Asian Hospital & Healthcare Management - Issue 52

I S S U E 52

2021

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INSIDE A GLOBAL LEADER IN MEDICAL IMAGING SOLUTIONS What’s behind the

success of Guerbet?

Mathieu Elie

Chief Commercial Officer, Asia Pacific, Member of Guerbet’s Executive Committee

Associate Partner

Priming Primary Healthcare Post-Pandemic Healthcare Practitioners’ Role in Keeping Stress at Bay www.asianhhm.com

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Foreword PANDEMIC SURGE Time to stay strong It has been more than a year since the COVID-19 pandemic hit the global population but the situation still hasn't come under control. Countries such as the US, India, Brazil, Italy and others are witnessing the new wave hitting hard with exponential rise in COVID patients.

Shortage of frontline workers, hospital beds, medicines, oxygen, and ventilators continues to hamper efforts to save lives, even as crematoriums and graveyards work non-stop to handle the mortality surge. Countries are taking some new steps to tackle this current wave. In India, some states have declared lockdowns, while others may take that route in the event cases continue to rise exponentially.

Vaccination is being looked at as the only option to prevent the virus from impacting more lives. Even as countries ramp up vaccination efforts, it’s only 3.2 per cent of the global population that is fully vaccinated.

The US has administered a record 232 million doses of vaccines, followed by India with 145 million and the UK with 47 million doses. When it comes to the fully vaccinated population, Israel tops the chart with 54 per cent, the UAE 38.8 per cent, the US with 29.5 per cent, the UK with almost 20 per cent and so on. But in India, less than 2 per cent of the population is fully vaccinated.

In India, with half production of vaccines going to the open market from vaccine manufacturers, the question begs to be asked: do the vaccine stock meet the requirements? The Serum Institute of India (SII) that is expected to meet 90 per cent of India’s COVID-19 vaccine demand produces 65 million doses a month.

With an average daily vaccination of 3.5 million doses, India would require almost 105 doses a month. And with the government now opening vaccination for the 18-45 age group, the world’s biggest vaccine exporter, is now struggling with a huge shortfall.

Amid all this, the COVID-19 pandemic has had a major effect on lives of people all over the world. To reduce the spread of this virus and care for the affected people, many are facing challenges that can be stressful, overwhelming, and cause strong emotions in adults and children. Staying at home and maintaining social distancing when going out, along with use of masks continue to be the norm to stay safe. Stay-at-home orders for long may be one of the reasons to make people feel isolated and lonely and can increase stress and anxiety. Lack of proper knowledge about how COVID-19 spreads may cause fears about disease and death resulting in social stigma. The impact on people is more psychological than physical. Learning to cope with stress in a positive and healthy way will make us strong enough to fight the menace and become more resilient. Coping with stress during a COVID-19 outbreak will make the one, their loved ones, and their community stronger. It’s time to stay positive and mentally strong to ensure well-being of self and loved ones.

In this issue, we have an article by Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition that focuses on stress-related illness, nutrition to combat stress and more importantly recommendations for healthcare practitioners to provide a more holistic service for their patients to deal with stress. Keep reading… Stay healthy and stay safe.

Prasanthi Sadhu

Editor

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CONTENTS 06 Priming Primary Healthcare Post-Pandemic Gurrit K Sethi, Strategic Advisor, Global Health Services, Global Strategic Analysis

08 Healthcare Practitioners’ Role in Keeping Stress at Bay Kent L Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition

12 Precision Approaches R B Smarta, Vice President (HADSA), CMD-Interlink

MEDICAL SCIENCES 18 ST-segment Elevation Myocardial Infarction during COVID-19 Pandemic Mario Gramegna, Luca Baldetti Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute

24 Challenges Faced in the Treatment of Acute Ischemic Stroke

COVER STORY

HEALTHCARE MANAGEMENT

INSIDE A GLOBAL LEADER IN MEDICAL IMAGING SOLUTIONS What’s behind the success of Guerbet?

Mathieu Elie, Chief Commercial Officer, Asia Pacific, Member of Guerbet's Executive Committee

Leonard Yeo, Acting Neurologist, Ng Teng Fong General Hospital and Senior Consultant, Division of Neurology, National University Hospital

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26 Remote Patient Monitoring Steadies Clinical Outcomes, Aims for Optimal Patient Comfort

SURGICAL SPECIALITY

Mudit Dandwate, CEO & Cofounder, Dozee

34 Personalising Management of Cardiac Surgery Patients Through Right Heart Biomarkers

28 Respiratory Care Insights on access and affordability

Louise Y Sun, Division of Cardiac Anesthesiology, University of Ottawa Heart Institute

Vinay Joshi, Chief Executive Officer, ABM Respiratory Care

30 Sacubitril Valsartan in HFrEF An observational series in ambulatory patients with HFrEF Luanda P Grazette, Cardiovascular Division, Miller School of Medicine, University of Miami Jeffrey S Tran, Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC) Ofer Havakuk, Head of Heart Failure Service, Tel Aviv Medical Center

DIAGNOSTICS 40 Radiology in the New Normal Per Edlund, Head of Radiology Commercial Operations Asia Pacific, Bayer Pharmaceuticals Division

42 Ambulatory Cancer Care Quicker expansion to bring more value and accessibility to patients Phoebe Ho, Chief Executive Officer, Integrated Oncology Centres (IOC)

INFORMATION TECHNOLOGY 46 Technology in Telehealth K Ganapathy, Director, Apollo Telemedicine Networking Foundation; Director, Apollo Tele Health Services

48 Books 50 Research insight

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Advisory Board

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

EDITOR Prasanthi Sadhu EDITORIAL TEAM Grace Jones Swetha M

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

ART DIRECTOR M Abdul Hannan PRODUCT MANAGER Jeff Kenney SENIOR PRODUCT ASSOCIATES Peter Thomas David Nelson Susanne Vincent

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

PRODUCT ASSOCIATE John Milton Veronica Wilson

Nicola Pastorello Data Analytics Manager Daisee

CIRCULATION TEAM Sam Smith SUBSCRIPTIONS IN-CHARGE Vijay Kumar Gaddam

Gurrit K Sethi Strategic Advisor, Global Health Services Global Strategic Analysis

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

HEAD-OPERATIONS S V Nageswara Rao

Associate Partner

In Association with

A member of Confederation of Indian Industry

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

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

Peter Gross Chair, Board of Managers HackensackAlliance ACO

Malcom J Underwood Chief, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital

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Priming Primary Healthcare Post-Pandemic While we can proudly say that we fared better than most developed nations with regards to the pandemic in the first wave, in the current surge, it has exposed our weak healthcare system, of course, along with it our grit and resourcefulness as well to get things done! Nevertheless, it is time to spruce up our health systems, and very specifically we need to start with the primary care. And we need to start at the grassroots in the rural areas. For, this is where will lie our prosperity—health wise as well as cost wise. Our primary systems need to be enabled to nip the evil in the bud.

Gurrit K Sethi, Strategic Advisor, Global Health Services, Global Strategic Analysis

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ndia has one of the largest primary healthcare set-ups in the world, from an infrastructure perspective. With our three-tiered primary health system, each sub-centre covers a population of three-to-five thousand people, each Primary Health Centre (PHC) covers a population of twenty-to-thirty thousand, and a Community Centre around eighty thousand to a lac. This three-tiered system covers every nook and corner of the country. Fact is, however, that despite this large spread across the length and breadth of the country, the health coverage remains scarce, especially in the rural areas. Eighty percent of health coverage is still provided by private players. However, this is also unevenly distributed with a concentration in large cities.

The moot question is that when we do have the basic infrastructure available for good primary healthcare services funded

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by the government, why is there still a lag in such a life critical service? The answer lies in the low doctor-patient and the nurse-patient ratios in our country. And this could be attributed to a considerable brain drain as well as owing to lack of opportunities. While the capacity for

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education in these streams has been increasing over the last few years, owing to the lack of quality of faculty and other resources, this is impacting the speed and quality of student output.

The private sector has lately seen the advent of the primary healthcare services or retail healthcare over the last few years. However, there are few success stories in primary care, or, rather the story in this sector is still evolving. The cost of the offering is high, profits low and thus few takers from the investment standpoint for the traditional brick and mortar models. And with the evolving needs for home healthcare and other specialised models, primary healthcare is taking a backseat.

The key concerns for availability of primary healthcare services, with this background, remain – accessibility, quality and cost. All three challenges

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require the presence of specialised skillset of laboratory technicians and physicians.

The evolution of connected devices is another area that can help in overcoming accessibility and availability challenges in the rural regions. This is supportive of regular monitoring of health conditions of patients suffering from chronic diseases leading to early interventions.

These early interventions prevent serious health deterioration episodes and of course lowers the cost of treatment eventually. There are a lot of our youth who are engaged in innovation of such devices and applications. It is indeed time to put these to use.

The primary healthcare system also needs to take a positive step towards wellness and prevention of diseases.

