Asian Hospital & Healthcare Management - Issue 60

Virtual Health Reimagining care delivery

In a landscape transformed by the pandemic, patients’ willingness to use telehealth solutions has grown exponentially and virtual care is becoming the new norm. Digital technologies have proved to be effective tools for patients to receive medical care from the comfort of their homes or any remote location. They have also empowered health centres and physicians to provide timely and efficient care to patients unable to visit them in person.

A Deloitte survey conducted in collaboration with American Telemedicine Association (ATA) found that by 2040, 50 per cent of executives surveyed thought at least a quarter of all outpatient care, preventive care, long-term care, and well-being services would move to virtual delivery.

Virtual health has enhanced patient-physician interactions in several ways, including remote patient monitoring and providing timely medical intervention. Patients use video conferencing, phone calls, or secure messaging to communicate with their physicians, eliminating the need to schedule in-person appointments or travel long distances to receive medical care. Physicians can use remote monitoring devices to track patients' vital signs and send alerts based on changes that require immediate attention. Virtual health has also allowed physicians to collaborate with other healthcare professionals and share patient information in real-time, thereby facilitating a more coordinated and effective care.

As technology continues to advance, we can expect virtual health to become even more sophisticated, enabling patients and physicians to connect and interact in even more innovative ways.

Virtual health can bridge the gap in healthcare access, particularly for those who live in rural or remote areas, or those who have difficulty traveling to a healthcare facility due to physical or financial barriers. However, virtual health can also exacerbate existing disparities in healthcare access if it is not implemented in an equitable manner. Care providers should analyse the potential gaps and take steps like providing training and resources to help patients and healthcare providers navigate virtual health platforms, ensuring their accessibility to everyone, and designing virtual health interventions that are culturally and linguistically appropriate for diverse populations. By doing so, we can ensure that virtual health benefits everyone, regardless of their background or circumstances.

In this issue, Stanley Li, Founder and CEO, DXY, and Mahira El Sayed, Professor of Dermatology, Ain Shams University, write about how virtual health is impacting in-person interactions. The authors provide their take on telemedicine, how it has transformed consultation experience and the impact of effective virtual patient engagement on better health outcomes. The issue also features insightful articles on AI in healthcare, IoMT, Neonatal care, Colorectal cancer, telehealth.

Send in your valuable feedback to prasanthi@ochre-media.com.

Prasanthi Sadhu Editor

CONTENTS

HEALTHCARE MANAGEMENT

06 Health of Healthcare Professionals

Gurrit K Sethi, Founder, Miindmymiind

10 Reminiscences of a Neurosurgeon/ Telehealth Evangelist

A 48-year story

Krishnan Ganapathy, Member, Board of Directors, Apollo Telemedicine Networking Foundation &, Apollo Telehealth Services INDIA

14 COVID-19 and the Great Resignation

How human resources can foster employee retention in a post-pandemic workforce in healthcare organisations

Uche Nwabueze, Instructional (Full) Professor, Chair of Program Assessment, Dept. of Maritime Administration,Texas A&M University

MEDICAL SCIENCES

22 Understanding the Growing Prevalence of Colorectal Cancer among Young Adults in Malaysia

An urgent call to action

Jenson Sow, Clinical Oncology, Aurelius Hospital Nilai

25 Neonatal Care

A global crisis in desperate need of innovation

Wisam Breegi, CEO, Breegi Scientific, Inc.

29 Predicting and Preventing the Next Pandemics

Alain L Fymat, International Institute of Medicine & Science

32 A Brief History of Metastatic Colon Cancer

Shikha Jain, Associate Professor, Director of Communication Strategies, University of Illinois Chicago

Lucia D, Notardonato, Hematology/Oncology Fellow, University of Illinois

36 Reduce Colon Cancer Risk with Exercise

Saint-Vil, Medical Director, Sports Medicine Department, Marietta Memorial Hospital

COVER STORY

Mind the Gap

How virtual health has improved in-person patient interactions

SURGICAL SPECIALITY

38 Surgeon Volume in Multi-Arterial Revascularisation and Long-Term Survival

Natalia Egorova, Professor, Icahn School of Medicine

Doaa Alsaleh, Candidate in clinical research, Icahn School of Medicine

DIAGNOSTICS

42 Chest Disease Detection

The power of deep learning in radiography

Moulay Akhloufi, Professor, Department of Computer Science, University of Moncton

TECHNOLOGY, EQUIPMENT

& DEVICES

46 Medical Device Security

Cybersecurity risk is now patient risk

John Giantsidis, President, CyberActa

INFORMATION TECHNOLOGY

54 IoMT for Improving Healthcare

Alex Nehmy, Director, Industry 4.0, Palo Alto Networks

56 Digital Health and Cardiac Rehabilitation

A paradigm shift offering care continuum of multidisciplinary holistic interventions

Alben Sigamani, Chief Scientific Officer, Numen Health

59 Artificial Intelligence in Healthcare Machine Learning for Clinical Outcome Prediction in Cerebrovascular Disorders

Benjamin W Y Lo, Department of Neurological Surgery, Lenox Hill Hospital

Stanley Li Founder and CEO, DXY

Mahira El Sayed Professor of Dermatology, Ain Shams University

Use

Grow your audience with increased reach, impact and user-friendliness

Rise above geographical boundaries

Generate new business

Gain the strong web presence differentiating yourself from competitors

Connect and engage with your target audience

Give more exposure to industry specific people

Increase your brand profile and share your capabilities with leading industry professionals

Advisory Board

Beverly A Jensen President/CEO Women's Medicine Bowl, LLC

David A Shore Adjunct Professor, Organisational Development Business School, University of Monterrey

Eiman Shafa Medical Director Spine Surgery Abbott Northwestern Hospital

Gabe Rijpma Sr. Director Health & Social Services for Asia

EDITOR

Prasanthi Sadhu

EDITORIAL TEAM

Debi Jones

Grace Jones

Harry Callum

Rohith Nuguri

Swetha M

ART DIRECTOR

M Abdul Hannan

PRODUCT MANAGER

Jeff Kenney

SENIOR PRODUCT ASSOCIATES

Ben Johnson

David Nelson

Peter Thomas

Susanne Vincent

Gurrit K Sethi Founder, Miindmymiind

Imelda Leslie Vargas Regional Quality Assurance Director Zuellig Pharma

K Ganapathy Director

Apollo Telemedicine Networking Foundation & Apollo Tele health Services

Luzviminda Nietes Vice-President, Business Planning & Development, Metro Manila

Nicola Pastorello Data Analytics Manager Daisee

Microsoft Piyanun Yenjit Founder & Managing Director APUK Co.,Ltd.

Pradeep Chowbey Chairman

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

Pradeep Kumar Ray Honorary Professor and Founder WHO Collaborating Centre on eHealth UNSW

Associate

Partner

PRODUCT ASSOCIATE

John Milton

CIRCULATION TEAM

Sam Smith

SUBSCRIPTIONS IN-CHARGE

Vijay Kumar Gaddam

HEAD-OPERATIONS

S V Nageswara Rao

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Health of Healthcare Professionals

Healthcare is one of the oldest, largest, most stressful professions in the world — it is also the most important. However, the health of healthcare professionals is rarely discussed. How do we correct this?

We often hear things like ‘it is darkest before dawn’ or ‘there’s darkest underneath the lamp’ (translated version of the Hindi proverb ‘diya tale andhera’). While the job of healthcare workers is to ensure healthy outcomes for everyone, are they healthy themselves?

Gurrit K Sethi, Founder, Miindmymiind

Ihave worked in healthcare for over two decades. I started from the shop floor working my way up. In all these years, spent across reputed organisations, never have I come across any programmes where there was a focus on the health of the healthcare workers. While we did deliver wellness talk for awareness to various industries as part of our sales and marketing initiatives, we were blind to the initiatives of these other organisations as they strived to create awareness about health for their employees through us. Despite being the instruments of care, there was no time or the inclination to share this care backwards.

It’s a well-known fact that healthcare organisations are the most stressful workplaces. More so for frontline health workers who support sick people,

look after them and manage their requirements. Most working hours are spent on these duties which add to as well as create a lot of psychological distress. This stress is compounded by various other challenges: shortage of manpower, shortage of skilled manpower, shortage of quality protective gear, possibility of exposure to dangerous diseases, lower salaries, no incentives, hardly any work life balance…the list goes on. The pandemic only complicated these issues.

However, what did we do about this? While the world talked about healthy living and healthy eating, has any of this percolated to the masses of healthcare workers? When I tried exploring data on the health of healthcare workers, hardly any findings came up. How many hospitals have deployed ‘employee assistance programmes’? How many organisations have invested in ‘wellness programmes’ other than the health insurance policies for their employees?

This article is meant to be a callout to all healthcare industry professionals — now is the time to fix this. While we cannot fix the environment that most healthcare professionals are exposed to because of the nature of the professions itself, what we can do is fix the surrounding factors to make it a good place.

The focus of ‘patient welfare’ also needs to extend to ‘employee welfare’ beyond the day-to-day courtesies. Drawing a parable from all other industries, this is also bound to result in faster growth, better business outcomes along with better patient outcomes. A happy employee is bound to deliver better work.

When I mention health, there is a need to stress that Good Health = Physical Health + Mental Health.

One drives the other. However, we ignore, especially, mental health most of the time. While the World Health Organization (WHO) has propagated blended care, integrative medicine for a while, mental health is often

overlooked — for patients as well as for professionals.

So, what is it that we can do to better the scenarios for the healthcare industry professionals? Some tips which we found useful, being used in other industries as part of Employee Assistance Programs:

Engagement and communication: A well-connected organisation is also the best performing. Keeping employees aware of what is happening across the organisation on a regular basis goes a long way in how connected an employee feels to his team and the workplace. This enhances their pride of work. So communication meetings are definitely not passe, rather we need to figure more effective strategies on conducting these.

Recognition: This is an important aspect of social existence. When efforts are duly recognised, it generally motivates people to perform better. Recognise potential at every step, recognise work done at every step. You will have a better bonded workplace.

Talent: Building talent, and ensuring this across the employee journey helps the organisation thrive. However, effectiveness is the most important ingredient here. Randomly put together training programmes cannot give you the desired results. In fact, divide your talent development into multiple parts — team cohesiveness, specific skills building and overall self-management and leadership development. The last would actually become a defining factor of success of the organisation over a period of time as this builds the internal branding.

Mental health: Recognise mental health as an important factor of performance. Especially for those in the front-line care delivery positions. Burnout rates are highest in healthcare professionals, especially nursing and the physicians. Building mental resilience to ensure performing teams is the most critical but also the least recognised factor in healthcare, especially in India. Having mental health supportive programmes for employees through psychologists can be extremely useful for busting stress as well as building resilience and bettering coping skills.

Culture: Creating a healthy work culture which allows for work life balance, recharge opportunities, time out with families is also essential. Policies need to be supportive of all of these.

Creating health awareness: While we do this for other industries, it is time to spell out these facts for ourselves too.

While almost every senior leader talks of all the aspects mentioned above, when it comes to delivery on site, these quickly become good to have philosophies. A cultural transformation has to start from the top with accountability and responsibility towards oneself first to ensure work life balance, respect others’ time, respect assertive communication and transparency, support quick decision making, accept that those who work will make mistakes sometimes and that we will help correct those.

Now this for sure is a mountain to scale for most leaders. But the buck starts and stops here.

AUTHOR BIO

The Rise of Altera Digital Health in Asia

As a new member of the N. Harris Computer Corporation family, Altera Digital Health, formally Allscripts, is one of the most prolific healthcare IT solution providers in Asia with dozens of leading hospitals and care sites across Singapore, the Philippines and Guam leveraging its Sunrise™ technology to improve patient care.

Altera Digital Health is a global healthcare IT innovator that is driving a new era of healthcare. As a new member of the N. Harris Computer Corporation family, Altera puts healthcare technology in downto-earth terms, and designs digital solutions that are simpler to understand and use at every step. Altera is positioned as one of the most prolific healthcare

IT solution providers in Asia with dozens of leading hospitals and care sites across Singapore, the Philippines and Guam leveraging its Sunrise™ technology to improve patient care. The Sunrise™ solution suite is a comprehensive, open platform that connects all aspects of care across multiple healthcare disciplines.

In Asia, Altera works closely with Singapore’s largest public healthcare group, SingHealth. SingHealth is a network of acute hospitals, national specialty centres, polyclinics and community hospitals with more than 40 clinical specialties. Its institutions have more than 4,800 beds, and see about 240,000 inpatient admissions per annum. SingHealth’s institutions have for many years leveraged Altera’s Sunrise platform in its delivery of care to patients. Beginning in 1998 when Sunrise™ went live at the flagship hospital of Singapore’s public healthcare system, Singapore General Hospital (SGH). With 1,939 beds, SGH is also the largest hospital in Singapore.

Other leading hospitals to go live on Sunrise™ include the KK Women's and Children's Hospital, Singapore’s largest tertiary referral centre for Obstetrics, Gynaecology, Paediatrics and Neonatology as well as Changi General Hospital which cares for more than 1 million people in Singapore. The implementation of Sunrise™ at these hospitals led to the extension of the platform to newer hospitals in the group, such as the Sengkang General Hospital, which opened its doors in 2018. Powered by Sunrise, it is a vital part of Singapore’s strategy to provide quality and accessible care to better serve the healthcare needs in northeastern Singapore.

In July 2022, Altera announced a multi-year agreement with SingHealth for the use of Sunrise suite of healthcare IT solutions across its group of institutions. The partnership is an extension of an agreement signed in 2017 and will continue through to 2029, providing SingHealth with ongoing support of Altera Digital Health’s electronic medical record (EMR) platform.

Altera’s successes in the Singapore public health system did not go unnoticed when the Ministry of Defence (MINDEF) was looking to upgrade its Electronic Medical Records system, first instituted in 1995. The Singapore Armed Forces (SAF) Medical Corps has applied the Sunrise™ powered PACES 3 system since 2016, which connects seamlessly with Singapore’s National Electronic Health Records system. Its user-friendly mobile eHealth portal that allows soldiers to conveniently book their own medical review appointments, retrieve information about their health visits and investigations, and enabled greater health ownership amongst soldiers. In 2017, PACES 3 was announced the winner of the “Digital-

ised Care to Support One Healthcare System” category at the National Health IT Excellence Awards 2017.

Outside of SingHealth and the public health system, Altera has also shared the benefits of its powerful and intuitive platform, Sunrise™, with hospitals in the private sector. In 2018, Sunrise went live at Singapore’s only not-for-profit Catholic acute tertiary care hospital, Mount Alvernia Hospital.

Sunrise is also live across all hospitals in Singapore’s largest private healthcare provider, IHH Healthcare Singapore, which operates Mount Elizabeth Hospital, Mount Elizabeth Novena Hospital, Gleneagles Hospital and Parkway East Hospital.

Altogether, Altera’s footprint in Singapore covers approximately 55 per cent of all major hospitals and healthcare centres.

Outside of Singapore, Altera’s presence is growing steadily. The Guam Regional Medical City, a privately run hospital, managed under the Philippines-based hospital network, has leveraged Sunrise since it opened its doors in 2017 and relies on Altera for its EMR solution, revenue cycle management, and overall budgeting and planning.

Altera Digital Health is committed to transforming digital health in Asia and today employs more than 30 highly qualified people across the region.

About Altera Digital Health

Altera Digital Health believes that healthcare should be easier to access, easier to understand and easier to navigate. Whether providing care or receiving it, people deserve a higher-level experience that fits and improves their everyday lives. Instead of just talking about bold moves that will catapult healthcare to a higher place, Altera sees the summit, designs digital health services to get there, and guides those we partner with all along the way. We’re bringing next-level healthcare within reach. To learn more, visit www.alterahealth.com

Reminiscences of a Neurosurgeon/ Telehealth Evangelist A 48-year story

I was taken aback when an MNC with 4000 + employees GS Lab | GAVS https://www. gavstech.com/gs-lab-and-gavs-join-hands/ asked me to virtually address their monthly Galvanizer Meet of senior executives across different continents. The surprise was with the topic given – not the invite per se. I was asked to share the Story of My Life emphasising how to develop empathy and care to others, handle tough life situations and obsess on excellence in whatever we do. Since 1975 as of date I have presented 592 papers in national and 193 in International conferences but this was the first time I was asked to talk about my personal story!! The Q&A session following the talk ( https:// ) indicated that the audience of 196 were genuinely interested in what they heard – hence this attempt at sharing my personal experience with a larger audience

Krishnan Ganapathy, Member, Board of Directors, Apollo Telemedicine Networking Foundation &, Apollo Telehealth Services INDIA

story! The Q&A session following the talk2 indicated that the audience of 196 were genuinely interested in what they heard — hence I agreed to share my personal story with a larger audience

Schooling

Iwas taken aback when an MNC with 4000 + employees GS Lab | GAVS1 asked me to virtually address their monthly Galvanizer Meet of senior executives across different continents. The surprise was with the topic given –

1 https://www.gavstech.com/gs-lab-and-gavs-join-hands/

not the invite per se. I was asked to share the Story of My Life emphasising how to handle tough life situations and obsess on excellence in whatever we do. Since 1975 as of date I have presented 592 papers in national and 193 in International conferences but this was the first time I was asked to talk about my personal

In 1961 studying in 6th grade I displayed skills as a entrepreneur by starting a paid magazine “The Bedean Times”. I published six issues before closing down. Topping the class in every exam till the 11th grade I was a regular contributor to the school magazine culminating in an article “St Bedes in 2064”3, not realising that I would develop an interest in Space Medicine and perhaps in my lifetime actually witness interplanetary travel. On August 3rd 1966 while in the 11th grade I got the news that my elder brother had

2 https://www.youtube.com/watch?v=3sG6Dj2brSY

3 https://www.innovaspace.org/blog/st-bedes-in-2064-ad

met with a fatal scooter accident. Going on 16, that minute I decided I would become a doctor and save the whole world. The rest as they say is history!

Undergraduate @ Madras Medical College (MMC)

Interested in research, I published papers as an undergraduate student4 and represented the state of Tamil Nadu at the National Science Fair. Indira Gandhi the then Prime minister of India spent 3 minutes looking at the 12 white mice with transplanted skin which I had brought with me. I had used chloroquine as an immunosuppressor. Fifty years later, chloroquine was initially recommended in managing the Corona Virus! Represented MMC in inter collegiate dramatics and debates bringing encomiums and accolades. On Nov 7th 1972 while studying for the University exam –got the news that my eldest brother also had met with a fatal scooter accident. Decided to become a Neurosurgeon and stay back with my devastated parents.

Postgraduate Neurosurgical residency

To do a five year post graduate course in 1975, after 6.5 years for a basic MBBS was a herculean task particularly as there was no stipend then. From 1976 Prof. Kalyanaraman my principal mentor ever since, employed me as his assistant to look after his private patients. In addition to Rs. 500 a month initially, I was also paid for assisting him in surgery. I would leave home at 5.15AM, do rounds in the nursing home, examine 10 plus patients, make meticulous entries in the case records and then reach the Institute of Neurology, Madras Medical College by 7.45 am. As a post graduate student I had to look after about 30 patients, many of them unconscious. Knowing that I had dabbled in research projects, Prof B. Ramamurthi also appointed me as a Senior Research Fellow in an Indian

4 https://pubmed.ncbi.nlm.nih.gov/4402191/10

Council of Medical Research project. I held three positions concurrently: Post graduate, SRF and Private Assistant to Dr Kalyanaraman. I would be working almost 90 hours a week including most Sundays and sleeping at home four to five days a week.

Travails of a Ph.D Scholar

In 1980, after a five year residency, I got the coveted Masters Degree in Neurosurgery from the Madras University. The next year I became the second in India to be certified in Neurosurgery by the National Board of Examinations Govt. of India. In 1984, I was encouraged to work for a Ph.D — easier said than done! I was now an Asst. Professor of Neurosurgery. Multiple visits, multiple times to the Director of Medical Education and the Health Secretary for permission to register for a Ph.D fell on deaf ears. Finally, to get rid of me the Health Minister acquiesced. A few weeks later I was transferred to a medical college with non-existent facilities. I persisted and got transferred back to MMC. Performing CT scans plain and repeat at 10mts, 1hr, 3hr and 24 hrs after contrast and take volumes of print outs for 250 patients, in a very busy government hospital was a herculean task. My Ph.D thesis was prepared using a dot matrix printer in 1989. The regulations had mentioned typed paper! A few weeks were spent convincing the Controller of Examinations and the Registrar of the Madras University to still accept the first computer printed Ph.D thesis submitted to the Madras University!

