Asian Hospital & Healthcare Management - Issue 62 by Ochre Media Pvt. Ltd.

I S S U E 62

2023

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Advancing Healthcare Through Digital Transformation Harnessing data and AI for improved patient care Revolutionising Cancer Care Moving towards healing and hop The Road to Optimising The Care Pathway Are we there yet?

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Foreword

Digital Transformation in Healthcare The role of AI and data tools In an era defined by rapid technological evolution, the

However,

with

great

promise

comes

great

healthcare industry stands at the cusp of a transformational

responsibility. As we embark on this transformative

journey. The convergence of digital innovation and

journey, it is imperative that we do so with a deep sense

healthcare has ushered in an unprecedented era of

of ethical consideration and a steadfast commitment to

possibilities, where data and artificial intelligence (AI) are

patient privacy and data security. Balancing innovation

poised to revolutionise patient care in ways previously

with the sanctity of the doctor-patient relationship is a task

unimaginable.

we approach with the utmost care and diligence.

Advancing healthcare through digital transformation is

In the cover story ‘Advancing Healthcare Through

not merely a catchphrase; it is a commitment to the very

Digital Transformation-Harnessing data and AI for

essence of our shared humanity. It represents a paradigm

improved patient care’ of Asian Hospital & Healthcare

shift, a collective endeavour to harness the power of data

Management, David Labajo Izquierdo, Vice President

and AI to elevate the standard of care we provide to our

Healthcare Digital EMEA, General Electric Healthcare

patients. It is a promise to enhance outcomes, improve

writes on how digital Transformation in Healthcare,

accessibility, and empower both healthcare professionals

through Data and Artificial Intelligence solutions, are

and patients alike.

the way to overcome the significant challenges the

With the integration of digital technologies, we gain the ability to analyse vast troves of patient data in real-

healthcare services are facing across the globe. Keep reading!

time, allowing for more precise diagnoses, tailored treatment plans, and proactive intervention strategies. Remote

monitoring,

telemedicine,

and

wearable

technologies are reshaping the patient experience, bringing care closer to home and ensuring that every individual, regardless of their geographical location, can access the care they need.

Prasanthi Sadhu Editor

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CONTENTS MEDICAL SCIENCES

COVER STORY

06 The Complex Spectrum of Chronic Kidney Disease in Diabetics

Advancing Healthcare Through Digital Transformation

Ram Shankar Upadhayaya, Chief Executive Officer, Laxai Life Sciences

09 Fracture Liaison Service Tackling the ‘Silent Threat’ and building stronger communities through public-private partnerships in Thailand

Harnessing data and AI for improved patient care

Chairoj Uerpairojkit, Deputy Medical Director, Lerdsin Hospital

Orthostatic Hypertension A Risk Factor for Adverse Cardiovascular Outcomes

David Labajo Izquierdo Digital Health Advisor, formerly Vice President Healthcare Digital EMEA, General Electric Healthcare

Paolo Palatini, Department of Medicine, University of Padova

Revolutionising Cancer Care Moving towards healing and hop

Pooja Toshniwal Paharia, Oral and Maxillofacial Physician and Radiologist, YMT Dental College

21 Pitfalls in Acute Ischemic Stroke Treatment

Zyad J Carr, Associate Professor, Anesthesiology, Yale University School of Medicine

SURGICAL SPECIALITY

FACILITIES & OPERATIONS MANAGEMENT 47

Becoming Climate-Smart The Indian health sector Alexander Thomas, Founder and Patron, Association of Healthcare Providers Divya Alexander, Independent Consultant

26 Revolutionising Cerebrovascular Surgery Unlocking the potential of artificial intelligence and robotics Stephen Wong, John S Dunn Presidential Distinguished Chair and Chief Research Informatics Officer, Houston Methodist Hospital

50 The Road to Optimising The Care Pathway Are we there yet? Dirk Dumortier, Director Strategic Partnerships APAC, Alcatel-Lucent Enterprise

Kelvin Wong, Director of Neuroimaging Research Ting Tsung and Wei Fong Chao Center for BRAIN

INFORMATION TECHNOLOGY

Rahul Ghosh, Biomedical Engineering, Texas A&M University

53 Teleconsultation Empowers Rapid Digital Pathology Diagnosis and Healthcare Solutions

30 Perioperative Assessment and Management of Patients with Aortic Stenosis Undergoing Non-Cardiac Surgery Sushil Allen Luis, MBBS, PhD, FRACP, FACC, FASE, Department of Cardiovascular Medicine, Mayo Clinic Serena Rahme, MD, Department of Cardiovascular Medicine, Mayo Clinic

TECHNOLOGY, EQUIPMENT & DEVICES 37 An Understanding of Orthopaedic Technological Trends

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

Arindam Sen, Director of i2i Telesolutions

56 Digital Transformation in China’s Healthcare Market Wu Junyang, CEO, Qianlu Management Consulting (Shanghai)

59 Navigating Telehealth Solutions A comprehensive approach to finding the right fit Marianna Petrea-Imenokhoeva, Digital Health Expert, Co-founder, Health Tech Without Borders Jarone Lee, Associate Professor, Harvard Medical School; Co-founder, Health Tech Without Borders

SPECIAL FEATURES 62 Books

Syed Imran, Orthopedic Surgeon, Manipal Hospitals

Robotics Revolutionising Healthcare in the Orthopaedic Landscape Pioneering precision and patient outcomes in joint replacement surgeries Kelvin Tan, Senior Consultant and Head of Service (Adult Reconstruction) Tan Tock Seng Hospital

Gergely Feher, Consultant Neurologist and Stroke Physician

24 Perioperative Pulmonary Complications in Geriatric Populations A costly problem for healthcare systems

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Introducing Advent of NEW-AGE HEALTHCARE REPORTING Scan to check websites

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Aspiring to be leading journals in the B2B landscape of Healthcare-Industry covering Medical Science, Business & Technology and all the latest innovations. Introducing a group of highly focused magazines for the American and European markets. Poised for bi-annual issuance, our new magazines bring a fresh outlook towards insightful and pragmatic Healthcare-Industry reporting.

Advisory Board

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

EDITOR Prasanthi Sadhu

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

EDITORIAL TEAM Debi Jones Grace Jones Harry Callum Rohith Nuguri Swetha M

Eiman Shafa Medical Director Spine Surgery Abbott Northwestern Hospital

ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney

Gabe Rijpma Sr. Director Health & Social Services for Asia Microsoft

SENIOR PRODUCT ASSOCIATES Ben Johnson David Nelson Peter Thomas Susanne Vincent

Gurrit K Sethi Founder, Miindmymiind

PRODUCT ASSOCIATE John Milton CIRCULATION TEAM Sam Smith

Imelda Leslie Vargas Regional Quality Assurance Director Zuellig Pharma

SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam HEAD-OPERATIONS S V Nageswara Rao

K Ganapathy Director Apollo Telemedicine Networking Foundation & Apollo Tele health Services Associate Partner

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

Nicola Pastorello Data Analytics Manager Daisee

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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

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MEDICAL SCIENCES

The Complex Spectrum of Chronic Kidney Disease in Diabetics

Diabetes is the cause of multiple complications, including cardiovascular, retinopathy, and chronic kidney disease (CKD). CKD, in diabetics, in particular, presents a complex spectrum as it encompasses both classical diabetic kidney disease (DKD), non-diabetic kidney disease (NDKD), and a combination of both. This article aims to briefly elucidate the epidemiology and pathology of both DKD and NDKD. Ram Shankar Upadhayaya, Chief Executive Officer, Laxai Life Sciences

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riggered primarily by lifestyle changes, diabetes is assuming menacing proportions. According to reports from IDF Diabetes Atlas-2021, 1 in 10 people worldwide suffers from diabetes. That translates to 537 million patients, of which 95 per cent are of Type 2 (T2DM). The predicted trajectory of progression is 643 million by 2030 and 783 million by 2045. It is debated that SARSCoV-2 infection may have led to the appearance of multiple de novo T2DM cases. The hallmark of diabetes is dysregulated glucose metabolism, either due to the malfunctioning of insulinproducing pancreatic beta cells or due to the inefficiency of the body to use insulin, leading to high blood glucose levels. High blood sugar leads to severe complications, including hypertension, diabetic retinopathy (DR), cardiovascular diseases, and CKD, to name a few! CKD is described as a time dependent progressive loss of kidney function. The spike in CKD observed over the last few decades has been attributed to the increasing cases of diabetes. Between

MEDICAL SCIENCES

1990 and 2017, the world witnessed a rise of 9.5 per cent in CKD cases, and in the same time frame, the incidence of global diabetes grew from 11.3 million to 22.9 million cases, a rise of more than 100 per cent. It is projected that nearly 50 per cent of all T2DM patients and over 33 per cent patients with type 1 diabetes (T1DM) will develop CKD. Although CKD can also occur in non-diabetics, the spectrum of CKD in people with diabetes is particularly complex. Classification

Regardless of disease etiology, the existing clinical classification of CKD is centered on the estimated glomerular filtration rate (eGFR) and albumin: creatinine ratio (ACR). Patients are stratified based on eGFR values as G1-G5 (G1 ≥90, G2=60-89, G3a= 45-59, G3b = 30-44, G4= 15-29, G5 <15), and on the ACR as A1-A3 (A1 <30, A2= 30-300 and A3 >300). G1 represents normal or high eGFR, whereas G5 represents kidney failure. On the ACR scale, A1 represents normal, whereas A3 represents severely increased albuminuria. This has greatly broadened the horizon of clinical presentations for diabetic kidney disease (DKD), identifying a distinct class of patients displaying the phenotype of non-albuminuric CKD. The term diabetic nephropathy (DN) is applicable for patients presenting persistent clinically detectable proteinuria, tandemly elevated blood pressure, and a concomitant decline in eGFR. Structural changes in the renal system are a signature profile in DN observed in kidney biopsies, both in T1DM and T2DM. However, the presence of predominant vasculopathy, interstitial fibrosis, tubular atrophy, and/or specific glomerular changes or near-normal renal structure has also been reported in biopsies obtained from patients with T2DM. This may be independent of eGFR, albuminuria status, or any other renal function parameter. Such cases are termed

non-diabetic kidney disease (NDKD). To make matters complex, cases have been reported where NDKD may occur alone or superimposed with DN presentations! Diabetic kidney disease (DKD)

DKD was initially described by Mogensen et al. in 1983 as a progressive disease that began with the loss of small amounts of albumin into the urine (30–300 mg per day), termed microalbuminuria or occult or incipient nephropathy. As the amounts of albumin continue to rise in urine and are detectable by traditional dipstick (>300 mg per day), then it is termed macroalbuminuria (proteinuria) or overt nephropathy. This transition may occur over a period of 10-15 years. End-stage renal disease (ESRD) is manifested in 50 per cent of T1DM patients with overt proteinuria within ten years and in >75 per cent by 20 years. Since T2DM is more often associated with late detection, a larger percentage

Between 1990 and 2017, the world witnessed a rise of 9.5 per cent in CKD cases, and in the same time frame, the incidence of global diabetes grew from 11.3 million to 22.9 million cases, a rise of more than 100 per cent. It is projected that nearly 50 per cent of all T2DM patients and over 33 per cent patients with type 1 diabetes (T1DM) will develop CKD.

of T2DM patients present established proteinuria at the time of diagnosis. Without definite clinical intervention, up to 40 per cent of T2DM patients with microalbuminuria progress to overt nephropathy. Statistically, only 20 per cent of the patients with overt nephropathy were found to progress to ESRD within 20 years of onset. DKD is pathologically classified based on renal biopsy findings. Class 1: Mild or non-specific light microscopy changes and electron microscopy–proven glomerular basement membrane (GBM) thickening. Class 2a: Mesangial expansion, mild. Class 2b: Mesangial expansion, severe. Class 3: Nodular sclerosis (Kimmelstiel– Wilson lesion) and Class 4: Advanced diabetic glomerulosclerosis (scarring).

The predominant type of lesion observed in patients displaying T1DM and DN is nodular glomerulosclerosis. Other common lesions include hyalinosis of afferent and efferent arterioles, glomerular capsular drops, diffuse glomerular lesions with capillary wall thickening, and mesangial matrix expansion. An atypical DKD phenotype characterised with low eGFR, but no microalbuminuria has been reported. This is termed normoalbuminuric CKD; nearly 25 per cent of diabetic patients are said to present this condition. On a structural aspect, glomerular or non-glomerular renal changes in T2DM are more heterogenous in normoalbuminuric than in albuminuric renal insufficiency. Research suggests uncontrolled hypertension may be the most important predictor for people with diabetes developing CKD (Source: National Kidney Foundation). Specific high blood pressure medications such as angiotensin-converting enzyme (ACE) inhibitors and the angiotensin-2 receptor

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MEDICAL SCIENCES

blockers (ARBs) blocking the reninangiotensin-aldosterone system (RAAS) pathway may be the most effective in preventing DKD. It is, hence, important for people with diabetes to keep their blood pressure under check. Non-diabetic kidney disease (NDKD)

In patients with diabetes, NDKD can also occur. NDKD can be either alone or superimposed with DKD. Glomerular causes of NDKD include membranous nephropathy, immunoglobulin A (IgA) nephropathy, hypertensive renal disease, glomerulonephritis, acute interstitial nephritis (AIN), focal segmental glomerulosclerosis (FSGS) and glomerulonephritis due to ANCAassociated disease and anti-GBM glomerulonephritis. The diagnosis of NDKD in diabetic patients is complicated by the overlapping histological findings of the mild glomerulonephritis associated with initial DKD changes. NDKD might also appear similar to Class I DN. Electron microscopy can be a valuable tool in assessing renal biopsy samples for the discrimination of NDKD.

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Various clinical predictors have been proposed to distinguish between NDKD and DKD. The presence of DR is strongly correlated with DKD. However, it is reported that up to 70 per cent of diabetic patients with no retinopathy can present albuminuria and concomitant DKD. This suggests that while DR is an essential tool to indicate either NDKD or DKD, it cannot be an absolute exclusion criterion. The onset time of diabetes is also helpful in distinguishing between

NDKD and DKD. It is generally accepted that T2DM less than five years is strongly suggestive of NDKD, whereas DKD has a usual onset time of nearly ten years. Apart from these, lower HbA1c, lower blood pressure, and the presence of hematuria can help distinguish NDKD, though incongruencies between studies have been reported. Notably, microscopic hematuria may be a feature of T2DM patients with biopsy-proven DKD and established proteinuria. Concurrent findings of systemic illness can also help to establish NDKD. IgA nephropathy and prior infection can be strong indicators of NDKD. Hence, it is postulated that renal biopsy can be proposed as a diagnostic tool for NDKD when eGFR is less than 60 ml/min/1.73m2 along with the absence of DR, short duration of diabetes (<5 years), atypical disease progression, presence of hematuria and other systemic diseases as well as nephrotic syndrome. Unlike DKD, NDKD can be treatable and reversible in many cases. Although DKD is a common cause of CKD, early differentiation can be helpful in isolating treatable forms of NDKD, thereby preventing potential mortality. References are available at www.asianhhm.com

AUTHOR BIO Dr. Ram Shankar Upadhayaya, an accomplished scientist and entrepreneur, specialises in infectious diseases. With a focus on COVID-19, he is developing drug molecules for cardio-protection and lung diseases. In addition to his research pursuits, Dr. Upadhayaya holds the position of Scientist at the Division of Nephrology, Harvard Medical School, Boston Children's Hospital. He is a recognized scientific expert serving on the Data Safety Monitoring Board (DSMB) for clinical trials on stem cells in India. He is a Distinguished Visiting Professor at the Plasma Bioscience Research Center/ Applied Medicine Research Center, Kwangwoon University, Seoul, Korea.

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MEDICAL SCIENCES

Fracture Liaison Service Tackling the ‘Silent Threat’ and building stronger communities through public-private partnerships in Thailand

Osteoporosis and fragility fractures are major causes of long-term morbidity and mortality, exerting a huge strain on healthcare systems and economies as societies age. Integrated, multi-sectoral partnerships in the form of fracture liaison services can help ensure patients receive holistic care and close off gaps in care. Chairoj Uerpairojkit, Deputy Medical Director, Lerdsin Hospital

he world’s population of people aged 65 and over is growing faster than all other age groups, with complex and wide-ranging implications. Addressing the needs of the elderly population while ensuring a productive society and strong economy is an ever more universal socioeconomic goal, with ramifications across the public and private sectors and impacts on people’s daily lives. The “silver tsunami” is particularly evident in Thailand, one of the world’s most rapidly ageing countries, which also has an alarmingly low birth rate. In 2022, Thailand was the only Asian country to report a negative birth rate, where the number of births is lower than the number of deaths.

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MEDICAL SCIENCES

As Thailand’s population gets older, the prevalence of diseases associated with ageing is expected to increase, including osteoporosis. Urbanisation and sedentary lifestyles have also contributed to a significant rise in osteoporosis and related fractures. With people aged over 50 projected to account for 45 per cent of Thailand’s population by 2030, osteoporosis has been at the forefront of the national health priority since 2018. Fragile bones lead to fragile communities

Osteoporosis is a common condition and a major cause of long-term morbidity. By 2050, more than 50 per cent of the world’s hip fractures are expected to occur in Asia-Pacific and more than 80,000 fractures will happen per year in Thailand by 2035. Hip fractures are considered the most serious type of fracture, as they can lead to a host of serious, life-altering and even life-threatening issues in elderly patients. Of all osteoporosis patients who have experienced at least one fracture, 10 per cent will suffer hip fractures, a quarter of which will be fatal. Osteoporosis and fragility fractures threaten a significant strain on healthcare systems and economies. In the United States, fractures cause more hospitalisations than heart attacks, strokes and breast cancer combined. In the Thai context, a 2017 systematic review considering indirect and intangible costs suggested that the economic burden of hip fractures exceeds one-third of GDP per capita. Integrated, multi-sectoral collaboration is critical

To reduce the burden of osteoporosis on healthcare systems and patients, Thailand needs to respond to the rising numbers of fractures and osteoporosis due to ageing. Research shows that tackling bone health through an integrated electronic health network

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overseen by a coordinator and using a dedicated database to identify, assess, and treat patients is more effective in preventing secondary fractures than an approach involving alerts to patients and/or education only. This is where the fracture liaison service (FLS) comes in. FLS is a multidisciplinary approach which integrates different elements of osteoporosis diagnosis and management for patients who have experienced a likely fragility fracture. It reduces the risk of secondary fracture risks by giving the patient a comprehensive bone assessment when they are admitted with a bone break and providing timely access to treatment. This clinical approach involves a multitude of healthcare workers, including orthopaedic surgeons, nurses, internists, geriatricians, and physiotherapists, to ensure optimal care and provide secondary prevention support. In addition to a patient’s in-hospital journey, the FLS approach also addresses the pre and post-fracture stages, assessing the causes of fractures as well as the patient’s risk of secondary fracture, and prescribing treatment plans accordingly. It has been shown that FLS is an effective, holistic treatment approach that delivers meaningful impacts to patient’s lives. Not only does it help patients recover from their injuries, it also reduces the risk of future fractures, improves quality of life and reduces costs associated with further fractures. FLS also ensures that both the patient and their caregivers have the knowledge and equipment to continue care and fracture prevention at home. A spotlight on fracture liaison services in Thailand

Engaging with a wide range of stakeholders in the healthcare industry can ensure patients receive holistic care and close off gaps in care. This transformation of osteoporosis prevention and care through multi-

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Multi-stakeholder collaboration can help to close off gaps in patient care and ensure patients receive holistic support. FLS programmes are a prime example of how adopting a collaborative and preventative healthcare model can lead to significant improvements to health and socioeconomic outcomes.

stakeholder support involves high-level policy support and financing. In 2017, health officials in Thailand recognised the need to take action to address the burden of osteoporosis, and in 2018 they included refracture prevention and osteoporosis treatment as national health goals. The use of refracture prevention protocols and establishment of FLS in the country was promoted. To facilitate collaboration, partnerships between stakeholders in the health ecosystem (government, health professionals, patient groups and NGOs) were established to ensure related policies and initiatives were supportive and aligned. This includes a Memorandum of Understanding between Thailand’s Ministry of Public Health and Lerdsin Hospital, a centre of excellence for orthopaedics and leading teaching hospital in Thailand, together with Amgen Thailand, a global leader in bone health, to launch a nationwide Refracture Prevention Programme.