Here again a lot of these PoC diagnostics and connected devices can be very useful for regular health checks. Digitisation can help through health trackers. A lot of these are now being deployed by insurance companies. An application of similar trackers at the PHC levels can be useful for promoting wellness and disease prevention.

Simple interventions can help in not only modernising our clinics but also enhancing the scope of disease management through digital mode.

Artificial Intelligence (AI) can also support in decision making on one hand as well as supporting population health management at the community level.

At the disease management level, AI can support not only simple decision making but also reducing judgment errors while also enriching the diagnosis with data

Gurrit K Sethi, Strategic Advisor for Global Health Services, Global Strategic Analysis, contributes to healthcare by helping providers build and better business efficiencies and concept development, also strives to contribute socially through the Swiss Foundation, Global Challenges Forum as Strategic Advisor, through conception of sustainable health initiatives. She started her career from the shop floor working her way up to lead different healthcare businesses in different domains and verticals. Her significant achievements have been in bringing to life different SMEs and SBUs signifying a change in the Indian healthcare scenarios, as the opportunity paved the way along the healthcare growth curve in the country.

With over 20 years in healthcare under her belt, she has carried transformational changes in the projects she has led, four of those being early stage start-ups. Gurrit is an avid traveller and voracious reader of varied genres, attributes which she says, provide her with incisive insights about people and systems and what drives them.

showing evidence of various treatment modalities. At the community level, data collected through these modalities can help in disease profiling and early pick up of signs of any mass illness / epidemic events more easily.

In a nutshell, the solution to our challenges of skill availability, quality and cost can all be overcome through the modern-day tools supporting and working in sync with the traditional models. They cannot for sure be seen as competition. The very possible solutions have been pushed aside in the past only because of the seemingly competitive positioning of these models. It is time for these to actually sync in with the rudimentary models offering them a boost. Digital health management is definitely in but the final solution comes only through these boosting the traditional models to start with. The delivery of primary healthcare services can contribute to the national health statistics way more effectively through digitisation. While digitisation has been adopted way more successfully over the past years at the tertiary level, the similar application can bring a boost to the neglected rural sectors.

There is a solution for each of the cited challenges, through varying modes of partnership, and, methodology of service provision. There also remains a good business promise with lowered cost.

And at the top of this will be a healthy community and a healthy nation.

AUTHOR BIO

because of the uneven distribution of available skillset outside of the urban areas. And the outcome of these challenges is the increased chronic disease burden, increased mortality, eventual higher cost of treatment and disability as a result of delayed treatment. Each of these aspects affect economic productivity and output apart from the cost burden of the public healthcare services through public health institutions or the public health instruments offering free treatment through the private sector.

Thus, it is imperative that to reduce the cost of provision of healthcare and the disease burden itself, good primary care as well as wellness be promoted and early diagnosis be done – nip the evil in the bud. This is only possible through provision of good primary healthcare services. Come to think of it, many lives have been lost in the pandemic itself because of delayed diagnosis and treatment, not just because of the disease itself.

It is time to infuse digital support to the basic rung of our healthcare system.

With the scarcity of doctors in general and doubly so for specialists and super specialists, this is one way to overcome the challenge of non-availability of physicians in the rural setups. A support system of physician assistants can greatly aid the system and the community.

It is also time to recognise benefits of Point of Care (PoC) diagnostics. With these, the early diagnosis in the primary facilities is eased and made possible because they do away with the need of elaborate lab setups. Also, these do not

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HEALTHCARE PRACTITIONERS’ ROLE IN KEEPING STRESS AT BAY The article focuses on stress-related illness, nutrition to combat stress and more importantly recommendations for healthcare practitioners to provide a more holistic service for their patients to deal with stress.

Kent L Bradley, Chief Health and Nutrition Officer Herbalife Nutrition

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ith the ongoing pandemic, it is increasing common for people to experience heightened stress-related ailments because of various economic and social disruptions. The Asia Pacific population faces similar challenges like the rest of the world.

Workplace stress is on the rise. A survey with more than 2,700 business leaders across APAC revealed that most respondents agreed their mental health, or that of their colleagues, had been negatively impacted. Fortunately there are more studies now available to better understand the mental health challenges and gaps in the support system of the respective countries.

Multiple behavioral studies have demonstrated that stressful events and depression can trigger inflammation. Stress-related ailments and issues include headaches, heart problems, high blood pressure, skin conditions, diabetes, asthma, arthritis, anxiety, and depression.

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In certain instances, the signs of stress may not be too visible or recognisable. These less obvious stress symptoms can range from excessive hair loss, memory loss, facial twitch, weakened immune system, chronic pain, and gastro issues. Ignoring high levels of anxiety can lead to an increased risk of high blood pressure, heart attack or even stroke. So, the consequences of stress are complex and impact our overall health.

In parallel, the pandemic has also spotlighted healthcare practitioners (HCPs) as one of the most credible sources of health and wellness information and advice.

HCPs can play a key role when it comes to stress-related illness and prevention by showing empathy to their situation, taking the time to understand their patients’ needs, and educating them on ways to manage their stress level by emphasizing overall good health through balanced nutrition, regular exercise, sleep, and connection with others.

Staying connected

One of the insights that 2020 taught us was how much we crave connection as social beings. The isolation from the pandemic has led to higher rates of depression. Studies have shown that social connection ‘can lower anxiety and depression, help us regulate our emotions, lead to higher self-esteem and empathy, and improve our immune systems’. As a health professional, I have found that many people benefit from eating healthy and losing weight when they are part of a community, all working, collaborating, and supporting one another. While many of these groups are unable to meet in person, they have blossomed online, and the camaraderie has been shown to help healthy weight loss and meet nutritional goals.

Fuel with good nutrition

We often overlook the additional benefits of eating a well-balanced diet. A

diet the provides good nutrition means getting the necessary micronutrients, phytonutrient, and bioactive intakes, along with the macronutrients, to help one’s body function at its best.

The advantages of eating healthy are manifold including maintaining the body’s systems to reducing food sources of heart-threatening bad cholesterol and improving emotional wellbeing.

In a research conducted on the healthy food traditions of Asia, it was shown that lack of nutrition causes health issues across the region.

Healthcare professionals can encourage the consumption of food that are readily available with nutritious benefits. For example, banana is one such fruit that is widely consumed in this region, and is a source of vitamins, minerals, pectin and dietary fiber. The fruit is also high in potassium content which is a vital mineral for keeping blood pressure low.

Another popular food would be nuts like cashew, peanuts, almonds, and soy nuts. Nuts are full of nutrients like healthy fatty acids and b vitamins that provide health benefits like lowering stress levels, supporting the immune system, reducing the risk for heart disease, improving blood sugar levels, and aiding in weight control.

Additionally, it has been shown that prolonged stress increases the metabolic needs of the body and causes many other

Healthcare Practitioners can be more observant to look out for signs of stress in terms of the patient’s body language, tone of voice, overall behaviour as well as any other visible triggers. changes. The increased metabolism leads to a rise in the use and excretion of many nutrients. Although stress alters nutrient needs, if a person has an existing nutrient deficiency, stress can make that deficiency even worse.

Counselling patients on stress management

Eating heathy is a must and so is having a balanced lifestyle. To minimize stress, one should look at all aspects to improve overall wellness. The HCP’s role here is constantly evolving to improve their patients’ overall wellbeing.

When speaking to or counselling patients on stress, it is important to identify what triggers their stress.

Studies show that there are internal stressor factors such as underlying illness or a framing of life events that

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Kent Bradley has worked in leadership roles in healthcare sector, strategizing health related policies and business decisions. He has also acted as strategic advisor for multiple health-tech companies.

A retired army Colonel, he has a Master’s Degree in Public Health from University of Minnesota and his medical degree from Uniformed Services University of Health Sciences, Maryland.

lead to excessive worry and external stressor factors such as pain, abusive relations and deteriorating working conditions. HCPs will have to identify the root cause of their patient’s stress to consult them appropriately with the right stress management.

Moreover, consultation with patients is shifting to online mediums with the rise of telehealth. HCPs can be more observant to look out for signs of stress in terms of the patient’s body language, tone of voice, overall behaviour as well as any other visible triggers. Certain symptoms of stress such as anxiety that causes trembling and rapid breathing can be recognised over video call. By observing patients in their own home, HCPs may be able to obtain valuable information on the patient's living conditions and other social determinants of health that can help with diagnosis. Virtual visits allow HCPs to easily consult with their patients while providing patients access to mental health services. Of course, you should also simply ask…are you experiencing stress in your life?