Support @ Home

During my residency, my brother-in-law also passed away and I had to look after my elder sister, as she had no children. Even today I believe that it was my parents and elder sister who “looked after me” till I was 55. Living in a joint family with four generations in the nineteen eighties, was an incredible experience. The tremendous family support enabled

me to be a guest at home and concentrate on neurosurgery. Normally one becomes Secretary of a National and International professional medical society when one is a dean/ director or at least HoD with staff and students to help. I was however “just” a consultant in a corporate hospital My wife however ensured that I ran these societies of 3500 + members with a clock work precision. Hence I was reelected for a second term of three and four years respectively.

Association with Neurological Society of India (NSI)

Starting 1975, I presented papers at almost every conference and gradually made my presence felt. Assisted Prof Kalyanaraman as part of the core team which introduced India’s first formal Continuing Medical Education (CME) programme — words unknown then. From Member Executive Committee, to CME Coordinator, Secretary and President was responsible for starting the first website5 of a professional society in 1996.

The Helmet Story

I demonstrated that operation outside the theatre saves more lives, by impleading myself in a PIL (Public Interest Litigation). Arguing before a division bench of the Madras High Court6 I helped in drafting Section 136 of the Motor Vehicles Act compulsory. Scores of talks were given in schools (Figure1), colleges, rotary clubs and Lions Clubs espousing the use of helmets. Articles were published in the print media. Message on Wearing Safety Helmets was telecast on closed circuit TVs @ Chennai Central station in April 2006 for 3 days so tens of thousands were at least exposed to the message.

Disseminating Medical Literature

Thirty-eight years ago, along with ten

5 https://neurosocietyindia.com/

6 https://www.thieme-connect.com/products/ejournals/abstract/10.1016/S0973-0508%2807%2980002-5

others we decided to make medical literature easily accessible, particularly to clinicians in suburban and rural India. We made available relevant, affordable reprints at their place of work using photocopying and the postal service. Disseminating medical literature and knowledge in India in the 1980s: the SMLRT story was published last year as a historical vignette7.

First Brain Death certified Multiple Organ Transplant in South Asia

December 25th 1995 was indeed an unforgettable day for me. Facilitating8 the first multiple organ transplant led to an emotional involvement with brain death certification and later on with death itself. Death was my constant companion for 40 years. I would have personally certified at least 2600 deaths. Several have had a permanent influence on me. These included nine deaths in the neurosurgery department encountered on Diwali day 1978 at the

7 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC8830371/

8 https://www.itnnews.co.in/indian-transplant-newsletter/ issue6/A-Gift-of-Life-143.htm

Govt General Hospital. How does one explain to a retired Professor of Surgery with multiple disseminated secondaries that no management can postpone the inevitable. How does one tell 70-yearold children that their 92-year-old mother, unconscious for three months, cannot legally have active euthanasia. At the same time I did everything humanly possible to keep a father alive so that the daughter’s marriage could take place. A terminally ill pregnant woman was kept alive to save the unborn.

Plunging into Stereotactic Radiosurgery and Robotic Radiosurgery

When one of my students became my boss I had no problem. When my student’s student got promoted 16 years after I qualified, I reluctantly resigned from government service (promotion depends only on your Government Service Commission. No Doctors senior to me in government service joining neurosurgery 10 years later got promoted even though I had more publications and presentations than all of them put together.) Starting the first Stereotactic Radiosurgery (SRS) Unit in

South Asia in May 1995 at the Apollo Speciality Hospitals Chennai was a difficult task. Colleagues suggested that lack of confidence in doing difficult long surgical procedures was the reason why I was getting into a non-invasive neurosurgical option. Decades later most aggressive neurosurgeons accepted that SRS was the treatment of choice in specific situations. In 2008 I became the first neurosurgeon in South Asia to be formally trained in Robotic Radiosurgery with the Cyberknife. It was a stupendous task to do SRS for cerebral AVMs (Arterio venous malformations) as I had to shift the patient with a stereotactic frame fixed on the head 5 km across the busiest road in Chennai from one hospital ( with Cath Lab) to another hospital which housed the Linear Accelerator. Organised the national conference of the Indian Society for Stereotactic and Functional Neurosurgery in 2011 at Chennai and was elected President of ISSFN (2011 to 2013).

Second career: Telemedicine

In 1998, I first heard the term “Telemedicine” and got hooked to it. (Figure 2) Competing with my legally wedded spouse and my first love Neurosurgery, Telemedicine became a competitor. Twenty-five years have elapsed. Initial infatuation has become a passion. Neurosurgery has given way to Telehealth. First in South Asia to start and develop Clinical Telemedicine in 2000, responsible for initiating Telemedicine in the Armed Forces of India in 2002 starting a Telehalth technology Course with Anna University and so on, some enterprising journalist even called me Father of Telemedicine9. Today several of the Founding Fathers have given way to the Next Generation.

In 2005 we carried out proofof-concept validation studies on the

9 https://www.google.com/search?q=Father+of+Telemedicin e+India&rlz=1C1CHZN_enIN1027IN1027&oq=Father +of+Telemedicine+India&aqs=chrome..69i57j33i160l4.1 4020j0j15&sourceid=chrome&ie=UTF-8

Figure 1: Propagating use of helmets

deployment of VSAT enabled fully equipped Hospital on Wheels (HoW). The entire team was concentrating on the vehicle, its contents and the satellite communication infrastructure. Not enough attention was paid to the low lying branches of trees and the quality of the mud roads in the villages where the HoW was to ply. Of course, we learnt the hard way that branches of trees would hit the VSAT changing its apogee and perigee! Subsequent VSAT receivers were made much smaller and even portable so that it could be fixed when required.

Erricson had requested me to carry out a clinical study of wireless transmission of heart sounds, ECG etc. when 3G was just becoming available. Arrangements had been made for a back-up generator as standby Due to a totally unexpected major mishap at the Tamil Nadu Electricity Board, the diesel in the generator was insufficient. It would take too long to get more diesel. The nearest source was 30KM away and it was a Sunday. Thinking on my feet I used the diesel from the Hospital on Wheels and from two other vans to tide over the crisis.

Reminiscences and Take Home Message

Today, India should no longer talk of achieving world-class. The world should talk of achieving India class. We should not follow high standards — we should set them. As a society we have commenced projecting our image overseas. “Made in India” is

on its way to becoming a superbrand. Coming together is a beginning, staying together is progress, and working together is success. The starting point of success is to move away from the comfort zone. Discontent can actually be a motivator. An innovator is one who does not know, that it cannot be done. An innovator is also the one, who sees what everyone sees, but thinks of what no one else thinks. Our activities should not be confined to just improving our individual professional competence. We are part of the community. The community’s problems therefore are our problems. It has been my privilege in the last five decades to have had a wonderful journey. Having been trained in the BC era I sincerely hope that technology will only be used as a means to an end and not an end by itself. Tender Loving Care should continue to be the clinician’s s mantra. What matters most is how one sees oneself. Never stop learning, because life never stops teaching. Our eyes are placed in front because it is more important to look ahead than look back. 72 is when one starts unlearning, relearning and getting future ready. Optimism is the name of the game. Those of us born at the commencement of the fifties now have the maturity to understand that AI will never ever replace natural NI — after all there is nothing artificial about our neurons. NI using AI judiciously would be a wonderful combination.

Addendum: The little that has been done was possible only because of the amazing family support received over the last 8 decades !! led by the CEO par excellence of Ganapathy Pvt Ltd !! - my spouse Vijayalakshmi - who made it possible for me to do what I want to do. Saying "Thank you" somehow seems so hopelessly inadequate

AUTHOR BIO

K GANAPATHY Former Secretary and Past President Neurological Society of India, Telemedicine Society of India & Indian Society for Stereotactic & Functional Neurosurgery Distinguished Visiting Professor IIT Kanpur, Distinguished Professor The TamilNadu Dr. MGR Medical University. Emeritus Professor National Academy of Medical Sciences, Formerly Member Roster of Experts Digital Health WHO. Director, Apollo Telemedicine Networking Foundation & Apollo Tele Health Services.

URL: www.kganapathy.in

E Mail: drkganapathy@gmail.com

Figure 2: Evangelising Telemedicine in 1998 !!

COVID-19 and the Great Resignation

How human resources can foster employee retention in a post-pandemic workforce in healthcare organisations

The paper posits that the negative impacts of remote work and the imposition of COVID-19 preventive measures to be the biggest drivers of the great resignation and quiet quitting. Structurally, hospital systems through HRM policies like flexible work schedules and employee participation in the decision-making process as it relates to post-pandemic measures will be effective in decreasing the number of employees who choose to leave their jobs.

In the spring of 2021, over a year after the COVID-19 pandemic entered the global stage, the U.S. Bureau of Labor Statistics reported a staggering calculation: over 4 million people had voluntarily quit their jobs (Cook, 2021). Many who remained employed decreased their working hours, which plummeted by 17.3 per cent shortly after the onset of the pandemic. This decrease in working hours, according to the International Labour Organization (ILO), is the equivalent of the loss of 495 million fulltime jobs (Cotofan et. al., 2021). These figures constitute a record percentage of workforce loss, a phenomenon has come to be widely referred to as the Great Resignation and calls attention to what should now be Human Resource’s top priority: solving the employee retention

problem (“How to Manage the Great Resignation,” 2021). The purpose of the following analysis is to isolate the factors driving the Great Resignation, connect their impact to employee resignation, and establish modern methods with which Human Resource personnel can incentivise employees to remain onboard. This paper hypothesises the negative impacts of remote work and the imposition of COVID-19 prevention measures to be the biggest drivers of the Great Resignation, and further hypothesises that the availability of a flexible work schedule, coupled with employee autonomy in participation with pandemic prevention measures, will be effective in decreasing the number of employees who choose to leave their jobs. The importance and urgency of

this research is echoed by the Journal of Human Resource Management, which states explicitly that “in response to the COVID-19 crisis, job retention should be seen as a central aim and practice of Human Resource Management” (Spencer, et. al., 2021).

How COVID-19 Re-Shaped the Workplace

To assess the factors that may be influencing millions of people to quit their jobs, we must initially examine the ways in which COVID-19 has transformed the workplace, as well as the reasons these transformations are linked to the factors influencing the mass exodus of the employed. To study such impacts that have been experienced on a universal, global scale, the following analysis will be focused on two factors that have widely impacted most of the workforce. The first of these factors is the proliferation of remote work; the second is the widespread imposition of politically charged COVID-19 prevention methods. The following sections will deep-dive into each of these factors, to assess the impacts of each and more effectively prescribe employee retention solutions as antidotes to the Great Resignation.

Uche Nwabueze, Instructional (Full) Professor, Chair of Program Assessment, Dept. of Maritime Administration,Texas A&M University

The Consequences of PandemicPrevention Methods

Because the impacts the pandemic has imposed on the workplace surely extend far past what can be adequately covered here, for purposes of conciseness we will now focus on a second, and far more politically charged example: the presence of COVID-19 prevention measures in the workplace. Though mandatory masking has undoubtedly been the culprit of much political discourse, the requirement (or lack thereof) that many employees either become vaccinated or forfeit their positions is undeniably the most contentious; thus, our attention will focus specifically on this factor. Indeed, while those employed by the federal government have had the choice made for them, private sector leaders are now faced with the thorny task of balancing the safety of some of their employees with the individual rights of others (McLeod, Pearce, 2021). The reluctance of many employees to receive the vaccine is apparent in the low compliance rates with vaccination when it is not mandatory, even in the presence of widespread persuasion campaigns (Brown, et. al., 2021). The cost savings

The Proliferation of Remote Work

We will begin with what is perhaps the most glaring example of the pandemic’s impact on the workplace, which is of course the transition to remote work. The significance of this transition is quantified by Oliver Baumann and Elizabeth Sander’s article “Psychological Impacts of Remote Working Under Social Distancing Restrictions,” which states that “in May 2020, 35 per cent of the US workforce worked entirely from home, compared to just 8 per cent in February 2020” (Baumann et al., 2021). The article went on to specify that “even industries that traditionally do not rely much on work-from-home arrangements were forced to introduce them,” information that effectively highlights the universal reach of remote

to the organisation that could potentially arise from mandating vaccines, preventing a potential sickness, and thus alleviating the costs associated with lost productivity and employee absence, must be balanced with the certainty of employee sickness and absence that will result from the assured adverse effects of the vaccine itself. Finally, it is important to note that “each employment context, of course, will differ… a mandatory vaccination policy that works well for a close-quarters or contact-heavy workplace, such as a healthcare facility or even a meatpacking plant, might be too heavy handed for a low-contact team of remote computer coders. Likewise, different states, cities, and industries may adopt very different workplace vaccination rules, creating a thicket of regulation” (Brown, et. al., 2021). Thus, the trickiness and sensitivity surrounding the issue of mandatory vaccination is made apparent.

This sensitivity is tied to employee retention in a multitude of ways. Removing employees’ ability to choose what goes into their bodies has a distinct probability of breeding resentment towards the obligating organisation that

work (Baumann et al., 2021). Thus, this information, coupled with the drastic reduction in working hours revealed in the introductory paragraph, blatantly illustrates the significance of the proliferation of remote work, as well as its selection as one of our primary impacts of COVID-19’s transformation of the workforce. Enacted as a measure of keeping instances of exposure to the virus at a minimum, this dramatic shift to remote work was accompanied by several either unexpected consequences or opportunities, depending on one’s point of view, the first of which is the broadening of employment horizons. Indeed, the removal of the requirement to report to work in person vastly increased the number of positions available to jobseekers, as applicants

can ultimately manifest in resignation (Brown, et. al., 2021). This risk has been quantified by a study featured in The Journal of Post-Acute and Long-Term Care Medicine, which showed that 7 per cent of employees faced with a mandatory vaccination policy chose to resign rather than comply with the policy (Dumyati et. al., 2021). While this figure may seem insignificant, when considered in the context of a short-staffed, small business, the ramifications of such a loss may seem more substantial, and once again serve to illustrate the inapplicability of a single solution for a range of organisational dynamics. Finally, though the number of potential resignations may appear small, the loss of experience and talent embodied by the individuals who comprise the resignation percentage cannot be discounted. Indeed, such a loss is historically likely, as evidenced by previous resignations and loss of experienced personnel when faced with loss of autonomy (Luthy et. al., 2016). With the previous information in mind, we have thus sufficiently established the quantitative and qualitative ties between pandemic prevention’s most contested policy and the Great Resignation.

were no longer constrained by location to be considered eligible. This surge of plausible job options shifted a significant portion of bargaining power back onto employees and is a likely explanation behind the boldness that enabled so many to resign (“How to Manage the Great Resignation,” 2021). A second impact of remote work is the fact that it has additionally resulted in spikes in feelings of loneliness because of social isolation, a factor well-established to have adverse impacts on wellbeing and life satisfaction (Cotofan et. al., 2021). In the absence of the social networks our workplaces can offer, as well as the support that accompanies them, it again becomes increasingly understandable why so many would not wish to continue with an employment that contributes

to one’s feelings of isolation, especially when one considers the unprecedented increase in other available opportunities. This hypothesis is supported by evidence offered by the US National Library of Medicine National Institute of Health, which found that loneliness is correlated to declines in in work performance and satisfaction (Galanti, et. al., 2021).

The latter factor is complimentary to an additional impact of remote work, which is the erosion of the ability to bond with one’s team members. Indeed, now that the coffee-break banter that previously greased the skids in between concrete work tasks is confined to the far-less-organic constraints of communication offered via Skype for Business or Microsoft Teams, the soft skills responsible for cohesive team facilitation have sadly been stifled. It is no longer uncommon for new hires to never have seen their coworkers face-toface, depriving them of the hands-on, in person training that typically facilitates job comprehension and autonomy. These factors combined account for a lack of loyalty and dedication to a job that is typically fostered by a sense of belonging and team membership; indeed, studies by the US National Library of Medicine National Institute of Health additionally found a time spent telecommunicating and individual team performance to be negatively correlated (Galanti, et. al., 2021). Thus, another explanation regarding the ease with which employees have been leaving their positions is revealed.

The impacts of remote work by no means stop at there. For many, the widespread expectation that employees work from home has imposed the coincidence of work and familial responsibilities, which encompass everything from meal preparation to general supervision to assistance with remote school, all to be accomplished in between check ins and Zoom calls (Galanti, et. al., 2021). It has additionally created a scarcity of workspace, due to the pandemic’s

necessitation that it be shared between any spouses or children an employee might have, thus providing additional rationale for resignation (Galanti, et. al., 2021). Finally, this meshing of work and home life has seeped into employees’ schedules, blurring the line between the hours allocated to labor or leisure. This is particularly evident in employees holding a tertiary degree, a group that the Institute of Labor Economics showed worked a much higher number of hours than those who are either selfemployed or who held lower educational degrees, with the predictable exception of those in fields deemed to be “essential” (Guadecker et. al., 2020). The reasoning behind longer hours worked in essential fields hardly requires explanation; one need not look further than the nearest overflowing hospital to make sense of this trend. Longer white-collar hours are understandable as well, for the newfound, widely normalised presence of work-related technology in the home has removed the ability of employees to leave work at work. The ease with which one’s boss can now contact a subordinate (or vice versa) at any given hour is unprecedented, and exacerbated by technology displaying whether employees are actively online. This trend’s coincidence with still less hours being worked overall, as mentioned in our introductory paragraph, is indicative of a shrinking number of people having

Research Results

to shoulder the burden of working hours left behind by those who have quit their jobs. The risk of burnout for those left behind because of unlimited working hours, coupled with the frustration of sacrificing uncapped quantities of personal time, and with it any semblance of a work-life balance, are additional factors contributing to the Great Resignation.

Solutions to the Consequences of Remote Work:

We will begin our prescribed organisational solutions with a response to the effects of remote work. Here, it is important to reiterate that not all these effects have been detrimental; indeed, as previously explored in this essay, remote work has additionally fostered numerous positive impacts. Such impacts have included a reduction or outright elimination of commute time, affording many employees what can amount to hours of free time given back to them daily. This dramatic cut in commute time can be extrapolated to additional impacts employees find beneficial; indeed, as well as the time given back to employees as a result of remote work, such as the reduction of wear and tear on one’s vehicle, its maintenance costs, the amount of money required to be spent on gas, price of eating out that might be necessitated by in-person work, etc. The monetary savings

Now that we have established the impacts to the workforce that have occurred because of COVID-19’s influence, assessed their resulting consequences, and tied these consequences to the rapidly declining employee retention rates, the initial portion of this paper’s hypothesis can be affirmed as true. We will now turn our attention to the ways in which such consequences can be mitigated. The following sections will focus on the methods organisations can and should employ to re-invigorate the wills of their employees to remain onboard, to provide companies with universally applicable, actionable prescriptions with which the Great Resignation can be slowed. Though these solutions will be broken out between the factors of remote work and the imposition of pandemic prevention measures, the findings of the following analysis reveal them to have many intermingling, positive effects in countering the negative impacts of both categories.

afforded by remote work are additionally not enjoyed exclusively by employees; indeed, employers while presumably able to benefits from each of the factors previously mentioned, may come to realise that in the absence of in-person work, the need for the provision of a physical workspace has become obsolete. This could result in the elimination of an organisation’s building lease payment, a significant cost savings that yields a multitude of potential avenues for re-investment in one’s company. This hypothesis is corroborated by Oliver Baumann’s article detailing the “Psychological Impacts of Remote Working Under Social Distancing Restrictions,” which emphasizes the “substantial reductions in direct costs for organisations” because of remote work (Baumann et. al., 2021). Baumann goes on to elaborate on the staying power of remote work, as it is increasingly facilitated by greater availability of technology and provides evidence that remote work has additionally been responsible for heightened employee productivity (Baumann et. al., 2021). The latter point unearths an additional cost savings to be enjoyed to the employers of telecommunicators, for with each incremental increase in employee efficiency, employers are in essence receiving a greater bang for their salary dollars. Thus, for all the previous reasons, and in spite of the drawbacks it additionally imposes, it would be unwise for organisations to combat the Great Resignation by disposing of remote work altogether, even once the subsiding pandemic enables this possibility. We shall instead turn our attention to the ways in which remote work can continue to be implemented in a more sustainable manner than it currently is.