MEDICAL SCIENCES

The Refracture Prevention Programme aims to reduce the burden of fractures by transforming Thailand’s treatment approach and upskilling healthcare workers through the FLS, improving infrastructure to support their work while also increasing public awareness. A centralised patient registry was also established to improve cross-district communication and data sharing, and to optimise treatment delivery. In 2018, the Thai Fracture Liaison Service Nurses Society was established to facilitate learning and communication between FLS nurses, who play a critical role as the programme managers of FLS programmes. A host of national and district-wide educational meetings and workshops was also organised, including the recent FLS Forum & Workshop 2023 held in Bangkok. The FLS Forum aimed to bolster the existing FLS system and workforce, and drive FLS expansion into primary and secondary prevention to reduce the economic burden of fractures and strengthen refracture prevention in Thailand.

FLS programmes have also proven to be a cost-effective way to reduce the economic burden on healthcare systems. National figures show that a hip fracture costs approximately THB 85,000 (USD $2,500) to treat. However, statistics have shown that FLS’s fasttrack approach yields cost savings of around THB 20,000 (USD $600) per case. The standard of care has also been raised, with greater knowledge sharing and collaboration among healthcare workers and care providers. Patients also experience a shortened wait for treatment or surgery, thus enhancing their quality of life and alleviating the financial burden of osteoporosis. Tackling the future challenges of osteoporosis

FLS programmes are a prime example of how adopting a preventative healthcare model and multi-sectoral collaboration

FLS programmes have been shown to improve outcomes of osteoporosisrelated fractures, with significant reductions in refracture incidence and mortality. In Thailand, the successful rollout of FLS across the nation has dramatically reduced refracture rates, and FLS has also become a national policy and will continue well beyond the initial three-year partnership. This success is a testament to the key role of publicprivate partnerships in supporting the world’s increasingly complex healthcare needs as our populations grow older. The effectiveness of the programme in Thailand has also enabled FLS programmes to be expanded to over 121 FLS teams in 13 healthcare districts across Thailand, with 15 hospitals now accredited by the International Osteoporosis Foundation.

AUTHOR BIO

Proven success of fracture liaison services

can lead to significant improvements to healthcare and socioeconomic outcomes. This comes as healthcare systems start to recognise the shift from the traditional reactive acute care (“break and fix” model) to proactive and preventive care (“predict and prevent” model). The support of Thailand’s policymakers in aligning stakeholders, prioritising osteoporosis among different stakeholders, and harnessing help from private sector partners has resulted in FLS’ nationwide implementation and adoption. Looking ahead, the integration of more FLS programmes worldwide has led to the widespread development and adoption of FLS standards. This may help healthcare providers to benchmark performance over time and is a positive step toward standardising processes and outcomes. Thailand is well-placed to play a role in this benchmarking process, with FLSs in multiple hospitals receiving at least a Bronze rating in FLS best practices, a result that puts it ahead of other countries in the region. FLS programmes are highly effective, having been shown to benefit patient outcomes, reduce subsequent fragility fractures and increase patients’ quality of life, whilst at the same time reducing the economic burden on healthcare systems. As countries look to implement and scale up FLS programmes in their countries, they can take onboard Thailand’s experience and efforts in ensuring that osteoporosis patients and caregivers receive the care and social support they need to achieve optimum health outcomes. Dr. Chairoj Uerpairojkit is the Director of the Institute of Orthopaedics and Deputy Medical Director of the Lerdsin Hospital, Department of Medical Services, under Thailand’s Ministry of Public Health. He is also President of The Thai Society for Surgery of the Hand and an internationally published researcher.

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RadArt Gallery by Guerbet When Medical Imaging Becomes a Piece of Art

When a piece of medical imaging scan becomes a piece of art, this creates a powerful impact whether to radiology community or to the world. Not only is it an untraditional way to allow radiologists to share their routine work, but also to bring hope to numerous lives of the needed children.

The Purpose We believe in the power of art and the importance of medical imaging. This is the purpose we created RadArt Gallery by Guerbet, a campaign

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that allows the radiology community to showcase their creativity using the latest scanning technology. Whether it is MRI, CT, ultrasound, or any other imaging technology, we encourage radiolo-

“It is not just about art; however, it is about bringing creativity and humanity together in the field of medical imaging science.”

gists to use scans taken for medical diagnostic purposes to create stunning artwork. It is not just about art; however, it is about bringing creativity and humanity together in the field of medical imaging science. We desire to show the world what radiologists and radiographers do daily and raise awareness and understanding of this important specialty. What makes the campaign more beautiful is the charity purpose. We are proud to partner with the Make-A-Wish Foundation to support children with critical illnesses. The organization aims to create impactful wish to children who suffer from critical illnesses. By purchasing our 2023 calendar, featuring 12 selected RadArt pieces, participants had a chance to make a meaningful change to the numerous lives and help fulfill the dreams of these brave children. It is a philanthropic cause that we are truly passionate about.

Achievements of the Campaign With our digital effort to the campaign, we have already made a significant impact. Over 1.5 million impressions and about 150,000 engagements have gained from 82 countries in 4 months, RadArt Gallery by Guerbet has captured the hearts of audiences worldwide. Eventually, we have received over 16 incredible art submissions and sold nearly 500 calendars.

USD8,000 was raised to support children in need. The fund raised through the campaign has brought hope and joy to the lives of seven children from the Philippines, Malaysia, and Taiwan, who were battling critical illnesses including heart diseases, leukemia, and brain tumors. RadArt Gallery has turned their dreams into reality, allowing them to experience the joy and fulfilment they deserve. Through RadArt Gallery by Guerbet, we have built lasting relationships with our stakeholders, including employees, healthcare professionals, patients, and the public. We have shown our care for customers, the radiology community, and patients. We have also demonstrated our commitment to innovation and corporate responsibility.

“RadArt Gallery has turned children's dreams into reality, allowing them to experience the joy and fulfilment they deserve.

About Guerbet At Guerbet, we build lasting relationships so that we enable people to live better. That is our purpose. A world leader in medical imaging, Guerbet is a publicly traded company on the Euronext Paris Stock Exchange, headquartered in France with offices and production facilities in Europe, the Americas and Asia-Pacific. It has a long-standing reputation as a pioneer in the research and development of contrast media for radiology. Today, Guerbet contributes to progress made in the diagnosis of major disease areas including cancer, cardiovascular, inflammatory, and neurodegenerative diseases. The company’s novel and effective imaging solutions help to improve patient management throughout the world. Guerbet offers a comprehensive range of imaging products, solutions, and services for Diagnostic Imaging –MRI, X Ray, Digital Solutions / AI – and Interventional Imaging, to enhance clinical decisionmaking, from diagnosis to treatment and follow-up, and improve patients’ quality of life. For more information, please visit www.guerbet.com. Advertorial www.asianhhm.com

MEDICAL SCIENCES

ORTHOSTATIC HYPERTENSION A Risk Factor for Adverse Cardiovascular Outcomes

A body of evidence has shown that an exaggerated blood pressure (BP) response to standing (BPRTS) is often present in the general population as well as in several chronic diseases and that it may be of clinical value. In recent years, evidence has accumulated that orthostatic hypertension (OH) is associated with increased risk of hypertension, hypertension mediated organ damage, cardiovascular (CV) disease and mortality. Most information on OH comes from studies performed in elderly subjects whereas much less is known about its prevalence and clinical significance in younger individuals. In this short review the available evidence regarding the prevalence, diagnosis, pathogenetic mechanisms and risk of adverse outcomes associated with OH will be presented.. Paolo Palatini, Department of Medicine, University of Padova

Definition and prevalence

A large number of different cut-offs have been used in the literature to define an exaggerated BPRTS. In the majority of the studies OH was defined as an increase of systolic BP ≥20 mmHg and/ or an increase of diastolic BP ≥10 mmHg

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with or without including absolute values of standing BP. The prevalence of this condition proved to be much larger in elderly individuals than in younger subjects. The highest prevalence was found in the elderly participants of the PARTAGE study (28 per cent) and the

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lowest in a study by Wu et al (1.1 per cent). Very low prevalence was found in young people. Other authors used lower systolic BP cut-offs to identify people with BPRTS ranging from 5 to 15 mmHg or included orthostatic BP in the definition. In a document of the American Autonomic Society and the Japanese Society of Hypertension OH was defined as an orthostatic systolic BP increase ≥ 20 mmHg associated with a systolic BP ≥ 140 mmHg on standing. Mechanisms of BPRTS

Assuming asupright posture triggers a sequence of hemodynamic changes that prevent a fall in peripheral BP (figure). On average, the final result is a slight decline of systolic BP and a slight increase in diastolic BP. However, in some individuals, the compensatory mechanisms may lead to an exaggerated BPRTS. There is general agreement that the mechanisms leading to OH may be influenced by age. Cardiovascular hyperreactivity seems to be the main

MEDICAL SCIENCES

mechanism in young adults and vascular stiffness the driving factor in older individuals. People with high BPRTS may have normal sympathetic activity at rest but increased sympathetic response to stressful stimuli. Previous research has shown that plasma catecholamines may increase dramatically after standing up. In the HARVEST study, hyperreactors to standing had a pronounced increase in 24-hour epinephrine urinary output. Sympathetic predominance has been found to be involved in the pathogenesis of OH also in children. Although arterial stiffness is considered the most important contributor to OH in the elderly, also baroreflex dysregulation and increased sympathetic discharge can be important determinants of OH in this age class. In summary, the pathogenesis of exaggerated BPRTS is multifactorial and our knowledge about the mechanisms involved is still incomplete. How BP should be assessed in the upright posture

To have a reliable estimate of BPRTS, BP should be measured starting one minute after standing up and at least three BP readings should be obtained after assuming the upright posture. In one study BPRTS was calculated using the average of the second and third measurements. Due to the limited reproducibility of BPRTS current guidelines recommend repeated orthostatic BP assessment on a different day. For screening purposes, seated to standing position can be used to assess BPRTS. However, BPRTS may be less pronounced when using seated BP and thus in subjects with suspected OH a more reliable diagnosis can be made using supine to standing measurement. The reproducibility of OH has been found to be limited. Hoshide et al. compared the reproducibility of OH identified with clinic versus home BP. Using home BP, the concordance in the definition of OH was good with a K coefficient ranging from 0.42 to 0.51. The agreement for OH

identified by clinic BP ranged between 0.13 and 0.24. A better reproducibility of BPRTS evaluated with office BP measurement was found by others within short between-measurement periods (10 to 34 days) with intraclass correlation coefficients of 0.70 to 0.86. In the Hypertension and Ambulatory Recording Venetia Study (HARVEST) the correlation coefficients between the orthostatic changes measured at baseline and after 3 months were 0.29 (p<0.001) for both systolic and diastolic BPs. The reproducibility of OH has been found to be very poor when BPRTS was re-measured after a long time interval. However, in the SPRINT trial, a fairly good concordance was found between OH measured at baseline and OH assessed 3 years later. Risk factors associated with OH

High activity of the sympathetic nervous system and/or baroreflex dysregulation, such as in the elderly, diabetes, and essential hypertension, are

often associated with OH. In elderly subjects, diabetes is more common in patients with OH than in subjects with normal orthostatic BP. An association with obesity and metabolic risk factors has been observed either in diabetic or non diabetic subjects. Chronic kidney disease and inflammatory biomarkers are other factors that have been found to be associated with OH. In a recent analysis of the HARVEST it was found that a higher office BP and a greater BP decline during supine BP measurements were predictors of a lower BPRTS. Prediction of hypertension An exaggerated BPRTS can be a predictor of masked hypertension and as well as of sustained hypertension. Hyperreactivity to standing has been found to be associated with masked hypertension in several studies. A cross-sectional investigation performed with home BP measurement has demonstrated that OH is an independent predictor of masked

ORTHOSTATIC POSTURE

Decrease of venous return

Fall of cardiac output Transient fall of peripheral BP Reflex increase in sympathetic activity

Increase in heart rate and cardiac contractility

Vasoconstriction

Slight decline of SBP Slight increase in DBP

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OH as risk factor for CV events and all-cause mortality

Several studies such as the ARIC, the Normative Aging, and the PARTAGE studies have shown that OH is associated with increased risk of coronary events and stroke. In a large Chinese cross-sectional communitybased study, both OH and orthostatic hypotension were associated with stroke and peripheral vascular involvement. In the SPRINT (Systolic Blood Pressure Intervention Trial), an association of OH with a composite CV outcome was found within the

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intensive treatment group. Recent research from the HARVEST study has shown that an association of OH with CV events may be present also in young individuals. An independent association of OH with mortality has been found in several studies which included mainly elderly subjects. However negative data have been reported by other investigators. Inconsistencies in methodology and different characteristics of the studied populations may partly explain these conflicting results. Conclusions

Hypertension guidelines recommend measuring BP on standing only in elderly subjects to prevent the possible detrimental effects of orthostatic hypotension. The increased risk of developing organ damage and CV events in people with OH suggests that BP should be measured in the upright posture also in young individuals with the main aim of detecting a possible exaggerated BPRTS. BP on standing should be measured especially in people with borderline values of office BP in the sitting posture who are more at risk of masked hypertension and OH. Ambulatory BP monitoring data may be acquired to have a more detailed picture of the BP changes during standing. If high average 24-hour BP and/or abnormalities of the diurnal BP rhythm are detected, close follow-up with repeated visits should be implemented and antihypertensive treatment may be considered.

AUTHOR BIO

hypertension. In another cross-sectional study in a general population assessed with ambulatory BP monitoring, the frequency of masked hypertension was significantly greater in subjects who showed a BPRTS >10 mmHg. Analyses of the HARVEST study have shown that baseline BPRTS was associated with masked hypertension assessed after 3 months. The risk of masked hypertension was quadrupled for the group of hyperreactors with high urinary epinephrine compared to the normoreactors with low epinephrine. An increased risk of office hypertension was shown in the ARIC study and in the young participants from the CARDIA study but not in the Normative Aging Study, after controlling for sitting levels of systolic and diastolic BPs. The relationship between OH and hypertension may be due to an increased large artery stiffness in people with exaggerated BPRTS especially in elderly subjects. In a multiple regression analysis the orthostatic change in systolic BP was significantly and positively correlated with pulse wave velocity in hypertensive patients whereas no association was observed in non hypertensive subjects. An association between orthostatic BP changes and large artery stiffness was found also in young and middle-aged adults.

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Whether a specific antihypertensive treatment should be used in hypertensive patients with OH is not known because no randomised clinical trial has been performed. Treatment with alpha blockers has provided encouraging results, but the lack of definite evidence suggests that subjects with OH should receive the same classes of drug as any other hypertensive patient. Studies on the clinical and prognostic significance of OH have often been inconsistent due to methodological heterogeneity in definition and diagnosis. The large majority of studies have used systolic BP in evaluating the clinical significance of BPRTS but also diastolic BP reactivity has been investigated often leading to conflicting results. Future research should address the issue of appropriate definitions of BPRST and OH for different age groups. References are available at www.asianhhm.com

Paolo Palatini MD is a Professor of Medicine and Senior Scholar at University of Padova, Italy. He is the Former Head, Vascular Medicine. Chairman of ESH Working Group on ABPM and BP Variability. He has published over 500 articles and reviews in international journals. Present H-index=86 with over 31,000 citations. Received Alberto Zanchetti Award from ESH in 2021.

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Revolutionising Cancer Care Moving towards healing and hop Cancer can affect any part of the body and devastate the mental, physical, and emotional well-being of the affected. The global cancer burden, although considerable, has been reduced over the years thanks to scientific advancements and technological innovations that enable early detection, prompt treatment, a better prognosis, and improved survival. Pooja Toshniwal Paharia, Oral and Maxillofacial Physician and Radiologist, YMT Dental College

ancer, a formidable enemy, has plagued humanity for centuries and continues to pose significant challenges to health and healthcare systems. A cancer diagnosis turns an individual’s world upside down, mentally, emotionally, financially, and physically, instilling a fear of death the moment it is diagnosed, given that cancer is the second leading cause of death worldwide.

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Cancer (or tumour) refers to the uncontrollable, uncoordinated, and excessive growth of cells that may damage normal body tissues and spread to neighbouring tissues by local extension (benign tumours) or metastasize to distant parts of the body through lymph nodes or blood (malignant tumours). Causes include genetic mutations, ageing, family history, tobacco consumption, smoking, sedentary lifestyles, dietary choices, and exposure to the sun (ultraviolet radiation), and the human papillomavirus (HPV). The warning signs and symptoms of cancer include a persistent sore, a change in the size or shape of moles, new lumps or masses, persistent indigestion or altered bowel habits, unexplained or abnormal bleeding from any openings in the body, blood in vomit or urine, a persistent cough or hoarseness in voice, persistent and unexplained muscle and joint pain or fever, and unexplained weight loss. Cancer diagnosis included biopsy, tumour markers, and positron emission tomography-computed tomography (PET-CT) scans, in addition to medical history and the clinical presentation of the disease. While biopsy provides histopathological data, tumour markers indicate cancer risks, types, and chances of metastasis, and PET-CT provides vital information on the extent of tumour involvement and metastasis. Screening tests for particular cancers include the Pap test (cervical cancer), mammography (breast cancer), and colonoscopy (colon cancer). Treatments depend on tumour size, stage, grade, and the patient’s age and includes surgery, chemotherapy, radiation therapy, immunotherapy, targeted therapy, or hormonal therapy. Surgery involves tumour removal by operation, whereas radiation therapy employs the use of high-energy X-rays to kill cancer cells and shrink tumours. Chemotherapy kills cancer cells with

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Advancements in Conventional Treatment Options

Cancer, a powerful foe, has long thrown a pall over the lives of countless individuals. However, due to incredible advances in science and technology, the cancer care landscape is changing, providing patients and their families with newfound hope. Precision medicine, early detection methods, and extensive support networks are changing the way doctors address cancers. From cutting-edge treatments and individualized treatments to comprehensive patient support, the path to a cancer-free future is gathering steam.

medication, and hormonal therapy is administered to slow down or stop cancer growth. The earlier cancer is detected, the sooner and better it can be cured. The stage of cancer indicates the extent of cancer’s spread, guides the choice of treatment, assesses treatment response, and ascertains prognosis and recurrence risks. As the stage advances, the prognosis becomes worse. Oncologists follow the TNM staging system for cancer, with T representing the tumour size, N representing lymph node involvement, and M representing metastasis. Tumour grade denotes its degree of resemblance (or differentiation) with healthy cells. A tumour that does not resemble healthy tissues is poorly differentiated or high-grade, spreads rapidly, has a poor prognosis, and is therefore increasingly difficult to treat.

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Amid the challenges and heartache, there is a ray of hope as advancements in cancer care pave the way for a better future. The relentless pursuit of innovative treatments, comprehensive support systems, and personalised therapies has transformed the cancer care landscape, offering renewed optimism to cancer patients and their families. Advancements in radiation therapy such as intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), 3D-conformal radiation therapy, proton-beam therapy, brachytherapy, and image-guided radiation therapy (IGRT) have improved treatment outcomes by delivering high radiation doses to cancerous tissues while reducing harm to neighbouring healthy tissues. Advancements in surgical options include laser surgery, robotic surgery, laparoscopy, and endoscopy. Surgeries not involving tissue cuts include cryosurgery, photodynamic therapy, hyperthermia, and laser. The emergence of non-invasive treatment has reduced recovery times, improved patient compliance, improved tumour response to other therapies, and decreased tissue loss, catering to the fear that accompanies conventional surgeries. Cancer care includes managing pain, nausea, and other side effects experienced by patients (palliative care) to improve their quality of life. Empowering Precision Medicine in cancer care

A remarkable breakthrough is the use of precision medicine, based on genes, to determine treatment and predict recurrence risks. While some genes protect against cancer, i.e., tumour suppressor genes or deoxyribonucleic acid (DNA) repair genes, such as p53, BRCA-1 and 2, oncogenes (such as RAS and HER2), or mutated genes (such as p53 mutations), promote cancer formation.