Recommendations for healthcare practitioners

Healthcare practitioners can regularly incorporate the following in their consultation sessions: 1. Display patient educational materials with content on mental wellness and managing stress 2. Be more open to talk about mental health by enquiring on how their patients feel 3. Educate patients on the signs to look out for when stressed or facing anxiety attacks 4. Creating a check list for patients on how to self-detect for any tell-tale signs and especially for less obvious stress signs 5. Share nutrition tips with an emphasis on consuming less salt, less oil, more greens, and fruits. HCPs can remind their patients of the nutritional benefits in food consumed daily and that are easily available 6. Share simple techniques to manage stress like focusing on breath, doing a daily body scan and self-affirmation meditation 7. Inform and encourage patients to download apps that assist to navigate stress-inducing scenarios such as Headspace and Calm 8. Recommend to patients that to achieve overall wellbeing, set a daily routine that includes nutrition, exercise, sleep and mental breaks 9. Encourage patients to invite humour into their lives as one of the stress management methods. Although finding humour in a stressful situation is not easy, laughing has been proven to reduce stress hormone levels 10. Suggest to patients to stay connected with their family and friends and express their feelings and emotions 11. Share with patients that there is no ‘quick fix’ for stress. It may require several rounds of consultations and/or virtual visits to adequately control the symptoms of stress. Encourage patients to keep you updated on their progress and to check in regularly The role of HCPs has evolved significantly when it comes to educating patients on preventive health measures. As HCPs provide more holistic consultation services and equip their patients with proper nutrition, lifestyle information and stress management methods, they will enable their patients to lead healthier lives.

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Repeat steps 1 and 2 increase the risk of a HCAI outbreak.

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Precision Approaches With the onset of Covid-19, patients’ perspective has drastically shifted toward targeted, predictive and personalised care which is insisting hospital’s management to become future-proof with advanced precision approaches to meet the future demand. With new research developments and initiatives by hospitals, precision health technologies are gaining much attention in today’s healthcare industry. ‘Predictive-preventivetreatment approach’ is the basic idea behind these precision-based technologies which has proved to be superior in recent times.

R B Smarta, Vice President (HADSA), CMD-Interlink

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hile talking about precision approaches in healthcare, the words ‘precision medicines’ pop up first in our mind. Based on patient’s unique genetic makeup, precision medicines are widely used to cure a number of deadly diseases which were literally impossible to treat in the past several decades. However, ‘precision health’ is much more beyond the concept of precision medicines.

Precision health

Precision health approaches not only include personalised medicines, but a variety of approaches related to

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hospitals, working procedures, systems, and number of allied frameworks in the healthcare facilities. Hospitals need to be well-precise in various aspects of their working in order to improve patient experience and support hospital management. Figure 1 depicts the journey of a patient through the technology-based precision approaches of hospital management toward recovery and rehabilitation.

In addition to personalised and patient-centred care, early detection and prevention along with the ease to make real-time decisions are some of the aspects which are considered under precision health approaches.

Bigdata enables doctors to surf through millions of patients records in a very short time. Knowing the symptom and characteristics, doctors are coming up with the possible best ways to treat their patients with the help of technological approaches which are being widely used in hospitals nowadays. (Figure 1) The Covid-19 pandemic has created an emergency for healthcare industry and patients are now expecting more promising high-tech offerings from hospitals. In order to meet this everrising demand, with the introduction of artificial intelligence (AI) in healthcare,

hospitals nowadays are upgrading themselves with advance technologybased precision approaches. These approaches are as follows 1. Precision approaches toward patient care

AI in precision medicines - Genomic science is one of the best discoveries forthe healthcare industry; and based on this, a number of leading healthcare providers are using new technological approaches toward more advancements in this area. Genomic data management strategies along with an optimistic execution plan which can engage a huge pool of patients at a time is one of the aims of such kind of approaches.

EHRs management - Most of the healthcare-related technological approaches are concentrated over the electronic health records (EHRs) owing to faster information transfer and efficiently integrated care. Today, hospitals are dealing with multiple EHRs as many have more than one

clinical information system which generates a need of integrative platform to coordinate across the entire system.

To handle this massive data and to ensure high degree of accuracy and reliability, hospitals are now exploring various systems which can offer greatest flexibility in this task.

Robotics - One of themost promising tools in healthcare, robotics is gaining much attention in hospitals due to its much precise and advanced capabilities.

Robot-assisted surgeries are successful most of the times as surgeons can operate such surgeries with a high-definition view along with mechanical arms.

This technology is highly beneficial for

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Figure 1 Total precision care in healthcare Source- Interlink Knowledge Cell

patients due to its high level of precision, control and flexibility with very few complications and scars.

3D printing technology - To attain a high-degree precision, surgeons today can replicate specifics organs of patients with 3D printing which are very useful for preparing for various procedures. In addition to this, 3D printing can even produce prosthetic limbs and realistic skin.

This technology is emerging as a ‘timemoney-resources saving’ technology in healthcare organisations. 3D printing technology is expected to simplify complex procedure to the greater extent in the near future. (Figure 2) Virtual reality- With the ease of surgery simulation in medical training, virtual reality (VR) is causing wonders in healthcare industry. With this technology, surgeons are able to view 3D images of a patient’s organs and other body parts which resulting into much precise surgeries or operating procedures. Along with doctors, patients are also benefiting with this amazing technology as they can understand their medical condition or treatment plans in much better way.

Wearable Techs - This area of technology is also gaining much attention in recent times. Owing to

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the precise results about their health status, patients are now becoming increasingly adaptive towards wearable tech and mobile applications. With recent advances,these smart devices are moving beyond the smartwatches and calorie intake to include electronic skin, smart gloves, monitoring patches, sweat sensors, etc.

2. Precision approaches toward hospital workflow-

Improving hospital patient flow with machine learning- Machine learning (ML) is turning out to be a best option in managing the patient flow in hospitals as it offers predictive models which help decision makers with patient flow information. This technology serves real-time data to make much precise decisions. Advantages of ML are as followsa. Minimises the chances of delay for surgical procedures, admissions and treatments b. Patient admission procedure is efficiently handled with prioritisation of patients based on their medical condition c. Prevents overcrowding and diversions in ED d. Staff schedules are effectively managed with the lesser need for overtime

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e. Improves discharge and bed capacity management, etc.

Assets tracking - Supply chain management is very crucial in hospitals as number of elements like retailers, distributors, wholesalers, manufacturers are involved in the process of maintaining inventory.

Technological advancements like ‘blockchain-enabled supply chain management system’ are used by various hospitals for better and precise management of their inventory.

Reordering quantity at predetermined timing is getting easier due to such kind of technological innovations in healthcare. With the help of trackers on items, the items are easily located, resulting in increased efficiency in the healthcare facilities.

Revenue series management Again, this can be efficiently managed through blockchain technology to improve precision and efficiency of the revenue cycle of hospital. Introducing blockchain technology in payment process system can minimise the chances of billing and payment errors due to incorrect coding. Automated calculations are one of the greatest advantages of this technology as it can be used while dealing with complex payment contracts. (Figure 3)

HEALTHCARE MANAGEMENT

In-hospital directing and patient alert- Many hospitals todayareequipped with navigation technologies in their architecture. This reduces the struggle of patients and visitors in finding specific section in large hospitals. This navigation features provide turn by turn directions along with messaging and alert systems in the applications.

Moreover, to notify the patient with automated reminders, many hospitals have adopted special technologies which precisely sent notifications to patients including appointment time and exact office/department number.

Such kind of alerts also inform patients about changes in time/location of an appointment.

Optimising the workflow in hospitals by improving patient engagement- By tracking and

investigating service slowdowns with the help of technology, performance of overall healthcare facility can be improved and precision in the work flow can be achieved. Latest technological advancements are enabling doctors to serve patients with timely monitoring.

AI and mobile technologies are enabling better and fruitful engagement between doctors and patients.

3. Precision approaches toward security and hospital design

Data security through blockchainBlockchain technology is very helpful in dealing with security issues which arise due to health information exchange.

Owing to the multiple permission layers in blockchain-driven health information exchange, patients can share only relevant parts of their health

AI IN PRECISION MEDICINE VIRTUAL REALITY

EHRS MANAGEMENT PRECISION APPROACHES TOWARD PATIENT CARE

WEARABLE TECHS

ROBOTICS

3D PRINTING TECHNOLOGY

Figure 2 Precision approaches toward patient care

records with the doctors by declining access to the entire data.

Improving hospital design for precise staff and patient managementStaying in hospitals is mostly stressful and boring, for patients as well as the hospital staff. To the certain extent, hospital designs can promote physical and mental health of patients and can improve their recovery. Moreover, in my opinion, it can also boost the productivity of staff by relieving their stress.

Customised patient rooms can be a good approach toward improving hospital architecture. Refreshing photos, customised music, video call facility with friends are some of the aspects which can be worked on in the hospital. To minimise patient anxiety and promote healing, smart premises can be built with surrounding of nature. Introducing relaxing furniture in staff rooms can reduce working stress and improve productivity of employees.

Proper lighting and noise management also play crucial role in upgrading overall environment of hospital. Mood and perception of pain of patients can be improved with such strategies.