An underlying theme in the previously mentioned benefits to remote work is flexibility. This theme is apparent most blatantly in the time savings that arises from the elimination of daily commutes, injecting an increase of individual freedom and flexibility

into a vast amount of the workforce. The importance of such flexibility is expanded upon by Christina Pazzanese’s study “How COVID-19 Experiences Will Reshape the Workplace,” which offers that “organisations that offer employees the ability to work flexible workday schedules, to choose when and how they come into the office… would be wise to maintain and emphasize work flexibility” (Pazzanese, 2021). Here, an important concept extrapolating from the benefits of workplace flexibility is introduced: the flexible work schedule. This course of action is supported by the spread of remote-work technology, which has been developed in response to the current pandemic, and further backed up by statements from an article published by the Journal of Political Economy, “The Value of Flexible Work,” which claim that “technology has facilitated new, nontraditional work arrangements” (Chen, et. al., 2020). With the scene set to explain the present environment’s facilitation of the success of such a practice, we will now more deeply explore some of its benefits.

Put simply, a flexible work schedule is one that allows employees to maintain a work schedule other than the standard hours previously established by one’s organisation (“COVID-19: Flexible Work Schedule,” 2021). A more general definition can be found in Heejung Chung’s article “Flexible Working, Work-Life Balance: Introduction” in which the authors contend that a flexible work schedule can be distilled to the presence of a worker’s control over when and where they work… that is, [a worker’s ability to] alternate the starting and ending times), and/or to change the numbers of hours worked per day or week—which can then be banked to take days off in certain circumstances” (Chung et. al., 2021). The latter article reports a critical perspective in terms of remote work, which is the fact that one particular demographic, millennials, are overwhelmingly in favor of their employers offering of opportunities

for remote work, to include both the option to work from home, as well as the option to work within a flex schedule. In addition to the undisputed benefit of catering to the workplace’s increasingly dominant and most represented demographic, offering a flex schedule provides recourse to the previously discussed conflict created by remote work between work and family life. Indeed, numerous studies have yielded results demonstrating that “flexible working can be used as a positive capability spanning resource useful for workers… to adapt their work to family demands,” as well as that “studies have shown that flexible working allows mothers to maintain their working hours after childbirth and to remain in human-capital-intensive jobs in times of high family demand… [finally showing that] this ability may increase women’s satisfaction with work–life balance by allowing women to maintain both” (Chung et. al., 2021). While the gender equality focusses of the previously cited article is not one that this analysis will be extrapolating on, its implications for increasing workforce retention are clear. By enabling members of the workforce greater flexibility in deciding what hours each allocates towards their own jobs, and what to allocate towards childcare or other family-related activities, a flex schedule removes the dichotomy between career and childbirth, and more broadly, the conflict between work and family life imposed by remote work. As we have previously demonstrated the consequences of forcing employees to choose between such obligations, the removal of this dilemma will undoubtedly positively influence retention rates for organisations willing to implement a long term, flexible work schedule policy, independently of the presence of a global pandemic.

Solutions to the Negative Impacts of Pandemic Prevention Measures:

We will now utilise the findings yielded from our analysis of pandemic-

prevention measures and their impacts in previous sections to offer a responsive course of action to organisations currently struggling with employee retention. While managers in the private sector continue in their efforts to navigate a path forward regarding the balance between employee safety and individual rights, the discretion they are afforded in making this decision should not be discounted. The ability to decide whether to mandate or not to mandate vaccinations in accordance with the wishes of one’s own subordinates should be given significant consideration. Indeed, who better to represent the best interests of one’s employees than the employees themselves? This proposed democratic approach is one we have seen successfully implemented across a multitude of case studies, each a module example of extraordinary employee retention rates, and is a proposal that is corroborated by the Human Resource Management Journal. Indeed, the Journal addresses the issue of democracy in the workplace through the lens of employee retention in the wake of the pandemic by stating that “The task for HRM researchers… is to draw out the potential benefits of job retention during crisis to promote a new post-COVID-19 social contract at work that may guide practitioners of HRM and harness and consolidate support amongst different stakeholders to secure more sustainable forms of social partnership” (Spencer, et. al., 2021). Of particular importance within the latter assertion is the concept of this “social contract” employees must foster, for it prescribes what essentially could be considered the necessity of voluntary consent of one’s employees to any proposed safety measures at hand. In other words, these “more sustainable forms of social partnership” can be created through allowing members of the workforce to have a say in their organisation’s COVID-prevention policies. The Human Resource Management Journal goes on to elaborate upon a model with which such a social

By enabling members of the workforce greater flexibility in deciding what hours each allocates towards their own jobs, and what to allocate towards childcare or other family-related activities, a flex schedule removes the dichotomy between career and childbirth, and more broadly, the conflict between work and family life imposed by remote work.

contract might be based, specifying its prioritization of “job security, good work and worker voice at the center of HRM… [in order to] create the basis for more democratic approaches to employment regulation whereby support for job retention is seen as a key element of any economic recovery” (Spencer, et. al., 2021). Thus, the connection between retaining employees in a postpandemic workplace and prioritising their representation, autonomy, and overall democracy of their organisation by allowing them to decide whether or not to get vaccinated, can be established, and an actionable method in which Human Resource Management practices can continue to combat factors driving the Great Resignation is revealed. This strategy effectively implements the negotiated response to crisis that the Journal has prescribed (Spencer, et. al., 2021).

For employers who still prefer to mandate vaccines in their workplace, it is important to firstly examine the legal parameters surrounding such decisions. These parameters essentially allow employers to mandate vaccines, so long as well-established processes for granting exceptions to such a mandate are in place. The requirement for concrete processes with which to grant

vaccine exceptions is supported in Jessica Brown’s article “An Employer Playbook for the COVID Vaccine Wars: Strategies and Considerations for Workplace Vaccination Policies,” which states that in the absence of thoughtful processes, “Human Resources (HR) [could be put] at risk of being overwhelmed by needing to decide, on a case-by case basis, who qualifies for an exemption (Brown, et. al., 2021). Such exceptions include medical disabilities that are covered by the Americans with Disabilities Act (ADA), as well as bona fide religious exemptions, as covered by Title VII of the 1964 Civil Rights Act (McLeod, Pearce, 2021). When employers who choose to move forward with the requirement that their employees be vaccinated encounter personnel who are not valid candidates to either such exceptions, but nonetheless opt to refuse the vaccine, the Risk and Insurance Management Society, Inc. recommends managers explore alternative courses of action prior to resorting to terminating the employee. Such alternative courses of action can be exemplified by exploring means of alternative working options, such as a schedule that does not coincide with those of other at-risk employees, or a transition to more permanent remote work, both of which ensure unnecessary hardship is not imposed on the unvaccinated employee McLeod, Pearce, 2021). However, the headaches of dealing with the previous scenarios could again be avoided by simply abstaining from vaccine mandating; indeed, when vaccination remains voluntary, “by contrast, no (or much less) formal process is needed” (Brown, et. a., 2021). Thus, allowing employees the autonomy to make vaccination decisions for themselves remains the clearest avenue for organisations to more effectively foster employee retention.

Versatility and Ease of Applicability of Proposed Solutions

We will now turn our attention to the cross-applicability of this paper’s

proposed solutions, to further emphasise the benefits organisations could enjoy should they be implemented. Indeed, the theme of employee autonomy covered in the previous sections has the potential to create positive impacts beyond the provision of a roadmap for organisational leaders to navigate contentious vaccine mandates. This becomes useful when we consider this paper has not yet addressed an issue it identified earlier, which is the feeling of isolation created by remote work. To reiterate, this isolation erodes a sense of team membership in employees, along with the loyalty one might feel towards respective workplace teams, ultimately degrading the will of an employee to remain employed with their present organisation (Galanti, et. al., 2021). Here is where this autonomy again becomes relevant, for while it enables employees to opt in or out of an organisation’s COVID-19 related policies, it is also the driving factor behind their decision to participate in a flexible working schedule. A flexible working schedule can provide employees with more than the freedom to choose what hours they spend working; indeed, it additionally enables the freedom for them to decide when they report to the office. This can be key in facilitating any existing desires of coworkers to work collaboratively in person once again, effectively proving a method with which employee loyalty and sense of team membership could be invigorated. Employees would likely coordinate their in-person working schedules with others that held similar stances regarding vaccination and the necessity of mask wearing, further reducing feelings of alienation and isolation, and demonstrating the versatility of employee autonomy as a solution to both pandemic prevention and the consequences of remote work.

It is important to note that this latest benefit revealed through employee autonomy is dependent upon an organisation’s decision whether to maintain a physical workspace. As we

have already established, they may be tempted to deem the physical workspace unnecessary and obsolete, for workers have demonstrated their ability to perform job functions remotely, and the cost savings of eliminating a rental expense from a business’s operating budget is substantial (Baumann et. al., 2021). However, in defense of the decision to retain a physical workspace, one must also consider the costs associated with the inability to retain one’s employees. Indeed, because we have shown team loyalty and the presence of a location in which employees can meet face-to-ace to have a positive impact on employee retention, it too should be considered a cost savings. This is due to the universally understood cost of having to train new employees, conduct turnover with the old, etc., both of which have very real time and monetary opportunity costs.

Such information may leave organisation leaders wondering how to proceed. Due to this paper’s emphasis on autonomy and universal applicability, we will refrain from prescribing a one-sizefits-all solution. Rather, companies should conduct their own cost-benefit analysis when determine whether to retain a physical workspace, in order to reach a solution and compromise that best suits its needs. Even more simply, the democratic approach this essay has previously recommended can be applied here, by simply polling one’s employees in order to discern their vision for what operating method of the company would best suit their needs. Once again,

this approach can foster loyalty and therefore retention in its ability to make one’s employees feel heard. Perhaps best of all, employment of the democratic approach is cost-free, an aspect that again demonstrates the universal applicability of this course of action.

Conclusion

The short answer to solving the Great Resignation? It’s complicated. As this paper has repeatedly demonstrated, the path forward for each organisation will vary widely according to its size, location, and internal culture. The only recommendation to be taken from this paper that will apply in all cases is that these organisations need to base their course of action on the wishes of their employees. Though the political rhetoric and outside pressure to act in one way or another is deafening, organisations must adhere religiously to a democratic approach, shutting out outside noise to hear to what is wanted within. Simply put, employers must protect the interests of their own people or risk losing them. Whether applied to the offering of a flexible work schedule or an optional vaccination policy, prioritising the preservation of employee’s individual autonomy has been shown to be the only constant factor positively influencing employee retention. Democratically deciding the path forward within each organisation is thus the best method for keeping one’s employees unified, and more importantly, on board.

References are available at www.asianhhm.com

Uche Nwabueze received his Ph.D from Sheffield Hallam University in the United Kingdom in 1995. For 28years, Dr. Nwabueze has dedicated himself to the advancement of the theory and practice of management through research, consulting work, and teaching across four continents (North America, Europe, Asia and Africa). His students describe their classroom experience with Dr. Uche as he is fondly called; as a scholarly adventure in critical thinking, problem-solving and reflective analysis. AUTHOR BIO

Getting Back to Business Let’s meet in Bangkok!

MEDICAL FAIR THAILAND 2023 | 13-15 September

Preparations are in full swing as MEDICAL FAIR THAILAND makes its way to Bangkok once again in 2023. After a three-year break, the 10th edition of the exhibition will run its physical edition from 13 to 15 September at BITEC, followed by a 7-day digital extension where exhibitors and visitors can engage further online through its AI-powered businessmatching system until 22 September. This is the first time MEDICAL FAIR THAILAND will be held in a ‘phygital format’.

Highlights this year include signature showcases such as the Community Care Pavilion and Start-Up Park, and also the introduction of the Medical Manufacturing pavilion. As the region’s leading specialist trade fair for the medical and healthcare sectors for the past two decades, MEDICAL FAIR THAILAND serves the full value chain and end-to-end needs of the medical and healthcare sectors. From diagnostics, wearable technology, connected healthcare solutions, rehabilitation and therapy equipment, 3D printing technology, and now - medical technology (MedTech) components, processes and solutionsthe exhibition offers the ideal destination for medical and healthcare buyers and professionals looking to meet their sourcing objectives, gain industry insights and to share best practices.

MEDICAL FAIR THAILAND 2023 comes against a

“We have been waiting for three years so we are excited and are gearing up for a big comeback for MEDICAL FAIR THAILAND 2023. With the positive feedback, industry commitment, and almost 80% bookings received for 2023, we should be on track to reach close to pre-pandemic levels by next year. On the back of a highly successful and wellreceived phygital edition of MEDICAL FAIR ASIA that was held in Singapore earlier this year, and as we navigate further in a post-pandemic landscape, we are confident by this year the industry will be more than ready to move into high gear and Thailand will be an ideal location.”

Gernot Ringling, Managing Director, Messe Düsseldorf Asia

strengthening backdrop where Thailand continues to firm its position as a medical hub of the region with its supportive government policies and incentives, making it a model investment destination for a wide range of medical and healthcare service sectors. In line with Thailand’s 4.0 policy, the Thai government considers the healthcare industry to be a priority sector for investment, thus the staging of MEDICAL FAIR THAILAND 2023 is well-positioned.

New! Medical Manufacturing Pavilion

A special themed pavilion focused on medical manufacturing processes and componentsfrom new materials, intermediate products, packaging and services, to microprocessors and nanotechnology. With Thailand’s growing reputation as a production and distribution base of medical devices both within and outside Thailand, it has become a natural market for medical devices.

According to data from the Office of Industrial Economics, Ministry of Industry (Medical Devices Intelligence Unit), there is much potential for investment opportunities in sophisticated medical devices particularly due to Thailand’s reliance on imports for this segment.

Community Care Pavilion Special Focus on Mental Health

With a special spotlight on mental health with a showcase featuring digital mental health technologies, from smart medicine to therapeutic medical equipment. Its mainstay of addressing the needs of ageing societies on the back of rising chronic diseases and an ageing population, the pavilion will also feature a full suite of geriatric medicine, rehabilitative equipment, assistive technology, and mobility products.

Thailand’s proportion of citizens aged over 60 years, is forecast to be one of the highest in ASEAN by 2045, and will also exceed countries such as Europe and the United States. Thailand’s fast-increasing ageing population and the estimated more than three million Thais suffering from poor mental health, is expected to further drive the demand for related healthcare services.

Start-up Park

A strategic platform for companies with ready-to-market healthcare solutions to meet relevant buyers and partners, industry influencers, experts, and potential investors. From innovative healthcare industry solutions, health apps and new tools for gathering and AI-supported analysis of health data, to robotic assistance systems and new approaches in diagnostics – the Start-Up Park is a must-attend for SMEs looking to scale-up their business.

The Start-Up Park plays a significant role as an enabler of the entrepreneurial ecosystem that encourages life sciences and medical and health innovation in Thailand. With the country’s vibrant start-up landscape propelled further by the government’s numerous grants and new regulations as part of Thailand’s ambitious plans to be a start-up-based country, the start-up scene has grown systematically over the years and is considered one of Asia’s hidden gems. At the last edition of MEDICAL FAIR THAILAND held in 2019, a total of 11 start-up companies participated from Singapore, Japan, South Korea, Hong Kong, Taiwan and Thailand.

Understanding the Growing Prevalence of Colorectal Cancer among Young Adults in Malaysia

An urgent call to action

Research shows approximately 49,000 people in Malaysia were estimated to be newly diagnosed with cancer in 2020, and the number is expected to rise to 66,000 new cases annually by 2030. Of the more prevalent cancer types, colorectal ranks among the highest in terms of prevalence.

Jenson Sow, Clinical Oncology, Aurelius Hospital Nilai

Colorectal cancer (CRC) is a pervasive and life-threatening disease that affects millions of people worldwide. Developing in the colon or rectum, which are critical components of the digestive system, CRC ranks as the third most prevalent form of cancer globally. Despite advancements in medical research and technology, the global burden of cancer is still increasing at an alarming rate, with an expected 75 per cent rise in new cases annually by 2030. Furthermore, the incidence of CRC is on the rise among young Malaysian adults, a trend that is particularly concerning since the disease has traditionally been associated with older people.

A 2018 study published in the Malaysian Journal of Medical Sciences revealed that the incidence of CRC among individuals aged 20-39 years old in Malaysia was 4.4 per 100,000 population. Additionally, according to the Malaysia National Cancer Registry

Report 2012-2016 by the Ministry of Health, CRC is the most common cancer among Malaysian men and the second most common cancer among Malaysian women. The report also indicated that the incidence of the disease was highest among Chinese, followed by Malays and Indians.

A look at the past and present CRC has become a significant public health issue in Malaysia due to its increasing incidence rate over the years.

Historically, CRC was not prevalent in Malaysia; however, the disease's incidence has risen rapidly over the past few decades. In the 1980s, the incidence of CRC in Malaysia was around 10 cases per 100,000 people. However, by the 2000s, the incidence rate had doubled to around 20 cases per 100,000 people. This trend highlights the need for increased awareness and action to address the growing burden of CRC in the country.

This type of cancer was once more prevalent in urban areas, but recent studies indicate that it is now affecting people from both urban and rural areas. Moreover, while CRC was traditionally more common among men, the incidence rate among women has been increasing in recent years. These trends suggest that it is becoming a significant public health issue across all demographics in Malaysia, and more targeted efforts are needed to address the disease.

The incidence of CRC in Malaysia continues to rise, with an estimated 6,000 new cases being diagnosed each year. This trend is attributed to changes in lifestyle and dietary habits, as well as an ageing population. Malaysians are increasingly consuming processed foods and red meat, both of which are known risk factors for CRC. Furthermore, a lack of physical activity and an increase in

obesity rates are also contributing factors. These behavioural and demographic changes underscore the need for more comprehensive public health initiatives aimed at preventing CRC in Malaysia.

Factors contributing to the rise of CRC in young Malaysian adults

Several factors may contribute to the increasing incidence of CRC in young adults in Malaysia. One of the primary contributors is the changing diet and lifestyles. Many Malaysians now consume more processed and highfat foods, which are low in fiber and other essential nutrients that promote colorectal health. This dietary shift has been linked to an increased risk of CRC, particularly among younger populations. Addressing these dietary and lifestyle factors is crucial to reducing the incidence of CRC in Malaysia, particularly among young adults.

In addition to dietary factors, lack of physical activity and sedentary lifestyles are also contributing factors to the development of CRC, particularly among young adults in Malaysia. Many young adults in Malaysia spend long hours sitting in front of computers or televisions, leading to a lack of physical activity. The rapid urbanisation and industrialisation in the country may have contributed to changes in lifestyle and dietary habits that have led to the increased incidence of CRC among young adults. Addressing these lifestyle factors is critical in reducing the burden of CRC in Malaysia, particularly among young adults.

The increasing prevalence of obesity in is another factor contributing to the rising incidence of CRC among young adults. Obesity is a known risk factor for CRC, and the rise in obesity rates may be linked to the increasing incidence of the disease in this population. Genetics may also play a role in the increasing incidence of CRC in young adults in Malaysia. Certain genetic mutations can increase the risk of developing CRC,

and these mutations can be inherited from one's parents. Understanding the genetic factors that contribute to the development of CRC is critical for identifying individuals at higher risk and developing targeted prevention strategies.

Despite the numerous risk factors for CRC, there is a lack of awareness and screening among young adults in Malaysia. Many young adults are not aware of the risk factors for CRC and may not seek screening until they experience symptoms. Moreover, symptoms of CRC such as rectal bleeding, abdominal pain, and changes in bowel habits are often ignored or attributed to other causes. A delay in diagnosis can lead to the cancer metastasising and becoming more challenging to treat. Increasing awareness about the importance of early screening and the symptoms of CRC is crucial in reducing the burden of this disease in young adults in Malaysia.

Symptoms of Colorectal Cancer

It is important to be aware of systemic symptoms that may indicate colon cancer. These symptoms do not only affect the colon but can also affect the entire body. However, it may be difficult to associate these symptoms with colon cancer due to their general nature. Despite this, they should not be ignored as they serve

as an important warning sign. Some of the systemic symptoms to watch out for include unexplained weight loss, loss of appetite, nausea, vomiting, weakness, and fatigue. It is worth noting that these symptoms can also be indicative of other health conditions, which is why it is important to seek medical attention and undergo appropriate testing to rule out other issues.