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Conventional treatments often employ a one-size-fits-all approach, whereas precision medicine recognises that every patient's tumour is unique and needs tailored therapies. By analysing individual genetic profiles, particular mutations driving the tumour’s growth can be identified, enabling targeted treatments that attack tumour cells while minimising damage to healthy tissues. Targeted therapies such as smallmolecule inhibitors, immunotherapies, and monoclonal antibodies act against particular genes and proteins that enable cancers to grow and survive and prevent the formation of new blood vessels. Precision medicine also includes the study of genetic responses to drugs (pharmacogenomics) to determine the choice of drug and assess its safety. Immunotherapy involves the use of immune checkpoint inhibitors, T-cell transfers, treatment vaccines, and immune system modulators to strengthen the immune system to fight cancer. The treatments have demonstrated success in various types of cancer, such as breast cancer, lung cancer, and melanoma. They increase overall survival, prevent tumour recurrence, and improve quality of life

with minimal side effects in comparison to conventional chemotherapy. Advancing Early Cancer Detection

Early detection and prompt treatment are critical to the successful treatment of cancer. Over time, significant strides have been made in diagnostic techniques, leading to more accurate and efficient detection methods. Advanced imaging techniques, such as magnetic resonance imaging (MRI), PET-CT), and molecular imaging, facilitate the early detection of tumours. In addition, liquid biopsies, which identify cancer cells or their deoxyribonucleic acid (DNA) in circulation, have emerged as non-invasive techniques to detect cancers in their initial stages and monitor their response to treatment. Screening programmes have become widespread for colorectal, cervical, and breast cancers, enabling early treatments and, therefore, better outcomes. Increase in Comprehensive Support Systems

Cancer care is not limited to medical therapy. Recognising the social, psychological, and emotional challenges faced by patients and their loved

ones, healthcare professionals have adopted a holistic approach to cancer care. Supportive programmes have integrated services like counselling, pain management, rehabilitation, and nutritional recommendations to address the multifaceted requirements of cancer patients. Moreover, online communities, community programmes, and patient support groups have become invaluable resources, building connections between patients and providing a platform to share knowledge and experiences and gather emotional support. Educational workshops and relevant publications are available to improve cancer awareness. A Call for Enhanced Care for Oral Cancer Patients

Oral cancer, an insidious and devastating disease affecting the lips, tongue, floor of the mouth, cheeks, hard and soft palate, sinuses, or throat, profoundly impacts swallowing, eating, speech, and the overall health-associated quality of life. Radiation therapy can cause dry mouth (xerostomia), salivary gland damage and decreased salivation, oral ulcers, severe tooth decay, periodontal disease, taste alterations, mucosal inflammation (mucositis), jaw stiffness,

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reduced mouth opening (trismus), and changes in the jaw bones, such as osteoradionecrosis. Chemotherapy may also result in oral bleeding, a burning tongue, and infections due to lower white blood cell counts and bone marrow suppression. Therefore, oral cancer demands utmost attention, early detection, multidisciplinary treatment, and holistic care to improve the lives of those affected. Early detection is paramount in the battle against oral cancer, as it facilitates timely intervention and the use of lessinvasive and more effective treatment. However, oral cancer screening remains dishearteningly low. Thus, public health initiatives must prioritise educational campaigns and emphasise the need for routine oral examinations. Risk factors for oral cancer include tobacco use, betel quid chewing, alcohol intake, nutritional deficiencies, HPV transmission during oral sex, sun exposure, age, and chronic irritation to the oral mucosa. Signs and symptoms include a white or red patch in the mouth; ulcers, lumps, or swelling in the mouth, jaw, or neck that persists beyond three weeks; pain when swallowing, chewing, speaking, or moving the jaw or tongue; numbness in the tongue or other areas of the mouth; hoarseness persisting beyond six weeks; unexplained loosening of teeth; and difficulty tolerating spicy foods. Oral Cancer Care: Before, During and After Cancer Treatment

AUTHOR BIO

Before initiating cancer treatment, any potential sources of dental infection must

be identified and eliminated. Teeth with cavities must be restored with fillings, and those with severe infections must be extracted at least a week before initiating chemotherapy or radiation treatment to allow for healing. Thorough scaling and oral prophylaxis must be performed, and all sharp areas must be smoothed to prevent mucosal irritation. Fluoride gel applications could help prevent tooth decay. During cancer treatment, soft brushes and fluoridated toothpaste must be used for toothbrushing, and dentures must be worn only during meals. Flossing may be avoided if it causes bleeding in the case of low platelet counts. Commercial alcohol-containing mouthwashes must also be avoided since alcohol may irritate the mucosa. Daily warm water or baking soda and water rinses could help maintain oral health. Analgesics may be used to reduce pain; however, non-steroidal antiinflammatory drugs such as aspirin must be avoided since they may cause bleeding problems. Caffeinated beverages must be avoided due to potential oral dryness. Citrus fruits and tomato juice may irritate mouth sores. Regular jaw exercises, artificial saliva substitutes, and medications that coat the oral mucosa to protect it while eating, along with topical anaesthetics, are also essential. Patients must use sugar-free gums or candies, hydrate, avoid hot, spicy, sharp, and crunchy foods that could irritate the mucosa, and refrain from tobacco and alcohol use. Lip moisturisers may prevent the lips from cracking. After cancer treatment, good oral hygiene must be maintained with

Dr. Pooja Toshniwal Paharia, an Oral and Maxillofacial Physician and Radiologist, practises evidence-based medicine and works as a medical writer for News Medical (freelance). With a strong belief that health awareness is the key to disease prevention, she desires to contribute to the community by providing updated health-related information.

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regular scaling and cleaning, and fluoride treatments must be continued. Dentures must be relined six months after treatment to adapt to changes in the mouth. Patients must adhere to low-sugar and nutritionally balanced diets, drink at least eight glasses of water daily, and continue to avoid caffeine, tobacco, and alcohol. Beyond medical treatment, holistic patient care is important to promote the psychological, physical, and emotional well-being of oral cancer patients. Supportive measures must include pain management strategies, dental rehabilitation, speech and swallowing therapy, psychological counselling, and nutritional support to alleviate the burden and promote the health of patients. Conclusion

The cancer care landscape has undergone an astounding transformation, offering new avenues for patients and their families. Precision medicine has revolutionised the approach to cancer therapy, allowing for tailored therapies that target the cause of cancer. Early detection techniques continue to advance, offering the assurance of detecting tumours in the initial stages and facilitating more effective treatment. The incorporation of comprehensive support systems into cancer care acknowledges the holistic requirements of patients, providing vital psychological and emotional support. Challenges such as improving accessibility to cancer care facilities and overcoming health disparities remain; however, the progress attained in recent times fuels the hope of a future excluding the catastrophic impact of cancer. Continued investments in cancer research and advanced technology, coupled with an empathetic approach to cancer care, could pave the way for a cancer-free world. References are available at www.asianhhm.com

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Pitfalls in Acute Ischemic Stroke Treatment

A recent analysis showed that one fourth of all ischemic stroke cases can be labelled as fake strokes. Furthermore, one out of four is treated as an acute stroke with a very good outcome, but severe complications occur in the minority of them. It raises the need for proper staff education as well as the inclusion of sophisticated brain imaging. Gergely Feher, Consultant Neurologist and Stroke Physician

schemic stroke (i.e., a brain vessel occluded by a blood clot) is the leading cause of disability and one of the leading causes of deaths worldwide. There are effective strategies in the treatment of acute ischemic stroke (AIS) including systemic thrombolysis

and endovascular procedures. Systemic thrombolysis means intravenous application of a thrombolytic (clot busting) agent to restore cerebral blood with subsequent improvement or resolution of neurologic deficits (clot busting therapy). Thrombectomy

involves artherial catheter insertion (thin tubes visible under X-rays) through the groin or the arm to reach the occluded vessel for clot removal (similar to the procedure in the case of myocardial infarction). There is a limited time window to carry out these procedures (usually 4.5-6 hours for systemic thrombolysis and 6-9 hours for thrombectomy, although exceptions occur) as their efficacy is time-dependent (time-is-brain concept), therefore shortening time window (from admission to procedure) is crucial in the emergency department. Enormous efforts have been recently made to improve the clinical outcome of stroke patients including testing up comprehensive stroke units and the increased availability of hyperacute stroke treatment and shortened procedure time also have lead to inappropriate inclusion and treatment of so-called ischemic stroke mimics (ie. non-stroke patients). A recent systemic review and analysis (in-depth and detailed summary of the existing medical literature) including the data of 61 studies with more than

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Table 1: Most common stroke mimics

62.000 participants showed that approximately one-in-four stroke calls in the emergency department is inappropriate. Fake stroke calls and admissions (stroke mimics) most likely include patients with vertigo/ dizziness, patients with intoxication or severe metabolic disturbances (hyperglycaemia, sepsis etc.), epileptic seizure with subsequent limb weakness, psychiatric disease (functional disorder) and complicated migraine (headache with preceeding neurological symptoms such as visual disturbances or slurred speach) as can be seen in Table 1. Vertigo/dizziness is a common complaint of patients seeking medical attendance, however, stroke syndromes are responsible for only 3–5 per cent of all emergency cases. In the case of acute stroke dizziness/vertigo usually accompanies other neurological symptoms and signs but it can be challenging. Interestingly, detailed head imaging including perfusion techniques (see below) are not as sensitive as simple physical manouvre called HINTS test (Head-Impulse—Nystagmus—Test-ofSkew). Metabolic/toxic disturbances were the second most common cause of stroke mimics in the mentioned comprehensive review. These are usually detectable in the laboratory, but the lack of detailed

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blood test results is not an exclusionary criteria based on current guidelines (taking blood sample is mandatory, but clot busting therapy can be carried out before blood tests can get ready to shorten procedure time). Seizure has been recognised as a cause of postictal paresis (subsequent weakness to epileptic seizure) since the 19th century. Postictal dysphasia (speech disturbance) has also been reported to follow dominant hemisphere seizures. If a previous seizure is unwittnessed these symptoms are easy to misdiagnose as a stroke or a transient neurological symptoms of vascular origin. Although seizures can occur due to ischemic strokes, especially in cortical lesions, but these are rarities, the presence of a seizure usually implies other etiology than ischemic stroke. Surprisingly, an underlying psychiatric disease (so called functional neurological disorder) is also a great imitator of ischemic stroke responsible for a significant number of fake stroke calls and admissions. History of psychitaric disease is usually common in these patients, neurological symptoms (weakness, speech disturbance etc) are usually atypical and fluctuating. Physical examination usually shows inconsistent findings with repeated examinations as concluded by the authors. Interestingly,

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a simple manouvre called Hoover sign – which means weakness of voluntary hip extension with normal involuntary hip extension during contralateral hip flexion against resistance – can be very specific in the diagnosis of functional stroke mimics. Migraine can also be a great imitator of stroke. Complicated migraine (so called migraine with aura) can be challenging as headache occurs after the presence of neurological symptoms (most likely visual disturbances, numbness and tingling, but speech disturbances or rarely one-sided weakness can also occur). Careful patient evaluation including questions about previous similar symptoms as well as the application of perfusion techniques are usually required (see below). Sudden onset of neurological symptoms also can develop in patients with intracranial tumors and primary intracranial malignancies may require extensive diagnostic workup including sophisticated head imaging as routine procedures (plain head computer tomography) can be misleading (false negative). Apart from the above mentioned etiologies collapsing/presyncope, mononeuropathy, acute confusion, dementia and spinal lesions are less common stroke imitators. These are usually easily detectable, but it can be challenging in the minority of cases as concluded by the authors. This analysis also showed that approximately 25 per cent of stroke mimics can be thrombolysed (clot busting therapy) so they receive conventional stroke therapy which can be associated with severe complications as major bleeding. Stroke mimics had very low overall intracranial bleeding and mortality rates comparing to ischemic stroke individuals and had more favourable outcome, which is not surprising as symptoms were not of cerebrovascular origin. The explanation of these findings is partially due to the fact that ischemic

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Suspected acute stroke <24 h

History and clinical examination with focus on established time of onset and vascular localization of the symptoms

High probability stroke mimic Cnsider MRI DWI and/or multimodal brain imaging Consider blood test and bedside toxicology (if necessary)

Possible stroke mimic Consider DWI and or multimodal brain imaging 1. If stroke is confirmed continue acut stroke/thrombolysis pathway 2. If no imaging abnormalitis consider blood test and toxicology (if necessary)

High probability stroke 1. Onset <4.5 h - Consider CTA to pick up extra- or intracranial stenosis or large vessel occlusion Consider thrombolysis/thrombectomy 2. Onset > 4.5 h — Consider CTA (see above) and CTP to detect penumbra (if there is any) Consider thrombolyis/thromectomy

Acute isolated vertigo with no definite neurological sings Consider MRT DWT Consider HINTS manouvre 1. If stroke is confirmed continue acute stroke/thrombolysis pathway 2. If no imaging abnormalitics consider blood tests and toxicology (if necessary)

Figure 1: Management of acute stroke and stroke mimics

stroke is usually an exclusionary clinical diagnosis in the emergency room. The differential diagnosis of ischemic stroke (so called ischemic stroke mimics) is an umbrella term rather than a single disease. As rapid diagnostic accuracy is required due to the ‘time-is-brain’ concept, sophisticated brain imaging, which can delineate arterial occlusion from other etiologies including seizures and complicated migraine such as magnetic resonance imaging (MRI) or multimodal brain imaging (perfusion CT or MRI) are sparse even in pending situations to avoid significant delay in revascularisation. Secondly, rapid assessment are attributable to the involvement of emergency staff as first contact who are not properly trained in the detection of stroke mimics, and the relatively low specificity of currently used stroke scales. Potential emergency management of stroke and stroke mimic patients can be seen in Figure 1. So the set up of comprehensive stroke centres including multimodal brain imaging as well ass strict attachment to

guidelines and the training of staff may help to avoid the unnecessary admission and treatment of stroke mimics. The United States is a front-runner in stroke management, however, results of the Get With The Guidelines–Stroke Registry showed that about 3.5 per cent of the treated patients can be labelled as stroke mimics and 2/3 of them had no definite

diagnosis on discharge. Furthermore, they have found an overall trend of treating fake strokes in recent years. The evaluation of stroke mimics merits further investigation and possible modification of the current guidelines. References are available at www.asianhhm.com

AUTHOR BIO Gergely Feher MD, PhD is a Consultant Neurologist and Stroke Physician. He was a Specialist Registrar in Stroke and Neurology at the East Kent Hospitals University NHS Foundation Trust (England). He took his profesional exam in neurology in 2011. He got his PhD degree in 2009 and habilitation in neurology in 2017. Based on his professional and scientific achievements, he was included in publication “Future Shapers of Medicine - TOP 25 Emerging Talents in Hungary” in 2014. He has previously held the position of Chief Medical Officer, and more recently he has focused on his research and teaching responsibilities in addition to outpatient care. He is a PhD program manager in the Doctoral School of Clinical Neurosciences at the University of Pécs, and he plays an imporant role in the professional training of Hungarian stroke physicians.

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Zyad J Carr

Perioperative Pulmonary Complications in Geriatric Populations A costly problem for healthcare systems

There is increasing recognition of the role that perioperative pulmonary complications play in the direct and indirect costs associated with surgery. Though current interventions to mitigate these costly complications are available, most remain unclear regarding efficacy. In this mini review, we’ll identify, define, and raise awareness regarding perioperative pulmonary complications. Zyad J Carr, Associate Professor, Anesthesiology, Yale University School of Medicine

nnually, more than 300 million surgical procedures are performed worldwide. Surgical volume has commensurately increased with the projected increase in global geriatric populations with an estimated

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two billion over the age of 60 years old by the end of 2050. Estimates of perioperative pulmonary complications (PPC) range from 6-9 per cent and substantially impact the cost and quality of care provided by surgical services1.

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For example, postoperative pneumonia (POP) is estimated to cost the United States healthcare system approximately US$11.9 billion dollars in additional expenditure per annum. This adds approximately US$717 dollars to the average cost of an elective surgical procedure and ~US$25,000 dollars per PPC2. These estimates are limited however by how PPC are measured. PPC endpoints are highly dependent on researcher or monitoring governmental agencies selection processes, a significant issue limiting precise estimates of cost of care and impact to national or international healthcare systems. It is highly probable that these costly complications are underreported. It is clear, however, that global healthcare systems should treat these adverse perioperative outcomes seriously as they generate substantial costs that negatively impact expected budgets, patient morbidity and mortality after elective surgical procedures. The increase in geriatric populations predicts an increase in perioperative pulmonary complications

The burgeoning global geriatric population is particularly prone to PPC, of which the causes are multifactorial and multisystemic. The ageing heart and lung (diastolic heart failure, pulmonary hypertension, and other age-related disorders), acquired disease

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Zyad J Carr (interstitial lung disease, smoking related emphysema, obstructive sleep apnea, and procedural invasiveness all independently contribute to PPC, adding length of stay, morbidity, and mortality. Comorbidities at particular risk for PPC include chronic obstructive pulmonary disease, interstitial lung disease and obstructive sleep apnea. These and many other disorders are associated with age-related increases, magnifying the risk of PPC-related morbidity in geriatric populations. Thoracic surgery, cardiac surgery and oncological surgery service lines are at heightened risk of substantial acquired cost of care related to PPC. How do we best reduce perioperative pulmonary complications?

AUTHOR BIO

The conundrum on how to best reduce PPC remains. There is active ongoing clinical and translational research in PPC but, at this time, few clinical interventions have been proven to definitively prevent or mitigate the risk of PPC. Complex risk assessment tools are available but are generally time consuming or unwieldy for the typical high volume of

preoperative patients seen by pre-surgical evaluation clinics3. Research has been performed in the area of preoperative risk stratification, particularly to target patient for pre-habilitative interventions before surgery. New evidence has supported the quantification of frailty as a superior measure to increasing age. Frailty may be defined as a condition of increased age-associated deterioration of physiology precipitating a lower cardiopulmonary reserve for stressors such as surgery or infection. Over 27 indices of frailty exist, although the most commonly used is the Phenotype of Frailty Index4,5. Appropriate identification is critical as there is supportive evidence that prehabilitation, defined as interventions performed with a focus on improving functional capacity prior to surgical procedure and the aim of reducing post-operative morbidity and mortality, may be effective interventions to reduce PPC6,7. These pre-habilitative interventions may be as simple as instructions regarding inspiratory muscle training or as complex as preoperative nutritional supplementation and physiotherapy. This is an active area of clinical research Zyad James Carr, Associate Professor, Anesthesiology at Yale University School of Medicine, Connecticut, USA. He is a fellow of the American Society of Anesthesiologists. His active research interests are preoperative risk stratification and perioperative pulmonary complications.

with encouraging findings regarding PPC reduction, however, the value is, as of yet, still unclear8. Some simple and costeffective intraoperative interventions have shown benefit such as application of lung-protective ventilatory strategies, appropriate selection of anaesthetic or neuromuscular blockade reversal9. After cardiac surgery, the selective use of noninvasive positive pressure ventilation devices has been observed to significantly reduce post-operative hypoxemia, pneumonia, reintubation, and intensive care unit readmission rates10. Simplified bundled respiratory care after surgery (aspiration precautions, oral care and incentive spirometry) have also shown promise in reducing PPC11,12. Conclusion

The cost burden of PPC, particularly with a rapidly aging global population and commensurate increase in demand for surgical services, is a challenge for global healthcare systems. Postoperative pneumonia, in particular, is a costly complication with significant morbidity and mortality. Patients deserve a high-quality healthcare experience with reduced risk of pulmonary complications. Thoughtful integration of PPC mitigation strategies will reduce perioperative morbidity and mortality. Identifying PPC patients early allows for close observation and in the case of pneumonia early treatment. Bundling small interventions (oral care, early mobilisation, incentive spirometry, etc.) may act as a force multiplier in exploiting low-cost, high yield interventions. Some interventions, such as prophylactic highflow nasal cannula, although costly, may provide reduced downstream cost. The goal is to always identify, quantify and intervene prior to PPC and I am optimistic that ongoing clinical and translational research into these high-risk complications will continue to improve clinical outcomes and reduce cost of care. References are available at www.asianhhm.com

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SURGICAL SPECIALITY

Revolutionising Cerebrovascular Surgery

Unlocking the potential of artificial intelligence and robotics

The integration of artificial intelligence and robotics in cerebrovascular surgery has the potential to bring about significant improvement in patient care, surgical outcomes, cost-efficiency, and training of cerebrovascular surgeons. These advancements can revolutionise neurointerventional procedures, address unmet needs in acute stroke care, and shape the future of cerebrovascular surgery globally. Stephen Wong, John S Dunn Presidential Distinguished Chair and Chief Research Informatics Officer, Houston Methodist Hospital Kelvin Wong, Director of Neuroimaging Research Ting Tsung and Wei Fong Chao Center for BRAIN Rahul Ghosh, Biomedical Engineering, Texas A&M University

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What is Cerebrovascular Surgery?

