dimensional (3D) digital optics, voice and laser guidance,

drape design that simplifies surgery prep, a lightweight, fully integrated endoscope, and proprietary surgical endoscopic instruments rigid endoscopes, blunt and sharp dissectors, scissors, scalpels, forceps, pick-ups, needle holders, and endoscopic retractors. The system enables optimized, foCont’d on page 4

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Hospital-Acquired Anemia Affects One-Third of Patients cont’d from cover

with HAA. Patients with anemia on admission or missing hematocrit values were excluded. The results revealed that one-third of the patients developed HAA – 21.6% with mild HAA; 10.1% with moderate HAA; and 1.4% with severe HAA. The most severe form of HAA – defined as a hematocrit of 27% or less at the time of discharge – was independently associated with a 39% increase in odds of being readmitted or dying within 30 days after hospital discharge. The two strongest potentially modifiable predictors of developing moderate or severe HAA were length of stay and a major procedure. The study was published in the May 2017 issue of the Journal of Hospital Medicine. “This is the first study of post-discharge adverse outcomes of hospital-acquired anemia among a diverse group of patients who were hospitalized for different reasons,” said lead author Anil Makam,

MD, of UT Southwestern. “Reducing blood loss during major surgeries and reducing unnecessary testing during hospital stays may lower a patient’s risk of developing severe hospital-acquired anemia, and potentially improve their recovery.” “This study shines a spotlight on a very common but underappreciated risk of hospitalization, hospital-acquired anemia, which has traditionally been viewed as an incidental change in the red blood count of no significance,” said senior author Professor Ethan Halm, MD, MPH. “However, our results showed that hospital-acquired anemia was associated with worse clinical outcomes after leaving the hospital, so it needs to be taken more seriously.” Hematocrit is the volume percentage of red blood cells (RBCs) in blood; it is normally 45% for men and 40% for women. It is considered an integral part of the complete blood count (CBC), together with hemoglobin concentration, white blood cell count,

and platelet count. Anemia refers to an abnormally low hematocrit, which could indicate life-threatening diseases such as bleeding, leukemia, malnutrition, water intoxication, and more. Image: Research shows hospital-acquired anemia is more prevalent than previously thought (Photo courtesy of Getty Images).

Smallest CPAP Redefines Sleep Apnea Therapy cont’d from cover

just 300 grams, but functions as a fully integrated system, offering proprietary AutoSet functionality, as well as the innovative HumidX and HumidX Plus built-in waterless heat and moisture exchangers (HMEs). Both HMEs capture the patient’s exhaled breath in the mask tube and redeliver it to them, allowing users to enjoy the benefits of humidification without the hassle of carrying around distilled water. The AirMini CPAP is compatible with ResMed’s AirFit N20 nasal and F20 full face masks, which offer an easy fit for a wide range of patients, as well as a special AirMini version of the AirFit P10 nasal pillows mask. The device can be controlled from any smartphone or tablet with the proprietary AirMini app, which connects to the device via Bluetooth to provide a range of comfort settings. Other optional accessories include the AirMini travel case and the AirMini mount system. “The ResMed (San Diego, CA, USA; www. resmed.com) AirMini has redefined CPAP therapy, providing patients with peace of mind, knowing they can easily get ResMed-quality therapy wherever they are. CPAP is now more portable and accessible than ever before,” said Mick Farrell, CEO of ResMed. “I have been traveling all over the world with a prototype of the AirMini system, using AutoSet, humidification, and an AirFit P10 pillows mask, and it has changed my travel life. I am so excited to see that this technology is now available to many millions of sleep apnea patients.” The World Health Organization (WHO) estimates that up to 6% of the global adult population suffer from OSA. If left untreated, it may lead to hypertension, stroke, congestive heart failure (CHF), atrial fibrillation (AF), type II diabetes, weight gain, depression, and traffic accidents. Approximately 20% of OSA patients in the first world have the benefit of some type of treatment, with CPAP as the established therapy for moderate to severe OSA; however, only 54% of patients OSA are able to comply with this method. LINKXPRESS COM

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Robotic System Improves Colorectal Procedures cont’d from cover

surgery (MIS) procedures that replace open surgical procedures for many parts of the anatomy that are difficult or previously impossible to reach. The maneuverability of the endoscope is gained from numerous mechanical linkages with concentric mechanisms; each mechanism can be placed into a rigid or a limp state. By employing a patented “follow-the-leader” movement strategy with these alternating states, the endoscope can be directed into any shape through the relative orientations of its linkages. The system is designed to provide a cost-effective non-linear, circuitous robot-assisted surgical platform for situations where conventional line-of-sight technologies are either not feasible or offer suboptimal results. An assist platform includes an onboard high-definition (HD) vision system and contains multiple open device channels that accept a variety of proprietary wristed 3mm Flex instruments or third party surgical and interventional instruments. The Flex System is a product of Medrobotics (Raynham, MA, USA; www.medrobotics.com), and has been approved by the U.S. Food and Drug Administration (FDA). “The human gastrointestinal system is full of twists and turns, and rigid surgical robots were not designed to operate in that environment; the Flex Robotic System was. Two years ago Medrobotics started revolutionizing treatment in the head and neck. We can now begin doing that in colorectal procedures,” said Samuel Straface, PhD, CEO of

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Medrobotics. “American hospitals, surgeons, and patients will be able to enjoy the benefits of the world’s only flexible, surgical robotic platform. It will easily integrate into hospitals due to its mobility and short learning curve.” “The Flex Robotic System offers the promise to treat select colorectal patients transanally with a more consistent and an easier approach, because it overcomes the limits of straight surgical instrumentation,” said Professor Alessio Pigazzi, PhD, of the University of California, Irvine (UCI; USA). “Medrobotics is ushering in the first of a new generation of shapeable and steerable robotic surgical systems that offer the potential to reduce the invasiveness of surgical procedures for more patients.”

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Cost-Effective Da Vinci Surgical Option Introduced cont’d from cover

The system enables optimized, focused-quadrant surgery for procedures such as prostatectomy, partial nephrectomy, hernia repair, benign hysterectomy and sacrocolpopexy, among many others. And as the da Vinci X uses the same vision cart and surgeon consoles found on the da Vinci Xi, it enables users the option of adding advanced capabilities, and provides a pathway for upgrading should they choose to do so as practice and needs grow. The da Vinci X System is a product of Intuitive Surgical (SunnyV

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vale, CA, USA; www.intuitivesurgical.com), and has received the European Community CE mark of approval. “The da Vinci X System is a value-oriented, highly capable offering that meets, and responds to, our customers’ economic and clinical needs,” said Damien Desmedt, general manager of Intuitive Surgical in the United Kingdom, Ireland, and Nordic countries. “In the countries we serve around the globe, we know that customers have different needs and wants, and we strive to provide an array of choices to meet their needs today and in the future. The da Vinci X System helps us to continue to do this.” “Over the past 21 years, Intuitive Surgical pioneered robotic-assisted surgery and we continue to lead the way in developing and bringing to market innovative technologies, outcomes-focused products, and value-oriented solutions,” said Gary Guthart, MD, CEO of Intuitive Surgical. “The da Vinci X product offering provides a lower-cost solution to meet the needs of customers who want a choice in price points, while offering access to many of our recent innovations.” The da Vinci surgical systems consist of an ergonomic surgeon console or consoles, a patient-side cart with three or four interactive surgical arms, a high-performance vision system, and other accessories, including devices for endoscopic tissue manipulation, grasping, cutting, dissection, approximation, ligation, suturing, and delivery and placement of microwave and cryogenic ablation probes.

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ISSN 0898-7270 Vol.35 No.4 • 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: Printkom Ltd. • İpkas Sanayi Sitesi 3. Etap C Blok • 34490 Başakşehir • İstanbul Yerel süreli yayındır. Yılda altı kere yayınlanır, ücretsiz dag˘ıtılır.

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Blood Group May Affect Heart Attack Risk cont’d from cover

heart attack risk factors cannot be changed, such as age, gender, and a family history of heart disease. A new study suggests that blood type should be added to the list. Scientists at the University Medical Centre Groningen (The Netherlands; www.umcg.nl) conducted a meta-analysis of studies that reported participants’ blood types and the incidence of cardiovascular events, including heart attack, heart disease, heart failure, and cardiovascular death. The data included more than 1.3 million adults who were a part of 11 cohorts across nine studies. The investigators used the data to assess how each blood group might impact the risk of coronary events, combined cardiovascular events, and fatal coronary events. The team identified 771,113 individuals with a non-O blood group and 519,743 individuals with an O blood group in the analysis of all coronary events. Among people with a non-O blood group, 1.5% (11,437) experienced a coronary event, compared with 1.4% (7,220) of people with an O blood group. In the analysis of combined cardiovascular events, they identified 708,276 people with a non-O blood group and 476,868 people with an O blood group. Among individuals with a non-O blood group, 2.5%

Molecular Test Rapidly Diagnoses Sepsis

(17,449) experienced a cardiovascular event, compared with 2.3% (10,916) who had an O blood group. The scientists noted the that individuals with non-O blood types have higher concentrations of a blood-clotting protein called von Willebrand factor, which previous studies have linked to thrombotic events. Additionally, they point out that people with non-O blood groups, especially those with an A blood type, tend to have higher cholesterol levels, which is a known risk factor for poor cardiovascular health. The odd ratio (OR) for combined cardiovascular events was significantly higher in non-O blood group carriers, at 1.09 (95% CI 1.06-1.11). Tessa Kole, a Master’s degree student and lead author of the study said, “We demonstrate that having a non-O blood group is associated with a 9% increased risk of coronary events and a 9% increased risk of cardiovascular events, especially myocardial infarction. In future, blood group should be consid-

ered in risk assessment for cardiovascular prevention, together with cholesterol, age, sex, and systolic blood pressure.” The study was presented at the annual meeting of the European Society of Cardiology, held April 29 to May 2, 2017, in Paris, France. Image: Research suggests healthcare professionals should consider a person‚Äôs blood group when assessing their cardiovascular risk (Photo courtesy of Shutterstock).

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reliably diagnose sepsis, a potentially life-threatening complication of bacterial infections. Scientists at the Tongde Hospital of Zhejiang Province (Hangzhou Shi, China; www.zj.gov.cn) designed primers and TaqMan probes that were to be complementary to conserved regions in the 16S rDNA gene of different kinds of bacteria. To evaluate accurately, sensitively, and specifically, the known bacteria samples (Standard strains, whole blood samples) are determined by TaqMan-Based Multiplex real-time polymerase chain reaction (PCR). In addition, 30 blood samples taken from patients with clinical symptoms of sepsis were tested by TaqMan-Based Multiplex real-time PCR and blood culture. The investigators found that the mean frequency of positive for Multiplex real-time PCR was 96% at a concentration of 100 colony-forming units (CFU)/mL, and it was 100% at a concentration greater than 1,000 CFU/mL. All the known blood samples and standard strains were detected positively by TaqMan-Based Multiplex PCR; no PCR products were detected when DNAs from other bacterium were used in the multiplex assay. Among the 30 patients with clinical symptoms of sepsis, 18 patients were confirmed positive by Multiplex realtime PCR and seven patients were confirmed positive by blood culture. The authors concluded that TaqMan-Based Multiplex real-time PCR assay with highly sensitivity, specificity and broad detection range was a rapid and accurate method in the detection of bacterial pathogens of sepsis and should have a promising usage in the diagnosis of sepsis. The study was published on May 17, 2017, in the Journal of Clinical Laboratory Analysis.

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DVT PREVENTIVE PUMP

ICU VENTILATOR

Hans Rudolph

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The SmartLab with Insight software is a flexible system for measurement/analysis of respiratory signals in research. The base module can accept up to three sensor modules for measuring flow and pressures. Optional items include an oximeter, CO2 sensor, temp and humidity and digital I/O.

The DVT preventive pump is designed to prevent the risk of DVT in hospitals or at home. The pump is clinically proven effective, offers a portable design for ambulation and one-button operation, and is easy to operate for personal daily use.