Regular screening is recommended for individuals who are at average risk of developing CRC, starting at age 45. However, for those with a family history of the disease or other risk factors, such as inflammatory bowel disease or genetic syndromes, screening may be recommended at an earlier age. There are several screening options available, including colonoscopy, fecal immunochemical test, and stool DNA test. It is essential for individuals to discuss with their healthcare provider to determine the best screening option based on their risk factors and preferences.

It is crucial to keep in mind that the symptoms of colon cancer can be similar to those of non-cancerous gastrointestinal disorders or other types of cancer. Additionally, there are rare and unusual symptoms that may be linked to a diagnosis of colon cancer. Even though these symptoms may be due to a non-cancerous condition, it is important to be mindful of any changes in your health and seek medical attention promptly if you experience persistent symptoms.

Uncommon symptoms of colon cancer should never be ignored, as they could indicate a more serious underlying issue. Some of these include sharp abdominal pain, bloatedness, severe constipation, stools that appear narrower or thinner than usual, continuous fatigue, iron deficiency that doesn't improve with treatment, and gradual weight loss. Even if these symptoms suggest another condition, seeking medical attention is important to rule out the possibility of colon cancer.

In the 1980s, the incidence of CRC in Malaysia was around 10 cases per 100,000 people. However, by the 2000s, the incidence rate had doubled to around 20 cases per 100,000 people.

A doctor can run appropriate tests to make an accurate diagnosis and provide proper treatment.

Diagnosis of Colorectal Cancer

Early detection is crucial for optimal treatment outcomes, therefore individuals experiencing these symptoms should promptly seek medical attention. Diagnostic tests for CRC may include a biopsy, blood tests to detect signs of cancer or abnormalities, colonoscopy, flexible sigmoidoscopy, computed tomography (CT) colonography (also known as virtual colonoscopy), and fecal tests such as fecal occult blood tests (FOBT) and fecal immunochemical tests (FIT). In cases where blood is not visible in fecal matter, a Guaiac-based fecal occult blood test (gFOBT) may be performed. Additionally, a fecal DNA test can be done to detect genetic mutations and blood products.

Colonoscopies are typically performed on an outpatient basis and are relatively painless thanks to modern anaesthesia techniques. During the procedure, a flexible tube with a light and camera on the end is inserted into the colon. The doctor navigates through the

colon and sends images to a computer screen for examination. The length of the procedure typically ranges from 60-90 minutes. With advancements in medical technology, health screenings have become more comfortable and less daunting for patients. Regular screenings can help detect health issues early and allow for discussions with the doctor regarding next steps if needed.

Treatment of Colorectal Cancer

The management of CRC among young Malaysian adults may be determined by factors such as the stage of cancer, the tumour's location, and the patient's overall health. The most prevalent treatment for CRC is surgery, and the surgeon may opt for colonoscopy, laparoscopic surgery, or open surgery, depending on the tumour's position.

In addition to surgery, patients with CRC may undergo chemotherapy, radiation therapy, targeted therapy, or immunotherapy depending on various factors such as the stage of cancer and the patient's overall health. Targeted therapy involves drugs that target specific proteins or genes that promote the growth of cancer cells. Immunotherapy stimulates the body's immune system to attack cancer cells and is often recommended for advanced CRC that has spread to other parts of the body.

It is important to note that treatment options for CRC are personalised and should be made in consultation with a medical professional. Early detection and

diagnosis can improve the effectiveness of treatment, so regular screening and check-ups are recommended, particularly for those with a family history of CRC.

Prevention of Colorectal Cancer

Although there is no fool proof method to prevent CRC, there are measures you can take to minimise your risk of developing the disease. These include adopting a balanced diet that is rich in fibre, fruits, and vegetables. Regular exercise is also crucial — doing at least 30 minutes of moderate physical activity, such as brisk walking or cycling, most days of the week can help reduce the risk. Additional preventative measures include maintaining a healthy weight, abstaining from smoking and excessive alcohol consumption, and undergoing routine CRC screenings.

The incidence rate of CRC among young adults in Malaysia has significantly increased over the years, making it a critical health issue. However, it is important to note that CRC is curable. Early detection through regular screening increases the chances of a cure. It is crucial to recognise the symptoms and seek medical attention promptly if there are any doubts about having the disease. Ignoring symptoms associated with CRC may lead to a delay in diagnosis, which could negatively impact the effectiveness of treatment.

Jenson Sow is a Clinical Oncologist at Aurelius Hospital Nilai. He pursued oncology as his specialty and has since provided oncology services at various hospitals including Hospital Kuala Lumpur, Sabah Women and Children Hospital, and Institut Kanser Negara. Committed to his profession, Dr. Jenson strives to provide better public understanding and education on cancer.

In conclusion, CRC is a serious health issue that requires prompt attention and regular screenings. Early detection and diagnosis are crucial in improving treatment outcomes and increasing the chances of a cure. While there are various treatment options available, prevention remains the best course of action. Adopting a healthy lifestyle, including a balanced diet, regular exercise, and avoiding smoking and excessive alcohol consumption, can significantly reduce the risk of developing CRC. By being proactive in our health and recognising potential symptoms, we can take steps to protect ourselves and reduce the impact of this disease.

NEONATAL CARE

A global crisis in desperate need of innovation

Despite considerable progress in other areas of healthcare, poor neonatal care causes devastating outcomes globally. Infant incubators play a leading role in reducing mortality and morbidity, but lack innovation making any meaningful progress costly and hard to achieve.

Wisam Breegi, CEO, Breegi Scientific, Inc.

Significant progress has been made in reducing global mortality in children under the age of five, and the world would be on track were it not for the lagging progress in reducing newborn mortality.

In 2016, the United Nations (UN) issued an urgent call for all participating nations in Sustainable Development Goals (SDGs) to reduce neonatal mortality rates. Since, progress in lowering mortality for newborns has been slower than that for older children under five—in fact, newborn mortality has increased according to the World Health Organization1 (WHO). In 2020, nearly half (47 per cent) of all under-5 deaths occurred in the newborn period (the first 28 days of life), an increase from 1990 (40 per cent). Every day, over 6,500 babies die in the first month of life. In 2020, an estimated 2.4 million newborns died worldwide. Considering other factors such as underreporting, the numbers are arguably much higher.

1 https://www.who.int/news-room/fact-sheets/detail/levelsand-trends-in-child-mortality-report-2021

The first month of life is the most vulnerable period for child survival. Preterm birth, intrapartumrelated complications (birth asphyxia or inability to breathe at birth), hypothermia (low body temperature), infections and birth defects are the

leading causes of most neonatal deaths. Most newborns who die within the first 28 days of birth suffer from conditions and diseases associated with lack of quality care at or immediately after birth and in the first days of life.

In this article, light will be shed on some of the reasons and factors for this relative lack of global progress with newborn healthcare and the high numbers of neonatal mortality. There is no silver bullet to reduce newborn mortality and more specifically neonatal morbidity, but there are glaring gaps in care and lack of adequate solutions.

Socioeconomics, maternal and newborn health are all closely linked, but newborns who are sick or born prematurely have unique clinical needs of their own. We have to understand and address the leading causes of global newborn mortality such as hypoxia, hypothermia, severe infections, and complications related to prematurity.

Simple interventions — from education and perinatal care before and after birth, to providing a clean environment, oxygen, heat, antiseptics and antibiotics to the newborn could save millions of lives, but they often fail to reach sick babies in a timely manner.

These issues hindering progress are not only in developing countries, but also in the developed world too. Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both sociodemographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. According to the March of Dimes2 2022 report, the U.S. preterm birth rate increased to 10.5 per cent in 2021 – a significant 4 per cent increase in just one year and the highest recorded rate since 2007. The highest majority were in Black and native American women.

The sad fact is many healthcare systems are understaffed and underbudget to deliver the appropriate care needed and where it is needed. It is no

2 https://www.marchofdimes.org/about/news/march-dimes2022-report-card-shows-us-preterm-birth-rate-hits-15year-high-rates#:~:text=March%252520of%252520Dim es%25252C%252520the%252520nation's,highest%252 520recorded%252520rate%252520since%2525202007.

The current neonatal care system is designed around century-old, expensive, complicated and hard to maintain technologies which were developed for high-income countries and yet are used in lowresource areas and LMIC countries.

can include maintaining a consistent temperature, humidity and oxygen levels, as well as protecting the infant from infection. In addition, they can also provide medical support, such as administering oxygen, tube feeding or phototherapy. There are several key factors that must be considered in order to properly maintain an infant incubator. Some of these include cleanliness to prevent nosocomial infections, maintenance and repairs, infant monitoring and staff training. Overall, the use of infant incubators can help improve the health and survival rate of premature or ill infants and prevent stunted growth, as well as future physical and mental development.

Unfortunately, globally we spent less than US$8.6 per newborn the whole year to purchase new incubators.

secret that staffing shortages are rampant or that providers are ill-equipped to provide the special care these babies need after delivery. A simple example is the use of Chlorhexidine solution3 to disinfect the umbilical cord, or provide heat, breathing support or phototherapy, which will save countless lives. More so than any other patient, sick babies rapidly deteriorate and need close, meticulous care even in low-resource and low-tech settings. This brings us to the most important device in saving newborns. The cornerstone of technical solutions to save a small life remains the infant incubator.

Neonatal incubators are a basic, but unique and highly specialised medical equipment designed as the patient’s own medical contained space to provide a clean and controlled environment for premature or ill newborns. Their use can help to reduce the risk of morbidity in premature or ill infants by providing a controlled environment that promotes growth and development with a direct health outcome for years to come. This

3 https://www.usp-pqm.org/sites/default/files/pqms/article/ chlorhexidine-for-umbilical-cord-care-cwg-2014-07.pdf

One of the driving factors is to rethink and overhaul the system, which include the lack of will and appetite to invest in affordable and practical innovation in the basic healthcare of neonates. This is a challenge we face despite the staggering number of babies dying annually or survive to live with disabilities for the rest of their lives, especially in developing countries, which costs four to seven 4times more for a preterm infant with common morbidities than babies born healthy. The economic fallout runs in the billions globally for infant morbidity and mortality, and is the single greatest socioeconomic burden on any society.

Locally appropriate and accessible “neonatal care units” need to be urgently developed and staffed with motivated and skilled neonatal nurses, and adequately equipped with lifesaving devices supported by simple yet innovative technologies that are affordable and practical to maintain and operate. We are not talking about preventable illness and diseases; we are talking about simple innovation of a gold-standard machine that has been using the same principal technology for over a century.

4 https://pubmed.ncbi.nlm.nih.gov/17606536/

Incubators must evolve

There can be several reasons for a shortage of infant incubators:

1. Lack of innovation: As we are building on top of a century-old technology, new technical developments only increase the price and complexity of the machine.

2. High cost to purchase: Infant incubators quite expensive, making them particularly difficult to afford in low and middle-income countries (LMIC).

3. High cost to maintain and clean: The nature of providing heat and humidity makes infant incubators notorious for harboring thriving pathogens, despite routine cleaning and disinfecting. This makes incubators a source of nosocomial (hospital-acquired) diseases.

4. Limited resources: Many healthcare facilities, particularly in LMIC, may not have the resources or funding to maintain or replace existing incubators. It is a known practice to use old refurbished and donated incubators with a lifespan of few months and unable to be repaired thereafter.

5. Limited access to electricity: With the lack of innovation, incubators are totally dependent on grid electricity. In many countries, especially in rural areas, electricity is unreliable or not widely available, which leads to tragic outcomes.

6. Limited access to spare parts: In some countries, spare parts for incubators may not be available to maintain or repair existing incubators and more so for the old and refurbished donated units.

7. Limited access to trained personnel: In some areas, there may be a shortage of trained personnel on site, such as technicians, neonatologists and neonatal intensive care unit (NICU) nurses, who are able to operate and maintain infant incubators.

8. Limited manufacturing: The lack of financial incentives for production of

infant incubators has led to scarcity in comparison to the number of sick babies.

9. Political will and economic instability: In many areas globally, political and economic instability can make it difficult for hospitals and healthcare facilities to secure funding for new equipment or to maintain existing equipment.

Overall, a shortage of infant incubators can be caused by a combination of many factors, but without seriously rethinking of the technology, a core problem which hinders any progress is hospitalacquired (nosocomial) infections for premature and ill newborns in the NICU. The main source of such a problem is the cleanliness of infant incubators. Nosocomial infections cause substantial harm to hospitalised neonates. They have considerable health and economic consequences, including increased morbidity and mortality, prolonged length of stay (LOS) and increased medical costs5. In North America, it is estimated that each episode of sepsis prolongs the duration of a neonate's hospital stay by two weeks, resulting in an incremental cost of US$25,000 per episode. This can compound to millions of dollars

5 https://publications.aap.org/pediatrics/article/129/4/ e1104/32369/Epidemiology-and-Diagnosis-of-HealthCare

for infants who stay months in the NICU.

Among medical devices, neonatal incubators have been well recognised as a source of pathogens involved in the spread of nosocomial infections. One study6 conducted in a French NICU over a 3-year period (2016 to 2018) investigated premature infants with bacteremia. Initially, several outbreak containment strategies were carried out without success. Next, outbreak investigation pinpointed the neonatal incubators as the primary reservoir and source of contamination in this outbreak, which led to their replacement, thus resulting in the containment of the outbreak.

Another study7 from Nepal indicated that almost 75 per cent of the NICU samples came back positive. The majority of infections were isolated from incubators and radiant warmers. Clearly, disinfection protocol, routine surveillance and supervision of the various aspects of the disinfection processes might not provide a safe environment avoiding harmful conditions for the newborns.

Unfortunately, the reality is continued mortality and morbidity, lengthier hospital stays, the lack of meaningful innovation, cost, complexity and valuable time spent by staff

6 https://journals.asm.org/doi/10.1128/spectrum.00964-22 7 https://aricjournal.biomedcentral.com/articles/10.1186/ s13756-021-00901-2

cleaning and disinfecting incubators instead of monitoring and caring for a sick baby. Nevertheless, such protocols will take many incubators, which are scarce in number to start with, out of commission.

Overall, maintaining the current NICU system in a hospital setting is costly and might not be sufficient without a new and innovative way of thinking. Smaller hospitals may not be able to afford to have a NICU fully equipped due to the high costs associated with specialised equipment, staffing and resources required to provide high-quality care for premature and critically ill infants. This is a global problem and no one country is spared, but devastating in low-resource areas. According to the United States Government Accountability Office 8 in 2022, research indicates that the number of rural hospitals providing obstetric services declined from 2004 through 2018 to half, according to the most recent data available. Studies showed that closures were focused in rural counties that had a majority of Black or Native American residents, and were considered low income. Vast swaths of the U.S. are in crisis, and the rates of prematurity is increasing and NICU’s are closing.

And yet, neonatal mortality and morbidity remain a silent global crisis with deep psychological, economic, social and ethical consequences.

The current neonatal care system is designed around century-old, expensive, complicated and hard to maintain technologies which were developed for high-income countries and yet are used in low-resource areas and LMIC countries. Such a system that lacks the fundamental understanding of the needs and circumstances on the ground for stakeholders, users and patients - is flawed. The current system is designed from the top down, rather from the base up.

8 https://www.gao.gov/assets/gao-23-105515.pdf

There is a great deal of information and countless scientific studies addressing the core cause of infant mortality and the shortage of care for ill newborns, some of which are the complex and expensive systems to run a NICU, the initial cost of infant incubators and their high cost to maintain and a lack of evolution that addresses those challenges.

It's important to note that the status quo with its complexity

and high-cost designs for developing countries and its use in low resource settings should not be “a matter of fact” consideration especially when it comes to neonatal care. We should design what works, without compromising quality of care.

We should rethink the quality of care and the health and well-being of the newborns with a new vision and foresight, promoting innovative thinking and technologies to leap forward.

Wisam Breegi is a forward thinker, medical researcher, entrepreneur and the CEO of Breegi Scientific ( www.breegiscientific.com ). He is the inventor of several groundbreaking medical devices such as the NICI™ that revolutionises a century old infant incubator design; and the (NPS), a patient biocontainment device for infectious diseases (EUA 203-200).

Predicting and Preventing the Next Pandemics

COVID-19 has revealed at least ten major global health problems. As painfully demonstrated during the pandemic, the devolving health threats endanger lives, disrupt families and societies, and wreck havoc on economies. A strategic path is set forth within a coordinated global framework for predicting and preventing the next pandemics.

Alain L Fymat, International Institute of Medicine & Science

Problems with global health

While a full analysis of each such problem would require separate presentations, here is a brief overview:

1. An unruly world of nearly eight billion people (and growing) who are not easily managed.

2. Glaring inequities among nations, particularly poor or less-developed ones, with insufficient or/and inadequate health infrastructures that precluded the local productions of medicines and vaccines.

3. A plethora of international organisations forming a complex and fragmented legal and institutional landscape. They continued to focus on their limited individual agendas, do not operate cooperatively or in synchrony, do not coordinate their respective programs, and have no enforcement power over individual nations.

4. Notwithstanding its otherwise great work, during COVID-19, the WHO was dilatory in

not heeding the early signs of the coming pandemic and took three or more critical months to declare a pandemic.

5. National decisions continue to be most often politically driven, international commitments are barely honoured, and no international consequences are levied for non-compliance.

6. There is an almost universal short memory regarding the past history of epidemics and pandemics.

7. The early signs of nascent epidemics / pandemics were not heeded despite reports, briefings, and warnings about viruses bearing traces of their animal origins.

8. The cardinal socio-economic factors of epidemics/pandemics have not heretofore been fully identified.

9. Regarding potential future epidemics / pandemics, the cause(s) have not been fully identified and strategies for their prediction / prevention have not been devised.

10. Enabling technologies for epidemiological / biological modelling have not been sufficiently developed to allow appropriate policy decisions.

Aa a consequence, nations and the world remain under-prepared to predict, detect, respond, and even less prevent infectious disease outbreaks and a fortiori pandemics.

Facing future health threats and pandemics

The required measures to allow effective detection and response to emerging zoonotic threats and ultimately predict and prevent pandemics are:

• Highlighting global health security.

• Promoting multidisciplinary engagement.

• Strengthening multi-sectoral coordination.

• Emphasising the importance of financial preparedness.

• Creating and strengthening necessary mechanisms.

• Improving early warning and detection.

• Collecting and sharing data in a timely manner.

• Conducting laboratory testing.

• Developing joint outbreak response capacities.

• Taking appropriate science-based actions.

Root causes of pandemics

From the ancestral domestication of plants and animals to the present times, we live on a microbially-unified planet.

The root causes of pandemics are ten intertwined socio-ecological cardinal factors that need to be remedied:

• Rapid growth of global human population.

• Increased globalisation.

• Environmental degradation and destabilisation of ecosystems.

• Creation of new urban or agricultural ecosystems.

• Economies of scale and monocultures in agriculture and dysfunctional agrifood systems.

• Loss of land and ocean biodiversity.

• Water scarcity.

• Human-induced climate change.

• Societal inequities.

• Irrational mass denialism of hard-won facts of science (vaccinations, antimicrobial overuse).

Some of these factors could be correlated with the United Nations' Sustainable Development Goals.

A blueprint for strategic pandemic prediction and prevention

“Pandemic prediction and prevention” is the organisation and management of appropriate measures (scientific, technical, economic, and political) as distinct from “pandemic preparedness or containment or mitigation”, which largely seek to reduce the severity and negative impacts of pending or established pandemics. Pandemic prediction and prevention seeks to:

1: A blueprint for strategic pandemic prediction and prevention Source: Fymat 2021.

• Reduce causes of new infectious diseases.

• Prevent outbreaks and epidemics from becoming pandemics.

• Prepare for potential future pandemics that could not be prevented.

• Ensure that the causing virus does not re-emerge thereafter (e.g., by sustaining itself in domestic animals).

The proposed strategic pandemic prediction and prevention is a multi-level inter-communicating structure comprising:

Under the UN umbrella, creating a new “World Environment Organization” (WEO) to respond to the nascent extreme climate change. WEO would have the power to censure countries for failing to keep with their commitments and pledges regarding the environment. Regretfully, its work may be hampered in several ways including: relying on countries to timely report outbreaks, assuming these countries will heed its advice and recommendations, and countries may not legally commit themselves to take appropriate remedial action when it comes to ill-defined pandemics.