Cerebrovascular surgery encompasses a range of specialised procedures performed by neurosurgeons to address blood vessel conditions affecting the brain. These surgeries can be broadly classified into two categories: open surgeries, which involve direct access

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and manipulation of cerebral vessels, and endovascular interventions (or neurointervention), which are minimally invasive procedures accessing cerebral vessels through distant sites in the wrist or thigh. With the intricate nature of the skull base and the significant burden on patients associated with open neurosurgery, endovascular interventions have emerged as the preferred initial approach in cerebrovascular surgery. Open surgery is reserved for cases with challenging anatomy or disease processes for endovascular treatments. Endovascular interventions involve the delicate navigation of wires and catheters through the brain's arteries using continuous X-ray fluoroscopy for real-time catheter positioning. Initially recognized for their effectiveness in treating aneurysms and arteriovenous malformations, these procedures have experienced significant growth in the treatment of acute ischemic stroke with mechanical thrombectomy. Acute ischemic stroke occurs when a blood clot obstructs an artery that supplies the brain, leading to oxygen deprivation and subsequent brain tissue damage. Several clinical trials have unequivocally demonstrated the superiority of mechanical thrombectomy, an endovascular procedure that removes blood clots from arteries, over traditional medical management for certain types of strokes caused by occlusion of major arteries supplying large portions of the brain. With a number-needed-to-treat of 2.6, mechanical thrombectomy carries the highest magnitude of benefit in reducing stroke-related disability among all stroke treatments, and is one of the most effective interventions. Mechanical thrombectomy not only offers improved functional independence for patients but also is cost-effective, resulting in savings of over US$18,000 per patient and more than US$105,000 per qualityadjusted year of life in a clinical outcome study conducted in Netherlands5. Despite the compelling evidence supporting mechanical thrombectomy,

AI and robotic technologies in cerebrovascular interventions herald a new era, extending expert care to remote regions and revolutionising patient treatment.

a global survey conducted by Mission Thrombectomy 2020+, a global network of experts focused on improving access mechanical thrombectomy, found that the median of 2.8% of eligible stroke patients across 67 countries undergo mechanical thrombectomy, highlighting a significant potential increase in demand for endovascular interventions and the pressing need to expand comprehensive stroke care systems. Gaps and Opportunities in Cerebrovascular Intervention

Stroke is a leading cause of mortality in China with an estimated 343 per 100,000 person-years. It remains the second-leading cause of death globally, with approximately 12 million new cases annually and an estimated global cost of over US$721 billion. Timely removal of the offending blood clot causing a stroke is critical to achieve favourable patient outcomes. Research suggests that approximately 1.9 million brain cells are lost per minute when a stroke is left untreated. Mechanical thrombectomy, a procedure capable of treating large vessel occlusions responsible for about 30 per cent of acute strokes, is highly effective at preventing stroke-related disability.

However, despite the proven benefits, among the 24 Asian countries included in the MT-GLASS study, a median of only 6.4 per cent of eligible patients received mechanical thrombectomy from 2020 to 2021, with a significant disparity between the countries with the highest (Bahrain, 45 per cent) and lowest (Bangladesh, 0.1 per cent) treatment rates among countries with a nonzero access to mechanical thrombectomy. Notably, the two most populous countries, China and India, reported only treating 7.3 per cent and 1.8 per cent of eligible patients, respectively, suggesting a massive patient population in Asia with an unmet need for neurointerventional stroke care. The underlying factors contributing to this care gap are multifaceted, stemming from the urgent nature of stroke treatment, the geographical distribution of potential stroke patients, and the scarcity of specialised centres and surgeons trained to deliver neurointerventional care. To illustrate, a significant percentage of stroke patients in the United States, especially those in rural areas (over 50 per cent of all stroke patients and 75 per cent of rural patients), with strokes caused by large vessel occlusions do not have immediate access to centres equipped for mechanical thrombectomy. Training additional surgeons and establishing more stroke centres seem like straightforward approaches, but they come with their own set of challenges. The training for neurointerventional surgeons is rigorous and lengthy, requiring fellowship-level training and exposure to a significantly volume of cases. Simply increasing the number of stroke intervention centres and staffing them with physicians may not guarantee the dissemination of high-quality care. Studies have shown that centres with higher case volumes consistently demonstrate better patient outcomes, suggesting that concentration of expertise leads to improved results. This creates a dilemma: expanding the number and geographic distribution of neurointerventional surgeons may reduce the time to treat, potentially

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improving outcomes. However, it may also dilute the level of expertise available, compromising patient outcomes. Achieving the ideal scenario of having an expert present everywhere simultaneously is impractical and costly. Artificial Intelligence & Robotics: A Solution to the Expert Dissemination Dilemma

Endovascular robotics and artificial intelligence (AI) provide promising solutions to this dilemma. Endovascular robots offer the possibility of remote presence, enabling a distributed network of robots that can extend the “hands” of an expert surgeon to areas where specialised expertise is limited. Coupled with AI, endovascular robotics can further present opportunities for improving the quality and accessibility of cerebrovascular surgery. AI algorithms can assimilate and learn from the collective experiences of numerous neurosurgeons, creating a "super expert" that can continuously improve over time. This “super expert” can serve as an autopilot during endovascular interventions, providing guidance and support to less-experienced surgeons or operating autonomously when needed. The integration of endovascular robotics and AI holds great promise for improving the accessibility, quality, and cost-effectiveness of cerebrovascular surgery. Benefits to Patients and Healthcare Systems

The integration of AI and robotics in cerebrovascular interventions has the potential to revolutionise healthcare systems by extending life-saving neurointerventional care to a significantly larger number of patients who would otherwise face barriers to accessing specialised centres promptly, which can lead to substantial improvements in patient outcomes, reduced disability, and cost savings. The combination of AI and robotics in neurointerventional procedures

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has the potential to enhance safety and accuracy by mitigating the risk of human errors, fatigue, and distraction, particularly during complex and lengthy procedures. Additionally, integrating AI with robotic systems can address the issue of varying skill levels and experience among human operators, thereby improving the standardisation and consistency of neurointerventional procedures. By automating tasks such as catheter navigation and device deployment, self-driving robots can maintain a consistently high level of precision and accuracy throughout the procedure, ultimately improving patient outcomes and reducing complications. This standardisation improves the predictability and reliability of results and promotes the adoption of best practices in the field. In addition to improving patient outcomes, AI-augmented robotic neurointerventions can increase the efficiency and productivity of healthcare centres. With automated systems performing certain tasks more efficiently, timely, and accurately, potentially leading to faster diagnoses and treatments. This increased efficiency allows medical centres to handle a greater volume of procedures, maximise resource utilisation, and enhance overall productivity. Furthermore, the integration of self-driving robotic systems in neurointerventional care has the potential for significant cost savings. By improving patient outcomes and reducing complications, there can be substantial savings associated with reduced disability and longterm healthcare costs. Additionally, the increased volume of procedures performed per centre, facilitated by the efficiency of robotic systems, can lead to cost savings through economies of scale and resource optimisation. Overall, the benefits of integrating AI and robotics in cerebrovascular interventions extend beyond improved patient access and outcomes. These advancements enhance the safety,

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consistency, and efficiency of procedures, leading to cost savings for the healthcare system. By leveraging advanced technology, healthcare centres can provide high-quality neurointerventional care to a larger patient population, improving lives and transforming healthcare delivery. Potential Benefits to Physicians

Endovascular robots have the potential to significantly enhance the productivity of the neurointerventional physicians by alleviating cognitive and orthopaedic stress, leveraging automation for timesaving precision, and revolutionising training through remote proctoring and automated feedback. By allowing operators to sit in a radiation-shielded enclosure, robotic systems minimise the occupational risks of ionising radiation and orthopaedic stress, providing a safer working environment for neurointerventional radiologists and neurosurgeons. The ergonomic setup allows the physician to view the fluoroscopy display from a sitting position, just a few feet away, without the burden of lead and sterile gowning. This proximity facilitates natural interaction with computer vision and image processing functionalities, enhancing the physician's ability to interpret and analyse complex anatomy. Moreover, endovascular robots enable superhuman dexterity, with large joystick deflections translated into precise millimeter-scale movements of intravascular devices. Automated force sensing further enhances the precision of procedures, making them less reliant on operators' physical senses and improving overall safety and consistency. Automation of certain aspects of interventions, such as navigation, can bring significant benefits to neurointerventional procedures by saving time and allowing interventional physicians to focus on higher-level tasks. For example, in mechanical thrombectomy for stroke, navigating through tortuous vessels can be

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AUTHOR BIO

challenging and time-consuming. Similarly, in diagnostic procedures, the primary task of the neurointerventional physician is to safely navigate the catheter to the target vessels. By relieving neurosurgeons or interventional radiologists from the burden of catheter navigation, automated systems can empower technologists and supporting staff to acquire angiography images, freeing up the physician's time for reviewing and interpreting the images. This logistical flexibility allows the physicians to efficiently schedule diagnostic procedures alongside their open surgeries and other interventional cases. Furthermore, the integration of robotics and AI has the potential to revolutionise the training experience for new neurosurgeons and extend

the reach of experienced mentors, addressing the shortage of skilled neurointerventional physicians. Robotic telepresence enables experienced neurointerventional physicians to teach and mentor new physicians remotely, overcoming geographical barriers. Computer vision techniques can further enhance the training experience by automatically assessing trainees' abilities, provide personalised feedback to trainees for improvement, and generate comprehensive recordings of their performance, similar to athletes reviewing game footage, enabling in-depth analysis and facilitating growth and learning. The automation capabilities of robotic systems can reduce the impact of individual skills and enable trainees to attain

Stephen T.C. Wong, Ph.D., P.E. is the John S. Dunn Presidential Distinguished Chair, Director the T.T. and W.F. Chao Center for BRAIN, and Associate Director of Neal Cancer Center, Houston Methodist Hospital, and a Professor of Radiology, Neuroscience, Pathology and Laboratory Medicine of Cornell University. He contributed significantly to the fields of AI in medicine, medical imaging, bioinformatics, systems medicine, and digital health for four decades. He is a fellow of IEEE, AIMBE, IAMBE, AMIA, and AAIA. Kelvin Wong, Ph.D. is the Director of Neuroimaging Research at the T.T. and W.F. Chao Center for BRAIN and an Associate Professor of Radiology at Houston Methodist Hospital and Weill Cornell Medicine, Cornell University. He has over twenty years of research and development experience in MRI and CT as well as AI applications in medical imaging.

Rahul Ghosh, M.Sc. is an M.D./Ph.D. candidate in Biomedical Engineering at Texas A&M University. His dissertation research at Houston Methodist Hospital under Dr. Stephen Wong aims to develop artificial intelligence methods to detect and localise intravascular devices during cerebrovascular interventions.

an expert level of proficiency at an accelerated pace. These strategies not only enhance the training pipeline but also foster the development of a robust neurointerventional workforce. Risks and Limitations

There are technical and operational challenges that could hinder wide adoption however. First, remote interventions cannot be conducted by a remote surgeon alone. At minimum, trained on-site technologists and an on-site physician capable of establishing the initial vascular access are necessary. Remote interventions are predicated on a stable and fast network connection, and delays between a surgeon’s input commands and catheter motion could impact safety and efficacy. Although rare, remote endovascular interventions may have intra-operative complications, such as bleeding, embolism or swelling, that may require conversion to open neurosurgery. Even in the absence of intra-operative complications, some patients will need to be monitored in neurological intensive care units. In these scenarios, transfer is inevitable, and attempting to save time with a remote intervention may have equivocal or negative impact on these patients’ final outcomes. Conclusion

The integration of AI and robotics in cerebrovascular surgery heralds a new era of innovation that offers substantial benefits to the healthcare system, neurointerventional physicians, and patients. These technologies have the potential to overcome barriers to patient access, improve outcomes, and enhance cost-efficiency. By empowering physicians with advanced capabilities, ensuring patient safety, improving training experiences, and enabling autonomous technology, these advancements will revolutionise the field of cerebrovascular surgery and deliver exceptional healthcare outcomes worldwide.

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Perioperative Assessment and Management of Patients with Aortic Stenosis Undergoing Non-Cardiac Surgery Aortic stenosis (AS) is a prevalent cardiac valve pathology, particularly in the elderly population, and is associated with increased morbidity and mortality. Common risk factors for AS include ageing, smoking, hypertension, and hyperlipidemia. AS is characterised by progressive valvular leaflet calcification, inflammation and lipid accumulation, resulting in rigidity, immobility and reduced leaflet opening. Additionally, left ventricular hypertrophy is frequently observed in patients with AS. Even in asymptomatic severe patients, the likelihood of cardiac mortality and need for surgical aortic valve replacement increases over time. Patients with severe AS face an elevated risk of developing major adverse cardiovascular events (MACE) after major non-cardiac surgery (NCS). While AS has been associated with high perioperative mortality, recent studies indicate a potential decrease in mortality rates. . Sushil Allen Luis, MBBS, PhD, FRACP, FACC, FASE, Department of Cardiovascular Medicine, Mayo Clinic Serena Rahme, MD, Department of Cardiovascular Medicine, Mayo Clinic

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ccurate preoperative assessment plays a crucial role in identifying high-risk patients and implementing appropriate management strategies. Preoperative assessment of AS involves evaluating the severity of AS and considering concurrent conditions, particularly coronary artery disease (CAD) and chronic kidney disease (CKD). Transthoracic echocardiography (TTE) is a valuable non-invasive tool for assessing AS severity, left ventricular systolic and diastolic function, left ventricular hypertrophy, and other valvular diseases. Current guidelines recommend perioperative TTE for patients with known AS to determine appropriate perioperative management, if echocardiography has not been performed within the past 12 months or if there have been significant changes in clinical status or physical examination since the prior evaluation. Progression

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of AS leads to an average annual increase in the transaortic pressure gradient of approximately 3mmHg per year and decrease in the aortic valve area by 0.3 cm2. It is recommended that the transaortic gradient be measured when the patient is normotensive, as systemic hypertension can augment valve obstruction and reduce forward flow, potentially leading to an underestimation of the severity of valvular disease. Concomitant diseases, such as coronary artery disease (CAD) and chronic kidney disease (CKD), should also be evaluated. CAD frequently coexists in patients with AS. CKD has a higher prevalence in patients with AS and is correlated with increased mortality. Baseline renal function should be assessed, as it is an important factor in determining the risk of acute kidney injury (AKI) after aortic valve replacement (AVR).

Patients with severe AS patients are at an increased risk of major adverse cardiovascular events (MACE), primarily due to hypotension and tachycardia induced by anaesthesia and surgical stress. Unforeseen surgical site bleeding can further worsen hemodynamics. A meta-analysis including just under 30,000 patients demonstrated that both symptomatic and asymptomatic AS patients were associated with an increased risk of myocardial infarction and MACE, without increased mortality. In a study, comparing severe AS patients who had and had not undergone AVR prior to non-emergent/non-urgent major non-cardiac surgery, higher rates of blood transfusions, hemodynamic monitoring, and catecholamine use were seen in those patients who did not undergo antecedent AVR. Increased MACE, driven primarily by a higher incidence of heart failure, was seen

amongst severe AS patients undergoing major NCS without antecedent AVR. However, there was no increase in the incidence of myocardial infarction or 30-day mortality regardless of whether or not AVR was performed prior to NCS. Limited evidence suggests that major NCS may accelerate the progression of AS, but further studies are needed. The estimation of cardiovascular morbidity and mortality in patients requires consideration of both individual comorbidities and the type of procedure or surgery. Surgical-related risks are determined by the nature and duration of the operation, and surgical risk assessment tools may be utilised to evaluate 30-day risk of cardiovascular mortality, myocardial infarction, and stroke. Tashiro et al identified need for emergency surgery, atrial fibrillation and kidney disease (serum creatinine>2mg/dL) as predictors

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Adults with symptomatic highgradient AS should be considered for AVR. The choice between SAVR and TAVR depends on factors such as age, comorbidities, and anticoagulation preferences.

AUTHOR BIO

of worse outcomes in patients with severe AS undergoing NCS. Similarly, Agarwal et al. also identified high-risk NCS, symptoms related to severe AS, coexistent moderate or severe mitral regurgitation, and known CAD as predictors of MACE at 30-days in AS patients undergoing major NCS. The 2020 ACC/AHA guidelines for management of patients with valvular heart disease provide numerous recommendations for aortic valve intervention in patients with severe AS, including Class I recommendations for intervention in symptomatic patients and those with reduced left ventricular systolic function (defined as LVEF <50 per cent). Severe AS patients meeting guideline indications for intervention should consider proceeding with aortic valve intervention prior to NCS, due to longer term prognostic implications related to their aortic valve disease and independent of their need for NCS. Asymptomatic patients with severe AS who do not have left ventricular dysfunction may consider elective NCS without prior aortic valve intervention, although close hemodynamic monitoring is recommended. Delaying NCS may be inappropriate in certain scenarios, such as aggressive malignancies, and proceeding with NCS may be reasonable in understanding the elevated risk of postoperative heart failure, albeit without a significant increase in periprocedural cardiac mortality. Where aortic valve replacement is pursued prior to NCS, the choice between surgical and transcatheter aortic valve replacement depends on a variety of factors including patient characteristics, age, comorbidities, and vascular access. Post-aortic valve recovery time prior to NCS may be an important consideration, and transcatheter AVR may allow a shorter convalescence prior to proceeding with NCS. Aortic balloon valvuloplasty may be considered for short-term relief

of AS prior to NCS in patients who are poor surgical or procedural candidates for aortic valve intervention. The perioperative management of patients with AS undergoing NCS requires careful assessment, risk stratification and consideration of aortic valve intervention strategies. Routine preoperative assessment should include transthoracic echocardiography, as well as evaluation for CAD and CKD. While NCS may be performed safely with close hemodynamic monitoring in asymptomatic patients with preserved left ventricular systolic function without preceding aortic valve replacement: patients with indications for aortic valve intervention based on current valvular heart disease guidelines should be considered prior to NCS. References are available at www.asianhhm.com

Serena Rahme pursued medical studies at Saint Joseph University in Beirut, Lebanon. She is currently a postdoctoral research fellow in the Cardiovascular Department at Mayo Clinic in Rochester, Minnesota, under the guidance of Drs. Luis and Nkomo. Her research interests revolve around cardiovascular imaging, with the goal of becoming a cardiologist.

S Allen Luis is the Associate Dean for Student and Faculty Affairs at the Mayo Clinic School of Health Sciences; Associate Chair for Education for the Department of Cardiovascular Diseases; and Medical Director for the Mayo Clinic School of Health Sciences Echocardiography and Advanced Cardiovascular Sonography Programs. He is also Co-director of the Pericardial Diseases Clinic and an Associate Professor of Medicine at Mayo Clinic (Rochester, Minnesota). His areas of clinical and research interests include valvular heart disease, echocardiography, pericardial diseases, and carcinoid heart disease.