The FLOW-i C30 enables clinicians to continuously adapt and improve anesthesia care to match the situation at hand, while maintaining stable respiratory conditions. It can be used across a wide range of patients, including those with acute respiratory demands and pediatric patients.

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Implanted Pacing System Attaches Directly to Heart novel leadless pacemaker provides patients with advanced pacing technology at onetenth the size of a traditional pacemaker. The Medtronic (Dublin, Ireland; www.medtronic. com) Micra Transcatheter Pacing System (TPS) is s a fully self-contained, miniaturized pacemaker designed to provide patients with bradycardia an advanced single chamber pacing technology via a minimally invasive approach. The size of a large vitamin capsule, it does not require electrical leads to deliver pacing therapy, attaching instead directly to the heart wall via small nitinol wires (tines) that hold the device and the electrodes in place. The Micra TPS is delivered via a percutaneous catheter through the femoral vein and positioned inside the right ventricle of the heart. It does not require a surgical “pocket” to be created under the skin, eliminating potential complications, and can be repeatedly repositioned to make sure heart activity and low electrical thresholds are optimal. Once positioned, the device responds to patients’ activity levels by automatically adjusting therapy. The Micra TPS has an estimated 12-year battery life, and is approved for full body 1.5 and 3 Tesla scans mag-

netic resonance imaging (MRI) scans. “Dating back to the development of the first external battery operated pacemaker more than 60 years ago, Medtronic has a long history of collaborating with clinicians to better understand the needs of patients, and then innovating new products to meet those needs,” said John Liddicoat, MD, senior vice president and president of the cardiac rhythm and heart failure division at Medtronic. “We’re looking forward to working with physicians and educating implanters to extend the positive results of our global clinical trial experience to even more patients.” “The device is small enough to be delivered through a catheter and implanted directly into the heart, providing a safe alternative to conventional pacemakers without the complications associated with leads,” said cardiologist Paul Schurmann, MD, of Houston Methodist Hospital (HMH; Houston, TX, USA; www.houstonmethodist.org). “The device also allows us to automatically adjust pacing therapy based on a patient’s activity levels and another positive is the battery can last up to 10 years. I believe this gives us another tool to help save lives

of patients with slow or irregular heart rhythms.” Bradycardia is defined as a heart rate of under 60 beats per minute (BPM) in adults. It typically does not cause symptoms until the rate drops below 50 BPM. Symptoms include fatigue, weakness, dizziness, and at very low rates, fainting. Highly trained athletes may also have athletic heart syndrome, a very slow resting heart rate that occurs as a sport adaptation and helps prevent tachycardia during training. Image: The Micra TPS alongside a vitamin capsule (Photo courtesy of Medtronic).

Automated Technology Monitors Key Blood Analytes novel device combines near-continuous glucose monitoring (CGM) with automatic serial monitoring of lactate levels, using the same micro-sample of the patient’s blood. The OptiScanner 6000 is an automated bedside monitoring system designed to overcome the limitations of manual monitoring of both glucose and lactate levels in intensive care unit (ICU) patients by serially measuring analytes in plasma, as opposed to whole blood. The system also measures lactate levels in order to optimize patient care in the ICU, as elevated lactate levels are common in patients with critical illnesses such as sepsis, burns, and trauma. Automated measurements are taken every 15 minutes using 0.13mL of plasma, provid-

ing trending capabilities and freeing nurses to perform direct patient care. The automated process also eliminates handling errors associated with samples drawn by intermittent, manually operated technologies. The range of features include a touch screen; a graphic user interface (GUI) that virtually eliminates the need for in-service to assist in set up or operation; and reagent-free measurements, which removes the need for daily calibration. The OptiScanner 6000 is based on the OptiScanner 5000, both products of OptiScan Biomedical (Hayward, CA, USA; www.optiscancorp.com), and has received the European Union CE mark of approval. “While near continuous monitoring of glucose in the ICU is critical, there are a number of addi-

tional metabolic analytes, including lactate, whose serial measurement is also important for optimizing patient care,” said Peter Rule, chairman and CEO of OptiScan Biomedical. “By providing ICU physicians the means to serially monitor both lactate and glucose in the same, single micro-sample of the patient’s blood, we believe that the OptiScanner 6000 will play an important role in continuing to elevate the level of care delivered to ICU patients.” It is estimated that approximately 20% of ICU patients have pre-existing diabetes and an additional 40-70% of ICU patients suffer from stress hyperglycemia, a temporary elevation of glucose levels, with all of these patients requiring accurate glucose monitoring to maintain tight glycemic control. HospiMedica International August-September/2017

Mandated Emergency Care For Sepsis Proves Effective new study reveals that rapid completion of a mandated three-hour bundle of sepsis care protocol (which includes blood cultures, broad-spectrum antibiotic agents, and lactate measurement) is associated with lower in-hospital mortality. Researchers at the University of Pittsburgh School of Medicine (Pitt; PA, USA; www.medschool.pitt.edu), Brown University (Providence, RI, USA; www.brown.edu), and other institutions studied data on 49,331 patients admitted to 149 hospitals in New York State from April 1, 2014, to June 30, 2016. The patients followed a sepsis protocol initiated within six hours after arrival in the emergency department (ED) and had all items in a sepsis 3-hour bundle of care completed within 12 hours. The researchers assessed the associations between the time until completion of the 3-hour bundle and risk-adjusted mortality. The results revealed that 82.5% of the patients had the 3-hour bundle completed on time. Median time to completion of the 3-hour bundle was 1.30 hours, the median time to the administration of antibiotics was 0.95 hours, and the median time to completion of the fluid bolus was 2.56 hours. Among patients who had the 3-hour bundle completed within 12 hours, higher riskadjusted in-hospital mortality was associated with longer time to completion, longer time to the administration of antibiotics, but not with the completion of a bolus of intravenous fluids. The study was published on May 21, 2017, in NEJM. “There is considerable controversy about how rapidly sepsis must be treated,” said lead author Christopher Seymour, MD, MSc, of the department of critical care medicine and emergency medicine at Pitt. “Some question the benefit of rapid treatment with protocols, saying they can have unintended side effects and be a distraction in busy emergency departments. After reviewing the data, we can finally say that faster is better when it comes to sepsis care.”

In 2013, following the widely publicized death of 12-year old Rory Staunton from undiagnosed sepsis, New York began issued protocols for the early identification and treatment of sepsis. Known as Rory’s Regulations, they require hospitals to follow protocols for early identification and treatment of sepsis, and submit data on compliance and outcomes. Hospitals can tailor how they implement the protocols, but must include a blood culture to test for infection, measurement of blood lactate, and administration of antibiotics within three hours of diagnosis, collectively known as the threehour bundle. Image: Two new studies show the dangers of delays in treatment of patients with sepsis (Photo courtesy of Questex).

Alzheimer's Mortality Rates Rose by Half in Past 15 Years new report reveals that deaths from Alzheimer’s disease (AD) rose by almost 50% between 1999 and 2014, and in many cases the heavy burden of caregiving has fallen on loved ones. Researchers at the U.S. Centers for Disease Control and Prevention (CDC, Atlanta, GA, USA; www.cdc.gov) examined U.S. state-level and county-level death certificate data from the National Vital Statistics System for the period between 1999 and 2014 in order to identify all deaths with AD reported as the underlying cause. A total of 93,541 such AD deaths occurred in the United States in 2014 at an age-adjusted rate of 25.4 deaths per 100,000, which represented a 54.5% increase compared with the 1999 rate of 16.5 deaths per 100,000. The data revealed that most AD deaths occurred in a nursing home or long-term care facility, with the percentage of those dying in a medical facility declining from 14.7% in 1999 to 6.6% in 2014, whereas the percentage of those who died at home increasing from 13.9% in 1999 to 24.9% in 2014. The CDC suggests that the significant increases in AD, coupled with

HospiMedica International August-September/2017

an increase in the number of persons with Alzheimer’s dying at home, have likely added to the burden placed on family members or other unpaid caregivers. The study was published on May 26, 2017, in CDC Morbidity and Mortality Weekly Report. “With more people dying at home, there is an increased need for caregivers, because in the late stages of Alzheimer’s, patients are completely dependent on caregivers. At home, a lot of times it’s done by friends and family,” said report author epidemiologist Christopher Taylor, PhD. AD, named after Dr. Alois Alzheimer, who first described it, is caused by protein build-up in the brain that form structures called plaques and tangles. This leads to the loss of connections between nerve cells, and eventually to their death of and loss of brain tissue. As AD progresses, problems with memory loss, communication, reasoning, and orientation become increasingly severe, and sufferers need more and more day-to-day support from caregivers. AD affects almost 50% of those over the age of 85, and is the sixth leading cause of death in the US. LINKXPRESS COM

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UNIVERSAL OXIMETRY SYSTEM

HEMOSTASIS VALVE

MIR - Medical International Research

Nonin Medical

Antmed

The Spirodoc incorporates a three-axis movement sensor to correlate the saturation level to the physical activity. It instantly provides simple and clear SpO2 and HR measurements, and can store up to 10,000 spirometry tests or 900 hours of oximetry recording in its internal memory.

The SenSmart X-100 provides a side-by-side view of cerebral oximetry, pulse oximetry and pulse rate values for real-time decision-making. It allows clinicians to use Nonin SenSmart-compatible rSO2 sensors and/or SpO2 sensors to monitor up to six sites on a patient.

The range of hemostasis valves offers good sealing performance and ease of use, with one-handed operations enhancing the efficiency of clinical work. They are available in a variety of specifications, such as normal bore, large bore, etc., to meet the needs of various clinical applications.

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Catheter Safeguards Reduce Hospital Infections uality improvement (QI) interventions designed to prevent bloodstream infections related to central venous catheters (CVCs) save lives and hospital expenditure, according to a new study. Researchers at Cedars-Sinai Medical Center (Los Angeles, CA, USA; www.cedars-sinai.edu), the RAND Corporation (Pittsburgh, PA, USA; www.rand.org), and other institutions conducted a systematic review of economic evaluations of QI interventions designed to prevent bloodstream infections in acute care hospitals, and which reported program and infection-related costs. For each study, the researchers performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. The results, gleaned from data published in the last decade on catheter-related bloodstream infections at 113 hospitals, show that safety interventions, on average, reduced the infection rate by 57% at these hospitals, while producing net savings of USD 1.85 million for each site over three years. For every USD 100,000 spent by the hospital, it realized an average USD 315,000 in savings because it treat-

ed fewer infected patients. The average cost of implementing such a program was USD 270,000 for each site. The study was published in the December 2016 issue of JAMA Internal Medicine. “Due to the high cost of caring for patients when central-line infections develop, even sizable up-front investments in infection prevention can be associated with large net savings,” said Teryl Nuckols, MD, MSHS, director of the division of general internal medicine in the Cedars-Sinai department of medicine. “On the basis of our findings, hospitals that have not yet achieved very low rates of infection can consider implementing a variety of safety practices.” Central–line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI) are linked to more than 60,000 primary bloodstream infections each year in the United States alone, with an estimated fatality rate of 12% or more. Hospitals in recent years have thus introduced safety procedures that contain checklists for attending staff that include donning sterile

gloves, covering catheters with antimicrobial dressings, and checking catheters daily for signs of movement or infection. Many hospitals also have invested in extra training, equipment, and supplies to improve safety. Image: A new study shows safety measures can reduce central catheter infection rates (Photo courtesy of Getty Images).