Under the auspices of the World Health Organisation (WHO), establishing a legally-binding “International Pandemic Treaty” (IPT) to better prepare the world for the next pandemic. The IPT would prevent countries who are doing vaccine research from maintaining intellectual property on important technologies. Sadly, despite the hoped-for existence of an IPT and a commitment to the principle of equitable allocations, member countries will regretfully not learn from past history and return to their past behaviour (competing with each other for supplies) when the next pandemic strikes.

Shifting the current health paradigm to the new “One-World/One-ecoHealth” paradigm that will be grounded by the IPT and other international laws while at the same time developing the needed infrastructures and the national/ regional/ international organisations to pursue this global health agenda.

Involving international, intergovernmental, regional, and national health organisations.

Incorporating the Global Human Virome Project (GHVP) to help identify the bulk of the viruses that threaten us (more than 1.5 million mammalian and waterfowl viruses) of which 631,000 - 827,000 unknown viruses might be zoonotic with the potential to infect humans after spillover from host animal populations. GHVP offers a pathway to improve our capacity to detect, diagnose, and discover viruses that potentially pose threats to human populations, could provide an early warning of future threats, data to improve prevention and reduction of these threats, and inputs for advance preparation of responses for unexpected outbreaks of unknown diseases.

Actively developing pandemic models (epidemiological, climate-type) with the enabling technologies, and databases.

Folding-in the development of vaccines & therapeutics by designing a globally-coordinated vaccine surveillance system for monitoring vaccine changes predicated on new SARS-CoV2

virus variants, and inform and advise national authorities and vaccine companies.

Accelerating pandemic research for a better understanding of how pathogens spread and cause disease, and to generate safety and efficacy data to support regulatory decisions on clearance, approval, licensure, and emergency use. (Figure: 1)

Summary and conclusions

COVID-19 has evidenced the current poor state of global health. Ten intertwined cardinal socio-ecological factors have been identified as the root causes of pandemics. A pathway and a blueprint have been presented for pandemic prediction and prevention that could be gauged by four identified measures. Within that blueprint, a stage could be reached wherein future pandemics could be predicted and prevented. The creation of a new World Environmental Organization, a new International Pandemic Treaty, and a shift to a One World-One ecoHealth paradigm have been advocated. It must be emphasized the the cost of failing to control outbreaks, ruining and losing lives, destabilising the social fabric, and decimating economies is considerably greater than the cost of prediction and prevention.

References are available at www.asianhhm.com

AUTHOR BIO

Alain Fymat, BA, BS, MA, MS, PhD, PhD, MNYAS, MEUAS is Founding Chair, President/ CEO & Institute Professor at International Institute of Medicine & Science with previous appointment as Executive Vice President/Chief Operating Officer & Professor at Weil Institute of Critical Care Medicine, both institutions in California. He was formerly Professor of Radiology, Radiological Sciences, Radiation Oncology, Critical Care Medicine, and Physics at several U.S. and European Universities.

The International Pandemic Treaty (IPT) would prevent countries who are doing vaccine research from maintaining intellectual property on important technologies.

A Brief History of Metastatic Colon Cancer

The treatment of metastatic colorectal cancer has evolved in the last several decades with the advent of new systemic therapies. This has led to improved patient outcomes and survival. While in many cases, metastatic colorectal cancer remains an incurable disease, further research and understanding of the molecular drivers of colorectal cancer will continue to advance the care of our patients.

Shikha Jain, Associate Professor, Director of Communication Strategies, University of Illinois Chicago Lucia D, Notardonato, Hematology/Oncology Fellow, University of Illinois

Colorectal cancer (CRC) continues to be a significant global public health challenge. In 2020, it was estimated that there were 1.9 million new CRC cases and 0.94 million CRC related deaths worldwide. With a global incidence of 10 per cent, it is the third most common cancer, and the second most common cause of global cancer-related deaths. It has been projected that the global incidence rate will continue to rise to

3.2 million by 2040. Fortunately, there have been significant advancements in the treatment of CRC in the last several decades such as improved surgical techniques, new therapeutics, a better understanding of precision oncology and next generation sequencing, and the adoption of metastatectomy and even liver transplant in certain patient populations with oligometastatic disease. When CRC is diagnosed in early stages, it is highly treatable and often curable. In the United States, the 5-year survival rate for localised and regional CRC is 92 per cent and 72 per cent, respectively. However, approximately 20 per cent of CRC presents as metastatic at time of diagnosis, which portends a poor prognosis with a 5-year survival rate of 14 per cent. While chemotherapy and surgical resection have shown to prolong survival in oligometastatic disease confined to a single organ, unresectable metastatic CRC poses a significant challenge for significant improvements in advances in overall survival benefits. The mainstay of treatment for unresectable metastatic CRC is systemic therapy. Here we will review current systemic treatment options for unresectable metastatic CRC.

Chemotherapy

The most used class of first-line treatment for unresectable metastatic CRC is chemotherapy. Intravenous fluorouracil, a fluoropyrimidine antimetabolite, was the first chemotherapy to be used for CRC starting in the late 1950s. It took an additional forty years before an oral prodrug of fluorouracil, capecitabine, was to be introduced to the chemotherapy arsenal. Around the same time in the early 2000s, two additional chemotherapy agents, oxaliplatin and irinotecan, were being evaluated in combination with fluorouracil for first-line treatment of metastatic CRC. Several randomised controlled trials demonstrated that FOLFOX (fluorouracil + leucovorin + oxaliplatin) and FOLFIRI (fluorouracil + leucovorin

+ irinotecan) had higher response rates and improved progression-free survival compared to fluorouracil monotherapy Overall survival was not shown to be improved compared to fluorouracil monotherapy in all studies, but this was attributed to significant cross-over between the groups. Several studies have demonstrated that FOLFOX and FOLFIRI are similarly effective as first-line treatment of metastatic CRC when compared head-to-head. This has established two lines of chemotherapy regimens that can be sequentially given after progression occurs. Lastly, capecitabine has been shown to be interchangeable with fluorouracil in either chemotherapy combination regimens. Two meta-analyses have demonstrated that there are no differences in overall survival between CAPOX (capecitabine + oxaliplatin) vs FOLFOX or CAPIRI (capecitabine + irinotecan) vs FOLFIRI.

Biologics

In addition to chemotherapy, biologic agents play an integral role in treatment for metastatic CRC. Vascular endothelial growth factor (VEGF) has been shown to be a key mediator in tumour-induced

angiogenesis in CRC. Bevacizumab is a humanised anti-VEGF monoclonal antibody that was first approved for metastatic CRC in combination with fluorouracil-based chemotherapy in 2004. Several studies have demonstrated improved progression-free survival with adding bevacizumab to fluorouracilbased chemotherapy. Bevacizumab has been approved for the first-line setting, the second-line setting, or to be continued into the second-line setting if the chemotherapy backbone has been changed. Other VEGF inhibitors include ramucirumab, a humanised anti-VEGF-R2 monoclonal antibody, and ziv-aflibercept, a recombinant fusion protein that acts as a VEGF inhibitor. Both ramucirumab and ziv-aflibercept have been approved in the second-line setting in combination with FOLFIRI after first-line FOLFOX based on research that demonstrated improved progression-free survival and overall survival compared to FOLFIRI + placebo. It is important to note that VEGF inhibitors need to be held before and after surgery for at least 4 weeks as they can lead to delayed wound healing.

EGFR inhibitors also have a role in treatment in certain patients with

metastatic CRC. Cetuximab and panitumumab are EGFR inhibitors that have been approved for RAS/ BRAF wild-type (WT) metastatic CRC in combination with chemotherapy. In a randomised controlled trial, there was no significant difference in progressionfree survival or overall survival in patients with KRAS WT metastatic CRC with first-line EGFR inhibitor (cetuximab) with chemotherapy compared to first-line VEGF inhibitor (bevacizumab) with chemotherapy. Additionally, EGFR inhibitors combined with chemotherapy are recommended in the first-line for left-sided, RAS/BRAF WT CRC. This has been postulated to be due to different embryologic origins, vascular

With a global incidence of 10 per cent, CRC is the third most common cancer, and the second most common cause of global cancer-related death. It has been projected that the global incidence rate will continue to rise to 3.2 million by 2040.

supply, and microenvironments that lead to different gene alterations seen between right- and left-sided CRC. A known mechanism of resistance that occurs with patients treated with chemotherapy and an EGFR inhibitor is acquisition of a RAS-mutant clone. It has been hypothesised that when next line treatment is used without an EGFR inhibitor, the acquiredRAS mutant clone cells will decay while the original RAS WT clones may proliferate. Thus, leading to the possibility of “re-challenging” the cancer by re-introducing an EGFR inhibitor when the RAS-mutant clone is no longer present as assessed by liquid biopsies (i.e. KRAS/BRAF WT metastatic CRC on liquid biopsy).

Immunotherapies

Immunotherapy has not been as successful in metastatic CRC compared to other solid tumour malignancies. However, immunotherapies are beneficial in the 5 per cent of metastatic CRC that are MSI-H/ MMR deficient. Three immunotherapy regimens have been approved in the first-line setting of MSI-H/MMR deficient metastatic CRC : (1) pembrolizumab, (2) nivolumab, and (3) nivolumab + ipilimumab. Both pembrolizumab and nivolumab are antiPDL1 monoclonal antibodies while ipilimumab is an anti-CTLA-4 monoclonal antibody. In a randomised controlled trial comparing pembrolizumab vs standard chemotherapy in the first-line setting of MSI-H/MMR deficient metastatic CRC, pembrolizumab demonstrated significantly improved progression free survival with a durable response. A single arm phase II trial demonstrated durable clinical benefit in patients treated with combination nivolumab + ipilimumab in the firstline setting. There has been no head-tohead comparison assessing nivolumab monotherapy vs nivolumab + ipilimumab

in the first line setting in this patient population. However, one study did demonstrate improved clinical benefit with combination nivolumab + ipilimumab vs nivolumab monotherapy in the chemotherapy-refractory setting.

Targeted therapies

While BRAF V600E variant CRC only comprises 5-10 per cent of metastatic CRCs, this particular subtype confers a poor prognosis with less benefit from standard chemotherapy regimens. An important mechanistic discovery was recently made that demonstrated that BRAF inhibition leads to upregulation of EGFR signaling in the BRAF mutant clones. This led to a phase III trial examining patients with BRAF V600E metastatic CRC who had progressed on at least one prior line of treatment that demonstrated improved overall survival with the combination of encorafenib (BRAF inhibitor) + cetuximab. Current trials are investigating the efficacy of encorafenib + cetuximab in the first-line setting with and without chemotherapy.

Other approved lines

In the third- and fourth-line settings, oral regorafenib, a multi-kinase inhibitor, and oral trifluridine-tipiracil, a fluropyrimidine derivative, have both been approved for metastatic CRC. Unfortunately, both have demonstrated a modest clinical benefit of less than two months in overall survival compared to supportive care.

Upcoming treatments

In the coming years, there will likely be more targeted therapy regimens available for metastatic CRC. Here, we will briefly highlight some of this promising research. In the last year, sotorasib and adagrasib were recently approved for the use of KRAS G12C mutated advanced lung cancer. KRAS G12C mutations are seen in about 3-4 per cent of metastatic CRC. There are two ongoing randomised phase III trials investigating the role of these agents in combination with EGFR inhibitors in non-first line settings compared to standard of care regimens in KRAS G12C metastatic CRC. Additionally, HER2 gene amplification is also seen in 2-3 per cent of CRC. There have been several small studies demonstrating clinical benefit with HER2 inhibition in the chemorefractory setting for CRC. Most of these studies utilised a dual HER2 blockade, such as trastuzumab, an anti-HER2 monoclonal antibody, in combination with lapatinib, a tyrosine kinase inhibitor of HER2 and EGFR1, or trastuzumab with pertuzumab, another HER2 monoclonal antibody. Most recently, trastuzumab-deruxtecan, an antibody-drug conjugate of a HER2 monoclonal antibody with a topoisomerase I inhibitor, was shown in a single arm, phase II study to have clinical benefit in the chemo-refractory setting of HER2 amplified metastatic CRC. Future randomised clinical trials will be needed to determine the efficacy of anti-HER2 treatment in the first-line setting.

Conclusion

While there have been significant advancements in treatment options for metastatic CRC in the last few decades, further research is imperative to continue to improve patient outcomes. Molecular profiling will continue to play an integral role in developing new treatment strategies and selecting the optimal treatment for a patient on a personalised level.

References are available at www.asianhhm.com

Dr. Shikha Jain is a board-certified hematology and oncology physician. She is a tenured associate professor of medicine in the Division of Hematology and Oncology at the University of Illinois in Chicago. She is the Director of Communications Strategies in Medicine and the Associate Director of Oncology Communication and Digital Innovation for the University of Illinois Cancer Center. Dr. Jain is the founder and President of the 501(c)(3) nonprofit Women in Medicine® and founder and chair of the Women in Medicine Summit. She is the CEO and Co-Founder of the action, advocacy and amplification organization IMPACT. Dr. Jain was named one of Medscapes 25 Rising Stars in Medicine in 2020, one of Modern Healthcare's Top 25 Emerging Leaders in 2019, and was also awarded the Rising Star award by the LEAD Oncology Conference in 2019.

She is a nationally renowned keynote speaker and has written for several national publications including USA Today, CNN, Good Morning America, Scientific American, The Hill, US News, Newsweek and has been interviewed in the New York Times and Washington Post. She is a regular tv contributor to FOX 32 and has also been a guest on ABC7, CBS, WGN and other national media outlets.

Dr. Lucia D. Notardonato is a Hematology/ Oncology fellow at the University of Illinois. Her research interests involve precision oncology in solid tumour malignancies.

Reduce Colon Cancer Risk with Exercise

Modifiable risk factors, such as a sedentary lifestyle, lack of exercise, poor diet, excess body weight, high alcohol intake, and tobacco use, contribute significantly to colon cancer. In contrast, physical activity is a protective measure that can significantly reduce the risk of colon cancer. One of the most extensive meta-analyses shows that even moderate-intensity exercise for 30-60 minutes a day can help reduce the risk of colon cancer by up to 25 per cent. Understanding that benefits of exercise extend beyond heart health and weight loss is vital. Exercise also helps reduce stress, enhance intestinal motility, and promote the production of beneficial compounds by the body that plays a crucial role in reducing colon cancer risk. The exercise can even benefit those undergoing chemotherapy by reducing physical fatigue, enhancing the quality of life, and increasing lifespan.

and excessive body weight are among significant contributors to cancer risk.

Colon cancer is a relatively common cancer type. It is the third most common cancer diagnosed in both men and women in the US. Every year, more than 100,000 individuals are diagnosed with colon cancer in the US. It is estimated that in 2023, colon cancer will cause more than 50,000 deaths in the US.

Understanding colon cancer risk factors

To lower the risk of colon cancer, it is vital to understand its risk factors. Moreover, it is vital to understand that lifestyle interventions can prevent colon cancer in many instances.

Some non-modifiable colon cancer risk factors are family history and certain genetic syndromes like familial adenomatous polyposis.

However, it is more important to understand modifiable risk factors. Some of the lifestyle choices known to increase colon cancer risk considerably are: Sedentary lifestyle – those who sit for long hours and do not engage in many physical activities are especially at risk.

· A diet low in fruits and vegetables – a diet rich in dietary fibre, antioxidants, and vitamins may lower cancer risk. Additionally, plant-based foods also contain phytocompounds known to suppress cancer growth.

· Overweight and obesity.

High alcohol intake and tobacco use.

Heart diseases and cancer are among the top two leading causes of mortality in the US. Though most people realise the benefits of physical activity in preventing heart attack, stroke, and diabetes, they barely

recognise that regular exercise may also help significantly reduce cancer risk.

It is vital to understand that those living with poor metabolic health are also at greater cancer risk. Thus, for example, studies suggest that a sedentary lifestyle

· A diet high in fats and low in dietary fibre – remember that excessive intake of fats causes an increase in body weight, influences intestinal motility, and causes low-grade inflammation. On the other hand, dietary fibre can enhance intestinal motility and

Saint-Vil, Medical Director, Sports Medicine Department, Marietta Memorial Hospital

may also positively influence gut microbiota.

Get active, and start exercising to minimise colon cancer risk

The National Institute of Cancer states that two effective ways of reducing your colon cancer risk are by reducing your exposure to risk factors and taking protective measures. And lifestyle changes like dietary measures and exercise are among the most effective protective measures.

Protective measures like exercise are essential, considering that many risk factors, like genetics are non-modifiable. In addition, many individuals have a sedentary lifestyle due to the nature of their job. For example, many need to work hours in front of the screen. In most cases, people cannot change their profession. However, they can exercise to counter prolonged sitting sessions' side effects.

The benefits of exercise in cancer prevention cannot be underrated, especially considering that exercise will help reduce the risk of not just cancer but other non-communicable diseases like heart attack, stroke, diabetes, and even mental health issues.

It is also vital to understand that you don’t have to spend hours exercising each day. Even some exercise can be highly beneficial. It appears that the benefits of exercise in colon cancer are experienced in a dose-dependent manner. It means that the more you exercise, the greater would be the benefit. It also means that even some exercise can help significantly.

Therefore, starting with something like 30 minutes of exercise a day, five times a week, is a good idea. One can begin with low-intensity exercises like walking and gradually increase exercise intensity and duration.

What kind of exercise is good for colon cancer prevention?

This is one of the common questions. Well, just any kind of exercise is good for

reducing your cancer risk. However, for maximum benefit, engage in moderateintensity exercise for 30-60 minutes daily. Some good examples of moderateintensity exercises are walking briskly, swimming, and even gardening.

How much can colon cancer risk be reduced through exercise?

It is good to know that exercise can reduce colon cancer risk. However, most people would like to know how much colon cancer risk reduction is possible through regular exercise. After all, any effort must be worth it. Well, studies suggest that regular exercise can help reduce colon cancer risk by one-fourth in almost everyone. However, that is an average. It means that some may benefit more significantly; thus, in some, exercise may even help cut down colon cancer risk by half!

In 2009, researchers carried out the most extensive meta-analysis to date. They analysed more than 500 published studies for colon cancer prevention and ultimately included 52 studies in their meta-analysis. They found that regular exercise, on average, can help reduce colon cancer risk by 24 per cent in both genders. These benefits can be even much higher when combined with other measures.

Therefore, remember that exercise reduces colon cancer risk dosedependently. Hence, the more you

AUTHOR BIO

exercise (regularly), the greater the benefits.

But what if someone has already been diagnosed with colon cancer? Can exercise help? Yes, studies show that exercise boosts the body’s production of insulin-like growth factors, prostaglandins, and other peptides that may increase the quality of life of those living with colon cancer.

It is also worth understanding that one can even benefit from exercise when undergoing chemotherapy. Studies show that exercise can help reduce physical fatigue, enhance the quality of life, and even increase lifespan.

Thus, it is time for people to realise that exercise benefits extend beyond heart health or weight loss. Exercise reduces stress, enhances intestinal motility, increases the release of beneficial compounds, and helps fight cancer, not just colon cancer.

Studies show that the benefits of exercise can be massive. If combined with other measures like dietary changes, adequate sleep, and stress management, it may even help reduce the risk of colon cancer by more than half. Exercise may be considered the most effective way to prevent colon cancer. Moreover, these are not just comprehensions; clinical studies confirm these benefits.

References are available at www.asianhhm.com

Saint-Vil is the founder of the ExerciseNow.org platform and the Medical Director of the Sports Medicine department at Marietta Memorial Hospital. He is a fellowshiptrained Sports Medicine physician and a published researcher who has published countless articles promoting healthy lifestyles on Sports Medicine and fitness-related topics. He believes exercise is the best health insurance. Among his academic interests is Platelet Rich Plasma's use to regenerate tendons, ligaments, cartilage, and other soft tissues.

Surgeon Volume in MultiArterial Revascularisation and Long-Term Survival

In cases of coronary artery bypass grafting surgery for patients with multiple diseased vessels, surgeons with high multi-arterial annual volume select older patients with multiple comorbidities for multi-arterial revascularisation and achieve a better long-term survival for their patients as compared to surgeons with lower volume of multi-arterial surgeries.

Natalia Egorova, Professor, Icahn School of Medicine Doaa Alsaleh, Candidate in clinical research, Icahn School of Medicine

The approach of coronary artery bypass graft surgery (CABG) has been changing throughout the years with regards to the type of the bypass graft used. The surgeon’s main goal is to optimise good conduit flow and long-term patency of the grafts when performing CABG surgery.