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CoverStory

Advancing Healthcare Through Digital Transformation Harnessing data and AI for improved patient care Digital transformation in Healthcare, through data and artificial intelligence (AI) solutions, is the way to overcome the significant challenges the healthcare services are facing across the globe. Despite substantial healthcare data, fragmentation limits its utility. AI can unlock its potential, aiding diagnostics, treatment, and patient care. Unified patient data platforms and AI-driven insights can improve healthcare accuracy, personalised treatment, and patient monitoring.

ealth is, most probably, the number one priority when we think about ourselves, our families, friends and our loved ones. It’s widely agreed that healthcare services, with the different models available across the globe, need to serve people in an effective and efficient way, to give us the best healthcare possible. But what does ‘the best healthcare possible’ really mean? If we try to ground this to more specific targets, ‘the best healthcare possible’ is about keeping us healthy for as long as possible, and to have a quick and

David Labajo Izquierdo Digital Health Advisor, formerly Vice President Healthcare Digital EMEA, General Electric Healthcare

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accurate diagnosis, to receive the right treatment fast and promptly, to get timely interventions, and to have convenient and sufficient follow-ups to ensure the right patient progress whenever a potential health issue appears. However, everywhere in the world healthcare services are facing major challenges preventing them to accomplish these objectives successfully: • A rapidly ageing population leading to a higher prevalence of chronic conditions with high cost for the healthcare systems, versus more acute patients and incidents predominant 50 years ago • An increasing incidence of oncology and cardiology conditions, due to ageing but also non-healthy lifestyle, placing higher pressure on healthcare resources and costs • The emergence of complex diagnostic technologies and specialised treatments that improve clinical outcomes but necessitate heightened specialisation among healthcare professionals, leading to increased costs • A shortage of healthcare professionals, with an estimated shortfall of around 18 million specialised professionals globally by 2030 , with no perspectives of substantial changes in the near, medium or long term. Under these conditions, the only way to overcome challenges and improve the outcomes of our healthcare services is

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to elevate its effectiveness and efficiency through digital transformation and the adoption of Digital Health solutions within healthcare organisations. Harnessing data and AI for Healthcare Transformation

Digital transformation in healthcare has been a subject of discussion for the past 15 years. However, the adoption of digital technologies within the sector remained sluggish until the arrival of the COVID-19 pandemic. The pandemic accelerated the urgency to transform healthcare delivery methods and redefine the relationships between citizens, healthcare professionals, and healthcare organisations. Nevertheless, substantial room for improvement remains in terms of digital transformation to significantly enhance healthcare services. One of the most promising areas is data and AI, and their benefits for patients, professionals and public and private healthcare institutions. In the realm of digital transformation, data takes centre stage, holding the promise of significant opportunities, with AI as the necessary tool to unlock the outcomes and value from this data. Healthcare data is expanding rapidly, generating around 50 petabytes annually for an average-sized hospital and growing at a rate close to 50 per cent per year. The potential value of the data is enormous,

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although we are still at the beginning of the journey to see it in action. As a reference, the European Commission estimated the value of using the healthcare data for patients’ benefits at €5.2 billion for the UK’s NHS alone. Despite these impressive figures, the reality is that healthcare data today remains siloed, disconnected, fragmented and unstructured. Various systems store the information in separate repositories, using different patient identifiers and codes, which obstructs the possibility of creating a unified and cohesive patient view. Healthcare professionals spend a significant amount of time and effort to populate information systems with patients’ data, but over 90 per cent of this data is never used again or generates value back to the professionals. Moreover, approximately 80 per cent of the healthcare data is unstructured , therefore not usable for analysis and processing, unless dedicating a huge amount of manual effort from the healthcare professionals. While electronic health records (EHRs/EMRs) serve as the primary repository for patient information, crucial data resides in systems like image diagnostic systems, laboratory information systems, pathology information systems, and genomic repositories. Unfortunately, these systems often operate in isolation, not connected between each other, preventing a comprehensive overview of patients' health information. This isolation extends to information sharing between hospitals, healthcare providers, and public and private entities. Hospitals, healthcare providers and public and private entities, rarely share and interconnect their information, ending in disconnected repositories across the different entities and disjointed information between different providers, hospitals and organisations. Additionally, not all the relevant information resides in the healthcare information systems (HIS). Often, there

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is crucial information that only the patient possesses. For example, a diabetes patients’ life habits are key: nutrition, physical activity, insulin injections etc. This information is only available through wearables and apps used by the patient, which today are not present in the HIS and, in general, not available for healthcare professionals. The Future of Healthcare is a ‘DataDriven Healthcare’

The potential for leveraging data in the realm of digital health is immense. Creating unified patient information repositories requires connecting data across disparate systems. This entails applying natural language processing to extract and structure information from PDF reports and free-text fields, as well as using advanced processing techniques for diagnostic images, pathology results, genomics data, and wearable device information. Master patient index solutions are also crucial

for consolidating patient information across systems with differing identifiers and codes. By creating a consolidated view of patient information, healthcare professionals gain quick access to relevant data, enabling informed decisions. For example, a professional could refrain from prescribing a contrast-enhanced CT exam if the patient has a history of radiotherapy and chemotherapy, and recent lab results show high creatinine levels indicating potential risk for the kidney if contrast dose is prescribed. Today, this critical task of gathering and consolidating patients’ information, is done by healthcare professionals, often requiring them to manually access multiple systems and applications looking for the information needed. In the best case, this consumes tons of time and effort from the professionals, which is directly impacting their capacity to attend to more patients. In the worst case, professionals could

be missing relevant information, and making suboptimal decisions for patients. Creating unified patients’ data platforms which automatically show all the relevant data to the healthcare professionals, will not only help to improve decision-making accuracy, but also reduce professionals’ time spent digging through diverse systems to find the right information and will improve their capacity to attend more patients with enhanced care. This holistic view of patient’s information, needs to be the foundational backbone for patient and disease management, and will enable what we call ‘Data-driven healthcare’ with advanced solutions and applications, including: • Population and disease health management: To analyse at a macro level how health and disease is evolving and behaving in the population, detecting health risks and enabling the healthcare services to take actions

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The Power of AI

AI is on everyone’s lips these days, and no doubt, healthcare is one of the sectors where it can have a very significant positive impact. AI has swiftly emerged as a transformative force within the healthcare sector, revolutionising medical services, diagnostics, treatment and intervention decisions and management. With its ability to analyse vast amounts of data and extract valuable insights, AI has already demonstrated remarkable successes. However, it also faces its fair share of challenges and barriers. AI and data are intrinsically related. To develop, validate and get outcomes from AI, vast volumes of data are needed with the right characteristics, quality and variety. At the same time, to be able to process, analyse, and get the right insights from the data, traditional techniques are not enough. AI in healthcare has multiple use cases, and the specific techniques, algorithms and maturity vary. Analysing research studies published in PubMed , the areas with a faster development are radiology, pathology, surgery, oncology and mental health. This indicates what’s coming to real medical practice in the near future. But when it comes to realities today, we need to have a look at what the US Food & Drug Administration (FDA) has approved for clinical use, where the areas most developed are Radiology , Cardiology and Oncology. Some of the most significant outcomes AI can bring to healthcare

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delivery can be summarised as follows: • Early diagnosis with improved accuracy: AI-powered diagnostic tools have showcased their potential in identifying diseases and conditions accurately, and in many cases much earlier than the existing methods. When it comes to imaging diagnostics, this is already a reality, although still in early stage. Multiple AI algorithms are used in daily diagnosis activity to detect different conditions like breast cancer, lung cancer, prostate cancer and fractures among others. • Personalised medicine: AI's data analysis capabilities enable the creation of personalised diagnosis and treatment plans. In complex conditions, especially in oncology, treatments in most of the cases are prescribed based on success probabilities. The patients receive the first chemotherapy treatment because it’s the one working in a higher percentage of cases. If that treatment doesn’t work, then clinicians jump to the second line of treatment, then the third and so on. Thanks to AI applied to personalised data including genomics, oncologists can identify the right treatment for each individual and prescribe it in the first approach. • Monitoring and follow up: For patients with chronic conditions or who are under treatments which require a focused follow up, AI can detect any deterioration or exacerbation in their conditions even before visible symptoms, and consequently clinicians can intervene and bring the patient back to

AUTHOR BIO

• Real world evidence: To analyse outcomes from treatments, interventions, technologies and programs in real life with real patients, to implement improvement actions to achieve even better outcomes • Personalised Medicine: One key factor for personalised medicine is to have the right information, at the right time, for the professionals to take the right decisions for each individual patient.

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stability, improving patients’ health outcomes, quality of live, but also saving emergency visits and hospital admissions. AI in healthcare is a reality today, and not as a potential future technology., The benefits it can bring leaves no other option rather than embrace it to build better, faster and more sustainable healthcare services. Nevertheless, we cannot ignore the barriers and challenges we are facing: regulatory certifications, data privacy and security, bias and ethics, physicians adoption and training are only some of the challenges that need to be treated with maximum care and rigour. Conclusion: A Transformative Future

Data and AI have the potential to reshape healthcare in remarkable ways; from improving diagnostics and treatment to enhancing patient outcomes and operational efficiency. While success stories are already there, we are still in the very beginning of this journey and challenges and barriers cannot be underestimated. As the industry continues to harness the power of data and AI, collaboration among healthcare professionals, technologists, regulators, and patients will be key to overcoming challenges and unlocking the full potential of a new era of data-driven healthcare. With careful navigation and innovation, the transformative influence on healthcare is poised to create a brighter, more efficient, and patient-centric future.

Digital Health Strategist and Business Leader, passionate about transforming Healthcare through the power of Digital, Data and Artificial Intelligence. David has developed his career as VP Healthcare Digital EMEA in GE Healthcare, Head of Digital in Roche Diabetes Care, and leading Digital Health unit in Telefonica during the last 20 years, together with strong collaboration with the start-ups ecosystem and with Business Schools as Associate Professor.

TECHNOLOGY, EQUIPMENT & DEVICES

AN UNDERSTANDING OF ORTHOPAEDIC TECHNOLOGICAL TRENDS With musculoskeletal conditions accounting for 12.6 per cent of global disabilities, keeping up with orthopaedic tech trends is crucial in modern medicine. Dr. Syed Imran outlines how emerging technologies, such as Trauma CAD, Templating Software, Holography, Robotics, Virtual Reality, and Google Lens, are imperative in preoperative planning and boosting surgery success. Syed Imran, Orthopedic Surgeon, Manipal Hospitals

rthopaedic treatment has traversed a long way in the past years. Revolutionary innovations in technology continue to make treatments more precise, personalised, and less invasive. The greatest measure of success is clearly reflected in improved patient outcomes and quality of life. Here are some key areas where technology has played a crucial role in orthopaedic treatments: 1. Robotics and Computer-Assisted Surgery 2. 3D Printing and Custom Implants 3. Regenerative Medicine and Tissue Engineering 4. Virtual Reality (VR) 5. Wearable Technology and Remote Monitoring Before we dive in, let's start with innovations regarding casts. Light-wiring polymer casts are made of silicon and photo resin. They are elastic and stretchable before use — meaning they can be moulded more precisely around an injury in order to set correctly. These casts are 100 per

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TECHNOLOGY, EQUIPMENT & DEVICES

cent waterproof, washable and bathfriendly, comfortably cushioned, and well-ventilated. Furthermore, lightwiring polymer casts are lightweight and high strength, offering maximal uniform stress distribution. Technological Trends: New Technology in Orthopaedic Treatments 1. Robotics

The goal of robotics is the enhancement of joint replacement surgery Robotic-assisted arthroplasty, often known as robotics in arthroplasty, is a fast-developing discipline that combines orthopaedic surgery and cutting-edge robotics technology. This strategy intends to increase the precision of joint replacement treatments. It allows surgeons to plan and execute surgeries with high accuracy, making procedures safer and more effective and improving patient outcomes. Accurate positioning and alignment of joint implants are critical for their long-term success. Robotics in arthroplasty surgery help reduce the risk of implant wear and loosening, potentially leading to longerlasting joint replacements. Scientific studies are needed to establish their claim in the long term. In addition to their surgical implementations, there are also AI Robots being used in rehabilitation. Platforms like Sword Rehab , Kaia Health , and Physitrack use therapy robots that can sense even the tiniest bit of progress and provide quantified information about incremental improvements. As the patient starts gaining strength and ability, the robot delivers less aid, enabling the patient to move with more confidence. 2. 3D Printing and Custom Implants

3D printing technology has revolutionised orthopaedics by enabling the creation of patient-specific implants, prosthetics, and surgical guides. Surgeons can now design and produce implants

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approaches to stimulate the body's natural healing processes and replace or repair damaged tissues.

The technology comes with limitations that simply cannot be overlooked when it comes to medical and surgical applications.

tailored to an individual's unique anatomy, leading to better outcomes and reduced intra-operative complications. 3D Models 3D models of the affected area can be used in pre-operative planning to increase precision and avoid complications during the actual surgery, greatly reducing risk to the patients. 3D modelling is also used in the development of porous metal implants and the creation of patientspecific instrumentation. 3. Regenerative Medicine and Tissue Engineering

Regenerative Medicine and Tissue Engineering are interdisciplinary branches of science and medicine that concentrate on creating new methods to replace or restore harmed, deteriorated, or damaged body tissues and organs. By utilising the body's natural capacity for regeneration or by developing synthetic tissue substitutes, these sectors seek to restore normal tissue function. While tissue engineering is a subset of regenerative medicine that focuses specifically on creating artificial tissues and organs in the lab for transplantation or research, regenerative medicine is a broad field that encompasses various

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3D Bioprinting A cutting-edge technology in the field of regenerative medicine, this process distributes cells, biomaterial, and supporting biological factors in a layerby-layer fashion to form living tissues and analogous organs. This medium of printing is composed of inert material that can support live cells. Examples include hydrogels, microcarriers, tissue spheroids, and tissue strands. Through the use of these materials, the metamorphosis of these cells into human tissue or organs is accomplished. Cartilage Bioprinting Cartilage bioprinting focuses on the development of methods to produce synthetic cartilage tissue using 3D bioprinting technology. It is part of regenerative medicine and tissue engineering. Cartilage is the connective tissue that cushions and supports joints like the knee, hip, and shoulder. It frequently has a low capacity for regeneration when damaged by an accident or degenerative diseases like osteoarthritis. Cartilage bioprinting seeks to solve this problem by producing functional, lab-grown cartilage that can be utilised for transplantation or for scientific research on cartilage biology. Bone Bioprinting Modern tissue engineering and regenerative medicine techniques called "bone bioprinting" are focused on employing 3D bioprinting to create artificial bone tissue. Bone bioprinting intends to produce functional bone structures for a variety of medicinal uses, such as bone repair, reconstruction, and regeneration. In order to accurately replicate the composition and characteristics of real bone tissue, bone bioprinting uses the exact deposition of biocompatible materials and living cells.

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Advantages Greatly adding to the potential benefit to patient safety, the technology aids in lowering the possibility of difficulties during actual procedures and enhances surgeon abilities acquired through VR training. Systems for monitoring and documenting a trainee's progress over time are frequently included in training platforms. This information can be helpful for determining a person's competency and certifying them for a particular technique. Disadvantages Since it is a nascent technology after all, VR in training for Arthroscopy requires a high level of expertise to implement. Furthermore, at this stage in time, the technology is only limited to certain procedures. A major disadvantage is cost, as this state-of-the-art technology does not often come cheap.

4. Virtual Reality (VR)

In order to improve patient care and outcomes, virtual reality (VR) technology is rapidly being used in orthopaedic therapy and rehabilitation. Orthopaedic patients can benefit from the immersive, interactive, and adaptable environments that virtual reality (VR) offers. Even though virtual reality (VR) technology in orthopaedic treatment is constantly growing and evolving, it has already shown promise in terms of boosting rehabilitation outcomes, increasing patient involvement, and offering cutting-edge tools for both surgeons and physical therapists. As technology develops, it is likely to be incorporated more into standard orthopaedic care, bringing new advantages to both patients and healthcare professionals.

VR technology uses 3D imaging and databases to create a simulated interactive environment, typically using a head-mounted display. It is currently used in psychiatric therapy, pain management, rehabilitation, and to treat traumatic brain injury — among its many other applications in the field of medical treatments. Furthermore, it can be used for surgical training, pre-op planning, and intra-op navigation. VR in Training for Arthroscopy The use of VR for training in Arthroscopy — a surgical procedure used to detect and treat sports injuries is also gaining traction. However, it is important to note that, in its current stage, it comes with both advantages and disadvantages.

Use of Google Lens as an Intraoperative Intervention Google lens studies acknowledge its potential for training, consultation, patient monitoring, and audiovisual recording. Picture recognition systems like Google Lens could very well have use in surgical interventions, given the rapid improvements in healthcare technology, including augmented reality (AR) and artificial intelligence (AI). However, the technology does come with several limitations. Google Lens – Usefulness Google Lens seems to provide the greatest benefit in surgical education. Short-distance, live streaming of surgeries by surgeons to trainees and its ability to provide augmented reality guidance in simulated surgeries has the potential to aid medical students in skill acquisition and task comprehension. The pros are ease of use, comfort, ability to aid attentiveness, and, most of all, image quality. In a non-educational capacity — by offering real-time image analysis during

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surgery, image recognition technology may be able to help surgeons as it can aid in locating and emphasising particular structures, anomalies, or crucial areas in the surgical field. Furthermore, surgeons can exchange photos and videos of the operating room in real-time with colleagues or experts for remote advice and direction using image recognition technology. Google Lens – Limitations The technology comes with limitations that simply cannot be overlooked when it comes to medical and surgical applications. The cons include glaring issues such as short battery life, "head tilt zooms" that can interfere with the seamlessness of delicate procedures and limited connectivity. Furthermore, major factors in terms of data protection, the confidentiality of sensitive information, and the patient's privacy in surgical or medical settings cannot be guaranteed without the intervention of regulatory bodies. The entire process is getting upgraded.

sensors. These sensors offer unbiased information for evaluating the success of rehabilitation. Smart braces that have sensors and Bluetooth connectivity can keep an eye on joint pressure and movement. They give patients and their medical professionals real-time feedback to make sure the right rehabilitation exercises are being carried out. Remote Monitoring By giving patients access to data and comments in real-time, remote monitoring encourages patients to take an active role in their treatment. During rehabilitation, this may increase patient compliance and motivation. Healthcare professionals can analyse patterns and decide on a patient's treatment plan by using wearable technology and remote monitoring systems to collect and send data. For instance, alterations to rehabilitation regimens may be required if activity levels or gait patterns vary. When a patient reports greater pain or discomfort or when predicted progress

5. Wearable Technology and Remote Monitoring

Dr. Syed Imran possesses 11+ years of experience in Orthopaedics, specialising in Joint Replacement, Fracture Management, and Arthroscopy. With specialised training from Europe's largest centre for Joint Replacement, he has worked at Fortis, Vikram and other leading hospitals in India, presently working at Manipal Hospital, Millers Road, where his patient-centric approach earned him the goodwill of patients and the admiration of fellow doctors.

Wearable Technology Fitness trackers and smartwatches are examples of wearable technology that may track a patient's daily activity levels, including steps taken, distance travelled, and calories burned. This data is useful for determining a patient's activity level and mobility after orthopaedic surgeries. Specific data related to orthopaedic diseases, such as joint range of motion, gait analysis, and muscle activation, can be monitored by advanced wearable

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To End With Technology adoption for better results and better outcomes is the norm of time, and it needs to be evaluated and tested before being applied. Presently, it is gaining acceptance across hospitals, surgeons and patients. In the world of information, with everything available at the click of a phone, medical innovation and technology need to be abreast with the whole technological ecosystem. I personally adapt to technology which is proven safe and sound to make patients achieve safer and better outcomes.

AUTHOR BIO

Remote monitoring and wearable technology are becoming more and more important in orthopaedic patient care and therapy. These innovations give orthopaedic patients the tools to evaluate their progress, get real-time feedback, and help medical professionals better monitor and take care of their patients' problems.

deviates from what is expected, remote monitoring systems can warn healthcare professionals. This makes it possible for prompt treatment plan modifications and early intervention. Through video conferencing, physical therapists can supervise patients' exercise performance from the comfort of their homes during remote physical therapy sessions. The therapist can track development and modify the treatment strategy as necessary.