High Levels of Nosocomial Infection Found in Pediatric ICUs ne in six children in pediatric intensive care units (pICU), and one in ten babies in neonatal intensive care units (nICU) develop a hospital-acquired infection (HAI), according to a new study. Researchers at the European Centre for Disease Control (ECDC; Solna, Sweden; www.ecdc. europa.eu), University of Geneva Hospitals (Switzerland; www.hug-ge.ch), St George’s University of London (SGUL; United Kingdom; www.sgul. ac.uk), and other institutions conducted a study that analyzed pediatric data from point-prevalence surveys conducted in 1,149 hospitals throughout the European Union, Iceland, Norway, and Croatia between May 2011 and November 2012. In all, data were collected by locally trained healthcare workers for 17,273 children

and adolescents from 29 countries. An analysis of he data revealed 770 HAIs reported in 726 children and adolescents, corresponding to a prevalence of 4.2%. Bloodstream infections were the most common type of infection (45% of all infections), followed by lower respiratory tract infections (22%), gastrointestinal infections (8%), eye, ear, nose, and throat infections (7%), urinary tract infections (5%), and surgical-site infections (4%). The prevalence of infections was highest in pICU (15.5%) and nICU (10.7%) wards. The study was published on January 12, 2017, in The Lancet Infectious Diseases. “This is the largest multi-national study describing healthcare-associated infections in children so far, providing detailed information about the prevalence and distribution of these infections in this spe-

cific population,” stated the ECDC. “A second point prevalence survey is ongoing in Europe, including improvements to address some of the limitations found during the development of the study, and its results will be published by the European Centre for Disease Prevention and Control after 2017.” HAIs are defined as those occurring 48 hours after admission, within three days of discharge, or within 30 days of surgery. They can be caused by organisms lurking on the bodies or clothing of healthcare workers and on hospital surfaces such as doorknobs, curtains, and furniture. Resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), erythromycin-resistant Enterococcus, and carbapenem-resistant Enterobacteriaceae acerbate the problem. HospiMedica International August-September/2017

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Critical Care

Forehead Sensor Facilitates Low Perfusion Pulse Oximetry n innovative transflectance sensor provides oxygen saturation measurements that are less susceptible to peripheral perfusion changes. The TFA-1 single-patient-use adhesive forehead sensor allows clinicians to detection desaturation and resaturation faster than via digit sensors when using Masimo SET measure-through motion and low perfusion pulse oximetry, by addressing low perfusion and motion artifact challenges. By harnessing adaptive filters to reduce measurement inaccuracy and the alternative forehead-monitoring site (rather than a finger), the TFA-1 provides easier access during surgery, resuscitation, and in patients with finger deformities. The TFA-1 is suitable for both pediatric and adult patients, and is available in both Masimo LNCS and M-LNCS connector versions, each provided with a flat cable for improved patient comfort. Using a forehead sensor also avoids crosscontamination risks that accompany reusable sensors, reduces the complexity associated with reusable sensors, such as cleaning, storage, and transport. The TFA-1 single-patient-use adhesive forehead sensor is a product of Masimo (Irvine, CA, USA; www.masimo.com), and has been approved by the U.S. Food and Drug Administration (FDA). “The TFA-1 transflectance forehead adhesive sensor offers clinicians yet another way to leverage the breakthrough measurement capability in Masimo SET pulse oximetry,” said Joe Kiani, founder and CEO of Masimo. “By continuing to take Masimo’s breakthrough technologies to new sites and applications, we are helping improve patient outcomes and safety while reducing cost of care.” Masimo SET is a noninvasive sensor technology that uses more than seven wavelengths of light to acquire blood constituent data. Advanced signal processing algorithms and unique adaptive filters work together to isolate, identify, and

quantify various hemoglobin species based on theur light absorption characteristics, delivering the results in numerical values. Masimo SET includes measurement of oxygen saturation (SpO2), pulse rate (PR), perfusion index (PI), and pleth variability index (PVI), a measure of the dynamic changes in perfusion index that occur during the respiratory cycle. Image: The TFA-1 forehead oximetry sensor (Photo courtesy of Masimo).

Clinical Tool Identifies Patients Who Do Not Require Cardiac Monitoring mergency departments (EDs) have a new clinical decision tool to identify patients with chest pain who can be removed safely from cardiac monitoring, according to a new study. Researchers at Ottawa Hospital (Canada; www.ottawahospital.on.ca) and the University of Ottawa (Canada; www.uottawa.ca) conducted a prospective study involving 796 patients (mean age 63.8 years, 55.8% male) who presented to the ED with chest pain, in order to validate the Ottawa Chest Pain Cardiac Monitoring Rule, a decision tool for safe removal of patients from cardiac monitoring after an initial evaluation in the ED. The researchers collected baseline characteristics, clinical evaluations, and patient predictors, such as electrocardiogram (ECG) readings. The researchers then calculated diagnostic characteristics for the clinical prediction rule. The outcome was a tool that helps identify arrhythmia requiring intervention while in the ED, or within eight hours of presentation. Study results showed that of all the patients monitored, only 1.9% suffered an arrhythmia during their stay in the ED. Following the new rule would have enabled 284 (35.7%) of these patients to be safely

HospiMedica International August-September/2017

removed from cardiac monitoring. The study was published on January 30, 2016, in the Canadian Medical Association Journal (CMAJ). “Overall, the management of chest pain patients has not changed much in the past 10 years, with most patients requiring serial blood tests to rule out heart attack and end up staying in the emergency department for few hours,” said senior author Venkatesh Thiruganasambandamoorthy, MD, PhD. “A substantial number of patients are unnecessarily being placed on cardiac monitoring, while this resource is needed for patients in the waiting room who are more ill.” “We recommend that patients who present to the emergency department with chest pain be removed from cardiac monitoring if they are free of chest pain at the time of assessment, and if the ECG is either normal or shows only nonspecific changes,” concluded Dr. Thiruganasambandamoorthy and colleagues. “The results, if implemented, should have a significant and positive impact on wait times and increase the availability of monitored beds for sicker patients.” Image: Dr. Venkatesh Thiruganasambandamoorthy of Ottawa Hospital (Photo courtesy of Ottawa Hospital). LINKXPRESS COM

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LUNG VENTILATOR

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The ri-former diagnostic station is a modular system offering up to five instrument handles with specula-dispenser, blood-pressure devices and thermometers. It is available as a wall-mount or mobile and is connected to the power circuit, making it independent of batteries.

The SIARETRON 4000 provides new options for operative modes management and is equipped with different ventilation functions. Key features include a 12-inch monitor for displaying the curves of pressure, flow, volume, the loops of breathing parameters, trends and ventilatory parameters.

The IntelliVue X3 is a compact, dual-purpose, transportable unit featuring intuitive smartphonestyle operation and offering a scalable set of clinical measurements. It helps streamline workflow and boost efficiency, making it ideal for uninterrupted monitoring at the bedside and in transport.

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CLI Patients Face High Readmission Rates atients with critical limb ischemia (CLI) have a high risk of readmission, with most of the readmissions unplanned, according to a new study. Researchers at Geisinger Medical Center (Danville, PA, USA; www.geisinger.org), Rutgers New Jersey Medical School (Newark, USA; www.njms.rutgers.edu), and other institutions conducted a study that analyzed all adult hospitalizations with a diagnosis code for CLI using state inpatient databases from Florida (2009 to 2013), New York (2010 to 2013), and California (2009 to 2011), in order to determine the incidence of readmission and factors affecting readmission. In all, 695,782 admissions from 212,241 patients were analyzed. The results showed that 284,189 of the total patient admissions were primary CLI admissions. At 30 days and at six months, all-cause readmis-

sion rates for the patients were 27.1% and 56.6%, respectively, and the rates of unplanned readmissions were 23.6% and 47.7%. Age, female sex, black or hispanic race, prior amputation, Charlson comorbidity index, and need for home health care or rehabilitation facility upon discharge were major predictors of six-month unplanned readmissions. When compared with patients with Medicaid, the uninsured, and Medicare populations, those covered by private insurance were least likely to have a readmission. There was also an inverse association for travel time to the hospital with sixmonth unplanned readmission rates, seen in all of the subgroups. Another direct association of sixmonth unplanned readmission identified was length of stay during index hospitalization. The study was published on April 18, 2017, in Journal of the American College of Cardiology (JACC).

“Readmissions constitute a major health care burden among critical limb ischemia patients, the majority of them being unplanned readmissions,” concluded lead author Shikhar Agarwal, MD, MPH, of Geisinger Medical Center, and colleagues. “Several demographic, clinical, and socioeconomic factors play important roles in predicting readmissions.” CLI is a severe blockage in the arteries of the lower extremities, which markedly reduces blood-flow. It is a serious form of peripheral arterial disease (PAD), but less common than claudication. PAD is caused by atherosclerosis, and results in severe pain in the feet or toes, even while resting, due to poor circulation. Complications include sores and wounds that will not heal in the legs and feet that if left untreated can result in amputation of the affected limb.

Clotting Assay Predicts Patient Transfusion Needs new test that quantifies clotting ability can help identify trauma patients who are most in need of a massive blood transfusion, according to a new study. The new test, developed by researchers at the University of Colorado School of Medicine (Aurora, USA; medschool.ucdenver.edu), modifies thrombelastography (TEG) – a test that measures the viscoelastic properties of whole blood to determine the ability of blood to clot – by adding tissue plasminogen activator (tPA) to the blood sample. As tPA saturates endogenous inhibitors, systemic hyperfibrinolysis occurs, which can help stratify the underlying degree of shock and identify early coagulation changes in order to predict progression to massive transfusion. To test this hypothesis, the researchers analyzed blood samples from 324 trauma patients, of which 17% required a massive blood transfusion. Trauma activations were analyzed using rapid TEG and the modified TEG-tPA test. Clinical

scores, which included shock index, assessment of blood consumption, and trauma-associated severe hemorrhage were then compared with TEG measurements to predict the need for massive transfusion, using areas under the receiver operating characteristic curves. The results showed that rapid TEG and tPATEG parameters were significantly different in all massive transfusion patients compared to nonmassive transfusion patients. Low-dose tPA lysis at 30 minutes had the largest the area under the receiver operating characteristic curve for prediction of massive transfusion, similar to the international normalized ratio (INR) of prothrombin time. When the tPA-TEG assay was used together with INR, it improved identification of patients in need of transfusion by 40%, and identified 97% of patients who did not, thereby preventing unnecessary transfusions. The study was published on May 15, 2017, in JACS. “The tPA-TEG identifies trauma patients who

require massive transfusion efficiently in a single assay that can be completed in a shorter time than other scoring systems, which has improved performance when combined with international normalized ratio,” concluded lead author Hunter B. Moore, MD, of the department of surgery. “This new method is consistent with our understanding of the molecular events responsible for trauma-induced coagulopathy.” TEG is performed by gently rotating a blood sample through approximately 5º six times a minute in order to imitate sluggish venous flow and to activate coagulation. The speed at which the sample coagulates on a thin wire probe depends on the activity of the plasma coagulation system, platelet function, fibrinolysis, and other factors. The patterns of changes in strength and elasticity in the clot provide information about how well the blood can perform hemostasis, and how well or poorly different factors are contributing to clot formation. HospiMedica International August-September/2017

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Critical Care

Wireless ICM Captures Vital Information he world’s first smartphoneenabled, insertable cardiac monitor (ICM) provides powerful data to help monitor irregular heartbeats, unexplained syncope, palpitations and suspected atrial fibrillation (AF). The Abbott (Abbott Park, IL, USA; www.abbott.com) Confirm Rx ICM is designed to continuously monitor a patient’s heart rhythm and proactively transmit the information via the myMerlin mobile app, allowing physicians to follow their patients remotely and accurately diagnose arrhythmias. Intuitive one-touch indication-based programming and remote monitoring via the Merlin.net Patient Care Network make the technology convenient for clinicians involved in the procedure and follow up based on the secure transmission

of patient data. Available in over 35 languages, the myMerlin mobile app helps patients record their symptoms on their own smartphone and note events such as fainting, or an episode of tachycardia. Patients can also confirm their data was transmitted to their physician and get automatic alerts when they have missed a scheduled transmission, saving the clinic from having to follow up with the patient. The Confirm Rx ICM is expected to undergo a full European release during the second quarter of 2017. “Incorporating wireless technology directly into our devices enhances the quality of remote monitoring and patient compliance,” said Mark Carlson, MD, chief medical officer of Abbott’s cardiac arrhythmias and neuromodulation businesses. “The Con-