Prior literature has demonstrated that arterial grafts are superior to venous grafts in terms of angiographic patency and survival rates. Several published observational research papers have reported that arterial grafts carry longer survival rates and have better mid and long-term patency rates than saphenous vein grafts. With this available information, arterial conduits have been recommended in U.S and European guidelines and in a recent Society of Thoracic Surgeons position paper. In patients with multi-vessel disease, single arterial conduits are more commonly used than multi-arterial conduits. The reason for this is that multi-arterial grafts’ benefits are still being debated and studied in both clinical trials and

retrospective observational research.

Deciding whether the patient will receive multi-arterial graft or singlearterial graft for their CABG surgery depends on several factors. The surgeon takes into account patients’ characteristics such as age, preoperative risk profile and the complexity of coronary disease.

While the use of multi-arterial graft CABG for treating patients with multi-vessel disease is recommended in recent published clinical guidelines, but statements such as "further research is needed" or "insufficient clinical trial data available" might have played a role in the decreased utilisation of this technique. Moreover, the clinical guidelines do not include specific recommendations for various clinical subgroups of patients who require CABG for multi-vessel disease. There are several other factors that account for the low rate of multi-arterial graft use, including the absence of significant evidence from large randomised clinical trials regarding survival and longterm outcomes, the surgical technical

challenges, complexities involved, and the longer operative times required for multi-arterial graft surgery.

Despite the reported superiority of multi-arterial graft compared to SAG, it is still utilised in fewer than 10 per cent of coronary bypass operations in the US, with extreme variation in frequency of use between individual surgeons. A recent report from the Society of Thoracic Surgeons database showed a decline in the utilisation of multi-arterial graft CABG for all patients from 2008 to 2018 despite the reported benefits and recommendations by guideline.

Do patients’ characteristics and long-term survival differ according to surgeon multi-arterial case volume?

To evaluate this relationship, we designed a retrospective cohort study using the mandatory New Jersey State Open Heart Registry to identify patients undergoing multi-arterial CABG between January 1, 2000 and December 31, 2016 and obtain their baseline characteristics such

as age, sex, medical history, preoperative risk factors and operative information. To obtain information on the long-term survival, we linked this large database to New Jersey vital statistics death registry. The last follow-up date was December 31, 2019.

We included New Jersey residents’ patients who were diagnosed with multiple coronary vessel disease comprising males and females from different age groups, patients with diabetes, peripheral vascular disease, left ventricular dysfunction, and patients with multiple comorbidities who underwent isolated multi-vessel CABGs containing at least two arterial conduits.

We excluded patients who underwent CABGs for single vessel disease, who underwent CABGs with only venous grafts or single arterial graft, patients who underwent previous heart surgeries, haemodynamic instability (pre-operative shock, cardiopulmonary resuscitation, or inotrope requirement), CABGs done in emergency settings and patients who are non-NJ residents.

To obtain multi-arterial CABG volumes, surgeon volume was calculated as the number of multi-arterial revascularisation surgeries in the 365 days prior to the index case. Surgeon volumes were categorised into tertiles: low (1-12), mid (>12 – 21), and high (>21) volume.

Low volume surgeons performed on average seven multi-arterial CABG/year, mid volume surgeons performed 17 multi-arterial CABG/year and surgeons from high volume group performed 40 multi-arterial CABG/year.

Our data constituted of 8,326 patients who underwent multi-arterial graft surgery; 2,760 (33.2 per cent) of the cases were performed by low-volume multi-arterial surgeons, 2,770 (33.3 per cent) by mid volume surgeons and 2,796 (33.6 per cent) by high volume surgeons.

Table 1 shows baseline characteristics of the patients included in the study in each surgeon multi-arterial graft volume group. There were significant differences

Table 1 Baseline characteristics of patients by multi-arterial graft coronary artery bypass surgery surgeon volume categories

in baseline patients’ characteristics between surgeon volume groups. Patients receiving multi-arterial grafts by high volume multi-arterial surgeons were on average two years older, had higher proportion of female patients, and patients with a higher prevalence of diabetes, peripheral vascular disease, renal failure, chronic lung disease, congestive heart failure and cerebrovascular disease, than those operated on by lower multi-arterial volume surgeons.

Patients were follow-up for 15 years. After adjusting for confounding factors (age, gender, BMI, race, comorbidities, and preoperative conditions), the hazard of death was significantly decreased by 13 per cent among patients who were treated by high-volume multi-arterial surgeons compared to mid, and low volume multi-arterial surgeons.

Our study showed significant differences in baseline patient characteristics between surgeon volume groups. Patients who were operated on by high multi-arterial graft volume surgeons were older and had more comorbidities than those operated on by lower multi-arterial volume surgeons. This finding points out at one of the important factors exploring surgeons’ preference in choosing patients for multi-arterial graft procedures. Surgeons who performed more multi-arterial graft procedures had a more aggressive approach in selecting patients for multi-arterial graft surgeries. This could mean that more training and experience is needed to select older patients and those with more comorbid conditions for multi-arterial graft procedures. This aligns with most of the descriptive baseline characteristics of patients in prior studies comparing multi-arterial graft vs single-arterial graft. A recent retrospective cohort study comparing long-term outcomes of multi-arterial vs single-arterial graft procedures showed that single-arterial

CABG patients were older (mean age 68 vs. 61 years; p < 0.001) and had more comorbidities.

Naturally, having multiple comorbid conditions in patients with multivessel disease contributes to worse outcomes after CABG surgery, thus offering multiarterial graft surgery to these patients could contribute to better outcomes. In our recently published work using the same registry, we compared long-term outcomes between multi-arterial and single-arterial procedures in 24,944 patients with diabetes. If diabetic patients underwent multi-arterial grafting, they demonstrated improved long-term survival, lower incidence of reoperations, stroke, and myocardial infarction when compared to the patients with single-arterial grafting.

The underutilisation and hesitancy to offer multi-arterial graft procedures need to be changed. It is important to explore the areas for improvement to further increase the use of multi-arterial graft procedures to improve longterm outcomes. The proposed areas of improvement from prior studies include the need of more high-quality evidence,

technical skills, and rigorous training to overcome the increased complexity of multi-arterial graft procedures.

The use of mandatory large clinical registries and administrative databases produced a large sample size, thereby increasing the power of the study. Using health registries resulted in a more representative sample of the general population.

Takeaway

Surgeons performing a high volume of multi-arterial CABG select older and sicker patients for multi-arterial revascularisation and they achieve the better outcomes as compared to surgeons with lower volume. Despite the better outcomes, utilisation of multiarterial procedures declined suggesting that coordinated efforts are needed to offer the multi-arterial grafts to more patients. It is necessary to educate new surgeons in this technique in order to overcome technical challenges and eliminate this practice gap.

References are available at www.asianhhm.com

The main theme of research of Professor Natalia Egorova, MPH, PhD is assessing the effectiveness of clinical interventions in actual practice settings. Currently, she focuses on comparative outcomes research using deterministic and probabilistic linkage and advanced analytics of clinical and administrative datasets to evaluate major knowledge and practice gaps in cardiovascular and peripheral vascular interventions, cancer therapy and quality improvement

Doaa Alsaleh, graduated with an MD degree from Arabian Gulf University, Bahrain. She completed a fellowship programme in clinical research at Weill Cornell in New York. She then joined Icahn School of Medicine at Mount Sinai, received a master in clinical research and is currently a PhD candidate in clinical research. Dr. Alsaleh is currently working on coronary artery bypass grafting outcomes using multiple state registries.

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Chest Disease Detection

The power of deep learning in radiography

Chest X-ray radiography is commonly used for detecting lifethreatening diseases but diagnosing them can be prone to errors. Computer-aided detection (CAD) using artificial intelligence techniques have shown potential in improving efficiency and accuracy. This article discusses recent advances in deep learning techniques applied to chest disease detection using radiography.

Chest X-ray (CXR) imaging is a cost-effective technique used by radiologists to diagnose various parts of the human body and detects diseases and abnormalities. The organs appear differently on the image based on the amount of radiation they absorb, with bones appearing white, the heart appearing in different shades of gray, and airways appearing black. CXR is a non-invasive, painless, and affordable tool for detecting diseases and monitoring therapy.

Chest diseases are among the most dangerous health issues globally, with

lung cancer, pneumonia, tuberculosis (TB), and COVID-19 causing many deaths daily. According to the World Health Organization (WHO), thoracic diseases have a high mortality rate, causing millions of deaths every year. Early detection of these diseases can save lives.

Radiologists might face challenges in interpreting CXR images due to multiple factors such as restricted resolution, similarity between disease symptoms, and lack of experience. Computer-aided detection/ diagnosis systems (CAD) that use machine learning and deep

learning algorithms have been proposed to assist radiologists in making decisions. Over the last decade, machine learning (ML) techniques have become more prevalent in medical imaging-based anomaly detection and classification, with high accuracy shown through numerous studies. ML has been used for various purposes in medical image analysis, including organ segmentation, disease detection, and classification. ML algorithms have been employed to classify several diseases such as TB, pneumonia, edema, cardiomegaly, and COVID-19.

Moulay Akhloufi, Professor, Department of Computer Science, University of Moncton

CXR Datasets

CAD systems require large amounts of data for training and testing the AI algorithms, which are typically collected in datasets that include patient information such as age, race, sex, and insurance type. Datasets aim to advance research in detecting diseases, and deep learning (DL) techniques have proven to be efficient and achieve expert-level performance in clinical tasks when trained in large datasets. Several CXR image datasets are available, including Indiana, ChestX-ray8, ChestX-ray14, KIT, Montgomery, JSRT, Shenzhen, and CheXpert. These datasets contain various CXR images with different abnormalities, some of them have metadata and are labeled using natural language processing (NLP) algorithms.

Preprocessing radiography images

Preprocessing X-ray images involves transforming them from their original format to a more informative and useful one to enhance their quality. CXR images are typically produced in DICOM format, which contains extensive metadata that can be difficult for non-radiology experts to understand. To make DICOM images more accessible in computer vision, they are often compressed into PNG or JPG formats using specific algorithms that preserve essential information. Preprocessing

typically involves de-identifying patient information and converting DICOM images into other formats while resizing them without sacrificing crucial details. Imbalanced or low-quality datasets can be improved using augmentation, enhancement, segmentation, and bone suppression techniques, which extract meaningful information and enhance the quality of the regions of interest.

Training a deep neural network on an imbalanced dataset may result in overfitting, leading to poor generalisation and poor performance. Researchers use various data augmentation techniques, such as position-based and colourbased augmentation, to mitigate this issue. These techniques increase the number of CXR samples, resulting in better accuracy. Techniques like histogram equalisation and filtering are used to adjust parameters like contrast,

brightness, noise suppression, and edge sharpness to enhance image quality, and making it more interpretable. Several studies have explored different enhancement techniques, including Gabor filters, contrast-limited adaptive histogram equalisation, unsharp masking, and gamma correction.

Also, image segmentation is used to divide CXR images into regions of interest (Figure 1), and various deep learning models like U-Net, FCN, pix2pix, and ARSeg have been used for this task. Segmentation improves the performance of deep convolutional neural networks (DCNN) for chest disease detection and classification. (Figure 1)

Bone suppression is also popular. This technique removes bones from CXR images to enhance visibility and prevent overlap with disease signs (Figure 2). Researchers have studied bone suppression using different methods, including using image filtering, gradient differences, or separating bone structures from soft tissue using a DCNN model. Bone suppression has been shown to improve the performance of deep models for detecting various diseases, including lung cancer and COVID-19. (Figure 2)

Deep learning for chest disease detection

Various CAD systems have been developed to detect chest diseases using different techniques. Early detection

Figure 1: Example of CXR lung segmentation (source [1])

Figure 2: Example of bone suppression (source [1])

of thoracic conditions is crucial for successful treatment as diseases such as pneumonia, pulmonary nodule, TB, COVID-19 can become more severe when they are advanced. In CXR images, three types of abnormalities can be observed: texture abnormalities, focal abnormalities, and abnormal form.

Pneumonia

Detecting pneumonia through CXR images can be challenging for radiologists due to the possibility of pneumonia being confused with other diseases. To avoid misdiagnosis, various methods have been developed, including the use of different DL architectures. One study proposed the Swin transformer model, which incorporated image enhancement and data-augmentation techniques and achieved high accuracy on two popular datasets. Another study utilised an attention mechanism-based DCNN model to classify CXR images as normal or pneumonia with high accuracy. Additionally, two DCNN models with transfer learning were implemented by other researchers, achieving high accuracy in binary classification of pneumonia cases. The CheXNet model, a 121-layer convolutional neural network, was developed by a different study and achieved high performance in detecting and localising pneumonia. More recently, researchers proposed a CAD system based on transfer learning with an ensemble learning of three different DCNN models. Various methods were used in other studies, such as customised CNN model, and different data-augmentation techniques, to overcome overfitting and achieve high accuracy in pneumonia detection.

Pulmonary nodule

Lung cancer is viewed by the WHO as a very serious condition, especially for men. It is the most frequent type of cancer in men and the third most

common in women. Early diagnosis of lung nodules, which are a manifestation of the disease, is crucial to ensure effective treatment. To evaluate the efficacy of deep learning (DL) systems in assisting radiologists in detecting pulmonary nodules in medical images, multiple studies have been conducted. DL algorithms have been shown to

perform well on different types of medical imaging, particularly X-ray radiographs. For instance, one study demonstrated that the performance of 12 radiologists in detecting malignant pulmonary nodules increased by more than 5 per cent when aided by a DL system. Likewise, another study reported that a ResNet-based model outperformed six radiologists in detecting operable lung cancer. Multiple recent studies have reported high accuracy and high sensitivity rates for DL models in detecting lung nodules in CXR images.

Tuberculosis

WHO ranks tuberculosis (TB) as one of the top 10 fatal diseases, with TB being the second deadliest infectious disease after COVID-19, and ahead of HIV/AIDS. In 2020, approximately 10 million persons were diagnosed with TB worldwide, with 1.1 million being children. Tuberculosis is an infection caused by a bacterium that primarily affects the lungs. It can be transmitted through the air when infected individuals cough or sneeze. Early detection of TB is essential,

Deep Learning techniques have proven effective, particularly with large datasets and high computation resources, which overcome the limitations of Machine Learning.

and DL has been used to detect TB from CXR images. Several approaches have been proposed, such as TBXNet, VGG16-CoordAttention, ConvNet, and an ensemble learning method using AlexNet and GoogleNet. These approaches achieved high accuracy rates ranging from 87.0 per cent to 99.75 per cent and were tested using different datasets. These DL methods offer a promising tool for the early detection of TB.

Covid-19

The emergence of COVID-19 in 2019 led to a pandemic that has resulted in millions of deaths worldwide. Traditional clinical techniques for detecting the virus are expensive and time-consuming, but the use of CXR images has shown promise in detecting and monitoring the effects of COVID19 on lung tissue. DL algorithms were used to classify CXR images as either normal, pneumonia, or COVID-19. Initially, researchers faced a challenge due to a lack of CXR images for positive cases, but open access CXR datasets with COVID-19 cases were eventually created. To improve the performance of DL models, techniques such as transfer learning, fine-tuning, and data augmentation have been utilised. Some models use multiple steps to detect the presence of pneumonia and distinguish between pneumonia and COVID-19. Several models have achieved high levels of accuracy, ranging from 93.94 per cent to 99.63 per cent.

Multiple diseases

In some cases, patients may suffer from multiple diseases simultaneously, which can increase the risk to their life. Detecting multiple pathologies using CXR images can be difficult for radiologists due to the similarity of disease symptoms. To overcome this challenge, various deep learning (DL) models have been proposed. These models have achieved high accuracy

in detecting various chest diseases, including pulmonary nodules, pleural effusion, cardiomegaly, and other types of abnormalities. Some of these models use weak-supervised methods, LSTM-based approaches, ensemble learning, and attention mechanisms to improve performance. The bestperforming models have achieved high AUC scores ranging from 73.00 per cent to 94.89 per cent. Other models have used cascade neural networks and multiple DCNN models to classify multiple diseases with an average AUC of 79.50 per cent to 85.37 per cent. EfficientNet-V2M and Xception models have also been used to classify CXR images into different classes with high accuracy.

Discussions and conclusion

Medical image analysis using deep learning has emerged as a promising research area at the intersection of medicine and computer science, offering a variety of methods and solutions for predicting and preventing diseases.

Initially, ML algorithms were utilised to automatically detect diseases in medical images and showed potential in small datasets. However, the process of anomaly detection using ML involves several technical components, such as manually extracting features and the intervention of specialists, which can hinder performance on large datasets.

DL techniques have proven effective, particularly with large datasets and high computation resources, which overcome the limitations of ML. Residual Networks have shown potential in effectively classifying various medical conditions, especially in situations where data is limited. However, DL models are considered black boxes, making it challenging to interpret their performance. To address this issue, researchers are developing explainable approaches for disease detection to output interpretable

results for radiologists by providing reports and heatmap visualisation. The purpose of AI and DL techniques is to collaborate with radiologists in order to enhance performance and expedite the diagnostic process.

This article summarises research in several areas, including the most widely used X-ray datasets, preprocessing techniques, and recent DL architectures, with a particular focus on chest disease classification.

Additional details about this topic can be found in the following open access paper:

Source [1] A. Ait Nasser and M. A. Akhloufi, “A Review of Recent Advances in Deep Learning Models for Chest Disease Detection Using Radiography,” Diagnostics, vol. 13, no. 1:159, Jan. 2023, https://doi.org/10.3390/ diagnostics13010159 .

Moulay Akhloufi is Professor in Computer Science, Head of the Perception, Robotics, and Intelligent Machines Lab (PRIME), and Director of the Center for AI NB Power at Université de Moncton (Canada). He has a B.Eng., M.Sc. and Ph.D. in Electrical Eng. He also holds an MBA. His research interests are in the areas of artificial intelligence and computer vision. He is a senior member of IEEE.

Medical Device Security

Cybersecurity risk is now patient risk

Cybercriminals are increasingly targeting healthcare organisations to steal information and disrupt operations. The entire health care ecosystem is under pressure to improve cybersecurity. Fines, audits, lawsuits, reputational damage, and patient safety are powerful catalysts. No healthcare organisation should think it is safe from cybercrime. Cybersecurity threats to healthcare organisations and patient safety are real. Cyber Safety is Patient Safety!

John Giantsidis, President, CyberActa

1. How important is medical device security in your opinion?

Connectivity and digitisation of healthcare and associated technologies has enhanced medical device functionality and increased benefits to both patients and users. Whenever connected medical devices connect to hospital or home networks or the internet, they get exposed to cyber threats that can lead to increased risk of harm to patients and users, both financial and safety. Medical devices are valuable to cyber attackers because of the information and data they contain and the profit they can make once that information reaches the dark web.

Since the medical device cybersecurity risk can be a safety concern, they are to be designed, manufactured and utilised in a way that ensures that any risks associated with the use of the device are acceptable risks when weighed against the intended benefit to the patient, and compatible with a high level of protection of health and safety.

2. What kind of medical devices require security measures?

Cybersecurity expectations shall be applicable to devices that contain software (including firmware) or programmable logic, as well as software as a medical device (SaMD)

or machine learning as a medical device (MLMD). I would not limit the security by design considerations to medical devices that are network-enabled or contain other connected capabilities.

3. What are the common risks associated with insecure medical devices?

Medical devices can be susceptible to the same security challenges faced by other code-enabled systems, such as vulnerabilities introduced during design, manufacturing/ assembly, implementation, configuration and retirement. Some are attributed to design of the medical device of (e.g., use of plaintext, hard-coded passwords), to coding flaws (e.g., buffer overflows, command injection), denial-of-service, and susceptibility to malware due to missing or improper security patching.

Medical device cybersecurity requires planning and action based on the applicable multiple environmental and use factors as the cybersecurity threat landscape is rapidly evolving. The potential harm to patients and users from an adverse medical device cybersecurity event could clearly include physical harm. There may also be other consequences for patients and users arising from a cybersecurity event including misdiagnosis or potential privacy breach by the disclosure of personal information.

One item that I truly try to remind healthcare providers and hospitals is that patient data is everlasting and cannot be altered or modified after a data leak – as you would with a credit card number for example.