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TECHNOLOGY, EQUIPMENT & DEVICES

Robotics Revolutionising Healthcare in the Orthopaedic Landscape Pioneering precision and patient outcomes in joint replacement surgeries The introduction of robotics has transformed healthcare by redefining a whole new level of surgical excellence. This impact of robotics in Orthopaedic Joint Replacement Surgeries has been nothing short of groundbreaking. Absolute surgical precision, consistency of execution, enhanced surgical efficiency and better patient outcomes are now readily attainable. Adj Asst Professor Kelvin Tan, Senior Consultant and Head of Service (Adult Reconstruction) Tan Tock Seng Hospital

Figure 1. Picture of Pharmacy Robot used in Tan Tock Seng Hospital, Singapore

he integration of robotics into healthcare has revolutionised numerous medical fields, from rehabilitation robots, COVID Swab robots, pharmacy robots and the widely known Da Vinci Surgical Robot used primarily in urological and general surgical procedures. Orthopaedic surgery is also standing at the forefront of this transformative wave with robotics offering a whole new dimension of surgical excellence, unparalleled precision, improved patient outcomes, and enhanced surgical efficiency. (Figure 1) Orthopaedic surgery deals with the treatment of musculoskeletal conditions, encompassing joint replacements, spinal surgeries, sports surgeries, trauma and fracture fixation surgeries. The incorporation of robotics in some of these domains has fundamentally altered the way orthopaedic procedures are performed, offering surgeons advanced tools to plan and execute surgeries with exceptional accuracy. Robotic systems in orthopaedic surgery typically utilises advanced imaging technology, computer-aided planning, and precise intraoperative guidance. These elements work in tandem to optimise patient-specific surgical plans, streamline surgical processes, precise surgical execution, and facilitate minimally invasive techniques. This article delves into the

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groundbreaking impact of robotics in orthopaedic surgery especially in the field of joint replacements, examining its applications, advantages, and the promising future it holds for the field. 1. Robotic-Assisted Joint Replacements: Precision Redefined

1.1 Preoperative Planning and Personalised Care Robotic-assisted joint replacements have revolutionised how surgeons approach knee and hip replacement surgeries. Before the procedure, advanced imaging, such as CT scans, is employed to generate a highly detailed 3D model of the patient's joint anatomy. This has proven to be far better than the traditional 2-dimensional templating which was susceptible to inaccuracies. The comprehensive virtual representation enables surgeons to customise surgical plans according to the patient's unique joint structure, biomechanics, and individual health factors. 1.2 Real-time Feedback and precise intraoperative execution During surgery, the robotic system serves as a virtual assistant to the surgeon, providing real-time feedback, dynamic joint balancing and ensuring the precise execution of the surgical plan. The key advantage of robotics in joint replacement surgery lies in its ability to deliver unparalleled precision and accuracy by executing movements with submillimeter accuracy, far surpassing the capabilities of human hands alone.This level of precision leads to better implant alignment, reduced soft tissue damage1, and improved joint mechanics. The minimally invasive nature of roboticassisted joint replacements results in smaller incisions, less postoperative pain, and quicker recovery times for patients. 1.3 Safety and Efficiency Some robotic systems employ state of the art haptic boundaries that prevent cutting tools from veering into vital

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neurovascular structures and therefore provide a safety check in modern robotic instrumentation. Also, with sophisticated 3-dimensional planning, implant sizes are known beforehand and this leads to improved Operating room efficiency and reduced need for cumbersome trays of heavy orthopaedic instruments. The precise guidance provided by robotic arms reduces the need for repeated corrections, thereby streamlining surgical workflows and shortening surgery duration and optimising operating room utilisation. (Figure 2) 2. Enhanced Outcomes and Patient Satisfaction

Numerous studies2 have demonstrated the superiority of robotic-assisted joint replacements compared to traditional techniques. Patients who undergo robotic-assisted procedures experience reduced postoperative pain, shorter hospital stays, and faster return to daily

activities3. Additionally, improved alignment and stability of the implanted joint contribute to enhanced longterm outcomes and increased patient satisfaction4. Through computer-aided planning, the optimal implant size and positioning are precisely determined to achieve optimal alignment and stability1. This personalised approach to joint replacements enhances the fit of the prosthesis, reduces the risk of complications, and extends the lifespan of the implant, leading to improved patient outcomes and longevity of the implant 2. Specific Applications in Joint Replacements 2.1 Unicompartmental Knee arthroplasty (UKA) (Figure 3) About 20 per cent of Osteoarthritis (OA) knees are confined to a single

Figure 2. Safety feature of a Robotic TKA Platform where the saw is switched off when it veers into danger zone

Figure 3. Robotic UKA plan and execution (left) and Robotic UKA implant model(right)

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TECHNOLOGY, EQUIPMENT & DEVICES

Figure 4. (Left to Right): X-rays of Medial Unicompartmental OA, UKA, Total Knee replacement, Picture of UKA wound, Picture of TKA wound

Figure KP14 Cumulative Percent Revision of Primary Unicompartmental Knee Replacement Since 2015 by Robotic Assistance (Primary Diagnosis OA)

Figure 5. Revision rate of Primary Unicompartmental Knee Replacement since 2015 by Robotic assistance (Primary Diagnosis OA)- Extracted from Australian Joint Registry 2022

Figure 6. Proportion of UKA performed with and without Robotic assistance since 2015Extracted from Australian Joint Registry 2022

compartment (usually medial). A medial unicompartmental knee arthroplasty (UKA) could have been performed for this group of patients instead of TKA which is commonly performed instead. A UKA is essentially a resurfacing procedure to replace the “lost” cartilage and bone while preserving all the cruciate ligaments, which are often sacrificed in a TKA. The advantages of performing a UKA over a TKA includes a smaller incision, lesser pain, blood loss and bone resection, faster return to work and more normal knee kinematic (Figure 4) Using conventional instruments to perform UKA is susceptible to considerable alignment, rotational, sizing errors as well complications such as peri-prosthetic fractures. This has resulted in suboptimal survivorship compared to TKA data and therefore lack of confidence in surgeons to perform conventional UKA for patients with isolated unicompartmental disease, despite the obvious superior benefits for UKA. Robotic UKA has proven to be a game-changer so far, resulting in consistently accurate alignment, reproducible results, optimal implant sizing, tracking, soft tissue balancing, better forgotten joint scores (a score that measures patients’ awareness of their joint after a joint replacement) and lower revision rate (Figure 5). The obvious superiority in outcomes has resulted in more than 3 fold increased adoption of robotics in UKA in Australia over the past 5 years.(Figure 6) 2.2 Total Knee Arthroplasty (TKA) TKA is typically done for patients suffering from end stage tricompartmental osteoarthritis. In contrast to a UKA, the entire tibio-femoral compartment is replaced (figure 7). Similar to UKA, adoption of Robotic in TKA has also seen an exponential increase in Australia since its worldwide launch in 2018. In contrast, TKA done without any form of technology assistance has seen a significant drop to about 30 per cent in 2021. (Figure 8) In addition to the aforementioned advantages, the precision in intraoperative execution of the preoperative plan (Figure 7) coupled with objective dynamic soft tissue

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Figure 7. Preoperative 3D plan for TKA

Figure 9. Intraop dynamic soft tissue balancing (Numbers showing gaps)

Figure KT61 Primary Total Knee Replacement by Technology Assistance (Primary Diagnosis

Figure KT68 Cumulative Percent Revision of Primary Total Knee Replacement since 2016 by Robotic Assistance (Primary Diagnosis OA)

Figure 8. Primary TKA by Technology Assistance (Primary Diagnosis OA) Extracted from Australian Joint Registry 2022

Figure 10. Revision rate of Primary Total Knee Replacement since 2016 by Robotic assistance (Primary Diagnosis OA)- Extracted from Australian Joint Registry 2022

balancing (Figure 9) has led to better outcomes4 and lower revision rates. (Figure 10) Multiple clinical studies have shown less soft tissue injury and less soft tissue releases to achieve balance therefore resulting in less postoperative pain, faster recovery and better functional outcomes3,4. 2.3 Total Hip Arthroplasty (THA) THA has been heralded as the operation

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of the century as it revolutionised management of elderly patients crippled with arthritis, with very good long-term results. The surgery involved replacing the damage hip joint with an artificial balland-socket joint. Robotic technology has enabled 3 Dimensional planning and precise component placement resulting in consistent and accurate acetabular cup placement compared to conventional “eyeball’ methods. This has led to lower postoperative complication rates such as

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dislocation and limb length discrepancy. (Figure 11 12, 13) 2.4 Complex Joint Arthroplasties Complex Joint replacements on severe deformity or prior hardware have been simplified with the advent of robotics. Meticulous 3D planning can allow execution of well balanced joint replacement without the need for additional surgical scars to remove prior hardware as they can be largely retained

TECHNOLOGY, EQUIPMENT & DEVICES

Figure 11. (L to R) Coronal Plan, Axial Plan, 3D Plan of Acetabular cup position

without compromising optimal surgical outcome in most cases. Real time and precise intraoperative tracking can allow removal of selective hardware that may cause impingement of the planned implant position. More importantly, most of these complex surgeries can now be performed in a single stage compared to traditional methods of 2 stage surgeries, saving patients much inconvenience and costs (Figure 14, 15) 3. Challenges and Future Directions

3.1 Initial Investment and Training One of the primary challenges of integrating robotics into orthopaedic surgery is the significant initial investment required for robotic systems. The cost of acquisition, maintenance, and ongoing training can be a deterrent for some healthcare institutions. As the technology becomes more mainstream, it is expected that the costs will gradually decrease, making roboticassisted surgery more accessible to patients.

Figure 12. Preoperative plan for a Robotic THA

Figure 13. Robotic (Blue) versus Manual Cup Placement (Green). Black Square indicate desired target zone

3.2 3D printing and Robotics 3D Printing coupled with robotics will bring about the next era of personalised Joint Replacements. This will make complex hip and knee surgeries even simpler and efficient, also negating the need for staged operations. This can bring about many conveniences and cost savings for patients. Presently, 3D printed implants are costly and resources are limited. In the future with improved 3D printing technology and resources, the accessibility and affordability would be better. 3.3 Advancements in Artificial Intelligence (AI) and Machine Learning The future of robotics in orthopaedics lies in its integration with artificial intelligence (AI) and machine learning (ML). AI-powered robotic systems have the potential to learn from vast datasets, optimise surgical plans, and adapt to real-time changes in the operating room. Machine learning algorithms can analyse patient data and surgical outcomes to identify trends and improve treatment protocols continually. Moreover, AI can assist in predictive analytics, risk assessment, and

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regarding patient safety, data privacy, and the role of human intervention in decision-making. As robotic systems become more autonomous, defining clear guidelines and standards for their use is essential to ensure patient wellbeing and ethical practice. Furthermore, regulatory bodies must adapt to the rapidly evolving landscape of robotic-assisted surgery to provide clear guidelines and standards for approval and usage. Conclusion

AUTHOR BIO

Figure 14. Preop and Postop Xrays of a patient with end stage osteoarthritis and prior hardware. Post xrays shows Primary TKA performed with retention of main implant with removal of only 2 screws.

The integration of robotics in orthopaedic surgery marks a technological leap in patient care, surgical precision, and surgical outcomes. Robotic-assisted joint replacements have showcased the transformative potential of this technology.

Figure 15. 3D Visualization of a intraoperative plan with real-time tracking to localise which implant or screw to remove that may cause impingement with planned implant position

personalised patient care, revolutionising the field of orthopaedics. 3.4 Telemedicine and Remote Surgery The rise of telemedicine and remote surgical capabilities presents exciting possibilities for the future of orthopaedics. Robotic-assisted telemedicine can enable

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expert surgeons to perform complex procedures on patients in remote locations, improving access to specialised care and reducing healthcare disparities. 3.5 Ethical and Regulatory Considerations The integration of robotics in healthcare raises ethical considerations, particularly

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Adj Asst Professor Kelvin Tan is currently serving as the head the Adult Reconstruction Joint Replacement unit in Tan Tock Seng Hospital, Singapore. I am a strong advocate of technologyenabling joint replacements such as computer navigation and roboticassisted surgeries that can improve patient outcomes and simplify complex surgeries. I am also the Enhanced Recovery after Surgery (ERAS) Clinical Lead for Knee Replacements in my institution.

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Becoming Climate-Smart The Indian health sector The global health sector contributes considerably to greenhouse gas emissions. This article explores how the Indian healthcare sector has responded to the challenges of climate change by detailing actions taken at the policy level, the community level, and at the level of the individual healthcare facility. Alexander Thomas, Founder and Patron, Association of Healthcare Providers Divya Alexander, Independent Consultant

limate change is, by now, a reality that has hit many countries hard, more so in recent years. India is one among them, having been ravaged by lethal heatwaves, forest fires, flooding, droughts, dust storms and cyclones, all against the background of a deadly pandemic. As the most populous country in the world, the consequences of these climate disasters have been significant, with vulnerable groups bearing the brunt of the impact. In addition to the disaster-related injuries, there have been climate-induced changes in disease patterns, with an increase in respiratory diseases, cardiovascular disease, non-communicable disease and heat stress. As has been reiterated repeatedly on the local, regional and global scale, there needs to be concerted action at every level in order to combat climate change. Studies have begun to establish what the health sector can do to reduce its

climate footprint while itself remaining resilient to the impact of climate change. The global health sector contributes significantly to greenhouse gas emissions, and according to a 2019 study by Health Care Without Harm and Arup, would be the fifth-largest emitter on the planet if it were a country, thereby contributing to the disease burden of the community that it is meant to protect. These considerable emissions come from the sector’s significant consumption of water and energy from running 24 hours a day, 365 days a year, catering to millions of patients, healthcare employees and visitors, using carbon-intensive supply chains for daily operations, and creating huge amounts of waste, both hazardous and non-hazardous, that need to be disposed of. Any reduction in these emissions will necessarily have to come from every individual healthcare facility adopting sustainable climate-smart changes to decrease its individual climate

footprint in order to reduce the overall impact by the health sector. This article explores how the Indian healthcare sector has responded to the challenges of climate change by detailing “climate-smart” actions taken at the policy level, the community level, and at the level of the individual healthcare facility. The policy level

India is a signatory to the Paris Agreement and has committed to decrease its emission intensity of GDP by 33-35 per cent of 2005 levels. India’s climate change policy enshrined in the National Action Plan on Climate Change has one mission under ‘Health’ and it is implemented by the National Centre of Disease Control under the Ministry of Health and Family Welfare (MoHFW). Acceding to calls that healthcare policy and climate policy be integrated, the Indian Government has instituted a National Expert Group

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of Climate Change and Human Health with experts from both arenas. These bodies deal specifically with the healthrelated impacts of climate change. For climate resilience of health facilities however, the National Disaster Management Authority (NDMA) is the nodal authority that supports the National Programme on Climate Change and Human Health, which incorporates the concepts of Green and Climate Resilient healthcare principals in revising the Indian Public Health Service guidelines according to which all government hospitals in the country operate. It also aims to bring about awareness and capacity building of healthcare professionals on the issues related to climate change. There is significant advocacy ongoing from the private health sector as well, which in India delivers the majority of healthcare to the population. The Health and Environmental Leadership Platform (HELP) which has over 7300 healthcare institutions (both government and private), is one platform to share best practices and showcase leadership in the adoption of climate-smart strategies. The Association of Healthcare Providers – India (AHPI) and the Centre for Environmental Health (CEH), a centre of excellence set up by the Public Health Foundation of India (PHFI), organised the National Health Conclave 2019, which gathered experts from academia, healthcare providers, policy makers and civil society to discuss climate concerns and make recommendations on climate preparedness for the Indian health sector that were presented to the Ministry of Health and Family Welfare, Govt. of India. The Ministry is in the process of facilitating the inclusion of climate change and health into the undergraduate, post-graduate medical, nursing and allied health curricula. The community level

Due to their profession, doctors, nurses and allied health workers are often considered “thought leaders” in their

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community. This gives their voices added value when messages about the impact of climate change are directed towards the general public, the media, and even policymakers. Hence, as first responders to the impact of the climate crises as well as thought leaders, health workers should use their position to educate their patients and their communities, who in turn should pressure their local leaders to take action. This is another reason for the importance of training and capacitybuilding of healthcare workers. Similarly, the position held by a hospital or healthcare facility in the community can be used to set an example to the rest of the community. When healthcare centres start using clean, renewable energy and implement conservation strategies, they become a model of leadership for ideas that can spread quickly into the wider economy. As major energy consumers and highly respected anchor institutions in their communities, health systems have a unique opportunity to bring about change and contribute to green local economies. The individual level: climate-smart healthcare facilities

The World Health Organization (WHO) explains a climate-smart health system as one that can anticipate, respond to, cope with and recover from climaterelated shocks and stresses, bringing about sustained improvements in population health, thus linking together decarbonisation and health equity. Climate-smart measures in a healthcare facility focus on decarbonisation of healthcare delivery, facilities and operations while building resilience to climate change. Every operational aspect of a healthcare facility can be targeted to reduce its climate footprint, beginning with green infrastructure and the effective management of water, energy, waste and transportation. The following suggestions have been summarised from Climate Change and the Health Sector: Healing the World (Thomas et al, 2021).

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Infrastructure

A green hospital can be described as one that reduces its environmental impact and ultimately eliminates its contribution to the burden of disease, is ideally made from environment-friendly and locally-sourced materials, and is designed to optimise available resources such as sunlight, water, ventilation and energy, and should be hazard-resilient and functional during a crisis. A hospital with no access to back-up energy sources during a natural disaster will have no role to play in delivering healthcare or saving lives. Kohinoor Hospital, in Mumbai, Maharashtra, is Asia’s first LEEDPlatinum certified hospital. It was built mostly using construction materials available locally or regionally, and used recycled material in its infrastructure. The façade and orientation of the building were designed around the solar path to ensure a cool yet naturallylit environment. Waste was recycled where possible, with the overhead tank foundation being constructed with scrap steel. Urinal sensors, low flow fixtures and grey water management features were installed for water efficiency, solar panels on the roof heat most of the hospital’s water requirements, and a windmill generates 90 per cent of the hospital’s energy needs. The hospital’s sewage treatment plant treats all the waste water, and the gardens require no irrigation. (Case study from page 133 of Climate Change and the Health Sector: Healing the World)1. Water

Water is one of the most essential commodities used in a hospital (sterilisation, sanitation, infection prevention, patient care, laundry, food preparation, etc.). Water conservation strategies can include rainwater harvesting, waste water treatment for recycling, and developing adequate storage facilities. The National Institute 1 Case study taken from the Center for Environmental Health, https://www.ceh.org.in/resources/case-studies/

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Energy

As over half of the health sector’s carbon footprint comes from its energy use, replacing expensive and unsustainable equipment with renewable energy sources and energy-effective equipment can significantly reduce the environmental impact. Solar power, wind energy, bio-energy and hydropower are possible sources of renewable energy that increase self-sufficiency and lead to significant financial savings. A public-private partnership with the Government of Assam launched boat clinics as a mobile health service in areas where the construction of permanent health infrastructure was challenging; initially powered by loud and expensive generators that ran on fossil fuels, the boat clinics now use clean energy generated by rooftop solar photovoltaic modules that are also more reliable and cost-effective .

goes for incineration, thus reducing both energy use and environmental impact. For non-hazardous waste, biomethanation and composting can be conducted on-site. The Dr. RN Cooper Municipal General Hospital, in Mumbai, Maharashtra, implemented a sustainable intervention in food waste management to reduce the amount of food waste being dumped and creating pressure on landfill sites. In collaboration with the BMC and a local non-profit, one vermi-compost pit and four bricklined compost pits were built on the hospital premises, saving 60 MT of waste from being dumped at the landfill and 200 kg of manure was generated from vermi-composting, saving on the cost of purchasing manure2.

and consider the use of modified hospital vehicles to reduce air pollution. Narayana Health City in Bengaluru, Karnataka, has a fleet of electric vehicles for their daily operations. The four buggies, with a capacity of 2.6 KW each, as well as reducing fossil fuel use, have resulted in a saving of about 22 lakh INR as compared to using diesel vehicles for the same operations3. Other hospitals can reduce their vehicle use by encouraging carpooling between employees, promoting cycling or walking by making appropriate changes to the campus landscape, regular maintenance checks for hospital vehicles, and instituting a committee to specifically monitor and advocate for these initiatives.