Intraoperative Ketamine Fails To Reduce Postoperative Pain new study concludes that ketamine, often used to reduce postoperative pain and the need for opioids following surgery, is ineffectual. Researchers at Washington University School of Medicine (WUSTL; St. Louis, MO, USA; www.medschool. wustl.edu), Harvard Medical School (HMS; Boston, MA, USA; https:// hms.harvard.edu), and other institutions conducted a multicenter, international randomized trial involving 672 surgical patients 60 years of age and older who underwent major cardiac and non-cardiac surgery under general anesthesia. In all, 222 patientswere assigned to the placebo group (normal saline), 227 to the low dose (0·5 mg/kg) ketamine group, and 223 to the high dose (1 mg/kg) ketamine group, which was delivered after induction of anesthesia, but before surgical incision. The patients were evaluated for several days after surgery, during which they were questioned about their pain, monitored for the amount of opioids needed to control their pain, and evaluated by staff twice daily for delirium, a state that can include confusion, agitation, and inability to recognize friends and family members. The results showed no difference in delirium incidence between patients in the combined ketamine groups and the placebo group, but did show more postoperative hal-

HospiMedica International August-September/2017

lucinations and nightmares with increasing ketamine doses, compared to placebo. The study was published on May 30, 2017, in The Lancet. “In recent years there’s been a big increase in the amount of ketamine given in the operating room, because clinicians are trying to prevent pain after surgery without relying on opioid drugs,” said lead author professor of anesthesiology and of surgery Michael Avidan, MD, MBBCh, of WUSTL. “In animal studies, ketamine could speed recovery from anesthesia in rodents, suggesting that the drug might help protect the brain; the new findings present a less encouraging picture. We were particularly surprised by the lack of an effect on postoperative pain,” said senior author Professor George Mashour, MD, PhD, of the University of Michigan Medical School. Ketamine is a rapidly acting dissociative anesthetic agent that can provide analgesia, sedation, and amnesia for rapid sequence intubation in critically ill patients. Short- and longterm effects include increased pulse and blood pressure, nausea, vomiting, numbness, depression, amnesia, hallucinations, and potentially fatal respiratory problems. Sub-anesthetic ketamine is often given intraoperatively for postoperative analgesia due to the detached, dreamlike state it creates.

firm Rx ICM addresses a broad range of indications, such as syncope, palpitations and atrial fibrillation. The technology has been designed with robust data privacy and security measures to ensure peace of mind for both patients and providers.” “The Confirm Rx ICM device will be an important tool for diagnosing patients with suspected arrhythmias, such as those who have experienced fainting or palpitations,” said Georg Nölker, MD, head of electrophysiolo-

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gy at Ruhr-University of Bad Oeynhausen (Germany). “The simple insertion procedure and small device size make this technology convenient for both patients and providers. Patients can record symptoms directly on their smartphone without the need for a bedside transmitter or separate activator.” Image: The world’s first smartphoneenabled insertable cardiac monitor (Photo courtesy of Abbott).

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PATIENT DOSE CALIBRATOR

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The E1 is a new hand-carried B/W ultrasound model equipped with comprehensive basic functions, which enhances its competitiveness as an entry-level ultrasound model. It not only provides satisfying diagnostics and image quality, but also offers a smooth workflow experience to users.

The PDC measures DAP, DAP-rate, Dose and Dose rate of installed DAP systems, and solves problems relating to variation of DAP, Patient Dose system and AEC calibration. It allows a full check of installed DAP meter calibration over a range of field sizes, shapes and beam qualities.

The Lumify allows clinicians to download the cloud-enabled Lumify Android ultrasound app on a compatible device, connect the USB transducer, and start scanning. It allows clinicians to store, review and share patient exams and high-quality images and clips right from their device.

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Echography Studies Examine How Air Pollution Impairs Lung Function wo transthoracic echocardiography studies including more than 16,000 individuals in Brussels, Belgium have shown the effect of air pollution on the hemodynamic functioning of the lungs. The studies were carried out between 2009 and 2013, and were presented at the EuroEcho-Imaging 2016 conference in Leizig, Germany. One study examined whether echocardiography parameters used to determine pulmonary circulation, and right ventricular function were affected by common levels of outdoor air pollution. In the second study, ten healthy male volunteers were exposed to either ambient air or to dilute diesel exhaust pollutants. Pulmonary vascular resistance was assessed using echocardiography at rest, as well as during a cardiac stress test. The results showed a reduced pulmonary acceleration time as well as increased pulmonary accel-

eration slope from pollutants, on the same day, over five days, and ten days exposure. There was also a deterioration of right ventricle function. Lead author of the study, Dr Jean-Francois Argacha, cardiologist at the University Hospital (UZ; Brussels, Belgium; www.uzbrussel.be), said, “This is the first human study to report an influence of air pollution on pulmonary vascular function. This is a major public health issue for people living in polluted urban areas where exercise could damage the lungs and potentially lead to decompensated heart failure. Such studies are important because if air pollution causes narrowing of the blood vessels in the lungs (vasoconstriction), this combined with the systemic effects of pollution could cause decompensated heart failure. Air pollution was associated with increased pulmonary vascular tone, which makes it more difficult for blood to flow to the lungs. Longer exposure to air pollution exposure

seems necessary to impair right ventricular systolic function. Patients with obstructive sleep apnea were at greater risk. This suggests that pollution is more harmful to the lung circulation during exercise. Our main advice is to limit physical activities during heavy air pollution.” Image: A transthoracic echocardiogram being performed in a patient (Photo courtesy of Specialist Cardiology).

Residual Gadolinium May Persist in Brain for Years ew studies reveal that gadolinium based contrast agents (GBCA) used in magnetic resonance imaging (MRI) exams may remain in the brain for years, but the long-term effects are unknown. A series of three recent studies raise new questions about residual gadolinium concentrations in the brains of patients with no history of kidney disease. The first, conducted at Teikyo University (Tokyo, Japan; www.teikyo-u.ac.jp), examined brain tissues from five autopsied patients who had undergone multiple GBCA MRI exams and five patients with no gadolinium history. The study, published in the November 2016 issue of the Japanese Journal of Radiology, found that even in patients without severe renal dysfunction, gadolinium accumulated in the brain. The findings of the Japanese study lend support to the results of a study at the Mayo Clinic (Rochester, MN, USA; www.mayoclinic.org), pub-

lished in the March 2016 issue of Radiology, which showed residual gadolinium deposits present in the postmortem brains of 13 patients who had undergone at least four GBCA contrast MRI exams. Neither the Teikyo University nor the Mayo clinic study was able to identify whether the residual gadolinium was in free or chelated form. A third study, by the University of Heidelberg (Germany; www.uni-heidelberg.de), published in the June 2015 issue of Radiology, retrospectively looked at two groups of 50 patients who had undergone at least six MRI exams, suggests that the molecular structure of the gadolinium contrast agent may play a role in retention. There are two structurally distinct categories of GBCA: linear and macrocyclic. In the macrocyclic structure, the gadolinium is bound more tightly to the chelating agent and, therefore, less likely to release free gadolinium into the body. “We now have clear evidence that the adminis-

tration of various gadolinium-based contrast agents results in notably varied levels of accumulation of residual gadolinium in the brain. What we still don’t know is the clinical significance, if any, of this observation,” commented professor of radiology and neuroradiology Emanuel Kanal, MD, director of magnetic resonance services at University of Pittsburgh Medical Center (UPMC, PA, USA; www.upmc.com). Gadolinium – a rare earth heavy metal – is used for enhancement during MRI. Neurotoxic effects have been seen in animals and when a GBCA is given intrathecally in humans. On its own, gadolinium can be toxic; therefore, when used in contrast agents, gadolinium is bonded with a molecule called a chelating agent, which controls the distribution of gadolinium within the body. In July 2015, the U.S. Food and Drug Administration (FDA) stated that it was unknown whether gadolinium deposits in the brain were harmful. HospiMedica International August-September/2017

Researchers Develop Faster Cardiovascular MR Protocol he results of an international study show that a new cardiovascular MR imaging protocol can reduce costs by 80%, and is three times as fast as current tests. The new protocol also changed clinical management in 33% of the patients scanned. Cardiovascular Magnetic Resonance (CMR) imaging exams are regularly used to diagnose cardiovascular diseases, to assess cardiac function and structure, and to investigate the likelihood of heart attacks. Researchers from Peru, the UK, the US, and Brazil collaborated on the Impact of Non-invasive CMR Assessment (INCA)-Peru study. The goal of the research was to develop a new cost-effective and faster imaging protocol specifically for use in developing countries. The initial CMR protocol was developed by researchers from University College London (UCL; London, UK; www.ucl.ac.uk) and was tested in Thailand. Next, the researchers modified the protocol by adding gadolinium, a CMR contrast agent, and tested it in a pilot INCA-Peru study involving 50 patients. In the current study the researchers again tested the CMR protocol with the contrast agent for two days in Peruvian hospitals. One hundred patients with suspected cardiomyopathy, and 11 healthy controls took part in the study. Each scan cost USD150, and took only 18 minutes on average. Lead author of the study, cardiologist Dr. Katia Menacho, University College London, said: “In Peru just two public hospitals offer CMR - each performs 12 scans on one day a week. Five private hospitals provide CMR at USD $600-800

per scan. Public hospitals without CMR refer to the private sector and it takes up to three months to approve the paperwork, delaying diagnosis and treatment. We showed that this ultrafast CMR protocol can be used to accurately diagnosis patients leading to changes in clinical management.” Image: A new generation 1.5-T adaptive cardiac and general MRI scanner (Photo courtesy of Siemens Healthineers).

Brain Abnormalities Discovered in Bipolar Patients he results of a new global MRI study show thinning of gray matter in patients with bipolar disorder. The researchers used the Magnetic Resonance Imaging (MRI) data from their study to build a roadmap of bipolar disorder, and the affects this condition has on the brain. The brain regions most affected by the disorder are used for inhibition, and emotions. The research was part of the international consortium ENIGMA (Enhancing Neuro Imaging Genetics

Through Meta Analysis), and was led by the University of Southern California Keck School of Medicine (USC; Los Angeles, CA, USA; http://keck.usc.edu) Stevens Neuroimaging and Informatics Institute. The research findings were published in the May 2, 2017, issue of the journal Molecular Psychiatry. For their study, the researchers used MRI scans of 2,447 adults suffering from bipolar disorder, as well as scans from 4,056 healthy control subjects. The results of the study showed thinning of brain gray matter in pa-

tients with the disorder, compared to the healthy control subjects. The researchers found that the greatest deficits were in the frontal and temporal regions of the brain controlling inhibition and motivation.

According to the researchers, the clear and consistent changes in key brain regions provide insight into the underlying mechanisms of the disorder, and could enable future research into new medications and treatments.

Integrated System Advances Liver Disease Management new integrated system that combines liver tissue quantification with ultrasound imaging and can visualize, and quantify liver disease in one exam has been announced. Chronic liver disease affects more than one billion people globally but because a lack of symptoms may not be detected before it develops into a serious condition such as liver cirrhosis or liver cancer. The integrated system for screening, diagnosis and monitoring of liver diseases was developed by Echosens (Paris, France; www.echosens.com) and GE Healthcare (Chalfont St Giles, Buckinghamshire, UK; www3. gehealthcare.co.uk). The system was unveiled at the International Liver Congress in Amsterdam, Netherlands, in April 2017.

HospiMedica International August-September/2017

The system is based on the GE LOGIQ S8 XDclear 2.0 premium ultrasound system together with the Echosens FibroScan liver tissue quantification tool. Echosens is largest global provider of of non-invasive diagnostic solutions for assessing chronic liver disease. FibroScan is intended for non-invasive measurements of liver fibrosis, cirrhosis and steatosis, and can help clinicians assess the condition of a patient’s liver. The test is intended to replace painful, invasive, and costly liver biopsies. FibroScan uses VibrationControlled Transient Elastography (VCTE) technology for measurements of tissue elasticity, and the CAP tool to measure ultrasound attenuation. VCTE produces quantitative, reproducible, real-time results in units called kiloPascal (kPa).

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Italray

The Senographe Pristina allows technologists to position patients while facing them, as well as move the tube head to a parked position away from their head. The contrast can be modified to accommodate user preferences, and the console and gantry are ready for use within minutes.