Case Study- Apollo Hospital’s precision oncology

Apollo hospital is one of the famous and much advanced healthcare facilities which is flourishing as a bold example of management adapting greater precision approaches at various levels in their facilities. Discussed ahead is very interesting approach atApollo toward cancer management called ‘precision oncology’.

Precision-diagnosis of cancerApollo hospitals perform their revolutionary tests for diagnosis which are known to be game changers in cancer treatment. Liquid biopsy precisely detects cancer with a blood test. Apollo hospitals is the first healthcare provider performing this test in India. Moreover, tumour tissue analysis at Apollo can test for around all known 20,000 cancer

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HEALTHCARE MANAGEMENT

1. Improving hospital patient flow with machine learning 2. Assets tracking 3. Revenue series management 4. In-hospital directing and patient alert 5. Optimising the workflow in hospitals by improving patient engagement Figure 3 Precision approaches toward hospital workflow Source- Interlink Knowledge Cell

Way forward

In many countries including India, demands of patients and hospital management are not fulfilled in time which is an ever-growing concern for entire nation. This needs government interventions on urgent basis and rethinking in terms of optimising

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inpatient and outpatient settings with the help of digital technologies into hospitals which can truly meet the demands on time.

AI has a very important role to play along with machine learning to develop precision medicines as well as precision

R B Smarta has designed management agendas for profitable growth, relevant expansion, launching new concepts, ideas and projects for National and Global clients in Pharmaceuticals, Nutraceuticals and Wellness.

Being in the industry for more than 4 decades & in consulting as a pioneer for 3 decades, he has a perfect blend of industry and consulting best practices.

He has added value and impact on performance of wide variety of clients, inclusive of start-ups to national and multinational corporate. His firm Interlink has created valuable insights and depth of knowledge in its knowledge bank, along with its consultants and associates.

AUTHOR BIO

pathways in tumour tissue. Apollo also does Gallium 68 scan which is wellknown to detect the precise location of the neuroendocrine tumours.

Precision-treatment of cancerHaving introduced technologies such as Tomotherapy and proton therapy (will be commissioned soon) for cancer treatment in India, Apollo hospitalshave a very precise approach toward chemotherapy, radiation, and also the surgeries. Offering personalised cancer therapies, these treatments (Cyberknife, Tomotherapy and proton therapy) ensure reduced damage to the healthy tissues and fewer side-effects.

Apollo tests for the chemo sensitivity by matching the genome of the cancer and patient. This enables the system to tailor personalised chemotherapy for individual patient. With the help of robotic technology, surgeries are carried out very precisely with lowering the incidences of risks. Moreover, Apollo’s expertise offers allogenic transplants along with autologous transplants.

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approaches in entire framework of the hospital. Early diagnosis and treatment is still somewhat challenging in certain aspects of medical conditions, technologies can overcome them in the near future.

Many hospitals and patients are still not very adaptive toward these new advancements in technology, artificial intelligence should be approved by regulators of hospitals and training should be provided to the organisations, doctors, medical staffs as well as patients. Although these technologies will not replace human clinicians, but will surely extend their efforts in much fruitful manner toward patients. So, it is very necessary to work collaboratively with these technologies in order to be persistent in a longer run.

References are available at www.asianhhm.com

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For more information or to contact us about a placement please quote AHHM20 to: vpp@gstt.nhs.uk or +44 (0)20 7188 1622 Or visit our website: www.guysandstthomasevents.co.uk/AsianHHM www.asianhhm.com

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ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION DURING COVID-19 PANDEMIC The COVID-19 pandemic may have profound indirect consequences on the epidemiology, phenotype, and management of acute cardiovascular diseases.

Our study shows, in a cardiovascular regional public service healthcare Hub, during COVID-19 pandemic, a significantly longer time from symptoms onset to hospital admission among patients with acute myocardial infarction compared to the same period in the previous two years.

Mario Gramegna, Luca Baldetti Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute

T

he coronavirus disease 2019 (COVID-19) pandemic has an enormous impact on social, economic, and healthcare networks.

Every sector of the healthcare system has been hit by the pandemic and must now face significant worldwide re-arrangements on access to cure and clinical priorities, including among the others, re-organisations of cardiovascular health systems. In particular, the 18

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Emergency Medical System (EMS) has been reshaped across the globe to optimise the management of COVID-19 patients and at the same time continue to guarantee adequate care for patients with acute cardiovascular conditions.

Acute Coronary Syndromes (ACS) is the term used to define a range of cardiovascular conditions associated with a sudden reduction of blood flow (ischemia) to the heart muscle IS S UE - 52, 2021

(myocardium). One of these most serious conditions is acute ST-segment Elevation Myocardial Infarction (STEMI). It is a frequent disease still associated with high mortality, mandating rapid management with reperfusion therapy, with the aim to promptly restore blood flow to the ischemic myocardium. Reperfusion therapies encompass primary percutaneous coronary interventions (PCI) and fibrinolytic therapy.

In the setting of STEMI, timely reperfusion therapy is crucial because a short ischemia time is associated with better clinical outcomes, lower short and long-term mortality. The impact of timing from the onset of symptoms to reperfusion as well as the creation of networks to supply around-the-clock fast access to primary PCI has definitely improved STEMI outcomes. Total delay from symptom onset to coronary reperfusion is both patient-dependent (delay from symptom onset to first

MEDICAL SCIENCES

medical contact) and healthcare systemdependent (delay from the first medical contact to coronary reperfusion). During COVID-19 pandemic both components were subject to increased delay.

We indeed showed that the delay from symptoms onset to hospital admission was at least 7-fold longer during COVID-19 outbreak compared to previous years, with a 50 per cent

rate of late presentation (i.e., patients presenting > 12 hours from the onset of the symptoms). This observation has been confirmed by other studies suggesting larger delays in seeking medical assistance despite worrisome symptoms during the epidemic.

Explanation of this phenomenon may involve several factors. The fearrelated medical care avoidance may be associated with high tolls in terms of outcomes, in any medical setting.

Fear can lead to an inappropriately high perceived risk related to hospital admission and medical evaluation. It can be a major determinant that makes patients reluctant to activate EMS. During epidemics, hospital avoidance behaviours have been reported and were traditionally associated with misconceptions about disease severity and transmission modes. For this reason, while the direct effect on deaths of COVID-19 has been substantial and obvious, concerns have also arisen about the indirect consequences of the pandemic. Hospitalisations for acute cardiovascular conditions have declined, suggesting that patients may be avoiding hospitals because of fear of contracting SARS-CoV-2. Our study somewhat confirms this observation: we, indeed, observed a lower-than-

ST-segment Elevation Myocardial Infarction During COVID-19 Pandemic: Insights From a Regional Public Service Healthcare Hub STEMI during COVID-19 2020

Time from symptoms onset to hospital admission 2020 vs. 2018-2019

In-hospital outcomes 2020 vs. 2018-2019

Evolved STEMI 50%

Death 15.4% vs.

9.5% (p=0.69)

Primary PCI 80.8%

Inotropic support 26.9% vs. 19.0% (p=0.73) 15.0 vs. 2.0 hours (p<0.01)

Fibrinolysis 0%

MCS 19.2% vs.

19.0% (p=0.99)

COVID-19 positive 26.9%

Thromboembolism 19.2% vs. 4.8% (p=0.20)

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expected rate (as compared to previous years) of STEMI admissions to our Institute after the first Italian case of COVID-19 in Lombardy.

Moreover, failure to distinguish cardiac ischemia and COVID-19 related symptoms is possible. Sometimes there can be an overlap of respiratory symptoms with atypical ACS presentation that may confound patient perception and further delay proper EMS activation.

From a healthcare perspective, an attempt to contain SARS-CoV-2 outbreak should not mitigate the efforts spent in minimising total myocardial ischemia time. The COVID-19 pandemic placed the management of STEMI patients in a challenging situation due to the need to balance timely reperfusion therapy and maintaining strict infection control practices. For this reason, COVID-19 pandemic has led to a reshaping of the healthcare system to provide timely response and care to ACS patients. Re-organisation of the cardiovascular emergency network in Hub and Spoke hospital may reduce

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the unjustified exposure of individuals (i.e., patients in need of non-urgent procedures and their relatives) to the hospital and surrounding environment and affecting only marginally total ischemia time.

For instance, in the north of Italy, the Lombardy region was one of the first worldwide to be hit hard by SARSCoV-2 infection, apart from China.

Under normal conditions, Lombardy has 55 cardiac catheterisation laboratories offering 24/7 service for ACS to approximately 10 million inhabitants. In order to continue to treat ACS patients according to current guidelines while preventing their exposure to SARS-CoV-2, the number of hospitals with catheterisation laboratories acting as Hubs has been reduced to 13, with the remaining hospitals working as Spokes.