Transportation

Conclusion

Healthcare premises see a large number of vehicles every day, whether they are ambulances, vehicles for daily operations and supply chain deliveries, medical equipment and products, or vehicles used for commuting by hospital employees, patients and visitors. Hospital management can encourage a shift to public transport

This article has provided an overview of the actions taken by the Indian health sector to combat climate change, become climate-smart and develop resilience in preparation for the increased burden of disease. It outlines some of the actions implemented at the policy/sectoral level, the community level and the individual healthcare facilities on the ground.

2 Case study taken from the Center for Environmental Health, https://www.ceh.org.in/resources/case-studies/

3 Case study taken from page 179 of Climate Change and the Health Sector: Healing the World

AUTHOR BIO

of Ophthalmology in Pune, Maharashtra, is a super-speciality eye hospital that implemented sustainable interventions onsite to reduce their water, energy and carbon footprints. The strategies used to save water on the premises included measures such as training their staff on water management (in accordance with their green policy and standards), putting up posters and visual reminders to use water carefully, installing water meters to measure consumption, checking plumbing regularly for leakages, and re-using non-infected water for cleaning purposes. (Case study taken from the Center for Environmental Health, https://www.ceh.org.in/resources/casestudies/).

Dr. Alexander Thomas is the Founder and Patron of the Association of Healthcare Providers – India (AHPI), the Consortium of Accredited Healthcare Organisations (CAHO) and the Association of National Board Accredited Institutions (ANBAI). He has effected far-reaching policy changes within the Indian healthcare landscape, is recognised nationally and internationally for his contributions, and has written several books for the health sector.

Waste

Healthcare facilities expend huge amounts of energy on waste treatment and disposal. While it may seem that the easiest option is to incinerate all waste, it is essential for healthcare organisations to follow segregation, storage and treatment policies. This decreases the amount of waste that

Ms. Divya Alexander MSt. (Oxon.) is an independent consultant with 15 years of expertise in health and public policy research, drawing up policy recommendations and legislation through her work with AHPI, UNFPA, and Amnesty International USA. She has co-edited five books and several papers for the health sector on policy issues.

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The Road to Optimising The Care Pathway Are we there yet? The article discusses the need to develop and implement technologies that help nurses, and not having nurses to work for technology. The piece emphasizes how integrating innovation enablers into current operations can help support nurses in their work to provide better patient care and increase job satisfaction. Dirk Dumortier, Director Strategic Partnerships APAC, Alcatel-Lucent Enterprise

igital transformation, Clinical AI, Population Health, Hospital@Home, are just a few of the many technology-supported healthcare (r)evolutions we hear and read about every day. A recent study from McKinsey & Company entitled “Reimagining the nursing workload: Finding time to close the workforce gap” got my immediate attention. People who know me, know that improving working conditions for nurses is high on my priority list after having experienced their struggle over a period of 12 years.

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The McKinsey & Company study is the first time I have read a report that touches on how technology can be used to optimise nursing teams’ efficiency from a nursing point of view together with analysts’ insights. The study provides clear indicators that efficiencies can be improved by approximately 30 per cent on roughly 45 per cent of nurses’ daily activities. And these figures don’t even take into account the ongoing digital transformations hospitals are undertaking. While the study is focused on finding a way to close the workforce gap (nurse shortages), which is without

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a doubt, a critical issue to be solved, I’m looking at the situation more from an individual nurse level. In the news we hear about nurse shortages, high burn-out rates, and requests for wage increases. It’s clear that all these elements are real and important and require more attention. My many interactions with nurses have taught me that the main reason people become nurses in the first place, is to provide care to patients. The McKinsey & Company study clearly validates this reasoning. Unfortunately, nurses currently only spend approximately 50 per cent of their time in direct contact with patients, with a strong request to increase it. And it’s my personal believe that increasing direct patient contact can help reduce burn-out rates and increase personal satisfaction on the job they do so well. Are we there yet? No!

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We need to develop and implement technologies that work for nurses rather than nurses working for the technology. A clear bad example of this were the early-stage hospital information systems and electronic medical records. Luckily things have changed for the good, however, there is still work to be done. Since, as you may have already noted, I’m not an HIS/EMR expert, I will focus my discussion on some insights that I believe are regularly overlooked, perhaps because they are not “high-tech” enough. It should be noted that nurses spend 90 per cent of the time on their feet , with 13 per cent to 18 per cent of the time walking , and 10 per cent to 14 per cent of the time searching for tools and people (staff) . The McKinsey and & Company study touches on technology and delegation requirements, which aligns with my first point: mobility must be the first consideration. Providing a mobile device, like a smartphone or even a DECT phone, to nurses to use at the point of care or anywhere they need it is essential. So, let’s talk about smartphone “connectivity” and “communications” as this is a critical element for IT because of the increased cybersecurity attack surface. And since the subject of smartphone cybersecurity requires more than a short article, I will try to keep this brief. If you choose Wi-Fi-based connectivity, as it is still the most comprehensive solution in a healthcare setting, you will need to setup a Wi-Fi network for smartphones similar to other Internet of Things (IoT) devices. This will require creating a dedicated but dynamic Wi-Fi segment (SSID Containment) with Role-based Access Control and Application Visibility with Enforcement, allowing all the necessary macroand micro-segmentation. Because you will need to support realtime applications, like collaboration, you will need to have the right enterprisegrade equipment to support fast roaming and other technical specifications. For

device management, you will need to consider a professional Enterprise Device Management solution that works easily with your selected smartphone brand. But we’ll come back to that later, when we discuss notifications. For DECT, it is straightforward, just install separate IP-DECT Base Stations and the rest is linked to- and managed by- the IP-PBX. Once connected, you need ‘communications’. For this discussion communications will refer to external calls, and links to patients, not comprehensive I know, but it will all make sense shortly. Communications are official conversations between the hospital and patients that require compliance. While it makes sense that a doctor should not provide their mobile number to a patient, sometimes it is important to have a record of conversations for compliance reasons. To ensure compliancy, all communications need to be controlled by a mission-critical IP-PBX (on premises or in the cloud) and provide an extension to the smartphone, regardless of whether the smartphone is connected using Wi-Fi or whether the staff is using it outside the hospital. A professionally implemented connectivity and communications solution is the “foundation” of everything. With a strong mobile foundation in place, we come to my second

point: optimising the care pathway by improving efficiencies is accomplished by combining the following three innovation enablers; Collaboration Services, Notification or Messaging Services and Location Services. All hospitals either have or are investigating these enablers. However, the real power doesn’t come from each individual service, but rather from integrating the three services into your operations. And so, the question remains — are we there yet? Let’s take a deeper dive into the three innovation enablers. Collaboration Services — the ability to text, call (audio or video), share (files, picture) one-to-one or in a group, having presence information and even the ability to register for information channels — is a very well-known solution. WhatsApp is just one example. However, whatever you select, please ensure that it is healthcare compliant. All data must belong to the organisation, including user management and data backup. Collaboration can help your staff get the information they need, in a mobile setting, when and how they need it. In the context of the recent global health crisis, collaboration was the tool of choice to provide contactless handover between shifts, to inform staff about changes in processes, as well as

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defined area (known as geofences), with the simple press of a button. These are pretty standard services provided by asset tracking solutions. However, if they include contact tracing and or have flexible alert methodologies that can be very helpful. As mentioned previously, when we combine location services with messaging and collaboration services the benefits are exponential. Streamlining processes is just one example. In the past, if a device or tool was faulty, a nurse would need to open a form or write an email or call someone, but nurses have no time for that. Today, just pressing a button, mounted to the device or tool, will automatically start the process. A technician will be informed about the faulty device using messaging and it will include the device or tool location. Together, these services drive efficient collaboration, workflows, processes and of course reduce the search time and loss of hospital equipment. They are key to optimising the care pathway for better outcomes and part of the technology advancements McKinsey & Company reference in their study. On a side note, we need to take a moment to talk about Staff Duress, a tool nurses can use when in distress. With the press of a button colleagues and/or security guards can be notified, using messaging, to come immediately to help out. With this tool they have the location information and the ability to

remotely connect using the smartphone to listen in on the situation as it unfolds. The good news is that in many organisations there are already some aspects of the three services. Integrating them must be the next step. And so, we ask again — are we there yet? Another area that requires consideration as identified in the McKinsey & Company study is delegation. Delegation is a method of reaching out to colleagues to transfer a task. Once collaboration and messaging services are in place, it becomes very easy to delegate tasks when needed. Additionally, providing patients with terminals, like tablets, enables them to make specific requests such as for water, or room cleaning, and allows staff to direct the requests, using messaging, to the appropriate individual. Everything we’ve talked about will not be simple, however, many aspects are already underway, in one form or another. But it is not just technology. It’s also about processes, procedures and compliance. Working with the right technology provider can help ensure you are headed in the right direction. As my catch phrase, ‘Are we there yet?’ suggests this is a journey. However, it’s one in which we are making clear advances as we help our nurses do the job they want to do, by optimising today’s technology to provide the best possible care for their patients.

Dirk Dumortier is ALE’s Director of Strategic Partnerships in Asia Pacific (APAC). He is an experienced director having worked with healthcare, education, hospitality, and government organisations in APAC to guide their digital transformation journeys. As a former Vice-President of Communications and Cloud sales leader in China, Dirk has a deep knowledge of end-to-end and converged solutions (network, communications, unified communications and collaboration, video, contact center, cloud, on-demand and XaaS models) and understands the regional challenges and requirements.

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AUTHOR BIO

to connect patients with their family members at home. A good collaboration tool that is compliant and connected with your communication tools is essential. But as I mentioned previously, it’s not just about collaboration. Location and context-aware collaborations are critical. One of the key technologies embedded in collaboration is presence, such as knowing when a person is behind their desk, online or busy. Now, imagine enriching that presence information with location information and context. For example, being able to see when a doctor is on duty or entering the hospital, or perhaps when they enter the operating room the presence identifier automatically changes to ‘do not disturb’. Additionally, we can think about when a nurse enters a ward, and they are automatically added to the ward’s collaboration group, making contactless handover a breeze. The advantages are endless. A question like, ‘can I speak with the doctor’ is simplified with location- and context-based collaboration. You can see the doctor’s presence status, when they are off duty you can see the replacement, and you can choose the best method to reach out, based on that status or urgency. Today’s modern collaboration tools are paving the way to replace existing pagers. Messaging services provide the ability to inform staff about events, from Code Blue notifications to other events that can help teams improve efficiency. A good messaging service must meet several criteria. It must be easy to integrate into the existing environment, have an open architecture and provide not just ‘messages’ but contextual messages, including information that can help resolve the issue. For example, a message coming from an alarm event, and enriched with contextual information, could be forwarded to the closest and available person able to attend to the situation. Location services let you track people and assets, find them when needed and get notified when they enter or leave a

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Teleconsultation Empowers Rapid Digital Pathology Diagnosis and Healthcare Solutions Medical teleconsultations and technological developments have revolutionised healthcare delivery during the Covid-19 pandemic. The integration of teleconsultations and digital pathology is the main topic of this article. Benefits of digital pathology include sample digitisation, remote access, and pathologist collaboration. Healthcare systems can offer effective and easily accessible diagnostic services, maximising resources and increasing patient outcomes, by combining teleconsultation with digital pathology. Arindam Sen, Director of i2i Telesolutions

n the midst of the Covid-19 pandemic, medical teleconsultations using advanced technologies have emerged as a pivotal tool in primary healthcare, facilitating communication between general practitioners (GPs) and patients. This transformative shift in healthcare delivery has been complemented by the profound impact of digital interventions on the sector as a whole. Indeed, technology has proven to be a blessing during the global crisis caused by the pandemic. Amidst the chaos, it has paved the way for remarkable advancements in diagnostics, opening doors to a world of new opportunities.

For instance, where expert pathologists and healthcare practitioners can remotely access a password-protected repository, allowing them to study patient cases from rural or distant regions. With the ability to examine digital images and make accurate diagnoses, they can take decisive action, providing the right treatment for each patient in need. Through the integration of teleconsultations and digital advancements, the healthcare landscape is undergoing a transformative revolution. This interconnected approach empowers healthcare professionals to bridge geographical boundaries, ensuring that patients receive the best care regardless of their location.

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Digital Pathology and Remote Diagnostics

Digital pathology has emerged as a transformative approach, revolutionising the field of pathology by incorporating technology into the analysis and interpretation of pathological samples. By harnessing the power of digital platforms, it offers numerous advantages over traditional pathology methods, enhancing efficiency and improving patient care. According to an Edelweiss report, Indian diagnostics is one of the fastest-growing markets in the healthcare industry. The segment is projected to be estimated at $9 billion and grow at a CAGR of approximately 10 percent by 2025. A key advantage of digital pathology is the ability to digitise and store pathological samples. Through specialised scanners, samples are converted into high-resolution digital images that can be easily accessed, stored, and shared electronically. This digitisation process not only streamlines data management but also facilitates collaboration and remote access to samples, enabling pathologists to engage in rapid evaluation and remote collaboration. By eliminating the reliance on physical slides and glass microscopy, digital pathology enhances accessibility and overcomes challenges associated with traditional methods. With digitised samples securely stored and readily accessible through computer systems, pathologists can easily retrieve specific cases, share them efficiently, and seek second opinions. This transparent and collaborative approach contributes to improved efficiency and productivity within the field. Let's explore the different aspects of pathology and the digital scope in more detail. Anatomical Pathology: This branch of pathology involves the examination of tissue samples obtained from biopsies, surgeries, or autopsies. Pathologists analyse these samples microscopically

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In India, accessing specialist pathologists for critical diagnoses, like cancer, can be challenging, especially outside tier 1 cities. Digital pathology offers a game-changing solution, enabling rapid and reliable diagnoses, and revolutionising healthcare accessibility.

to identify abnormalities, determine the nature of diseases, and provide accurate diagnoses. Digital pathology enables the digitisation of glass slides, allowing pathologists to view and analyse tissue samples remotely using digital imaging systems. This technology improves efficiency, facilitates second opinions, and enables data sharing for research and educational purposes. Clinical Pathology: Clinical pathology encompasses the laboratorybased analysis of body fluids, such as blood, urine, and cerebrospinal fluid, to diagnose and monitor diseases. It involves various laboratory techniques, including hematology, clinical chemistry, microbiology, immunology, and molecular pathology. Digital solutions in clinical pathology enable automated and high-throughput testing, result interpretation algorithms, and integration with electronic health records (EHRs), enhancing efficiency and accuracy in laboratory diagnostics. Education and Training: Digital pathology platforms provide valuable tools for education and training purposes. Pathology residents and medical students can access digitized slides, virtual microscopy, and e-learning resources to enhance their learning

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experience. Teleconferencing and webinars enable interactive teaching sessions, remote slide reviews, and discussions with experts from different locations, promoting knowledge sharing and professional development. Image Analysis and Artificial Intelligence (AI): Digital pathology leverages image analysis algorithms and AI techniques to assist pathologists in the interpretation of complex and large datasets. AI-based tools can aid in automated detection, quantification, and classification of pathological features, improving diagnostic accuracy and efficiency. Machine learning algorithms can learn from large datasets to identify patterns, predict disease outcomes, and assist in personalised treatment decisions. The effectiveness of digital pathology in remote settings is supported by studies and statistics. Research demonstrates its diagnostic accuracy comparable to traditional microscopy, highlighting its reliability and potential for widespread adoption. Teleconsultation using digital pathology has also shown to improve access to specialist consultations, reducing delays in diagnosis and treatment initiation. By integrating digital pathology and teleconsultation, healthcare systems can optimise resources and provide efficient and accessible diagnostic services. This interconnected approach bridges geographical barriers, enabling patients from remote or underserved areas to receive expert opinions without the constraints of physical proximity. The streamlined process expedites the delivery of appropriate treatments, ultimately improving patient outcomes. Teleconsultation in Pathology

Teleconsultation serves as a vital bridge, connecting pathologists, patients, and healthcare providers in different locations, revolutionising the way healthcare is delivered. Through advanced communication technologies, it overcomes geographical barriers and facilitates seamless collaboration.

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between different healthcare providers. This integrated approach streamlines healthcare delivery, reduces duplication of tests, and optimises treatment planning. Future Directions

While teleconsultation and digital pathology have revolutionised healthcare, there are several challenges and limitations that need to be addressed for their continued growth and success. Efforts are underway to address challenges and enhance the teleconsultation experience. Infrastructure development initiatives aim to improve internet connectivity in underserved areas, promoting equitable

Arindam Sen is the Director at i2i Telesolutions, bringing with him two decades of experience in Healthcare Technology. Arindam holds a Bachelor's degree in Engineering from IIEST and a PG from IIM. He has actively mentored young professionals and supported initiatives that promote gender and ethnic diversity in the Health-tech industry.

AUTHOR BIO

The process of uploading and sharing digital pathology images securely for remote consultation begins with the scanning of physical slides using specialised scanners. The resulting digital images are typically stored in a standardised format, such as Whole Slide Imaging (WSI) files. These files can be uploaded to a secure digital platform or repository, where authorised users, such as pathologists or healthcare providers, can access and review them remotely. Encryption techniques and secure authentication methods are employed to safeguard the confidentiality of patient data during transmission and storage. Teleconsultation brings forth a multitude of benefits for both pathologists and patients. One significant advantage is the reduced turnaround time for diagnoses and treatment decisions. With the ability to access digital pathology images remotely, pathologists can evaluate cases promptly and provide timely recommendations. This expedites the diagnostic process, leading to quicker treatment initiation and improved patient outcomes. Teleconsultation in pathology also facilitates continuity of care. Patients can have their pathology images and reports readily available for future reference, enabling seamless coordination

access to teleconsultation services. Publicprivate collaborations and government initiatives are focused on expanding network coverage and investing in telecommunication infrastructure. To further enhance teleconsultation and digital pathology, future directions are focused on leveraging advancements in artificial intelligence (AI) and machine learning (ML). AI algorithms can assist in automated analysis and interpretation of digital pathology images, aiding pathologists in faster and more accurate diagnoses. ML algorithms can learn from vast datasets and improve decision support systems, leading to enhanced clinical decision-making. Remote robotic assistance is another promising direction for teleconsultation and digital pathology. With the integration of robotics and teleoperation technologies, pathologists can remotely manipulate instruments and perform procedures on patient samples in realtime. This enables precise and efficient interventions, even in remote locations, while leveraging the expertise of specialised pathologists. While teleconsultation and digital pathology have transformed healthcare, challenges such as connectivity issues, data privacy concerns, and regulatory considerations persist. Ongoing efforts to improve infrastructure, enhance data security, and address regulatory complexities are underway. The future of teleconsultation and digital pathology holds promise with advancements in AI, ML, and remote robotic assistance, paving the way for more accurate diagnoses, efficient workflows, and improved patient outcomes.