The ACUSON P500 FROSK edition offers new high-end imaging technology in a compact notebook format. Weighing less than seven kilograms, it can be easily carried and positioned in almost any clinical environment, helping clinicians make quick decisions in difficult scanning conditions.

The CARMEX features a microprocessor-controlled X-ray generator operating at high frequency. It can be equipped with either stationary or rotating anode X-ray tubes and is ideal for various applications including orthopedics, urology, cardiology, interventional radiology and ERs.

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MRI Studies Show Link Between Cognitive Decline and Structural Brain Changes esearchers in Italy have found that the cognitive impairment caused by Parkinson’s disease could be a result of the disruption of complex structural networks in the brain. The results of the study were published in the December 2016 issue of the journal Radiology, and showed that Parkinson’s patients with Mild Cognitive Impairment (MCI) suffered from significant changes in brain networks. The study group included 170 Parkinson’s patients, 116 without MCI, 54 with MCI, and a control group of 41 healthy individuals. According to the researchers, the results indicate that cognitive impairment in patients with Parkinson’s disease may be a result of the disruption of complex structural brain networks,

and not of the degeneration of individual white matter bundles. The researchers used a Magnetic Resonance Imaging (MRI) technique called diffusion tractography, and found that MRI could be used to monitor Parkinson’s disease in patients. Patients with Parkinson’s disease suffer from tremors, trembling, limb stiffness, balance and coordination problems, MCI, and cognitive decline. Co-author of the study, Federica Agosta, MD, PhD, San Raffaele Scientific Institute (Milan, Italy; www. hsr.it/research/about-us), said “Cognitive impairment in PD is one of the major non-motor complications of the disease, as well as one of the major concerns of patients and caregivers at the time of diagnosis.

Image: The impaired structural sub-network connectivity in the brains of patients with Parkinson disease and MCI, and those without MCI (Photo courtesy of RSNA).

Study of the changes related to cognitive impairment in PD is imperative in order to be able to answer patients’ questions and finally be able to predict the future development of this condition. If confirmed

and replicated by other studies, these results would suggest the use of MRI in PD to support the clinicians in monitoring the disease and predicting the occurrence of cognitive complications.”

Mobile Digital Radiography System Enhances Usability premium mobile digital radiography (DR) system provides exceptional mobility, userconvenience, and a high image quality to meet the demands of modern radiography. The Samsung Electronics (Seoul, Korea; www. samsung.com) GM85 digital radiography (DR) system provides easy navigation due to its compact design, with a collapsible column that gives users clear visibility when moving the system and broadens access to smaller spaces, and an adaptive softdriving control and front-bumper sensor to help make navigation safer. And, thanks to a narrow 555 mm width and a light 349 kg in weight, the GM85 allows easy access around tight spaces, including elevators. A guide supports detailed device positioning,

with multiple source to image distance (SID) guide settings; an S-Align function displays the detector’s angle to the tube head unit (THU) for precise alignment in order to enhance image quality; and quickpositioning functionality allows handle-free, precise body movement by simple button clicks on the THU. In addition, quick charging and a long-lasting battery improve work efficiency by powering up to 100% in only two to four hours, and going on for all day. Other features include S-Vue, an advanced imaging engine that enhances image sharpness and clarity, and SimGrid, which provides high-quality images without the need for a conventional grid, thus reducing scatter radiation effects. Radiographers can also lower retake rates, as S-Vue eliminates

alignment errors that often occur with a conventional grid. Finally, THU and line enhancement brings improved clarity of the tube and line in chest images through single on-screen click. “Driven by Samsung’s relentless spirit of innovation, the GM85’s enhanced mobility and streamlined workflow will enable users to experience a new level of efficiency with a mobile DR system without jeopardizing image quality”, said Dongsoo Jun, president of health and medical equipment business at Samsung Electronics. “Leveraging Samsung’s deep expertise in user-friendly functions and advanced imaging technology, Samsung will take the lead in providing a spectrum of diagnostic and patient-centric tools to meet the various needs of both care provider and patient.” HospiMedica International August-September/2017

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Medical Imaging

MRI Reveals Changes in Brains of Pregnant Women agnetic resonance imaging (MRI) scans reveals that the brains of pregnant women show significant reductions in grey matter in regions associated with social cognition. Researchers at Universitat Autònoma de Barcelona (UAB, Spain; www. uab.cat), Fundació IMIM (Barcelona, Spain; www.imim.cat), Leiden University (The Netherlands; www. universiteitleiden.nl), and other institutions conducted a study that compared MRI scans of 25 first-time mothers before and after their pregnancy, of 19 of their male partners, and of a control group formed by 20 women who were not and had never been pregnant and 17 of their male partners. The data was gathered during a period of five years and four months. The results of the study showed a symmetrical reduction in the volume of grey matter in the medial frontal and posterior cortex line, as well as in specific sections of, mainly, prefrontal and temporal cortex in pregnant women. The reductions in grey mat-

ter were practically identical variations in both women who underwent fertility treatments and women who became pregnant naturally. In MRI scans taken two years later, the gray matter loss remained, except in the hippocampus, where most volume had been restored. The changes were so consistent that a computer algorithm could predict with 100% accuracy whether a woman had been pregnant from her MRI scan. According to the researchers, the grey matter areas corresponded with a neural network that is associated with processes involved in social cognition and self-focused processing, with a similar decline in gray matter volume occurring during adolescence. The study was published on December 19, 2016, in Nature Neuroscience. “We certainly don’t want to put a message out there along the lines of ‘pregnancy makes you lose your brain’. Gray matter volume loss can also represent a beneficial process of maturation or specialization, an adaptive process of functional specializa-

tion towards motherhood,” said lead author neuroscientist Elseline Hoekzema, PhD, of UAB and Leiden University. “These changes may reflect, at least in part, a mechanism of synaptic pruning, where weak synapses are eliminated giving way to more efficient and specialized neural networks.” “The loss of grey matter does not imply any cognitive deficits, but rather points to an adaptive process related to the benefits of better de-

tecting the needs of the child, such as identifying the newborn’s emotional state,” added senior author Oscar Vilarroya, PhD, of the UAB cognitive neuroscience research unit. “Moreover, they provide primary clues regarding the neural basis of motherhood, perinatal mental health, and brain plasticity in general.” Image: Grey matter reduction in pregnant women (orange), compared to controls (Photo courtesy of UAB).

New CT Imaging Protocols Improve Liver Lesion Diagnoses esearchers in Germany have shown that new dual-contrast Computed Tomography (CT) imaging protocols can improve the diagnosis of liver diseases while at the same time reducing radiation dose. In the new technique the researchers simultaneously administered an iodine contrast agent for the arterial phase, and a gadolinium agent for the venous phase of the liver, and then used a modality called Spectral Photon Counting CT (SPCCT) to simultaneously assess the agent enhancement in the liver in various contrast phases. The new technique was presented at the annual Radiological Society of North America (RSNA 2016) meeting by researchers from the Technical University Munich (Munich, Germany; www.tum.de). The new protocols could enable clinicians to differentiate hemangioma and other liver abnormalities from Hepato-Cellular Carcinoma (HCC), for example, and spare patients with only small benign liver lesions, from undergoing unnecessary and expensive procedures.

HospiMedica International August-September/2017

The Results showed that by using SPCCT and an optimized contrast injection protocol, it was possible to provide contrast-enhanced images in a single CT scan, reducing radiation dose. The scan showed both arterial gadolinium distribution, and the portal-venous phase of iodine. The liver lesions, as well as the arterial and portal-venous contrast enhancement patterns were also visible in the scan. According to the researchers, the new technique eliminates mistaken registration of artifacts between acquisitions. Daniela Muenzel, MD, Laboratory for Advanced Computed Tomography Imaging, Technical University of Munich, said, “This multi-phase visualization of the liver at one time point by a single CT scan exhibits perfect co-registration of the images in different phases, allowing for more accurate and quantitative subsequent voxel-by-voxel post processing and a significant reduction in radiation dose. By using two contrast agents and different uptake characteristics in liver lesions, we can classify cysts, hemangiomas, HCC and metastases in a single CT scan.

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PRODUCT NEWS SURGICAL SMOKE EVACUATOR

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The da Vinci system features an ergonomically designed console, a side cart, interactive robotic arms, 3D HD vision system, and EndoWrist instruments. It is powered by robotic technology that allows the surgeon’s hand movements to be scaled, filtered and translated into precise movements.

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Transient Fluorescent Tattoos Mark Surgical Sites new study describes a novel ink to mark surgery targets on the skin, which glows only under certain light conditions and disappears altogether after a period of time. Developed by researchers at the California NanoSystems Institute (CNSI; Santa Barbara, CA, USA; www.cnsi.ucsb.edu), Academia Sinica (Taipei, Taiwan; www.sinica.edu.tw), and other institutions, the time-limited pigment is based on cross-linked fluorescent supramolecular nanoparticles (c-FSNPs), which encapsulate a fluorescent conjugated polymer into a core via a supramolecular synthetic approach. The result is micrometersized c-FSNPs, which exhibit an ideal size-dependent intradermal retention time of up to three months. The temporary pigment has optimized photophysical properties and intradermal retention time for successful in vivo finite tattooing. Under ambient lighting, the nanoparticles are invisible, avoiding unwanted markings on a patient’s skin; but under a light at a wavelength of 465 nanometers, the pigment glows fluorescently, marking the surgical

target. In addition, the inflammatory responses induced by c-FSNPs are undetectable after tattooing. The study describing the new pigment was published on November 30, 2016, in ACS Nano. “Commercially available tattoo pigments possess several issues, which include causing poor cosmesis, being mistaken for a melanocytic lesion, requiring additional removal procedures when no longer desired, and potentially inducing inflammatory responses,” concluded senior author HsianRong Tseng, PhD, of CNSI, and colleagues. “We believe that the c-FSNPs can serve as a ‘finite tattoo’ pigment to label potential malignant nonmelanoma skin cancer lesions.” Tattooing has been utilized by the medical community for precisely demarcating anatomic landmarks, which is especially important for identifying biopsy sites of nonmelanoma skin cancer (NMSC) due to the long interval between the initial diagnostic biopsy and surgical treatment.

Image: A new temporary pigment marks dermal surgical sites (Photo courtesy Hsian-Rong Tseng/ CNSI).