Excess strain on health care systems, imposed by the COVID-19 outbreaks, may also play a detrimental role. Of note, the indirect health impact of a pandemic was already described during other

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pandemics. During 2014-2015 Ebola outbreak in Africa, healthcare systems were overwhelmed with a significant negative impact on diagnosing and treating the region's major endemic diseases: malaria, HIV/AIDS, and tuberculosis. The deaths caused by these diseases almost equaled the deaths caused

by Ebola. During the 2009 influenza pandemic, an increase in mortality attributable to acute myocardial infarction and stroke was observed in the US. Similar phenomena may have also occurred during current COVID19 pandemic. Indeed, in some regions of the United States, during the initial phase of the COVID-19 pandemic,there was an increase in deaths caused by ischemic heart disease and hypertensive diseases. A recent study based on an autopsy series of deaths during the pandemicfound that reduced access to health care systems (for conditions such as myocardial infarction) was further likely to be identified as a contributory factor to death, rather than undiagnosed COVID-19.

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In the setting of STEMI, timely reperfusion therapy is crucial because a short ischemia time is associated with better clinical outcomes, lower short and long-term mortality. with serious cardiovascular diseases with profound prognostic impact.

Finally, SARS-CoV-2 infection might also have had a possible direct pathogenetic contribution to cardiovascular events. Preliminary reports suggest an increased risk of cardiac complications among patients with COVID-19, including myocardial injury, myocarditis, ventricular arrhythmias, and cardiogenic shock, associated with a higher risk of mortality.

In summary, SARS-CoV-2 pandemic has profound consequences for cardiovascular diseases. Effects are both direct and indirect, leading

AUTHOR BIO

Treatment recommendations and guidelines may require a revision to minimise the SARS-CoV-2 spreading and prevent infection. European and American guidelines recommend primary PCI as the preferred reperfusion therapy, provided that total ischemia time is acceptable. However, during the COVID-19 pandemic, some expert claimed that PCI might be not the preferred reperfusion therapy. As mentioned above, the clinical benefit is mainly dependent on rapidly achieving first medical contact-to-reperfusion time within 90 to 120 minutes, and this may have been difficult to realise during the pandemic. In addition, isolation and infection control policies may increase the in-hospital delay when activating the catheterisation laboratory. Building on this, the Chinese Society of Cardiology has released a consensus statement: to cope with logistic issues and minimise healthcare workers exposure, fibrinolytic therapy is preferred over primary PCI for haemodynamically stable STEMI patients diagnosed with or suspected to have COVID-19 infection.

In some regions, healthcare systems were pushed to adapt and reallocate resources rapidly to care for the surge of patients with COVID-19.It has led to a bed shortage that might have hampered best care delivery to acute cardiovascular patients. Many cardiac intensive care units and cardiology wards have, indeed, been transformed in COVID-19 wards. In parallel, this may have led to delays in access to care or the delivery of suboptimal inpatient and procedural care for non– COVID-19 patients. The cancellation of outpatient cardiovascular visits has deferred access to medication prescriptions/refills and important diagnostic testing, which may have had direct detrimental consequences, especially in high-risk patients. In addition, the delay of semi-elective cardiovascular procedures (e.g., transcatheter aortic valve replacement) may have adversely affected patients

to a significant impact on patient management and prognosis. Besides direct factors, complex logistic, social, psychologic, and educational factors may impact the clinical picture and epidemiology of acute cardiovascular diseases.

There is a clear urgent need to improve public health messaging, communication, and education to ensure that patients with emergent conditions seek and receive proper medical care, particularly in regions currently experiencing surges or resurgences of COVID-19 cases.

Patient education programmes can critically reduce total ischemic time by rising the awareness of ischemic symptoms and prompting immediate EMS contact. In this challenging scenario, telemedicine might provide an alternative avenue to provide medical education for STEMI patients and avoid unnecessary mortality. The medical community needs to balance the utmost efforts to limit the propagation of the COVID-19 pandemic with the imperative to prevent compromise in acute cardiovascular care.

References are avaiabe at www.asianhhm.com

Mario Gramegna is a cardiologist at cardiac intensive care unit of IRCCS San Raffaele Scientific Institute in Milan, Italy. He is member of the Young Acute CardioVascular Care Community. He is an author and co-author of numerous scientific articles.

He has special interest in acute cardiac care and mechanical circulatory support.

Luca Baldetti is an Italian consultantcardiologist.

He currently works at the Intensive Cardiac Care Unit of the “IRCCS San Raffaele Hospital” in Milan. His research interests include: heart failure, acute myocardial infarction, cardiogenic shock, mechanical circulatory support (LVAD, intra-aortic balloon counterpulsation and Impella device), and pulmonary thromboembolic disease.

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MEDICAL SCIENCES

Challenges Faced in the Treatment of Acute Ischemic Stroke

A

recent CERENOVUS study led

by Leonard Yeo revealed that achieving first-pass success in mechanical thrombectomy improves functional outcomes for patients and lowers the cost of treating acute ischemic stroke in Asia Pacific. Against a backdrop of increasing burden of stroke, such findings provide healthcare professionals with an opportunity to advance the delivery of care.

1. How is the rising prevalence of stroke affecting healthcare systems in Asia-Pacific (APAC)?

A recent CERENOVUS study led by Leonard Yeo revealed that achieving first-pass success in mechanical thrombectomy improves functional outcomes for patients and lowers the cost of treating acute ischemic stroke in Asia Pacific.

Against a backdrop of increasing burden of stroke, such findings provide healthcare professionals with an opportunity to advance the delivery of care.

Leonard Yeo, Acting Neurologist, Ng Teng Fong General Hospital and Senior Consultant, National University Hospital’s Division of Neurology

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IS S UE - 52, 2021

More than 13 million people across the world face stroke every year. These numbers are only expected to increase – in fact as much as 34 per cent by the time we reach 2035. With APAC home to a majority of the world's population, countries in the region are experiencing a significant share in the burden – not just from a clinical perspective, but an economic one, as well.

Stroke-associated healthcare costs in select economies, including Thailand, China, Singapore and Australia, have reached as much as US$38.2 billion annually. Representing between 0.2 per cent and 2.6 per cent of their respective GDP, it’s clear that there is a significant financial impact, both on individuals and the healthcare systems in our region.

Now, more than ever, there’s a need for all healthcare professionals to explore how they can improve functional outcomes for stroke patients and ultimately reduce the substantial cost.

2. What types of surgical techniques are adopted in the treatment of stroke? What is an ideal outcome for surgeons in utilising such techniques?

AUTHOR BIO Leonard Yeo is a Senior Consultant at the Division of Neurology in the National University Hospital (NUH) and holds a joint academic position as Assistant Professor in the Yong Loo Lin School of Medicine. He is on the clinical competency committee for neurology training in NUH and serves as the section editor of the interventional neuroradiology journal. He is an author of over 130 peer-reviewed journal articles and over 80 conference presentations and book chapters. Outside of work, he volunteers as a doctor for HealthServe Clinics serving underprivileged foreign workers.

For acute ischemic stroke, physicians generally seek to remove any obstructions and restore blood flow to the brain.

Accordingly, mechanical thrombectomy by stent retriever or direct aspiration are increasingly adopted as primary treatment options with excellent evidence on their safety profile and utility.

An ideal outcome using these methods would be to achieve complete reperfusion in a single thrombectomy pass, also known as first-pass effect (FPE). There are several factors that can determine the success rate of FPE, ranging from the equipment available to the treating physician to clot composition in patients. However, several studies have shown that techniques incorporating balloon guide catheters and the combined use of stent retrievers and intermediate catheters at the beginning of the procedure can help to improve the rate of FPE. 3. How does achieving first-pass success in thrombectomy help improve functional outcomes for stroke patients?

Being able to achieve complete reperfusion in one pass can help to shorten the procedural time while reducing the risk of vessel injury and complications. With a growing body of data showing that achieving FPE can lead to favorable functional outcomes for patients, it has increasingly become an optimal goal for endovascular therapy in treating acute ischemic stroke.

4. What are the economic benefits of achieving first-pass effect to patients and healthcare systems?

I recently led a research project with CERENOVUS published in the Journal of Stroke , titled Health Economic Impact of First Pass Success: An Asia-Pacific Cost Analysis of the

ARISE II Study. In the study, we evaluated the economic impact of FPE in the region, enabling us to ascertain the positive impact that first-pass success can have on improving patient outcomes and reducing economic costs. We concluded that patients who achieved FPE were discharged earlier, with their length of stay reduced by 3.38 days. Furthermore, fewer devices were needed during the procedure.

Together, these factors caused acute episode costs to fall by nearly a third across all the countries studied, ranging from 32 per cent in Australia to 27 per cent in India.

Longer-term savings were also found to be largely driven by improvements in functional outcomes for patients achieving FPE. Reduced disability post stroke has been linked to lower use of healthcare resources, as well as lower costs for patients.

5. Are there any outcomes you hope to see in the delivery of care for stroke patients following publication of the findings?

Our study reinforced the value of FPE in improving both patient outcomes and healthcare resource utilisation. By lowering cost in the treatment of acute ischemic stroke in Asia Pacific, there is a ripple effect of positive benefit, cascading from the individual patient through to their healthcare systems.