4. What are the challenges associated with securing medical devices?

Medical devices often collect, measure, or generate data during their operation, calibration and maintenance. Transmission of such data can become a source of risk if the medical device is capturing Personally Identifiable Information (PII) or other data with privacy implications. Another great challenge is the third party support and medical device network connectivity because of third-party access. Hospitals may provide this access for remote management functions, maintenance, software/ firmware updates, or features/functionality.

The minimal medical device cybersecurity expectations are to provide protection against unauthorised access, unauthorised influence or unauthorised manipulation, minimise risks associated with known cybersecurity vulnerabilities and facilitate the application of updates, patches, compensating controls and other improvements, including making available sufficient information for a user to make decision with respect to the safety of applying or not applying these.

The challenge, in my opinion, is to evaluate and design medical device cybersecurity to address off-label use of devices, exploitation of previously unknown vulnerabilities in the device software or hardware, unsupported or unauthorised user modification of devices to customise a device to perceived needs or preferences and use of device in operating environments that are not or may not be secure.

5. What are some best practices for securing medical devices?

I truly believe that best, easiest and cheapest way is to secure a medical device by design by developing an understanding of cybersecurity vulnerabilities associated with the medical device and the potential risk during the initial design and development phase, like the following:

• The medical device has a unique, unforgeable identity that is inseparable from its hardware

• The integrity of the medical device software is secured by hardware

• The medical device remains secured even if one of its security mechanisms is breached

John Giantsidis President CyberActa

• The medical device’s security enforcement code is protected from bugs in other software on the medical device itself

• The failure in one component of the medical device is contained to that component

• New medical device software components can be added in the field to address new cybersecurity threats

• The medical device authenticates itself with certificates or other tokens signed by the hardware root of trust

• The medical device reports errors for analysis to enable verification of the correctness of in-field execution and identification of new threats

• The medical device software can be updated automatically.

Another foundational activity to medical device cybersecurity is threat modeling, and I have written a short guide on how to best conduct one. Threat modeling is an important aspect of the security development lifecycle, which is a process aiming to build better and more secure systems or software. It is a technique, which aims to find assets, analyse potential threats and mitigate them. The following threats can be considered in the evaluation process:

1 Patients/users leave their login credentials on a public place (e.g., write them down on a piece of paper) or share them with family, friends or relatives

2 Healthcare providers (doctors, nurses, technicians) leave their login credentials in public places or share them with others

3 Medical devices may be spoofed by attackers, which may lead to incorrect data being delivered to the patient

4 There unauthorised access to medical device data using shared (or stolen) passwords

5 Patients/users intentionally or accidentally modify, add and/or delete data because of over-privileges or inapplicable access control of a medical device

6 Improperly protected data stored in patients' medical devices could allow attackers to read information not intended for disclosure.

6. How can healthcare organisations ensure that their medical devices are secure?

It is important to understand the importance of healthcare professionals in establishing and maintaining cybersecurity in a medical device. I encourage health care professionals, users, and patients to ask questions about the clinical and cybersecurity risk associated with use of the medical device, how security of the medical device must be maintained, what they must do in the event of a suspected cybersecurity breach and what they must do in the event of a suspected cyber security vulnerability.

Procurement is the greatest spot to ask manufacturers and distributors questions about cybersecurity. The concerns include:

Medical devices can be susceptible to the same security challenges faced by other code-enabled systems, such as vulnerabilities introduced during design, manufacturing/assembly, implementation, configuration and retirement.

1 What security measures have been built into the medical device?

2 What measures are in place to protect patient safety?

3 What measures are in place to protect the confidentiality, availability and integrity of patient data?

4 How has security been addressed at each level, e.g., hardware, firmware, OS, network, and user interface?

5 What security protocols and frameworks have been used?

6 What IT environmental requirements are needed for secure operation of the device?

7 What are the known cyber security vulnerabilities for the device?

8 Have you assessed the cybersecurity of key components within the medical device (i.e. the supply chain)?

9 Do you, the manufacturer, provide an ongoing service to manage the security of your medical device(s), and how will you respond to future cyber security incidents?

10 A medical device often has a long lifecycle—do you, the manufacturer, have enough resources to support the security requirements throughout the lifecycle?

If the medical device is to be a connected part of the hospital’s network, then it is imperative to set up a vulnerability management process to monitor and address newly identified vulnerabilities of medical devices via timely patching.

7. What is the role of regulatory bodies in ensuring medical device security?

Cybersecurity incidents have rendered medical devices and hospital networks inoperable, disrupting the delivery of patient care across healthcare facilities in every country. There has been considerable effort by most, if not all, regulatory agencies to grasp the importance of cybersecurity to patient safety and mandating that medical device manufacturers and healthcare organisations consider and plan patient safety.

8. How can healthcare providers educate patients and staff about medical device security? It is imperative to educate and inform users (patients and staff) of relevant security information to help mitigate cybersecurity risks and help ensure the continued safety and effectiveness of a device. Utilise the medical device instructions and product specifications related to recommended cybersecurity controls appropriate for the intended use environment (e.g., anti-malware software, use of a firewall, password requirements). Finally, assemble the answers/directions to the following questions:

1. What constitutes a cyber security risk?

2. What are the risks, particularly cybersecurity risks, associated with use of a specific device and what alternative device options exist?

3. What default security settings are there to protect the user?

4. What are the cybersecurity implications of changes to the device settings?

5. When and how does the device connect to the internet?

6. What data is collected by the device, where does it go, and who has access to it?

7. How can a user tell if a device has been hacked or compromised and who can they talk to if this is suspected?

8. Who should the user talk to if they learn about vulnerabilities that might affect the device?

9. What does the user need to do to maintain the device (e.g. software updates)?

10.How do I report a known or suspected cybersecurity breach via a medical device to my healthcare professional and the manufacturer?

9. What are some emerging trends in medical device security?

There is a great infographic that was issued by ENISA (EU Agency for Cybersecurity) that really captures what will be dealing with in the foreseeable future, whether in the medical device security or cybersecurity in general:

10. Any other comments?

Technology is revolutionising the way we do business and behave. The emergence of artificial intelligence (AI) as a tool for better health care offers unprecedented opportunities to improve patient and clinical team outcomes, reduce costs, and impact population health. The cost for storing and managing data, data collection via electronic health records, and exponential consumer health data generation have rendered most healthcare ecosystems as data-rich targets. The prevalent use of AI and the emerging regulatory landscape has led to an increased need for standards to define good practice and provide guidance to improve trust and market adoption. The International Organization for Standardization (ISO) and the International Electrotechnical Commission (IEC) are developing AI standards, including defining key terminology and concepts, risk management, governance implications, data quality, and various topics related to trustworthiness.

Nonetheless, AI security cannot be considered in isolation of existing risk-based security, privacy, and governance foundations, which can address many of the threats that arise using AI systems.

John Giantsidis is the President of CyberActa, a boutique consultancy empowering clients in their regulatory, cybersecurity, privacy, data, and commercialisation endeavors. With deep regulatory and technology background, a broad range of experience over a 27-year career, and a sharp focus on tackling emerging risks, John affords his clients with strategic yet pragmatic perspectives on addressing critical risks in a business-focused and impactful manner. John is a Cyber Aux with the U.S. Marine Corps, a member of the Cybersecurity & Infrastructure Security Agency (“CISA”) Healthcare POC, an advisor to the National Telecommunications and Information Administration (“NTIA”) in its Software Component Transparency efforts, and a past voting member of Association for the Advancement of Medical Instrumentation (“AAMI”) in Health IT Security matters.

TECHNOLOGY

Mind the Gap

How virtual health has improved in-person patient interactions

This article will explore how virtual health is impacting in-person interactions. It will offer a different take on Telemedicine: how has equipping healthcare professionals with online consultation skills affected the classic consultation experience? How can closing the gap online improve patient engagement and health outcomes offline?

Stanley Li, Founder and CEO, DXY Mahira El Sayed, Professor of Dermatology, Ain Shams University

Telemedicine is by no means a new idea, but over the past few years we have seen unprecedented expansion, evolution, and a greater understanding of its potential to improve healthcare. It might be strange to discover that this impact has not been confined to the online setting but has also created ripples that impact offline care too.

Even before the pandemic, China saw the potential of telemedicine, leading to a boom in the use of virtual health services starting in 2014. This only accelerated in 2020 when the pandemic hit, creating a tipping point, changing both the way that hospitals and doctors were able to provide care, as well as how patients were able to access it. As a result, the mindsets of both physicians and patients and their behaviour towards telemedicine had to change quickly to adapt to a new era of healthcare.

Of course, this shift was felt across all aspects of healthcare, including health literacy. When the Alliance & Partnerships for Patient Innovation & Solutions (APPIS) community came together in March, their discussion around health literacy focused in on how to empower meaningful conversations between patients and healthcare providers, including in an online setting. Bringing together perspectives from different stakeholders from across the health community, including physicians, patient organisations, academics and policy makers, the in-depth discussions looked at improving online health literacy as part of a broader drive towards accelerating access for patients.

As virtual health and telemedicine have evolved, they have created new challenges around health literacy yet at the same time they have presented opportunities to improve healthcare outcomes for patients. In fact, telemedicine has created surprising, lasting improvements for both patients and physicians in three main ways: more practical training for physicians; increased health literacy for patients; and deeper relationships between patients and physicians.

As we find ourselves at another crossroads in the provision of healthcare — this time, transitioning from care that is heavily reliant on telemedicine to a hybrid era that includes both virtual and in-person interactions — we need to build on the learnings of the last few years to ensure we are giving patients access to the best care possible, no matter where that might be.

More practical training for physicians

Before the pandemic, there were existing problems with in-person patient care in China. For example, Chinese physicians had limited time to see patients, as they often saw up to 80-90 in a day. At a rate this high, it was extremely difficult to provide quality care to each patient, as it meant that physicians only had a few

APPIS is a platform that is organized and funded by Novartis, and co-created by the APPIS Council, a panel of patient and healthcare leaders in Asia Pacific, Middle East and Africa. Since 2021, the platform has convened the healthcare community from more than 60 countries to accelerate access for patients by aligning on healthcare challenges and prioritising action towards better patient outcomes

minutes with each patient. In addition to diagnostic care, it also caused a lack of meaningful interaction or relationship, which was seen in indicators such as little to no eye contact. This kind of behaviour could lead a patient to think that the physician is not listening attentively and has little interest in the patient and what he or she has to say, diminishing the level of trust and overall patient experience.

When doctors moved onto virtual platforms during COVID-19, we saw them bring some of these familiar, bad habits to the online setting. One major cause for the ongoing issue was that many physicians did not receive proper training to provide online services for patients. To ensure physicians have the resources they need to give patients the best care possible, comprehensive training is key. As an example, our team at DXY.cn spent a lot of time training physicians through curriculums that focused on not only medical knowledge, but patient communication. This was further supplemented by peer reviews and practical hands-on scenarios with patient volunteers to make sure the training involved real-life situations. The goal of this comprehensive training is to train doctors to think beyond the

illness or condition and treat the patient based on his or her individual, holistic needs.

This training proved to be invaluable for virtual health consultations during COVID-19. As doctors went back to in-person consultations, we noticed a continued positive impact: the virtual training that physicians went through stuck. Physicians came back to in-person consultations with the disease education and patient communications skills to provide better service to patients compared to pre-pandemic times. Doctors also became more motivated to learn and gain knowledge, and started to expect more education from services like DXY. According to DXY’s “2021 Chinese Doctor Insight Report - Online Medical Behavior Analysis,” after conducting more online consultations in 2021, more than 80 per cent of doctors expected the platform to provide training content on advanced disease progression, sharing new drugs and therapies (62 per cent), and patient-doctor communication (13 per cent) to improve their medical skills further. As a result of their increased knowledge and training, doctors also became more willing to proactively share information with patients, with 60 per cent of doctors willing to carry out science popularisation. And through better patient communication skills, doctors delivered their knowledge in a way that patients could better understand.

Increased health literacy resources for patients

More practical training for physicians had a direct impact on the patient experience in the form of more attentive care towards patients, as well as practical resources that they could use to increase their understanding of medical conditions. These resources were provided to doctors as part of the physician training at DXY. The materials, including simplified content templates, provided in-depth and practical guidance for a variety of different scenarios, covering topics from explaining diseases to patients, to

Doctors' expectations of the training content provided by the consultation platform [Doctor %]

Source: "DXY Internet Medical Platform Analysis Report", obtained through DXY research and analysis in June 2021 Base: N = 617, all doctors

Q: What training content is expected to be provided by the online consultation platform for doctors?

Q: What kind of review mechanism is reasonable on the online consultation platform?

educating patients on long-term care, and offering comfort for patients in difficult times.

The guidance within these materials not only proved to be valuable for physicians when working in a virtual health setting, but they also contributed to improved patient experiences offline. In addition to resources for doctors, we also provided resources for doctors to share with their patients. These digestible materials included both print-outs and QR codes that led patients to general Q&A content to learn more. We found that patients really appreciated these resources, as they helped them to better understand their health. They also strengthened the local reputations of the doctors who were providing excellent care by going above and beyond to provide as much

information as possible to their patients. This was evidenced at DXY, where 99.6 per cent of patients gave a five-star rating for their physicians, and 33 per cent of patients noted that they would continue with online consultations after their first visit.

Deeper relationships between patients and physicians

The combination of improved care from physicians and more resources provided for patients has resulted in deeper, more meaningful relationships between the two groups, in both online and offline interactions. Now that patients are going back to in-person consultations, some may have expected the number of virtual consultations to drop. However, DXY did not see a significant change in the number of virtual health visits. In

2019, the platform saw 5,000 average daily consultations. This increased to 7,000 in 2020 and dropped slightly to 6,000 in 2023. This is largely due to the fact that patients are becoming more comfortable with telemedicine when it comes to preventative medicine. For example, young mothers who are seeking general knowledge about their babies’ development are finding that their questions can be answered quickly through a virtual consultation, rather than visiting a physician in-person. There is a rising demand for people who are proactively looking for ways to improve their quality of life, rather than reactively seeking care when something is wrong.

In these cases, virtual care is seen as a source of knowledge, allowing people to quickly access the information they are

“As healthcare practitioners, we have to listen more and learn from our patients,” said Dr. Mahira El Sayed, Professor of Dermatology and Venereology, Ain Sham University & Board Member of the International Psoriasis Council. “Open communication is key to empowering meaningful conversations between patients and healthcare professionals, and in turn, improving health literacy, patient experience, and outcomes. It’s encouraging to see that as virtual health evolves, it has created a positive, lasting impact on health literacy and deeper relationships between patients and physicians. Virtual health can clearly play an important role alongside more traditional, in-person care — specifically, by creating a platform for providing credible and easy to understand resources for patients and offering the opportunity for us, as healthcare professionals, to inform patients about their care, while fighting health misinformation.”

looking for, without the need to travel to a clinic where they could potentially be exposed to illness.

This approach allows in-person visits to be more focused on situations around specific diseases. In cases like these, diagnostic results and physical checks are necessary to provide specific results and meaningful care to patients. Although there is always a gray area, this clearer division of online vs. offline care post-Covid has allowed doctors in both scenarios to offer more time for the patients they can help the most, allowing them to build patients’ trust. In fact, our report found that the doctor-patient interactions saw improvement in 2021, as doctors were willing to devote more time to online consultation, with 41 per cent of doctors willing to spend 10-20 minutes for a single consultation.

Strengthening the patient-physician relationship will continue to be key

In the years to come, there is a huge potential for technology to continue to help physicians work effectively, while expanding access to patients in remote areas. As innovative technologies make their way to healthcare, there is an opportunity for us to embrace them. For example, Large Language Model (LLM) can help alleviate physicians’ workloads and even work as a partner or copilot by helping physicians to communicate with remote patients more efficiently. At DXY, we are already starting to use LLM to help doctors collect patients’ complaints and summarise them into a more clear and systematic information flow, so that we can use the information to provide better care for patients.

As we learn to adapt with these new and exciting technologies, we should keep in mind that while there are exciting developments happening virtually, we must ensure that more traditional, offline care is not left behind. In-person interactions will remain a critical part of delivering care to patients. Continuing to build a strong patient-physician relationship –both online and offline – will be key to ensuring that patients receive the best care possible, no matter where technology takes us!

Stanley Li, is the founder and chairman of DXY and an APPIS 2023 Council Member. DXY is a leading digital healthcare technology company in China, which covers over 70% of Chinese doctors nationwide. DXY provided the first COVID-19 map in the world in January 2020, and it became the working basis of the Johns Hopkins Coronavirus Resource Center. Stanley holds a bachelor's degree in clinical medicine and a master's in tumor immunology from Harbin Medical University. AUTHOR

Professor Mahira El Sayed is a Professor of Dermatology and Venereology at Ain Shams University in Cairo, Egypt, as well as an APPIS 2023 Council Member. She has served as the Administrative Director of the Department since 2000. Professor El Sayed is the Head of the Egyptian Board of Dermatology, a member of multiple national and international dermatology societies and has organized many congresses.

You can visit www.appisinitiative.com learn more about APPIS 2023 and watch the presentations on health literacy.

IoMT FOR IMPROVING HEALTHCARE

The last few years have witnessed the healthcare industry’s journey toward digitisation.Securing a healthcare service provider’s medical infrastructure needs to be prioritised, as cyberattacks continue to target critical equipment that support patient care. Most IoMT devices were not designed with security in mind, making them especially vulnerable to compromise. A robust medical device security strategy is important to free healthcare organisations from the worry of cyberattacks to focus on bringing about positive patient outcomes.

1. What are some of the vulnerabilities that are plaguing today's connected medical devices. Which are the key devices that are susceptible to risks?

As hospital systems adopt a broad range of medical IoT applications, many are adding connected medical devices that put their healthcare operations — and patient lives — at risk. The proliferation of unmanaged and unaccounted IoMT devices, their disparate nature, lack of security by design, and dependence on unsupported operating systems, together with network and internet connectivity, considerably widens the attack surface.

Smart medical devices are needed for critical patient care around the clock and cannot necessarily be taken offline for patching and security maintenance. This leaves the devices operating in a vulnerable state in the field.

Research by Palo Alto Networks Unit 42 Threat Research 1 found that medical devices are the weakest link

1 https://unit42.paloaltonetworks.com/infusion-pumpvulnerabilities/

on the hospital network as they bear critical vulnerabilities. 75 per cent of infusion pumps studied had at least one vulnerability or threw up at least one security alert. Imaging devices, such as X-Ray, MRI and CT scanners, were particularly vulnerable. 20 per cent of common imaging devices were running an unsupported version of Windows, and 44 per cent of CT scanners and 31 per cent of MRI machines were exposed to high-severity vulnerabilities.

2. How can cybercriminals exploit such devices and what are the repercussions for patients and healthcare service providers?

The healthcare industry continues to be a top target for threat actors. As the industry rapidly adopts new and innovative medical technologies, exposure to cyber threats also increases. The biggest challenge for healthcare organisations with unmanaged devices is that many of them were introduced to the hospital network without IT visibility or proper documentation over the years. The corporate IT and security teams often do not have great visibility of

exactly where these devices are, how and why they connect to the network, what type of business functions they perform, what type of data is being processed and stored locally, and what type of vulnerabilities are present on these devices.

Relying heavily on a legacy, perimeter-based security is no longer adequate for protecting a healthcare organisation’s assets. Mobile users and devices moving on and off the corporate network, data and applications moving to the cloud, covert malware, and attacks masquerading as legitimate applications or hiding in encrypted traffic have blurred the edges of that perimeter.

When these events occur, there can be a significant impact on individuals who have their information disclosed and a loss of trust in the organisations that were breached. A substantial financial impact due to loss of business, damage to reputation, and potential fines resulting from the breach can also pose a material risk to the impacted organisations. It does not matter if the loss occurred because of accidental exposure or a malicious act; the impact

Alex Nehmy, Director, Industry 4.0, Palo Alto Networks

to a healthcare organisation that has a breach or data loss event is real.

3.How can manufacturers of clinical devices and procurement teams work together to minimise risks posed to organisations and their patients?

Manufacturers of medical devices should invest in cybersecurity upskilling and capabilities that would minimise any vulnerabilities in their devices. Manufacturers have a responsibility to ensure their devices are secure by design and in fact, the issue of critical medical devices being manufactured in an insecure state has resulted in many jurisdictions passing legislation to mandate minimum level of cyber security for all new IoT devices.