New Guidelines Recommend Surgical Ablation to Reduce Atrial Fibrillation ew clinical practice guidelines issued by the Society of Thoracic Surgeons (STS; Chicago, IL, USA; www.sts.org) conclude that surgical ablation as a treatment option for atrial fibrillation (AF) has experienced continued development over the last 30 years, with its frequency and success steadily increasing, and as such deserves a more prominent role in adult cardiac surgery. In developing the new guidelines, the STS writing committee assessed the safety of surgical ablation for three surgical approaches: primary open atrial operations, where the left atrium is already being opened, such as in mitral valve and/or tricuspid valve repair or replacement; primary closed atrial operations, when the left atrium would not otherwise be open, such as coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) operations; and standalone operations when the on-

ly goal is to perform surgical ablation to treat AF. The new clinical practice guidelines offer evidence-based recommendations that include surgical ablation for AF at the time of concomitant mitral operations to restore cardiac rhythm; surgical ablation for AF at the time of concomitant isolated AVR, isolated CABG, and AVR+CABG operations to restore cardiac rhythm; and surgical ablation as a primary standalone procedure to restore cardiac rhythm for symptomatic AF that is resistant to medication or catheter ablation. The new guidelines were published in the January 2017 issue of The Annals of Thoracic Surgery. “These guidelines represent nearly two years of effort by some of the nation’s leading experts in the surgical treatment of atrial fibrillation,” said co-author Professor Vinay Badhwar, MD, of the West Virginia University Heart & Vascular Institute (Morgan-

town, USA; http://wvumedicine.org/heart). “It is recognized that surgical ablation impacts long-term outcomes with improvements in normal heart rhythm, quality of life, and stroke reduction. Current evidence reveals that surgical ablation can be performed without significant impact to major complications or death.” In patients with AF, rapid, disorganized electrical signals cause the atria to quiver, disturbing the normal rhythm between the atria and the ventricles. As a result, the ventricles may beat faster and without a regular rhythm, leading to blood clots, strokes, heart failure, and other complications. Surgical ablation, also known as the maze procedure, involves creating specific and defined lesions in the heart. The resulting scar tissue blocks the abnormal electrical signals, while also creating a controlled path for electricity in the heart to follow. HospiMedica International August-September/2017

Surgical Navigation System Facilitates Neurosurgery Procedures n advanced navigation solution offers neurosurgeons enhanced workflows and more comprehensive data integration. The StealthStation S8 surgical navigation system, the latest iteration of the Medtronic (Dublin, Ireland; www.medtronic.com) StealthStation image guidance platform, combines hardware, software, tracking algorithms, various image data, and specialized surgical instruments to help neurosurgeons plan their procedures. Intuitive software workflows provide new tools for advanced visualization that allow the surgeon to also use the data intraoperatively, with interfaces to iMRI, iCT, C-arms, and the Medtronic O-arm surgical imaging system that helps orient surgeons to the patient’s anatomy. Improvements in patient registration allow the surgeon even more flexibility in data integration, such as touch and trace techniques within the same registration process, while providing quantitative feedback. The combined patient data and segment structures are translated into three-dimensional (3D) images displayed on two high-definition 27” touch screen monitors. An intuitive user interface support multi-touch gestures like pinch-and-zoom and drag-and-drop, allowing user to create, store, and simulate progression along one or more surgical trajectories. StealthStation offers both optical and electromagnetic surgical instrument tracking, integration with external devices such as microscopes and ultrasound, a broad array of instrument offerings, and core software applications for cranial neurosurgery procedures, including biopsy, resection, and deep brain stimulation lead placement. Both single and dual cart configurations are available for greater flexibility, and wireless connectivity to hospital and medical devices allows the import and export of exams from anywhere within the hospital network. “The StealthStation S8 demonstrates Medtronic’s continued commitment to innovation, helping surgeons make critical decisions and enhancing the OR environment for all surgical staff,” said Brett Wall, senior vice president and president of Medtronic’s Brain Therapies division. “We look forward to seeing how this next generation of the Stealth system will contribute to the continued transformation of how neurosurgeons treat brain and spine disorders around the world.”

Bioceramic Surgical Screw Implants Bond with Bone new bioceramic implant screw nail, dubbed a “scrail,” is made of calcium phosphate, which greatly resembles the composition of bone material. Developed by researchers at the Fraunhofer Institute for Manufacturing Technology and Advanced Materials (IFAM; Bremen, Germany; www.ifam.fraunhofer.de), University Hospital Giessen-Marburg (Marburg, Germany; www.ukgm.de) and other institutions, the scrail, contrary to medical screws made of titanium or polymer, is not designed be screwed into the bone. Instead, it’s intended to be carefully hammered into place, with a specially shaped thread that involves a minimum number of rotations, thus reducing the risk of damage to tendons and bones. In contrast to metal components, the ceramic scrail integrates into the bone and does not have to be removed, since the two components – calcium phosphate and hydroxyapatite – are very similar to bone material. The greatest challenge was attaining the maximum strength of the material, since ceramics are fairly breakable. This was solved using injection molding, with hydroxyapatite powder poured into scrail molds and then heated. The procedure is particularly suited to mass production, but can also be used in conjunction with three-dimensional (3D) printers, allowing production of patient-specific implants. “Ceramic-based screw nails do not disintegrate, but instead bond with the bone. Ideally, they can even accelerate bone growth,” said Sebastian Hein, PhD, of Fraunhofer IFAM. “This is a distinct advantage over polymer screws, which disintegrate in the body. Degradation products from polymer screws can cause inflammation; additionally, after the disintegration of the screws, cavities can form in bones, rendering them unstable and more prone to breaking.” Implant screws can be used for attachment of implants to bone, bone to bone fixation, soft tissue fixation, or anchorage. They are designed to maximize initial contact and distribute the mechanical load by enhancing surface area, dissipating and distributing stresses at the screw-bone interface, and increasing pullout strength. When used with plates, they act to increase the friction between the plate and the bone.

HospiMedica International August-September/2017

Image: StealthStation S8 surgical navigation system (Photo courtesy of Medtronic) S TOR Y IBU APPL R T O DIS ED T IT INV

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Novel Technique Safely Removes Failed IVC Filters

new study describes a technique to successfully remove permanent inferior vena cava (IVC) filters that can cause thrombo-

sis. Developed by researchers at Rush University Medical Center (Chicago, IL, USA; www.rush.edu) and Rush Oak Park Hospital (Oak Park, IL, USA; www.roph.org), the new minimally invasive technique is used to carefully snare the IVC filter, hold it in place, and then cover it to prevent sections breaking free. Percutaneous access (PCA) under Xray guidance is used to manipulate the wires, catheters, alligator forceps and excimer laser necessary to remove the IVC filter, which can be up to 29 mm in length. The procedure is performed on an outpatient basis using conscious sedation in the interventional radiology suite. In case of a more advanced retrieval, it is performed using general anesthesia due to the time it may take to remove the filter. Thanks to the

new method, the researchers have achieved a 100% retrieval rate over the past five years, including difficult-to-remove filters from patients who have been referred to Rush from other hospitals. The study describing the technique was published in the November 2016 issue of the Journal of Vascular and Interventional Radiology. “We have both the standard retrieval methods as well as the most advanced tools to remove any type of filter, and we have the medical expertise to treat any complications from the filter being implanted,” said lead author interventional radiologist Osman Ahmed, MD, of Rush University Medical Center and Rush Oak Park Hospital. An IVC filter is placed into the inferior vena cava in order to prevent pulmonary emboli (PE). But while IVC filters can reduce the incidence of PE,

they can also increase the incidence of deep vein thrombosis (DVT). The many long-term complications of permanent IVC filters include device migration, embolization after detachment of device components, perforation of the IVC, and filter fracture. These adverse events have led to the introduction of retrievable IVC filters. Image: An IVC filter inside the inferior vena cava (Photo courtesy of Shutterstock).

Body Composition Affects Risk of Urinary Incontinence new study suggests that stress and urgency urinary incontinence is twice as prevalent in older women with a high body mass index (BMI). Researchers at the University of California, San Francisco (UCSF; USA; www.ucsf.edu), VU University Medical Center (Amsterdam, The Netherlands; www.vumc.com), and other institutions conducted a study in 1,475 women (initially aged 70-79) in order to evaluate prospective relationships between body composition and muscle strength with predominantly stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). Urinary incontinence was assessed using structured questionnaires. Body mass index (BMI), grip strength, quadriceps torque, and walking speed were assessed using physical examination and performance testing. Appendicular lean body mass

(ALM) and whole-body fat mass were measured using dual-energy X-ray absorptiometry. At baseline, 14% of the women reported at least monthly predominantly SUI, and 16% at least monthly predominantly UUI. At three years, 14% had new or persistent SUI, and 28% had new or persistent UUI. The results showed that women had greater odds of new or persistent SUI if they demonstrated a 5% or greater decrease in grip strength, and lower odds of new or persistent SUI if they demonstrated a 5% or greater decrease in BMI, a 5% or greater increase in ALM corrected for BMI, or a 5% or greater decrease in fat mass. Only a 5% or greater increase in walking speed was associated with new or persistent UUI over three years. The study was published in the November 2016 issue of the Journal of the American Geriatrics Society.

“The findings suggest that higher BMI and fat mass are important markers of risk for SUI and UII in older women, and that their risk of SUI may be partially reversible through weight loss,” said lead author Anne Suskind, MD, MSc, of UCSF. “Changes in body composition and grip strength were associated with changes in SUI, but not in UUI, frequency over time. These findings suggest that optimization of body composition may help to modify the risk of SUI, but not necessarily UUI.” SUI is the loss of bladder control or involuntary loss of urine when coughing, laughing, sneezing, getting up from a chair, or during heavy lifting. It is the most common type of incontinence suffered by women, especially older women. Causes include weak pelvic muscles or a weak sphincter muscle, and giving birth. Chronic coughing, smoking, and obesity may also lead to SUI. HospiMedica International August-September/2017

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Surgical Techniques

Miniaturized Robotics Advance Surgical Innovation iniature robotic systems could provide increased precision, minimally invasive access, and highly accurate navigation for a wide variety of clinical procedures that cannot be carried out with current surgical robots. The Axsis prototype surgical robot is the size of a soda can and use instruments only 1.8 millimeters in diameter. The smaller robot allows surgeons and doctors to work with multiple sets of tools, and to get closer to the patient without the barrier of large equipment. It also makes the procedures less invasive by enabling surgeons to create much smaller incisions. The smaller size of the robot also results in cost savings, lowering the barrier to entry for less experienced robotic surgeons and smaller hospitals, as robotic tools can be swapped in and out as needed. Traditional surgical robots are large by design, stemming from the need to control long, straight instruments inserted into the patient. The need for systems to be physically large is heightened by the forces they need to exert during surgery, the requirement to adapt to multiple configurations, and the degrees of freedom needed to effectively operate them. By using flexible instruments instead of straight ones, Axsis eliminates the need for a large range of motion outside the body. The flexible instrument design also allows the outer diameter of the minimally invasive access point to be reduced. Designed and developed by Cambridge Consultants (UK; www.cambridgeconsultants.com), Axsis technology was demonstrated during simulated

Image: The Axsis prototype surgical robot could revolutionize cataract surgery (Photo courtesy of Cambridge Consultants).

cataract surgery as an example of a procedure that could benefit from miniature robotics. But the novel system design could allow for robotics to be used in procedures that are currently only performed by hand, such as the placement of certain neurostimulation implants, or other high precision surgical procedures that are not possible with current robotic systems. “Axsis proves that it is not only possible to create surgical robots that are smaller than ever before

– but also to target surgical procedures with robotics that were previously out of reach,” said Chris Wagner, head of advanced surgical systems at Cambridge Consultants. “Take cataract surgery, for example. It is performed by hand, under a microscope, with tools that are about two millimetres in diameter. If we can build robots at this size scale, surgeons of all levels of experience can benefit, improving procedure outcomes and allowing more facilities to offer cataract procedures.”

Maternal Health Interventions Can Reduce Mortality new doctoral thesis provides insights into the effectiveness of local interventions to reduce maternal mortality in Ethiopia, and could provide a strong empirical basis for decision-making by health authorities. The thesis, Hagos Godefay, MSc, of Umea University (Sweden; www.umu.se) studied current efforts to reduce maternal mortality in northern Ethiopia. The study investigated the level and determinants of maternal mortality in six randomly selected rural districts of Tigray Region. A census of all households in the six districts was conducted to identify all live births and all deaths of women of reproductive age between May 2012 and September 2013. Pregnancy-related deaths were screened through verbal autopsy to estimate Maternal Mortality Ratio (MMR). To identify independent determinants of maternal mortality, all pregnancyrelated deaths were matched geographically. Use of ambulance services was determined retrospectively from logbooks, and trends in pregnancy-related death were analyzed against ambulance utilization, distance from nearest health center, and mobile network coverage at local area level. Lastly, implementation of the Family Folder paper health register, and its potential for accurately capturing demographic and health events, were evaluated using a capture-recapture assessment. In all, 181 deaths and 19,179 live births were documented during the study period; 51 of the deaths were pregnancy-related. The MMR for Tigray region was calculated at 266 deaths per 100,000 live births. District–level MMRs showed strong inverse correlation with population density. Direct obstetric causes accounted for 61% of all pregnancy–related deaths, with hemorrhage accounting for 34%. Other factors associated with increased risk included low husband or partner involvement during pregnancy, pre-existing history of other illness, and never having used contraceptives. Importantly, utilization of free ambulance transportation service was strongly associated with reduced MMR at the district level. Districts with above-average ambulance utilization had an MMR of 149 per 100,000, compared with 350 per 100,000 in districts with below average utilization. The Family Folder implementation assessment revealed some inconsistencies in the way health

HospiMedica International August-September/2017

workers utilize the Family Folders to record demographic and health events. The thesis was presented in December 2016 at Umea University. “We see encouraging results of improved reproductive health and reduced pregnancy-related deaths in the Tigray region. A key reason for this has been the creation of small local women’s groups of volunteers who act as ambassadors for the benefits of utilizing the existing health services,” said thesis author epidemiologist Hagos Godefay. “Creating a conducive environment, where women living in the rural areas can meet and discuss together based on their own agenda, can make a big difference in reducing maternal mortality.”