When we can improve patient outcomes while reducing treatment costs, we have an opportunity to advance healthcare – for all critical stakeholders across the spectrum of care. That intersection of technology, procedural efficacy, and cost savings is truly where we can make a far-reaching impact. www.asianhhm.com

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Remote Patient Monitoring Steadies Clinical Outcomes, Aims for Optimal Patient Comfort

A

s we hope for a drop in the COVID-19 contraction rate, we are also witnessing a steady growth in the demand for remote patient monitoring devices. Especially now, at a time when doing anything remotely has become the new normal, thanks to the pandemic that has made us almost immobile over the last few months. Remote Patient Monitoring is a technology enabling close monitoring of patients outside of conventional clinical settings. It comes with the promise of constant review of the factors resulting in improved clinical outcomes.

India’s Remote Patient Monitoring (RPM) market is expected to see a CAGR rate of 6.4 per cent from 2020 to 2025 as per the latest report. Also, the global market size for RPM devices is anticipated to hit the USD 1.8 Billion mark by 2026 from US$920 Million in 2020, at a CAGR of 10.64 per cent over the next five years, reveals data. Studies conducted by the National Centre for Biotechnology Information (NCBI) have shown how RPM considerably helps in improving clinical outcomes in patients with cardiac failure, atrial fibrillation, ventricular arrhythmias, respiratory disorders. This, quite obviously, brings in a host of good news for the healthcare industry. Enhanced patient outcomes is 26

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Remote Patient Monitoring (RPM) reduces hospital visits and hospital stays, improves patient retention and adherence to follow-up schedules. It also allows automatic alert and early detection of device malfunctions or events like atrial fibrillation, ventricular arrhythmias, and heart failure suitable for clinical intervention. RPM brings in a win-win situation for both patients and healthcare providers, guaranteeing a huge scope of efficient transformation to healthcare.

Mudit Dandwate, CEO & Cofounder, Dozee

IS S UE - 52, 2021

MEDICAL SCIENCES

one among them that will be observed as we start implementing Remote Patient Monitoring significantly across the country.

While healthcare continues to be one of the fastest growing industries in days to come, healthcare providers are looking at solutions which not just meet the patients' needs but also vouch for better clinical outcomes. As healthcare providers start using remote monitoring technology more, the RPM industry will see magnanimous growth in the next decade.

How can Remote Patient Monitoring improve clinical outcome?

Below are several ways by which Remote Patient Monitoring can impact clinical outcomes for patients.

1. RPM improves responsiveness: Time is of immense value when it comes to treating and managing a medical condition. RPM aids medical practitioners in tracking their patients real-time. Thus, in case their body vitals fall out of an appropriate level, the healthcare unit can respond to it effectively at the appropriate time and with the right course of treatment.

2. RPM helps in proper escalation, saves treatment cost: RPM enables appropriate control of excessive responsiveness among anxious patients.

Too much responsiveness may lead to inappropriate escalation and related hospitalisation. This inevitably amps up the unnecessary treatment cost and may adversely affect the patient's quality of life.

3. RPM makes compliance tracking hassle-free: To check if the patients are adequately complying with their prescriptions is perhaps one of the most difficult jobs for the doctors.

RPM's compliance tracker makes that simple for the healthcare providers.

While medication is a vital part of the treatment regimen, compliance is certainly an integral part ensuring optimal patient outcome. Remote Patient Monitoring devices provide

The global market size for Remote Patient Monitoring devices is anticipated to hit the US$1.8 Billion mark by 2026 from US$920 Million in 2020, at a CAGR of 10.64 per cent over the next five years, as per the latest report. reminders to patients about taking medicines on time and likewise, alert healthcare providers in case the patient do not follow the instructions.

4. RPM increases the scope of availability of a dedicated help24/7: RPM comes with a clinical support for connected care technology to help patients and their families understand the ways of addressing technical challenges. With RPM in place, one may have accessibility to a telehealth technical support for patients who can help in addressing any issues and prevent improper medical diagnosis, considerably upscaling clinical

outcomes on patients.

5. RPM serves as back-end support for staff: Healthcare staff is the frontline warriors ensuring effective clinical outcomes. However, most healthcare organisations struggle to provide the bandwidth required to fulfill all the back-end administrative functions related to connected medical devices.

With RPM technology, the healthcare staff can get rid of administrative technologies like manual data entry, logging into digital systems, data plotting and more and focus on their primary clinical responsibility, thereby, improving clinical outcomes.

Remote Patient Monitoring, the perfect dose of comfort for patients

Benefits of Remote Patient Controlling are immense when it comes to providing ultimate relief to patients.

It reduces hospital visits and hospital stays, improves patient retention and adherence to follow-up schedules and allows automatic alert and early detection of device malfunctions or events like atrial fibrillation, ventricular arrhythmias, and heart failure suitable for clinical intervention.

RPM brings in a win-win situation for both patients and healthcare providers, guaranteeing a huge scope of efficient transformation to healthcare.

Mudit and his team at Dozee are on a mission to simplify and transform healthcare for millions in India. Launched in 2019, Dozee is India’s first contactless health monitoring solution which is pioneering remote health monitoring in hospitals and at home. Made In India, Dozee’s contactless AI-powered technology tracks key vitals of the human body and helps in early detection of health deterioration for timely medical intervention.

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Respiratory Care

Insights on access and affordability In this article, Vinay Joshi discusses respiratory care during a time when vaccinations are the hot topic. He also provides insight on access and affordability for respiratory care in Asia, and future challenges for remote respiratory healthcare.

Vinay Joshi, Chief Executive Officer, ABM Respiratory Care

COVID-19 has created a shortage of ventilators globally. What do you think is the way forward for respiratory care in Asia with the advent of vaccinations?

COVID-19 has created awareness of ventilators and the importance of respiratory care. The people who battled COVID-19 and survived will need to continue to manage their respiratory care, regardless of whether they receive a vaccination. Recovering lung function and maintaining lung health is a lifelong journey after COVID-19. People will need to keep their lungs healthy to live their life to the fullest. Additionally, we are seeing mutations of COVID-19 globally so the need for ventilators will not go away.

The pandemic has highlighted a shortage of ventilators and a shortage of trained healthcare professionals to manage the large volume of ventilators when needed. In addition, frequent bedside visits by healthcare professionals to adjust and monitor ventilators increase the infection risk thereby pushing an already fragile healthcare system into a further grim situation.

Our ventilator addresses both issues by enabling healthcare professionals to securely monitor and adjust ventilator settings through their online portal from any location.

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Could you provide some insight on access and affordability in respiratory healthcare in Asia?

In general, access to healthcare in rural areas is a challenge. Asia has a diverse population and their access to respiratory healthcare is influenced by social, economic, and environmental factors. Access to respiratory healthcare in Asia varies greatly between countries.

There is ongoing work to accelerate equal access to everyone through policy initiatives and strategic contracting of services by health ministries.

Digital technologies can expand access to respiratory healthcare in rural areas of Asia. Resource constrained health systems in rural and remote regions

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could benefit from shared resources available via digital health and telecare solutions. These types of remote respiratory care solutions can provide affordable healthcare, through reducing out-of-pocket payments, reducing the cost of traveling long distances and reducing lost wages from missing work.

What challenges do you foresee for the field of remote respiratory healthcare in the next five years?

I see a rise in tele-health over the next few years. However, tele-health platforms need to evolve to allow a more holistic approach to managing patients at home.

This includes the ability to capture diagnostics remotely, video conference

What are the solutions for addressing the urgent need for ventilators for COVID-19 patients? What are the challenges you have seen or encountered thus far in implementing these solutions?

The COVID-19 pandemic not only highlighted a shortage of ventilators but also a shortage of trained healthcare professionals to manage the large volume of ventilators when and where needed. In addition, frequent bedside visits by healthcare professionals to adjust and monitor ventilators increase the possibility of infection through continued exposure. The solution is to move treatment out of the ICU as soon as possible, either into a step-down unit

Recovering lung function and maintaining lung health is a lifelong journey after COVID-19. or outpatient setting where the same care can be delivered at a lower cost.

The challenge is how to make the complex technology needed to manage COVID-19 and other respiratory compromised patients more accessible and scalable in the environment out of the ICU. ABM Respiratory Care is focused on providing a solution for scalable, remotely managed ventilation as well as broader lung health. COVID-19 damages people’s lungs so airway clearance therapy, beyond ventilation, is needed to ensure the lungs are able to get the oxygen to the blood and remove the buildup of carbon dioxide.

When novel respiratory viruses are suspected, such as the novel coronavirus that caused COVID-19, how do you think other current severe acute respiratory infections should be managed? What should be the protocol?

There is an intermediate step which has to happen, and that is what will

AUTHOR BIO

and share information across the entire care team.

Additionally, with the rise of telehealth, data security could be a concern. Tele-health platforms need to enhance their security to ensure the protection of patients and healthcare providers information.