Procurement teams of medical devices should do their due diligence by researching and ensuring the manufacturers they buy from incorporate security measures in making the devices. Medical institutions can provide an optimum, secure patient experience by implementing zero-trust policies through automated device discovery, contextual segmentation, least privilege policy recommendations and one-click enforcement of policies.

4.Existing IoT and IoMT security solutions lack threat prevention or policy enforcement. How can organisations deploy a comprehensive end-to-end security strategy on their network?

IoMT security needs to be taken seriously, making it vital for all healthcare security chiefs to develop and implement successful IoMT security strategies.

A robust medical device security strategy can free up healthcare organisations from the worry of cyberattacks to focus on bringing about positive patient outcomes.

Healthcare service providers will need an ironclad strategy that offers complete visibility on how people will interact with them and ensure that security is baked in all steps of their approach, from the planning stages all the way through the running phase. They should look to protect the data they collect whilst applying the principle of “Trust nothing, validate everything”, or Zero Trust. Current IT systems will have to evolve in order to manage the new and evolving cyber threats in today’s digital landscape.

Healthcare organisations face an urgent need to tackle IoMT security challenges head-on. The most basic step in securing IoMT begins with obtaining trusted visibility and classifying all IoMT devices across hospital networks, data centres, endpoints, remote clinics, mobile assets and cloud environments. By doing this, healthcare IT teams will be empowered to take a preventionfirst instead of an alert-only approach to keeping medical devices safe from potential threats.

5. How can medical institutions leverage automated Zero Trust policies to enhance care delivery and provide an optimum, secure patient experience?

Traditional perimeter-based security wrongly assumes that all users and devices inside the organisation’s network can be trusted and that a full security stack at the internet edge is sufficient for

securing the organisation’s data. In this approach, implicit trust is granted in the private zone of the perimeter firewall.

Attacks on sensitive data rarely use just a single exploit or compromised credential. Attackers use a combination of exploits, malware, compromised credentials, and other methods together to work their way from their beachhead in an organisation to the target system. Often attackers use one method after another.

The biggest challenge for many organisations is defining a consistent security model that holistically provides the required security controls across the organisation. Adopting a Zero Trust approach helps remedy the vulnerabilities associated with implicit trust in current security policies.

The Zero Trust approach is based on the principle that no user, device, or transaction from inside or outside of the network can be trusted. Eliminating implicit trust promotes a consistent security policy regardless of the situation. The framework focuses on resource protection and the premise that trust is never granted implicitly but must be continually evaluated. The concept of zero trust has gained popularity in the healthcare industry. Many vendors and industry experts often use the term to describe a holistic approach to improving your cybersecurity strategy.

Alex Nehmy is Director of Industry 4.0 at Palo Alto Networks. Alex has specialised in cyber security for the past 20 years. Alex has consulted nationally and internationally for KPMG as well as led cyber security for Australia’s largest defence prime. Alex built the cyber security capabilities for The University of Adelaide and also SA Power Networks, where he brought the IT and Operational Technology groups together to secure the South Australian electricity grid and watched the disruption from the green energy revolution play out with the huge growth of rooftop solar and initiatives such as the virtual power plant with Tesla.

Digital Health and Cardiac Rehabilitation

A paradigm shift offering care continuum of multidisciplinary holistic interventions

Digital health platforms have improved access and reliability of nonpharmacological interventions for disease modification, reducing the risk of re-hospitalisation, repeat vascular events, and death. Digital health integration into cardiology practice enables remote access to secondary prevention interventions such as cardiac rehabilitation. Post a coronary event or intervention, and in patients with heart failure, cardiac rehabilitation is strongly recommended.

Alben Sigamani, Chief Scientific Officer, Numen Health

What is cardiac rehabilitation?

In case of a cardiovascular disease (CVD) diagnosis, cardiac rehabilitation (CR) is an effective modality that enhances the probability of reversal or recovery. CR reduces all-cause mortality and the risk of frequent hospital admissions. In many people, CR also improves the health-related quality of life (QoL). CR helps patients to learn and adopt lessons for secondary prevention. CR also enhances motivation to perform exercise routines and become compliant with lifestyle changes.

Enrolment in a formal cardiac rehabilitation programmeme is evidence-based. A Cochrane review compares home-based to centre-based cardiac rehabilitation showing they were equivalent with added benefits to the patient. Studies in India have reported low availability, affordability, and awareness of cardiac rehabilitation facilities. A comprehensive cardiac rehabilitation facility needs physicians, technicians, nurses, and other health workers and could be expensive. Virtual cardiac rehabilitation delivered at home reduces cost and increases referral and uptake. Studies from the UK and USA have shown that virtual or digital cardiac rehabilitation is effective.

Why digital health?

Digital health is an emerging tool that has the potential to help address health system challenges. ‘digital health’ refers to e-learning, tele-monitoring, text messaging, structured phone support, tele-rehabilitation, tele-consultation, M-health applications, wearables, and artificial intelligence (AI). Managing patients with medical conditions such as CVD, conducting research, and monitoring public health, Digital health modalities can efficiently share medical information with patients, providers, and decision-makers, deliver personalised care, improve patient compliance and adherence, and enable remote patient monitoring and support, disease prediction, and monitoring vital signs.

From the patient's perspective, digital health technologies offer valuable resources for self-management of diseases. Each of these patientcentred care modalities improves the health outcomes of people with CVD. Digital smartphone platforms provide opportunities for active patient participation in their health management. This task-shifting improves clinical outcomes for patients with multiple chronic comorbidities.

Digital health and cardiac rehabilitation

CR is a multi-faceted, medically supervised programme. Core components of guideline-directed therapy include baseline patient assessments, nutritional counselling, risk factor modification (including management of lipids, blood pressure, weight, diabetes mellitus, and smoking), psychosocial interventions, and physical activity counselling and exercise training. AI and machine learning (ML) play essential roles in diagnosis and therapy, including identifying key risk factors, predicting and controlling cardiac arrhythmias, and improving cardiac imaging5.

Digital and modern communication technologies deliver personalised care through remote access to patients' instructions, control, and monitoring during physical exercises. Digital health also guides emergency care and records daily clinical data from implanted medical (e.g., pacemakers, defibrillators) or patient wearable devices (blood pressure monitors).

In the primary and secondary prevention of cardiovascular disease, digital technologies such as mobile apps, text messaging, sensor monitoring devices, and online behavioural counselling help understand and change behaviour by providing personalised guidelines for lifestyle changes such as hearthealthy lifestyles, such as medication adherence and positive behaviour change. Particularly against poor diet, smoking, and lack of physical activity, achieve positive health outcomes.

According to a systematic review (2018), smartphone apps reduce re-hospitalisation, improve patient knowledge, quality of life, and mental wellness, and aid in managing CVD risk factors. Smartphone and smartwatch apps can now distinguish between atrial fibrillation and sinus rhythm with sensitivity and specificity similar to electrocardiography (ECG). Mobile

Digital health is creating a paradigm shift from evidencebased healthcare to evidence-based well-being.

INFORMATION TECHNOLOGY

apps assist physicians and cardiologists in detecting heart failure. It supports decision making for implanting an implantable cardioverter defibrillator or cardiac resynchronisation therapy. Smartphone apps allow patients to self-perform simple diagnostic tests, such as the six-minute walk test, to assess cardiopulmonary functions, potentially reducing hospital facilities and staff costs. Therefore, digital health technologies help patients improve their health literacy and self-management skills. Similarly, digital health interventions improve access, participation, and cardiac rehabilitation adherence, improving exercise capacity and improve cardiovascular fitness.

Role of digital health in heart failure

Heart failure (HF) is a complex clinical syndrome that imposes a massive clinical, societal, and economic burden. After the age of 60, the prevalence of HF increases by 3.9 per cent, and the number of years lost due to disability has increased by 4.5 per cent in the last 28 years. According to multiple studies, Indians are more vulnerable to ischemic heart disease (IHD) related heart failure with a higher casefatality rate than western populations. Smoking, high cholesterol, physical inactivity, diabetes, high blood pressure, and obesity are all risk factors for developing IHD, leading to exacerbations and decompensation in HF.

Today, the increasing prevalence of CVD poses challenges to health systems in providing optimal care, and therefore, patient engagement and self-care are becoming increasingly relevant.The internet and smartphone apps are promising tools in cardiology to increase health literacy, which is essential for maintaining health and self-care, as well as understanding health information, medication adherence, and for altering treatment

plans to prevent exacerbation of heart failure.

These technologies provide a convenient way to quickly deliver health information to a large cohort of patients, particularly those who lack access to specialised heart failure clinics. Telehealth technologies allow patients to report symptoms remotely and their needs to their healthcare providers through audio and video interaction. Using asynchronous textbased communication via websites or patient portals helps with basic healthcare needs such as filling prescriptions, receiving test results, scheduling an upcoming screening, and ordering diagnostic tests.

New technology in digital cardiac care

Not only digital technologies target physicians and patients, but also the general public. ECG, angiography, echocardiography, digital subtraction angiography, and photoplethysmography (PPG) are some of the digital diagnostic tools used in cardiology. PPG is a highly researched, non-invasive, low-cost, and convenient diagnostic tool that can detect heart rate with an average 1–1.5 per cent error rate using a smartphone. Applying deep machine learning to PPG data also helps categorise patients' risk of hypertension. Artificial intelligence facilitates faster interpretation of ECG data and even detects signals and patterns humans cannot recognise.

Why a paradigm shift?

Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) suggest which core components of CR to focus and on how is a technology used in digital interventions for CR to achieve comprehensiveness of these programmes. Digital health is creating a paradigm shift from evidence-based healthcare to evidence-based wellbeing. We believe greater adoption of digital health tools will change practices of referring and remaining compliant with cardiac rehabilitation. With higher adoption of cardiac rehabilitation, we will see lower incidences of re-hospitalisation and improved quality of life.

References are available at www. asianhhm.com

AUTHOR

Artificial Intelligence in Healthcare

Machine Learning for Clinical Outcome

Prediction in Cerebrovascular Disorders

Clinical prognostic models help clinicians tailor treatments for alterations in the brain-body interface to maximise chances of survival and recovery after aneurysmal subarachnoid haemorrhage. This article uses regression analysis, classification and regression tree analysis, as well as machine learning technique of artificial neural networks to create a prognostic decision making tool for cerebrovascular disorders.

Benjamin W Y Lo, Department of Neurological Surgery, Lenox Hill Hospital

Clinical outcome prediction model was created using the 3551-patient Tirilazad database to investigate clinical factors that influence outcome in patients with ruptured brain aneurysms (Figure 1). Dependent variable used for statistical analysis is the dichotomised Glasgow

Outcome Score (GOS) at three months post aneurysmal subarachnoid haemorrhage. Good outcome represents functional independence (GOS 5 or 4). Poor outcome represents functional dependence (GOS 3), persistent vegetative state (GOS 2) or death (GOS 1).

Regression Analysis

The main effects logistic regression model confirmed the significance of neurological grade, age, stroke, and time to surgery in outcome prognosis in aneurysmal SAH (Table 1).

This study also demonstrates that the odds of poor neurological outcome is increased by a factor of 4 in aneurysmal SAH patients who develop post-admission strokes (OR: 4.03, 95% CI: 2.11–7.69, p < 0.01). Cerebral infarction after aneurysmal SAH may occur early after aneurysmal rupture or in a delayed manner. Factors associated with the development of cerebral infarction include admission neurological status, treatment related complications, and occurrence of symptomatic vasospasm.

In addition, we make the observation that development of cerebral edema, in the context of history of hypertension and liver disease, has a significant impact on neurologic outcome deterioration in aneurysmal SAH. By itself, the

6-PERILESIONAL

2-INCREASED INTRACRANIAL PRESSURE

7-REPERFUSION

8-MICROCIRCILATORY

5-INCREASED

development of cerebral edema may predispose the aneurysmal SAH patient to poor neurological outcome. Examination of systemic factors revealed that aneurysmal SAH patients with a history of hypertension and development of cerebral edema have 2.7 fold increased odds of poor neurologic outcome (OR: 2.66, 95% CI 1.59–4.45, p< 0.01). Patients with a history of hypertension are prone to defective cerebral autoregulation. When disrupted cerebral autoregulation is present after aneurysmal SAH, brain engorgement can occur as plasma proteins leak from capillaries with increased permeability. Extracellular vasogenic edema may follow as a result of increased hydrostatic pressures, with

3-ANAEROBIC

9-IMBALANCE

4-CEREBRAL EDEMA

a predilection for posterior cerebral circulation territories.

This study also makes the observation that development of cerebral edema in aneurysmal SAH patients with a history of liver dysfunction markedly increases likelihood for poor outcome (OR: 5.47, 95% CI: 1.13–26.46, p = 0.03). Similar to patients with hypertensive history, patients with chronic liver disease have been shown to have altered cerebral autoregulation and cerebral blood flow with decreased cerebral blood flow in the anterior cingulum and increased blood flow in the basal ganglia and occipital lobes at baseline. In acute states of ruptured cerebral aneurysms, these patients’

blood brain barriers become disrupted with marked increased cerebral blood flow secondary to luxury perfusion, thus, predisposing them to development of vasogenic edema. In addition, cytotoxic osmoregulatory mechanisms are involved whereby astrocytes swell secondary to the toxic effects of ammonia and glutamate. The end result is a vicious cycle of neuronal swelling and death, a marked increase in cerebral blood flow (cerebral hyperemia), and cerebral edema. It is important, therefore, to prevent the development of hepatic encephalopathy and monitor for cerebral edema in aneurysmal SAH patients who have chronic liver dysfunction.

12 - CELL-MEDIATED APOPTOSIS

11 - DEOXYHEMOGLOBIN DECREASED NITRIC OXIDE OXYHEMOGLOBIN INCREASED ENDOTHELIN-1 REACTIVE OXYGEN SPECIES CALCIUM INFLUX

10- NEURONAL MEMBRANE DYSFUNCTION & RELEASE OF EXCITATORY NEUROTRANSMITTERS

BETWEEN OXYGEN SUPPLY & DEMAND

THROMBI & SPASM

& CORTICAL SPREADING ISCHEMIA

PRIMARY INJURY

SECONDARY INJURY SPECTRUM

METABOLISM & LACTIC ACIDOSIS

OSMOTIC PRESSURE

1-ANEURYSM RUPTURE

Figure 1: Brain injury cascades post aneurysmal rupture.

Seizures increase mortality after cerebral aneurysmal rupture. In this study, we observed that seizures in the clinical setting of post–admission fever and background history of myocardial infarction significantly increase morbidity and mortality. The epileptic aneurysmal SAH patient who develops post–admission fever is predisposed to poor outcome (OR: 2.39, 95% CI: 1.86–3.06, p< 0.01). Fevers increase cerebral metabolic rate and can exacerbate the secondary injury. Early onset fevers can be secondary to dysfunction of temperature regulation centres in the hypothalamus whereas late onset fevers are more likely to be infectious, but can include fevers secondary to central damage, drugs, deep venous thrombosis and pulmonary embolism. Exogenous and endogenous pyrogens increase the propensity for fevers and seizure development. In febrile states, inflammatory cytokines increase neuronal excitability via temperature sensitive ion channels leading to the increased likelihood of synchronised neuronal activity. Not only is it essential to monitor, prevent and treat

Table 2: Clinical prognostic decision making algorithm in aneurysmal subarachnoid haemorrhage created using classification and regression tree analysis.

Table 1: Significant clinical terms found in regression analysis.

both seizures and fevers themselves, it is also important to search for underlying etiologies, including infections, venous thrombosis and pulmonary embolism, drug-drug interactions and delayed strokes which may alter seizure thresholds in the febrile aneurysmal SAH patient.

Lastly, our regression analysis makes the observation that seizures in the setting of a history of myocardial infarction increase the odds of poor outcome by a factor of 3.05 (95% CI: 1.35–6.87, p = 0.01). Repetitive autonomic stimulation can occur in the actively seizing aneurysmal SAH

patient in a lock-step phenomenon, which can trigger the development of cardiac ictal arrthymias. Continuous cardiac sympathetic discharges and cortical epileptiform activity can occur in a synchronised time-locked manner. These repetitive synchronised autonomic sympathetic discharges lead to cardiac ischemia and structural damage to the myocardium. In aneurysmal SAH, patients with pre-existing coronary artery disease and seizures, the propensity of cardiac ischemia is increased, along with potentially fatal multi-systemic complications, including development

of neurogenic pulmonary edema and respiratory suppression associated with fatal cardiac tachy- or bradyarrthymias, or cardiac asystole. Multisystem critical care cardiovascular and respiratory supports, therefore, are essential in these epileptic aneurysmal SAH patients in order to maximise their chances of survival.

Aneurysmal Subarachnoid Haemorrhage Prognostic Decision Making Algorithm using Classification and Regression Tree Analysis

Clinical prediction tools facilitate the process of prognostication and clinical decision making for both

Figure 2: Artificial neural network output diagram with insets for each layer.

clinicians and patient families. In the 3551-patient Tirilazad database, unfavourable outcome (functional dependence, persistent vegetative state, and death) at three months after aneurysmal rupture was observed in 1061 (30%) of patients. Our current classification and regression tree makes use of the two most frequently retained clinical prognostic factors for long term neurologic outcome, namely, neurological grade and age. It also demonstrates the significance of both post-admission stroke and fever in outcome prediction (Table 2).

In the present study, the occurrence of post-admission stroke increases the proportion of unfavourable neurologic outcome in aneurysmal SAH patients originally presenting with favourable admission neurological grades by 30%. Patients experiencing vasospasm are at an increased risk of post-admission strokes. In addition, several secondary injury cascade events may predispose these patients to post-admission strokes, including: (1) microthrombi formation, (2) cortical spreading depression, (3) microvascular constriction, (4) proliferation of pro-inflammatory cascade, (5) presence of blood–brain barrier disruption, and (6) inadequate collateral circulation. Fever is often a clinical indicator of neurological deterioration because it also triggers events in the secondary cascade of neurological injury. The various causes of post-admission late onset fevers, including nosocomial infections, central neurological injury, thromboembolic events, and drug-drug interactions, can lead to neurological complications, including increased intracranial pressures, cerebral edema, and post-admission strokes. Aggressive symptomatic control and rigorous search for underlying etiology are, therefore, warranted.

Clinical Outcome Prediction in Aneurysmal Subarachnoid Hemorrhage using Machine Learning Techniques

Exploratory analysis using artificial neural networks reveals the complexity of brain-body interactions in aneurysmal subarachnoid haemorrhage (Figure 2). In addition to the aforementioned variables, other variables, not directly measured, also influence clinical outcomes in aneurysmal subarachnoid haemorrhage patients. These include:

1 Disrupted cerebral autoregulation contributing to both ischemia and cerebral edema after subarachnoid haemorrhage

2 Biochemical markers of brain injury predisposing to cortical spreading depression

3 Cellular markers demonstrating physiologic dysfunction (such as mitochondrial dysfunction as reflected by the imbalance of oxygen supply and consumption)

4 Genetic factors affecting the outcome (such as inheritance of genetic markers predisposing to micro-thrombotic events in the cerebral microvasculature disrupting cerebral blood flow)

5 Multiple drug-drug interactions, especially in the elderly aneurysmal subarachnoid haemorrhage patient population with multiple pre-existing comorbidities and

6 Multi-organ systemic dysfunctions, including interactions between the central nervous system and neuro-endocrinologic, metabolic homeostasis, haematologic, hepatic and splenic systems.

Conclusion

Using clinical prognostic models, the clinician can tailor individual-specific treatment efforts to prevent and treat various alterations in the brain-body interface in order to maximise the chances of survival and recovery after aneurysmal subarachnoid haemorrhage.

Acknowledgement

Dr. Loch Macdonald is acknowledged for his expertise in this clinical area as well as the provision of a database.

References are available at www.asianhhm.com

AUTHOR BIO

Benjamin W Y Lo is a Neurosurgeon and Neuro-ICU specialist. His clinical focus is cerebrovascular disorders. His research focus characterises brain-body interactions in Neurocritical care patients with cerebrovascular disorders. Dr. Lo’s qualifications include FRCSC certification in Neurosurgery (2009), FRCSC certification in critical care medicine (2011), and MSc and PhD degrees in clinical epidemiology and biostatistics from McMaster University, Canada.

Exploratory analysis using artificial neural networks reveals the complexity of brainbody interactions in aneurysmal subarachnoid hemorrhage.