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Genomic Testing Health Data Support Healthcare Decisions irect-to-consumer personal genomic testing (DTC-PGT) services are generally perceived as useful in shaping informed future health choices, according to a new study. Researchers at the University of Michigan (U-M; Ann Arbor, USA; www.umich.edu), Brigham and Women’s Hospital (Boston, MA, USA; www. brighamandwomens.org), and other institutions conducted three web surveys among customers of 23andMe (Mountain View, CA, USA; www. 23andme.com) and Pathway Genomics (San Diego, CA, USA; www.pathway.com) in order to better understanding who got tested and how they perceived the harms, benefits, and limitations of the data. In all, 1,648 consumers from the two companies completed Web surveys before and after receiving the genomic test results. The results showed that prior to testing, DTCPGT consumers were as interested in ancestry (74%) and trait information (72%) as they were in disease risks (72%). Among disease risks, heart disease (68%), breast cancer (67%), and Alzheimer disease (66%) raised the most interest. Interest in disease risks was associated with female gender and poorer

self-reported health. In addition, 38% of the consumers did not consider the possibility of unwanted information before purchasing services; this group was more likely to be older, male, and less educated. After receiving their test results, 59% of respondents said the test information would influence future management of their health; 2% regretted seeking testing; and one percent reported harm from results. The conditions of greatest interest for genetic risk information were more prevalent among women and people with poorer self-reported health that showed high interest in these types of information. In all, 93% felt genetic testing was a right decision, and 94% said they would do it again. The study was published on January 10, 2017, in Public Health Genomics. “As consumers have been able to learn more about their genetic makeup in recent years through personal genomic testing, one big criticism has been that without someone to interpret it, the health information could be harmful to the receivers,” said lead author Scott Roberts, PhD, of the U-M School of Public Health. Personal genomics is a branch of genomics that

deals with the sequencing and analysis of the genome of individuals, which can then be compared to published literature to identify the likelihood of disease risks and trait expressions of genetically inherited diseases such as sickle cell anemia, thalassemia, and cystic fibrosis. With advances in DNA sequencing techniques and data analytics, the cost of genetic testing has been falling rapidly, making it more affordable. Image: A new study suggests personal genomic data promotes informed healthcare (Photo courtesy of Shutterstock).

Human Heartbeat Could Safeguard Electronic Medical Data new study describes how an electrocardiograph (ECG) could be used as password to access the information encrypted in a patient’s electronic health record (EHR). Researchers at Binghamton University (NY, USA; www.binghamton.edu) conducted a study to investigate an innovative psychophysiological approach for secure and trustworthy user authentication via non-volitional components of an ECG. Identifying reproducible, unique features of the ECG, they developed a method to accurately recognize and authenticate people by extracting time-invariant and context-invariant ECG passwords. In essence, the patient’s heartbeat is used as the password to access their EHR.

Since an ECG may change due to age, illness, or injury, the researchers are currently working out ways to incorporate those variables. The identification scheme for ECG is a combination of previous work by the researchers that used a person’s unique brainprint instead of traditional passwords to access computers and buildings, which was combined with cyber-security approaches. The study was presented at the IEEE Global Communications Conference (GLOBECOM 2016), held during December 2016 in Washington (DC, USA). “The ECG signal is one of the most important and common physiological parameters collected and analyzed to understand a patient’s’ health,” said study co-author Zhanpeng Jin, PhD, of the de-

partment of electrical and computer engineering. “While ECG signals are collected for clinical diagnosis and transmitted through networks to electronic health records, we strategically reused the ECG signals for the data encryption.” “The cost and complexity of traditional encryption solutions prevent them being directly applied to telemedicine or mobile healthcare. Those systems are gradually replacing clinic-centered healthcare, and we wanted to find a unique solution to protect sensitive personal health data with something simple, available, and cost-effective,” concluded Dr. Jin. “Through this strategy, the security and privacy can be enhanced while minimum cost will be added.” HospiMedica International August-September/2017

3D-Printed Organs Help Clarify Anatomical Quandaries hree-dimensional (3D) printed anatomical models of internal organs can offer patients added insight by showing them what’s really going on inside their bodies. Researchers at the GE (Waukesha, WI, USA; www.gehealthcare.com) Advanced Manufacturing & Engineering Center (AMEC) are searching for ways to efficiently translate images from computerized tomography (CT), magnetic resonance imaging (MRI), and ultrasound scanners into printable files, so that 3D printed medical models can be produced as quickly as pushing the “Play” button on Netflix. But making such 3D model printing a reality is difficult, due to the vast amount of data. For instance, in just one second, a CT scanner can generate and transmit enough data to make up 6,000 Netflix movies. To try and streamline and speed up the process, another GE business unit, GE Additive (Boston, MA, USA; www.geadditive. com), which develops 3D printers and other additive manufacturing methods, is working with AMEC to explore whether a custom machine that prints organs from data files derived from imaging software is feasible. Currently, to print organs, up to three weeks are needed to transform the data to an image that can be translated to an additive printer production file. AMEC has already printed several such organs, such as a liver, a lung, and a heart. “You can show the patient the body part that has the problem. When they hold it in their hands and see it clearly, rather than look at a grayscale 2D image on-screen, they can quickly grasp what needs to be fixed,” said Jimmie Beacham, chief engineer for advanced manufacturing at GE Healthcare. “I think as people get more informed about health, they will want to be a bigger part of the solution. Helping them see the problem clearly will build more trust between the doctor and the patient. It translates into quicker action.” Additive manufacturing describes technologies that build 3D objects by adding layer-upon-layer of material, using computer aided design (CAD) modeling software,

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machine equipment, and layering material. Once a CAD sketch is produced, the data is relayed to the printer, which lays downs or adds successive layers of liquid, powder, sheet material or other, in a layer-upon-layer fashion to fabricate a 3D object. Many technologies are included in this definition, such as rapid prototyping, direct digital manufacturing, layered manufacturing, and additive fabrication. Image: A 3D model of a heart printed with additive manufacturing technology (Photo courtesy of GE Healthcare).

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The Synapse VNA can be configured to manage the data and transactions using the same shared infrastructure for multiple sites, facilities and departments. It efficiently integrates multiple clinical IT environments and improves patient care by simplifying the sharing of all clinical content.

The CXDI Control Software NE helps optimize workflow and reduce the steps needed to complete exams. It provides quick image confirmation and timely network distribution, supports multiple study acquisition, and can be easily tailored to individual clinical preferences.

The Exa offers a diagnostic quality Zero Footprint Universal Viewer for DICOM and non-DICOM images that minimizes unwanted exposure to data. The platform provides hospitals and imaging centers the ability to view images across departments and facilities, regardless of image source.

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3D Bioprinter Produces Functional Human Skin novel three-dimensional (3D) printing technology uses human components to produce active skin that makes its own collagen. Researchers at Hospital General Universitario Gregorio Marañón (Gregorio Marañón; Madrid, Spain; www.madrid.org/hospitalgregorio maranon), Universidad Carlos III de Madrid (UC3M, Spain; www.uc3m.es), and other institutions 3D printed a human bilayered (epidermis and ermis) skin using bioinks containing human plasma, primary human fibroblasts, and keratinocytes obtained from skin biopsies. The researchers were able to generate 100 cm2 – a standard P100 tissue culture plate – of printed skin in less than 35 min, including the 30 minutes required for fibrin gelation. When using histological and immunohistochemical methods to analyze the structure and function of the printed skin in immunodeficient mice, they found that both in the 3D and in vitro cultures it was similar to human skin and, furthermore was indistinguishable from hand-made dermo-epidermal equivalents, which usually take

three weeks to fabricate. The researchers claim that the human skin produced is adequate for transplant into patients, or for testing drugs and cosmetics. The study describing the technique was published on December 5, 2016, in Biofabrication. “Knowing how to mix the biological components, in what conditions to work with them so that the cells don’t deteriorate, and how to correctly deposit the product is critical to the system,” said study co-author Juan Francisco del Cañizo, MD, of Gregorio Marañón Hospital. “It prints the epidermis, including the stratum corneum, the protective outermost layer comprising keratinized cells. Then, it prints the deeper, thicker dermis, complete with fibroblasts that make collagen.” “This method of bioprinting allows skin to be generated in a standardized, automated way, and the process is less expensive than manual produc-

tion,” said Alfredo Brisac, CEO of BioDan Group (Madrid, Spain; www.biodangroup.com), a private Spanish bioengineering firm that is commercializing the technology. “The 3D bioprinter has been submitted for approval by various European regulators. The approval is needed to ensure that the printed skin is suitable for transplanting into patients with burns and other skin conditions.” Image: A novel 3D bioprinter prints bi-layered human skin (Photo courtesy of UC3M).

New Gaming App Helps Smokers Kick the Habit

novel smartphone application helps smokers combat cigarette cravings and quit smoking by playing behavioral changing

games. Developed by researchers at Kingston University London (KUL; United Kingdom; www.kingston. ac.uk) and Queen Mary, University of London (QMUL; United Kingdom; www.qmul.ac.uk), the Cigbreak Free app incorporates a combination of 37 theory-based methods for changing behavior as selected by psychologists to help smokers quit. In the game, players have to swipe a certain number of cigarettes to break them within a time limit. There are also mini-games where players have to clear smoke from a room to reveal a health message. As in regular smartphone games, players have to

complete tasks to progress through levels, gaining rewards and gold stars along the way as a form of providing smokers with instant positive feedback. As well as progressing through levels, the app includes a quit journal where users can calculate how much money they are saving. The app has been commissioned for use by five London boroughs as part of their public health smoking cessation services; local residents can download it, enter their postcode and use the app for free. “Craving is a short-term thing, so if you get a craving at 11am, you can play the game in the warm until it passes, rather than going out into the cold for a cigarette. You’ve also got something to do with your hands other than smoke,” said app co-developer Hope Caton, of the KUL school of comput-

er science and mathematics. “The good thing about a smartphone gaming app is that you can play it anywhere. We’ve had people smoking 25 cigarettes a day quit, some who’ve gone from 25 to four. It shows it can be effective.” “Some of the health messages and behavior change techniques we have used in the game are based on our previous research, and include showing players the health consequences of a behavior, gaining points for grabbing healthy items, or providing virtual financial incentives,” added app co-developer Professor Robert Walton, MD, of QMUL. “We’re essentially trying to ‘gamify’ these messages and techniques as a way of embedding them in a person’s mind, in the hope that they will then be able to quit smoking.” HospiMedica International August-September/2017

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Health IT

Video Camera Streams Surgery Using Virtual Reality novel 360-degree video camera was used to stream bariatric surgery to hundreds of viewers using virtual reality (VR) headsets. The ALLie Camera provides 24/7 viewing, recording, live streaming, still-capture, social sharing, and VR viewing capabilities. Because the view angle can be controlled by each individual viewer in order to see the entire surgical area, users can simply set it up in the room and not worry about camera angles or blind spots for their audience. It does not require batteries, and can be mounted on walls and ceilings, or even stand on most surfaces. Unlike other 360° video cameras, the ALLie provides the ability to record video all the time, making it an ideal solution for capturing medical training scenarios in clear 4K resolution, and for providing a fully immersive experience through a low-cost VR headset. This allows both practicing surgeons and students to be immersed in a completely interactive educational experience in a risk-free, non-intrusive environment. A two-way communication feature even allows users to interact through the camera remotely. Other features include dual 8-megapixel sensors that support 2048x2048 pixel resolution at 20fps; a free companion mobile app; night vision and infrared functionality; an “Away Mode” that stores video to a cloud for 24, 48, 72, or a custom amount of hours; a “Home Mode” which utilizes local Wi-Fi to record in the best possible resolution and store it on a mobile device. The camera also updates itself remotely with new software features as they become available. The ALLie Camera is a product of ALLie (Dublin, Ireland; https:// allie.camera). “We are blazing the trail for surgeons around the world by bringing these incredibly interactive and immersive 360 video technologies into the operating room,” said Ariel Ortiz Lagardere, MD, of the Obesity Control Center (Baja, Mexico) who performed the procedure during the 18th annual International Bariatric Club Symposium. “Together with the team at ALLie, our sights are fo-

cused on continuing to further the educational possibilities that 360-degree cameras and VR headsets can bring to medical learning environments.” While technology in the medical industry continues to advance, medical errors such as misdiagnoses, ‘botched’ surgeries and medication errors are the third leading cause of death in the United States, according to recent report in the British Medical Journal. Image: The ALLie 360-degree video camera (Photo courtesy of ALLie).