Providing access to tele-health technology in remote areas is a potential challenge. The pandemic is unlikely to ease up in the short term. In areas where hospitals are overburdened and there is a severe staff shortage compared to the number of patients, caring for and managing critical patients in their own homes is ideal for reducing the burden on healthcare systems. The challenge I see here, is how to make intensive care unit (ICU) technology accessible and scalable in environments outside the hospital.

Our ventilator has huge potential to save lives not only in hospital networks, but also the most remote parts of the globe. Produced at less than half the cost of a normal ventilator, our ventilator increases access to hospitals and countries. The ventilator is also able to connect to any Wi-Fi or cellular hotspot and thus is easy to set up. As it can be accessed and managed remotely, it will help to reduce the burden of healthcare professionals and healthcare systems.

happen in next five years, which is making devices more connected, more intelligent, and making them so simple that they can be used not just in the hospital, but outside the hospitals as well.

New challenges demand novel approaches to advance the standard of care in treating chronic and acute respiratory diseases and conditions— wherever and whenever needed. That’s what the future holds for lung health and that’s what my team is focused on delivering today.

The challenge is how to make complex lung health technology accessible and scalable outside the hospital.

Post-COVID care will require managing complete lung health, from ventilation to airway clearance with intelligent and integrated care solutions. That means integrated airway clearance designed for at-home use. It means tele-ventilation to ensure scalability. And it means platform-based remote monitoring to keep patients connected and potentially reduce readmissions.

Do you have any other comments on respiratory care during the current pandemic situation?

I think in a post-coronavirus world, there will be a strong shift towards healthcare at home for patients with more intelligent and connected devices. Medical devices always seem to lag in terms of connectivity and ease of access as compared to banks, Ubers and Twitters of the world and that paradigm has to change if we want to prepare ourselves for the future.

Vinay Joshi is an entrepreneur with two decades of experience in the medical device industry.

In addition to managing early-stage start-up companies, Joshi held senior roles with GE Healthcare and Hill-Rom, where his responsibilities were focused on respiratory health products in the disciplines of product development and marketing.

At GE Healthcare, he worked on diagnostic imaging and life support systems like ICU ventilation. At Hill-Rom, he worked on their airway clearance product portfolio

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MEDICAL SCIENCES

Sacubitril Valsartan in HFrEF

An observational series in ambulatory patients with HFrEF Sacubitril valsartan combines renin-angiotensinaldosterone system (RAAS) inhibition with amplification of natriuretic peptides. In addition to well-described effects, on increased natriuresis and diuresis, natriuretic peptides can also exert direct effects on pulmonary vasculature. The effect of sacubitril valsartan on pulmonary artery pressure in patients with heart failure has not been fully defined.

This was a retrospective case-series of pulmonary artery pressure changes following transition from Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) to sacubitril valsartan in patients with Heart Failure reduced Ejection Fraction (HFrEF) and a previously implanted cardioMEMs pulmonary pressure monitoring sensor.

Luanda P Grazette, Cardiovascular Division, Miller School of Medicine, University of Miami Jeffrey S Tran, Department of Internal Medicine, Keck School of Medicine of the University of Southern California (USC) Ofer Havakuk, Head of Heart Failure Service, Tel Aviv Medical Center

I

n this retrospective case series, transition from angiotensin converting enzyme inhibitor or angiotensin receptor blocker to sacubitril-valsartan was associated with an early and significant decrease in pulmonary artery pressure.

Introduction

Pulmonary Hypertension (PH) is a common comorbidity in heart failure, which may be present in over half of patients with heart failure with reduced ejection fraction. Although PH is

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associated with a considerably worse prognosis with increase morbidity as well as increased mortality, there have been no successful therapies that directly address pulmonary artery hypertension and unequivocally improve clinical outcomes in patients with heart failure.

Sacubitril valsartan combines renin angiotensin aldosterone system (RAAS) antagonism with amplification of the natriuretic peptide system conferring beneficial compensatory effects in heart failure. Well-defined effects through increased levels of natriuretic peptides,

IS S UE - 52, 2021

include sustained natriuresis, diuresis and improved myocardial structure and function. Natriuretic peptides, which are increased by sacubitril valsartan, are also expressed in the pulmonary vasculature, where they mediate multiple effects, including vasorelaxation and reverse remodelling. In an exploration of possible clinical consequences of sacubitril/ valsartan on pulmonary vascular pressure in “real world” ambulatory patients with heart failure pulmonary artery pressures were compiled, before and after the transition to sacubitril valsartan, in a

MEDICAL SCIENCES

The cohort included 18 patients, 72 per cent male, mean age 60.1±13.6 years. There was a significant decrease in pulmonary artery pressure associated with transition from angiotensin converting enzyme inhibitor or angiotensin receptor blocker to sacubitril valsartan.

The median (interquartile range) pre- and post-treatment change in mean, systolic and diastolic pulmonary artery pressure were -3.6 (-9.8, -0.7) mmHg (p<0.001), -6.5 (-15.0, -2.0) mmHg (p=0.001) and -2.5 (-5.7, -0.7) (p=0.001), respectively. The decrease in pulmonary artery pressure was independent of TPG (F(1,16) = 0.49, p = 0.49).

measurements in the 5 days after transition for each patient. Two patients on angiotensin receptor inhibitor were started on sacubitril/valsartan after a 24-hour washout period. The remainder were on an angiotensin receptor blocker and transitioned directly to sacubitril/ valsartan.All subjects were transitioned to the 24mg/26mg sacubitril valsartan dosage.

The medical charts were also audited in order to verify that other medications that could influence pulmonary artery pressures were not added or changed during the observation window. There were 47 independent measurements prior and 51 measurements following the first sacubitril/valsartan dose. Comparisons of the hemodynamics were performed using Wilcoxon rank-sum testing and two way repeated measures analysis of variance (ANOVA) was performed to assess the effect of transpulmonary gradient on the magnitude of changes in pulmonary artery mean pressures (PAMPs). STATA 14.2. was used for statistical analysis and data management.

Discussion

While the majority of patients had pulmonary vascular resistance that was within the normal range 137 (73, 172) at baseline, 6 patients had elevated pulmonary vascular resistance and transpulmonary gradients suggestive

series of 18 adults using the cardioMEMs pulmonary pressure monitoring system.

Study Overview and Design

All 18 subjects had a prior diagnosis of Heart Failure with reduced Ejection Fraction (HFfEF), had been previously implanted with a cardioMEMs monitor, and were being treated with an Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB).Baseline pulmonary capillary wedge, pressure pulmonary artery pressure and pulmonary

vascular resistance were all collected at the time of the cardioMEMs implant and abstracted from the medical record.

Patients transitioned from angiotensin receptor blocker or an angiotensin receptor inhibitor to sacubitril valsartan were identified, retrospectively, from the medical record and pulmonary pressures were collected from the Merlin website.

Up to 3 consecutive, daily pulmonary artery pressures were averaged for each patient from 5 days before transition to sacubitril valsartan and compared with the average of up to 3 daily consecutive

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MEDICAL SCIENCES

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amelioration of left heart related, postcapillary pulmonary artery hypertension.

In addition, the previously discussed studies, along with ours, are part of a growing body of evidence supporting a direct role of natriuretic peptides on pulmonary vascular tone. Such a role might also indicate a potential benefit of neprilysin inhibition in the treatment of patients with abnormal pulmonary vascular pressures and heart failure.

In conclusion, in a small cohort of patients with heart failure with reduced ejection fraction, previously implanted with a cardioMEMs pulmonary artery pressure sensor we demonstrated a significant and acute decline in pulmonary artery pressures after transitioning to sacubitril valsartan fromACEI orARB. Although it is beyond both the scope and the observation window of this exploratory study to determine the long-term benefits of these findings, the results are nevertheless provocative. The acute

AUTHOR BIO

of mixed or combined pre and postcapillary pulmonary hypertension with pulmonary vascular resistance 357 (320, 548).

Regardless of baseline pulmonary vascular resistance, transpulmonary gradient or diastolic pressure gradient, there were significant pulmonary artery pressure falls.There was a -3.6 mm/ Hg (-9.8, -0.7, p < .0001) fall in the ‘low’ pulmonary vascular resistance group and -4.5mm/Hg (-9.8, -3.3, p =0.028), within 5 days of transitioning from angiotensin receptor blocker or an angiotensin receptor inhibitor to sacubitril valsartan for the cohort.Most patients with elevated transpulmonary gradientdemonstrated a “hyperacute response”, which we defined as a >1 standard deviation reduction in pulmonary artery mean pressure within 48 hours of sacubitril valsartan initiation.

Pulmonary hypertension is highly prevalent in heart failure and its presence is associated with considerably worse quality of life, morbidity and survival.

Despite this association there are no identified therapies which directly mitigate this risk. Natriuretic peptides, in addition to their role in natriuresis, diuresis and peripheral vasodilation may also play a role in pulmonary vascular tone.