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China's healthcare and its digital revolution are being accelerated by Digital China and Healthy China policies. This major shift, coupled with digital transformation, are often plagued by challenges such as misalignment of current positioning, transformation leadership and digital readiness. This article examines these factors to better understand the effort. Wu Junyang, CEO, Qianlu Management Consulting (Shanghai)

Digital Transformation in China’s Healthcare Market D

igital transformation is now one of the hottest buzzwords in China’s healthcare industry, owing to the twin engine, Digital China and Healthy China policy. The former advocates creating a new digital economy with emphasis on data and data-driven technology, while the latter rewrites the foundational logic, shifting from a treatment-centric to a health management centric perspective. The vast increment in scope and hastening of tempo for healthcare organisations driven by these two policies has brought about a fundamental transformation in how medicine is practised and how healthcare services are delivered. However, digital transformation is extremely challenging, and is of

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no difference for Chinese healthcare organisations. One of the fundamental reasons is a misappropriate alignment of current positioning which ends up barking up the wrong tree. Hence this article summarises a couple of the key lessons learnt from recent digital transformation efforts to provide organisation leaders with a clearer perspective on alignment. Phasing Matrix to align the internal situation

Due to various reasons and complex descriptions, there are many users and decision makers who are often confused about what they asked for and what they really need. A common scenario is a leader who is pushing for digital transformation realising what he had been advocating

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is really part of the enterprise system and business intelligence. The following table summarises the three phases of development of organisations. Most healthcare organisations in China started with the age of electronic record and software in the 90s, with a handful a decade earlier. By early 2010s, most organisations had deployed more than 50 software. The main focus in this age was on creating software with functions that can replace manual operations. A full array of systems started to evolve— from a billing-centric HIS to various ancillary and specialised systems. Moving into the mid 2010s, with the proliferation of integration tools, organisations moved into the age of systems and automation, where multi-

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savvy or have potential to manage changes 3. Digital transformation is a good platform for experimenting with ideas, especially ideas that will reshape relationships, and stakeholders. With this understanding, it will be easier to align the strategic intent with actual execution, and also appreciate why the following pitfalls occur. Common Pitfall 1: misinterpretation of current positioning

business lines started collaborating and exchanging data to fully automate operations. Simple decision tools emerged in the form of warnings, alerts and restrictions. Domain-based, such as outpatient, inpatient clinical systems, EMR, CDR were the main actors in this age. The sophisticated data exchanges, siloed specialised systems and the need to have smarter decision support rallied the rise of the digital twin. Operations support and decision support are now in demand as IT systems need to decipher user situations, needs and potential risks in a holistic and immediate responsive manner, raising the stakes for digital systems to an unprecedented height. Fortunately, breakthroughs in technology such as large language

models, ultra-high speed computing, smart sensory systems, opened the door and paved the way into the age of digital twin. Systems are now configured and perform around the role of users, with a wealth of models and knowledge bank supporting real-time. Before we move into the pitfalls and recommendations, we need to understand why, besides policy, organisational leaders are pushing digital transformation: 1. Digital transformation will give leadership a toolkit to dive into the current situation and have a first hand understanding of the frontline issues that are formerly masked in the reports 2. Transformation initiatives are a good filter for employees who are digitally

As an organisation matures, one can observe its shift in focus. This brings about the first pitfall that many organisations fall into: misinterpretation of current position. For example, Hospital A is still in the beginning of integrating the dozens of siloed systems installed and has not yet standardised its data standards and business processes. The management learn about digital twins and decide to invest heavily in digital products and digital twin systems. The gap in foundational data and crossfunctional integration will cause severe hurdles in the digital twins efforts, lowering the overall value created by the investment. End users may conveniently shift the blame to the digital systems, or make it a white elephant. Hence, it is critical for the leadership, IT team and business departments to carefully examine and identify its actual current position, and put sufficient emphasis and effort to build the necessary foundations. Common Pitfall 2: Digital transformation is an IT-led effort

The biggest difference between the age of the digital twin and its predecessors is the need to digitalise the underlying logic and causal relationships between different elements, roles, tasks and data. Unlike functionalities and data integration, this is a much more submerged relationship that requires careful studying or highly experienced digital and business experts to thread the relationship so that it reflects and predicts accurately the causal effect, and

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Common Pitfall 3: Top-down only effort is sufficient for digital transformation

While it is absolutely critical for top leadership to command and control the transformation effort, relying solely on high level management and a small core teams is far from sufficient to promote a digital transformation effort. A common denominator for all digital transformation success is an all-in involvement from top leaders to the frontline users. The application of digital twins is often instantaneous, automated, and relies on a strong and wide data foundation. It is extremely difficult for a handful of leaders to manoeuvre the changes at this scale. The transformation effort needs to be executed at the edge of the organisation to ensure both the quality of the input and the suitability of the output tools. Hence, the digital literacy and readiness of the various echelons becomes a deciding factor on how fast and in what way the digital transformation is practised. The myth of using a single strong leader or a small core team to realise digital transformation needs to be recognized, and sufficient effort and resource needs to be put in roadshows, digital education, skillset training and other initiatives to improve the overall readiness level. This necessitates a roadmap and transformation toolkit at your organisation’s disposal for planning and executing a digital transformation. The following are some tips to improve the success rate.

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Recommended tip No. 1: Create a vision and outlook that can be translated to every member of the organisation

Digital transformation is an extremely challenging journey that, at critical junctures, requires a sense of belief to overcome hurdles. It is also a delayed response effort that requires its disciples to wait through the darkest hour before the light appears at the end of the tunnel. Hence it is important for every member of the organisation to understand why the organisation needs to transform and what value it can bring to the individual or the cause that the individual is serving. The lack of such translation will render the grand vision a fable that will be challenged and overthrown when difficulties mount. This calls for the vision to be simple to understand, fitting to the organisation’s history and culture and noble to the mission born by the organisation. It also means that extensive promotional effort is necessary to drive the message into every individual’s calling. Recommended tip No.2: Know where each line of business is in terms of digital readiness

Within the organisation, different departments will likely be in different stagesof IT or digital maturity. Using the matrix above to map the current positioning realistically will enhance the feasibility of the roadmap and a better estimated investment scale. This will allow expectations to be better managed at the onset before the sense

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illustrates the twin-effect correctly. This need to understand both digital tech and business is the exact reason why IT engineers often fail to deliver digital transformation. Superficial mimicking or surface level observations cannot satisfy the deployment requirement of digital twins. Hence, it is dangerous to let IT lead digital transformation efforts and allow business leaders to take the back seat. The sequence should be the reverse to ensure success.

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of misalignment ruins the morale and confidence of the team. Recommended tip No.3: Let a digital-savvy business leader take the lead instead of not the IT guy Any digital transformation journey will need a leader to achieve measurable success with low-lying fruits intermittently as the entire organisation pushes along the transformation effort. This will need the leadership and foundation of a business leader who can make immediate and direct decisions to affect digital initiatives. It is very challenging for IT leaders to take this pole position and overcome cross-department difficulties as well as possess the delicate sense of precise delivery needed in early stage effort to validate success. Business leaders will also be able to calibrate the right amount of measurable milestones that are audacious yet within reach, to achieve the greatest role model effect for the new transformation journey. Conclusion

Politics, technology, market and regulatory requirements are the various reasons driving organisations in China to initiate digital transformation. It is important for the leadership to go in with eyes wide open and be ready to realign and re-innovate to tide through the journey and get the best out of the deal. Planning and management, execution and business value, frank self-assessment and acting with the risk tolerance of the organisation will be key success factors to avoid most pitfalls in digital transformation.

Junyang, as the co-founder of Qianlu, is now advising healthcare providers, government and healthcare technology companies in digital transformation. Junyang is also chairing the digital transformation committee in the China Health Service Industry Alliance. Prior to Qianlu, he was the Country Manager of Dorenfest China Healthcare group, offering strategic advisory to public and private sector.

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NAVIGATING TELEHEALTH SOLUTIONS A comprehensive approach to finding the right fit As telehealth gains prominence, this article provides a comprehensive guide for organisations seeking optimal solutions. It navigates divergent definitions, the scope of telehealth, and the strategic steps to identify, prioritise, and evaluate requirements. With insights from demos and pilots, leaders can make informed decisions for effective telehealth integration. Marianna Petrea-Imenokhoeva, Digital Health Expert, Co-founder Health Tech Without Borders Jarone Lee, Associate Professor, Harvard Medical School; Co-founder Health Tech Without Borders

n today's landscape, telehealth has become a familiar term among both clinicians and patients. However, its exact definition may vary. The global telehealth market showcases its diversity through various vendors offering solutions. A cursory web search reveals the top contenders and an extensive list of over 200 providers.

Defining Telehealth

Telehealth1, as outlined by the U.S. Health Resources and Services 1 What is telehealth? How is telehealth different from telemedicine? | HealthIT.gov

Administration, employs electronic information and telecommunications technologies to enable remote clinical healthcare, health-related education for patients and professionals, public health endeavours, and administrative functions. These technologies encompass a range of tools including videoconferencing, internet connectivity, streaming media, store-and-forward imaging, as well as terrestrial and wireless communication methods. Telehealth and telemedicine diverge in their scopes, with telehealth encompassing a more comprehensive

range of remote healthcare services than telemedicine. Specifically, telemedicine pertains to remote clinical services, while telehealth encompasses a broader spectrum, incorporating non-clinical offerings like provider training, administrative meetings, continuing medical education, and clinical services. Telehealth Solutions

Telehealth solutions encompass both synchronous and asynchronous modes, often integrating remote monitoring. These solutions span an extensive array of clinical specialties, ranging from general medicine, paediatrics, psychiatry, and endocrinology to rheumatology, and many others. Telehealth can combine various medical organisations and specialties into a single virtual network, overseen by a central hub. This network may involve different physical locations, including central and remote clinics, both public and private healthcare centres, rehabilitation facilities, preventive health centres, as well as the private offices of doctors. All registered patients within these areas can be part of this network.

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Alternatively, telehealth could also function as a virtual community of healthcare providers, offering assistance during disasters and humanitarian crises. The Constant Core

Although the fundamental functionality of telehealth remains consistent, innovative features cater to the unique needs of healthcare organisations and specific use cases. The question arises with this array of possibilities: where should one begin? While the COVID-19 pandemic accelerated Telehealth’s adoption, implementing telehealth requires a clear operational, infrastructure, and strategic plan for long-term success. Similarly, success requires a regulatory and policy environment friendly to telehealth.

In this era of innovation, making the right choice ensures that telehealth continues to serve as a vital and seamless bridge between healthcare providers and the communities they serve.

The Journey to Find the Right Solution

Embarking on the journey to find the most suitable telehealth solution involves a deliberate approach: Assemble a Collaborative Team and Identify Needs: Forming a dedicated project team is paramount, encompassing key stakeholders and users. This collective effort focuses on recognizing critical organisational needs and overcoming challenges. Defining metrics for success also guides and focuses the implementation strategy. Specific examples include using telehealth solutions to ensure continuity of care to address clinician shortages; to expand access to care in underserved and rural regions; to better track, contain, and treat the spread of illnesses like COVID-19; and even support displaced populations and refugees in austere environments. Throughout this stage, active involvement and backing are crucial not only from key stakeholders but also from users. Telehealth serves as a prime illustration of healthcare technology that demands a level of digital literacy from both clinicians and patients, designating them as pivotal users.

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Defining Requirements The subsequent step entails establishing the organisation's requirements. These are the conditions or capabilities necessary for solving problems or achieving objectives. Crafting a comprehensive list ensures clarity and uniformity. These requisites ensure adherence to formal documents, standards, or contracts. Organisations must compile a comprehensive list of these requirements based on their implementation requirements and expectations. To establish these requirements effectively, organisations must engage relevant stakeholders and provide comprehensive explanations to ensure a common baseline of understanding among all participants. During this stage, an extensive list is advantageous. Here are some initial requirements to consider including: • Synchronous, audio and video conferencing capabilities • Asynchronous, secure messaging and chat capabilities • Electronic scheduling features

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• Analytics and comprehensive reporting • Billing, reimbursement, and online payment features • Personalised intake forms and visit summaries • Image and document uploads • Existing data migration and scalability provisions • Interoperability and security measures • Compliance with local regulatory requirements (e.g. HIPAA in the U.S. and GDPR for the EU) • User authentication and authorization processes • Branding and customization options • Language localization capabilities • User interfaces tailored for clinicians, patients, and administrators • Comprehensive customer service during and post-implementation, inclusive of user training, a 24/7 hotline, and technical support • Cybersecurity requirements Other important considerations include: Unrestricted Device Access: All users possess the flexibility to utilise diverse devices, ranging from computers to smartphones, for connecting and actively engaging in video and audioconferencing sessions, as well as exchanging vital information. Patient Data Inclusion: Patients' data encompasses a spectrum of essential details, including general personal information, primary examination outcomes from local clinics, results of lab tests, as well as data from medical digital devices like Magnetic Resonance Imaging (MRI), Computed Tomography (CT) scans, Electrocardiography (ECG) results, and more. Including an Electronic Medical Record (EMR) that is interoperative with other systems and HL7 compliant would be ideal. The project team can systematically categorise these requirements into segments like business, stakeholder,

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clinical, technological, and financial aspects for streamlined evaluation and implementation. Involving relevant stakeholders and providing clear explanations promotes a shared understanding. Prioritise Strategically Prioritising requirements demands asking pertinent questions and aligning them with the organisation's longterm goals. Employing a prioritisation matrix, which assigns weightage to different needs, aids in identifying must-haves versus nice-to-haves. Additionally, it outlines the Minimum Viable Product (MVP), representing the minimal functionality essential for a successful launch. Engage in Demos and Pilot Phase To thoroughly understand if the requirements mentioned earlier are met and to make a well-informed

decision, the best approach is to test potential solutions or at least ask for a detailed demonstration. The main goal of this pilot phase is to confirm if the chosen solution works well for current and future telehealth needs. A patient advocate can be involved to get feedback on ease of use. They can see if the interfaces are user-friendly and if the solution works on the full range of devices like computers and tablets to smartphones and tablets. Evaluate and Choose The results from the demo and pilot phases allow for comprehensive evaluation. By assigning ratings and priority weightage to each requirement, an overall score is derived for each solution. This approach simplifies vendor comparison. Additionally, analysing detailed budget calculations, business references, and prior experience helps leadership make an informed decision.

AUTHOR BIO Marianna Petrea-Imenokhoeva, MS, a Digital Health expert with 25 years in Tech, is the co-founder of Health Tech Without Borders. With a strong background in emergency deployments for various types of disasters, Marianna's expertise spans key domains such as Telehealth, AI/ML, and Big Data. Proficient in resource investigation, allocation, and utilisation, she contributes to healthcare advancement through digital health solutions.

Jarone Lee, MD, MPH, Associate Professor at Harvard Medical School, and co-founder of Health Tech Without Borders, a global, nonprofit organisation that supports communities affected by sudden humanitarian emergencies with digital health solutions, such as telehealth. He also advises the U.S. Government’s National Emergency Tele-Critical Care Network (NETCCN) and Massachusetts General Hospital’s program on medical device interoperability & cybersecurity (MD PnP). Get Konnected and Boston Foundation named him one of Boston's most influential AAPI leaders in 2023.

Continuous Quality and Process Improvement After the initial pilot and implementation, the organisation must continue to evaluate and improve the telehealth system. This process should be circular and iterative, and feedback to the beginning to implement the lessons learned for the next round of improvements. Many frameworks exist to support this process. One example is the Plan-Do-Study-Act (PDSA) framework. Conclusion:

As we navigate the realm of telehealth solutions, it becomes evident that finding the right fit requires a thoughtful and strategic approach. The landscape of telehealth is vast, encompassing a diverse range of options from providers worldwide. Amidst this diversity, the importance of understanding telehealth's scope and its alignment with organisational needs cannot be overstated. These six steps, encompassing collaboration, requirement definition, strategic prioritisation, practical testing, informed evaluation, and continuous improvement, guide organisations toward telehealth solutions tailored to their unique current and future needs. The journey to finding the right telehealth solution is intricate, and marked by collaboration, analysis, and adaptation. While the path may seem complex, the ultimate goal remains clear: to embrace telehealth as a strategic and transformative tool that caters to the diverse and evolving needs of healthcare organisations, clinicians, and patients alike. In this era of innovation, making the right choice ensures that telehealth continues to serve as a vital and seamless bridge between healthcare providers and the communities they serve. Lastly, telehealth is not the panacea of health care and there remains many ethical considerations as we all look to telehealth to solve our healthcare problems.

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BOOKS

Digital Transformation in Healthcare in PostCOVID-19 Times (Next Generation Technology Driven Personalized Medicine And Smart Healthcare)

Transformations Through Blockchain Technology: The New Digital Revolution

Healthcare in the Digital Era : Technology-Driven Solutions for Modern Medicine

Author: Sheikh Mohammad Idree, Mariusz Nowostawski

Author: David Hunter

Author: Miltiadis Lytras, Abdulrahman Housawi, Basim Alsaywid

Year of Publishing: 2023

No of Pages: 258 Year of Publishing: 2023 Description: Digital Transformation in Healthcare in Post-Covid19 Times discusses recent advances in patient care and offers critical comparative insights into their application across multiple domains in healthcare. By showcasing key problems, best practices and emerging challenges, the book offers a state-of-art review of opportunities and prospects in the process of delivering smart sustainable healthcare services. Topics discussed include healthcare challenges in the post-COVID-19 era, enabling technologies for digital transformation, value driven approaches to the delivery of patient centric topquality health services, and analytics and enhanced decision making. In addition, the book updates knowledge on best practices for training towards digital transformation and sustainable health.

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No of Pages: 357 Description: The book serves as a connecting medium between various domains and Blockchain technology, discussing and embracing how Blockchain technology is transforming all the major sectors of the society. The book facilitates sharing of information, case studies, theoretical and practical knowledge required for Blockchain transformations in various sectors. The book covers different areas that provide the foundational knowledge and comprehensive information about the transformations by Blockchain technology in the fields of business, healthcare, finance, education, supplychain, sustainability and governance. The book pertains to students, academics, researchers, professionals, and policy makers working in the area of Blockchain technology and related fields.

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No of Pages: 176 Year of Publishing: 2023 Description: "Healthcare in the Digital Era: Technology-Driven Solutions for Modern Medicine" explores the evolving world of medicine as it interweaves with the swift advancements in digital technology. From artificial intelligence in diagnostics to virtual patient consultations, this illuminating book offers a comprehensive overview of groundbreaking tech innovations changing the face of healthcare. It exposes readers to the vast potentials of digital technology within the medical field, raises critical questions about privacy and ethics while outlining strategies for implementing these digital solutions. Ideal for healthcare professionals, tech enthusiasts, students, and policymakers, it serves as a beacon, guiding us through what the future may hold for modern medicine. Discover how you are being healed in the digital era!

Digital Health Transformation with Blockchain and Artificial Intelligence (Advances in Smart Healthcare Technologies) Author: Chinmay Chakraborty No of Pages: 321 Year of Publishing: 2022 Description: The book Digital Health Transformation with Blockchain and Artificial Intelligencecovers the global digital revolution in the field of healthcare sector. The population has been overcoming the COVID-19 period; therefore, we need to establish intelligent digital healthcare systems using various emerging technologies like Blockchain and Artificial Intelligence. Internet of Medical Things is the technological revolution that has included the element of "smartness" in the healthcare industry and also identifying, monitoring, and informing service providers about the patient’s clinical information with faster delivery of care services.

Artificial intelligence, Big data, blockchain and 5G for the digital transformation of the healthcare industry: A movement Towards more resilient and ... Technologies in Healthcare Industry)

Accelerating Strategic Changes for Digital Transformation in the Healthcare Industry (Information Technologies in Healthcare Industry)

Author: Patricia Ordonez de Pablos PhD., Xi Zhang

No of Pages: 424

No of Pages: 316

Description: Accelerating Strategic Changes for Digital Transformation in the Healthcare Industry discusses innovative conceptual frameworks, tools and solutions to tackle the challenges of mitigating major disruption caused by COVID-19 in the healthcare sector and society. It emphasizes global case studies and empirical studies, providing a comprehensive view of best lessons on digital tools to manage the health crisis. The book focuses on the role of advances in digital and collaborative technologies to offer rapid and effective tools for better health solutions for new and emerging health problems. Researchers, students, policymakers and members of the biomedical and medical fields will find this information invaluable.

Year of Publishing: 2023 Description: Artificial intelligence, Big data, Blockchain and 5G for Digital Transformation of Healthcare Industry: A Movement Towards More Resilient and Inclusive Societies delivers a collection of relevant innovative research on digital healthcare, with a three mains goals: 1) study the successes and failures in the field of IT and digital health during the pandemic, and analyze the lessons from these cases; 2) discuss the latest advances in the field of digital healthcare, with a special focus on Artificial Intelligence, Big Data, Blockchain and 5G; and 3) discuss implications for main stakeholders (patients, doctors, IT experts, directors, policy managers. The global outbreak caused by covid-19 caused global disruption in societies, healthcare systems, and economies around the world.

Author: Patricia Ordonez de Pablos, Xi Zhang Year of Publishing: 2023

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