New Version of Imaging Platform Offers Advanced VNA Capabilities new version of an award-winning enterprise imaging platform that supports additional specialties, provides improved collaboration, and offers advanced Vendor Neutral Archive (VNA) capabilities, has been announced. The platform features new workflow rules, intelligent image and archive management, livestreaming capabilities, ophthalmology and dental imaging workflows, and business Intelligence reports. The new Enterprise Imaging platform version was announced by Agfa HealthCare (Mortsel, Belgium; www. agfahealthcare.com), and includes workflows for academic, research, teaching, multi-site, and other medical imaging specialties. The platform can be used for virtual conferences using a browser and the universal XERO viewer. Remove viewing and live streaming during surgery and endoscopies, real-time audio, and video consultation are made possible using the Agfa Orpheus system. A report published in November

HospiMedica International August-September/2017

2015, by peer60, based on an industry survey including more than 500 healthcare providers, and entitled “Trends in Medical Imaging Technology” selected the Enterprise Imaging platform as the Number 1 Enterprise Imaging solution. James Jay, VP, Agfa HealthCare Imaging IT solutions, said, “With this latest Enterprise Imaging release, Agfa HealthCare confirms its focus on delivering a highly integrated platform to improve the management and sharing of images across the healthcare enterprise.” Image: A new version of the Enterprise Imaging platform has been announced (Photo courtesy of Agfa HealthCare). LINKXPRESS COM

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Hospital News I

New Adelaide Hospital to Be Australia's Largest and Most Advanced he new Royal Adelaide Hospital (RAH; Australia; www. rah.sa.gov.au), the largest ever undertaken in Australia, will provide South Australia with a center for major emergencies such as heart attacks and stroke, as well as serving as the complex multi-trauma destination for the state. The new RAH has been designed to accommodate 700 single beds, with a capacity of more than 80,000 patients per annum, and an emergency department (ED) capable of treating an extra 24,000 patients each year. In addition, there are 40 technical operating suites supported by 180 recovery bays, a 60-bed intensive care unit (ICU), and associated clinical support areas, including distributed diagnostic areas, a renal dialysis center, an oncology clinic, and a hyperbaric unit. A fleet of automatically guided vehicles will triage equipment and supplies throughout the hospital. The hospital is designed around a patient-centered “journey to health” model, where clinical care is brought

to the patient in their own bedrooms. Each RAH room is a healing environment incorporating an emphasis on privacy, passive surveillance, the opportunity to display artwork, and a place for visiting family to stay. The single en-suite rooms are designed for treatment and rehabilitation, with reduced risk of infection, and advanced information technology (IT) systems for improved patient safety and clinical and patient information. A hospital-wide, purpose-designed information communication technology (ICT) engine integrates patient records, clinical systems, patient systems, and facility management support systems. Other technology features including patient weighing beds, wireless technology and equipment tracking capability, and intelligent information systems such as bedside entertainment and on-line meal ordering for patients. The ICT network and technology features are projected to make the RAH Australia’s most technologically advanced hospital. “The opening of the state-of-the-

Image: The new Royal Adelaide Hospital (Photo courtesy of Silver Thomas Hanley)

art new Royal Adelaide Hospital will be one of the most significant events in our great state’s history. Moving to the new site is a huge undertaking for all involved, and I know the community is excited about the new hospital opening its doors to inpatients in September,” said South Australia Premier Jay Weatherill. “There’s been a huge amount of interest from the community, so we will be holding tour days so the public can see inside this wonderful facility for themselves sometime in July.”

The RAH design also incorporates an innovative ecological approach to office space, teaching and research facilities, and green spaces, with extensive environmentally sustainable design initiatives, including rainwater harvesting to be used to offset potable water requirements; high efficiency water fittings throughout the hospital; extensive water metering and reporting strategy to identify and manage water consumption; water sensitive landscaping; and a water efficient thermal plant.

Mortality Rates Lower at Major Teaching Hospitals dmission to an academic medical center (AMC) is associated with a lower overall 30-day risk of death compared with admission to a non-teaching hospital, according to a new study. Researchers at Harvard School of Public Health (HSPH; Boston, MA, USA; www.hsph.harvard. edu), Massachusetts General Hospital (MGH; Boston, USA; www.massgeneral.org), and other institutions conducted a study using U.S. national Medicare data to compare mortality rates in teaching and non-teaching hospitals for common medical and surgical conditions among beneficiaries 65 years and older. The sample consisted of 21,451,824 total hospitalizations at 4,483 hospitals, of which 250 (5.6%) were major teaching, 894 (19.9%) were minor teaching, and 3,339 (74.3%) were non-teaching hospitals. The main outcomes and measures were 30-day mortality rate for all hospitalizations and for 15 common medical and 6 surgical conditions. Secondary outcomes included 30-day mortality stratified by hospital size, and 7-day mortality and 90day mortality for all hospitalizations, as well as for individual medical and surgical conditions. The results revealed that unadjusted 30-day mortality was 8.1% at major teaching hospitals, 9.2% at minor

teaching hospitals, and 9.6% at non-teaching hospitals, representing a 1.5% mortality difference between major teaching hospitals and non-teaching hospitals. After adjusting for patient and hospital characteristics, the same pattern persisted, but the difference in mortality between major and non-teaching hospitals was smaller. Further stratification by hospital size showed that 187 large (over 400 beds) AMCs had lower adjusted overall 30-day mortality (8.1%) relative to 76 large non-teaching hospitals (9.4%). The same pattern was observed in mediumsized hospitals. Among smaller hospitals, with less than 100 beds hospitals, minor teaching hospitals had lower overall 30-day mortality relative to nonteaching hospitals. The study was published on May 23, 2017, in JAMA. “Academic medical centers provide a unique environment, with 24-hour availability of specialty services, advanced technologies, and some of the most expert physicians in the country. This seems to pay off for patients,” said lead author Laura Burke, MD, of HSPS. “While obviously not all patients can receive care in major teaching hospitals, understanding which strategies and resources are particularly important to patient outcomes, and how they can be replicated among nonteaching

hospitals, is critically important to improve care for all patients.” “We found to our surprise that across a wide range of medical and surgical conditions, patients at teaching hospitals did better; they were less likely to die,” added senior author Ashish Jha, MD, MPH, of HSPS. “While mortality may not be the only indicator that matters, it certainly is the most important one. We know that short term mortality is driven largely by how well the hospital does in taking care of patients.” AMCs are often considered more expensive than community hospitals and some insurers have excluded them from their networks in an attempt to control costs, assuming that quality is comparable. Image: The Harvard School of Public Health (Photo courtesy of Wikimedia). HospiMedica International August-September/2017

Industry News

Stryker Acquisition Expands Surgical Visualization Offerings tryker Corporation (Kalamazoo, MI, USA; www.stryker. com), a medical devices and equipment manufacturing firm, has entered into a definitive agreement to acquire NOVADAQ Technologies Inc., (Mississauga, Canada; www. novadaq.com), a provider of fluorescence imaging solutions for minimally invasive and open surgeries. Stryker offers a diverse array of innovative products and services in orthopedics, medical and surgical, and neurotechnology and spine that help improve patient and hospital outcomes. NOVADAQ develops fluorescence imaging technology that provides surgeons with visualization of blood flow in vessels, and related tis-

sue perfusion in cardiac, cardiovascular, gastrointestinal, plastic, microsurgical, and reconstructive procedures. “This acquisition aligns with Stryker's focus on enabling our customers to see and do more by enhancing cross-specialty surgical visualization,” said Timothy J. Scannell, Group President, MedSurg and NeuroTechnology. “NOVADAQ’S unique innovative technology complements Stryker's advanced imaging portfolio and expands our product offerings into open and plastic reconstructive surgery. NOVADAQ’S innovative technology can reduce post-procedure complication rates and the cost of care for a broad variety of surgical treatments.”

Philips Inks Acquisition of Vascular Imaging Developer oyal Philips (Amsterdam, the Netherlands; www.philips. com) has entered into a definitive merger agreement to acquire the Spectranetics Corporation (Colorado Springs, CO, USA; www. spectranetics.com), a provider of vascular intervention and lead management solutions. Philips is a health technology company with a focus on diagnostic imaging, image-guided therapy, patient monitoring and health informatics, as well as in consumer health and home care. The company’s portfolio for the image-guided therapy market comprises of interventional imaging systems and devices, planning and navigation software, and services. Spectranetics develops, manufactures, markets and distributes medical de-

vices used in minimally invasive procedures within the cardiovascular system. The company’s products are used to treat arterial blockages in the heart and legs and in the removal of pacemaker and defibrillator leads. Spectranetics' device portfolio includes a range of laser atherectomy catheters for treatment of blockages with laser energy in both coronary and peripheral arteries. The acquisition of Spectranetics will further expand and strengthen Philips’ Image-Guided Therapy Business Group. With the acquisition, Philips expects new product introductions across a highly synergistic therapy device portfolio and further geographical expansion of Spectranetics’ products and commercialization opportunities in new, adjacent segments.

Virtual Reality Finds Increasing Applications in Healthcare he virtual reality (VR) in the U.S. healthcare market grew from USD 525 million in 2012 to an estimated USD 976 million in 2017, and the U.S. VR and augmented reality (AR) in healthcare market is expected to grow at roughly that level. These are the latest findings of Kalorama Information, (New York, NY, USA; www.kaloramainformation.com), an independent medical market research firm. The predominant markets for VR and AR in healthcare are in surgery, medical education, professional training in healthcare, physical rehabilitation, pain management, and behavioral therapy. According to Kalorama,

HospiMedica International August-September/2017

there are scores of applications for VR in healthcare, such as surgery, pain management, and medical education, among others. The market for VR and AR in surgery includes technologies such as surgical navigation, robot-assisted surgery (RAS), and treatment planning and patient alignment in radiotherapy. VR technology is proving to be particularly useful in robot-assisted orthopedic surgery. VR in healthcare is also finding application in pain management due to its immersive qualities, which can significantly reduce patients' active attention to painful procedures such as wound cleaning and needle insertion.

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SEPTEMBER 2017 Medical Fair Thailand 2017. Sep 8-9; Bangkok, Thailand; Web: www.medicalfair-thailand.com Minimally Invasive Surgery Week 2017. Sep 6-9; San Francisco, CA, USA; Web: http://sls.org 36th Annual ESRA Congress 2016 The European Society of Regional Anaesthesia and Pain Therapy. Sep 13-16; Lugano, Switzerland; Web: http://esraeurope.org 27th World Congress on Ultrasound in Obstetrics and Gynecology. Sep 1720; Vienna, Austria; Web: www.isuog.org CIRSE 2017. Sep 16-20; Copenhagen, Denmark; Web: www.cirse.org Euroson 2017 – Congress of the European Federation of Societies for Ultrasound. Sep 22-25; Antalya, Turkey; Web: www.efsumb.org ERS 2017 – Annual Congress of European Respiratory Society. Sep 9-13; Milan, Italy; Web: www.erscongress.org 17th World Congress of Anesthesiologist. September; Prague, Czech Republic; Web: www.wfsahq.org

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