Natriuretic peptides have been identified in animal studies to be secreted and degraded in the lungs and the levels of natriuretic peptides have been noted to be increased in animal models of pulmonary hypertension. Sacubitril valsartan has also been shown to reduce right ventricular pressure in an animal model of pulmonary hypertension. In humans a study by Zern and colleagues showed a rapid fall in pulmonary arterial hypertension and pulmonary vascular resistance in five patients who were hospitalised on inotropic therapy waiting for transplant.Recognised effects of sacubitril valsartan such as increased natriuresis and diuresis, can partly explain the mechanisms of reduction in pulmonary artery pressures through an

change in pulmonary artery pressure may represent an attribute of sacubitril valsartan that could have important clinical implications, given the strong correlation between pulmonary hypertension and the increased risk of morbidity and mortality in patients with heart failure reduced ejection fraction.

This study also highlights the potential utility and promise of remote sensor technology in assessing clinical response to therapy in ‘real world’ settings.

Tran JS, Havakuk O, McLeod JM, Hwang J, Kwong HY, Shavelle D, Zile MR, Elkayam U, Fong MW, Grazette LP. Acute pulmonary pressure changes after transition to sacubitril/valsartan in patients with heart failure reduced ejection fraction. ESC Heart Fail. 2021 Apr;8(2):1706-1710. doi: 10.1002/ ehf2.13225. Epub 2021 Jan 31. PMID: 33522140; PMCID: PMC8006690.

References are available at www.asianhhm.com

Grazette is Director of Advanced Heart Failure and Cardio Oncology for UHealth, University of Miami. She is an Associate Professor of Medicine of the Miller School of Medicine and is responsible for the Heart Failure Recovery, Innovation and Treatment Program. She has published in numerous high impact clinical and scientific journals. In addition to her clinical responsibilities, Grazette remains actively engaged in clinical and translational research investigating the mechanisms of cardiac toxicity, plasticity and survival.

Ofer Havakuk is working as head of heart failure service at the Tel Aviv Medical Center, Tel Aviv, Israel and serves as an attending physician in the cardiology department.

He has a 10 years experience in cardiology and was also trained in advanced heart failure at the USC school of medicine, LA, California. Havakuk attends regularly in international medical conferences and is the co-author of 57 scientific publications.

Jeffrey S Tran is a Fellow, Cardiovascular Disease in the Department of Internal Medicine at Keck School of Medicine of the University of Southern California (USC)

IS S UE - 52, 2021

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Local partners. Global solutions. www.international-assistance-group.com + 33 1 55 30 09 10 netiag@netiag.com M E D I C A L & T R AV E L A S S I S TA N C E • R O A D S I D E A S S I S TA N C E • C O S T C O N TA I N M E N T • T PA • S E C U R I T Y S E R V I C E S

SURGICAL SPECIALITY

Personalising Management of Cardiac Surgery Patients Through Right Heart Biomarkers The field of biomarker discovery has advanced rapidly over past decades.

Many cardiovascular biomarkers are available to assist in the management of ischemia and left heart failure. However, perioperative Right Heart (RH) failure remains an underexplored area. We propose ST-2, sST-2 and Gal-3 as potential RH-specific markers to provide rapid, non-invasive insight for personalized, etiology-specific therapy, to be validated in the perioperative setting.

Louise Y Sun, Division of Cardiac Anesthesiology, University of Ottawa Heart Institute

B

iomarkers were first introduced to clinical practice in the 1980s and have since become a staple of diagnosis and prognosis in many areas of medicine. A variety of biomarkers have been implicated in clinical care and research in the cardiovascular realm.

These are used mostly in the diagnosis and evaluation of left heart failure and pulmonary hypertension, with little attention paid to the diagnosis and response to treatment for Right Heart Failure (RHF). The right heart is often overlooked in medical practice, and RHF has especially been poorly understood in the dynamic perioperative setting, where the stakes are higher. We in this article will summarize the importance of the

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perioperative RHF and introduce new, non-invasive adjuncts for RHF diagnosis and prognosis in this setting.

Why is RHF important?

Medicine and medical research have traditionally focused on diseases of the left heart, where much advance has been made over the past few decades.

Progress on RHF has lagged behind that of the left heart, and there are relatively few options for the treatment of RHF. RHF is especially relevant to clinical management and patient outcomes in the perioperative setting. In the setting of cardiac surgery, it contributes highly to end organ complications such as stroke, acute kidney failure and death. It

IS S UE - 52, 2021

is also implicated in poor later survival after cardiac surgery. RHF is especially deadly when occurring in combination with left heart failure. It is much more common in the context of cardiac as compared to non-cardiac surgery, and is most frequent after heart transplantation and implantation of Left Ventricular Assist Devices (LVAD).The prediction and diagnosis of RHF are difficult, and treatment is often challenging in the perioperative setting.

Practical challenges

In a broad sense, RHF is defined as the inability of the right heart to support the circulation when preload is optimal.

The most common cause of RHF is left

SURGICAL S PECIALITY

heart failure. In patients undergoing cardiac surgery, other potential causes for RHF could be classified according to that arising from increased after load, increased circulating volume, as well as intrinsic failure of the right heart myocardium.

RHF in the perioperative setting is complex and heterogeneous in nature.

Clinicians still have trouble in coming up with a universal perioperative definition of RHF in non-LVAD patients in the modern era, although criteria such as haemodynamic instability, reduction in right heart contractile function

by Transesophageal Echocardiogram (TEE) and direct visual inspection have been proposed. To complicate things further, there is no consistent and reproducible method for measuring right heart function in the perioperative setting. This is in part due to dynamic fluctuations in preload, the presence of mechanical ventilation, as well as changes in intrathoracic pressure during different stages of cardiac surgery.

The so-called gold standard for right heart function assessment are cardiac Magnetic Resonance Imaging (MRI) and right heart catheterisation.

MRI is non-invasive but costly, and is limited by long scanning sessions and incompatibility in patients with pacemakers and other metallic implants and devices. Pulmonary artery catheters are invasive procedures, are associated with complications and are impractical in the context of certain congenital or acquired cardiac structural abnormalities.

Several modalities have been implicated in the assessment of right heart function in the perioperative setting. Pulmonary artery pressure and cardiac index used to be a routine part of intraoperative monitoring for cardiac surgery. However, these measures could be confounded by the presence of left ventricular systolic or diastolic dysfunction, raised intrathoracic pressure in mechanically ventilated patients, pre-existing pulmonary hypertension and tricuspid regurgitation. Although a

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mainstay of perioperative monitoring, two-dimensional TEE is limited by the complex geometry of the right heart and is subject to inter- and intra-observer variability. Additionally, there is often a disconnect between how the right heart looks on TEE, and the actual degree of clinical deterioration.

Biomarkers as an innovative, noninvasive solution

There has been escalating interest in the utilisation of biomarkers to provide diagnosis and prognostication in patients with heart failure. Biomarkers provide information at the cellular and molecular level, and offer important mechanistic insight to help with personalised monitoring and management. As an overview, heart failure biomarkers are generally classified into four categories: 1) inflammation, 2) myocyte stress/ injury, 3) neurohormonal activation, and 4) extracellular matrix turnover.

The majority of publications on heart failure biomarkers have centred on the

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SURGICAL SPECIALITY

left heart, with many studies describing the role of natriuretic peptides in disease diagnosis and prognostication across a variety of clinical settings. Natriuretic peptides are now a routine part of clinical care in patients with or suspected of having heart failure. In contrast, studies of right heart biomarkers have mostly been exploratory in nature. For instance, unique microRNAs and protein metabolites, and some inflammatory and stress/injury biomarkers are thought to have prognostic significance for the right heart in non-operative settings. We in this paper will highlight suppressor of tumorgenicity 2/soluble ST2 (ST2/sST2) and Galectin 3 (Gal-3) as Food and Drug Administration (FDA)-approved biomarkers that could be further investigated as specific measures of right heart function. These biomarkers may also help to predict the onset of clinically significant RHF, and offer prognostic insight in the perioperative setting.

ST2 and sST2 are inflammatory cytokinesfrom the interleukin -1 family, that is released in the presence of tissue injury. These biomarkers have been evaluated both in the context of left and right heart failure in non-operative settings. In the general context, high serum levels of sST2 are moderately predictive of one-year mortality in patients presenting with acute decompensated heart failure. These biomarkers also correlate with many aspects of right heart size and function, preload (i.e.,

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personalized therapy. This is especially valuable in the high-acuity perioperative cardiac surgery setting, where changes are dynamic and rapid. Biomarkers could also be measured in a sequential manner, to assess disease progression and monitor response to treatment. We advocate for discovery and investigation of biomarkers as non-invasive adjuncts to overcome the limitations of existing diagnostic modalities for RHF, to help to piece together a comprehensive snapshot of right heart structure, function, and loading conditions. It should also be noted that multiple biomarkers could be profiled together to provide a more comprehensive picture at the molecular level. Before widespread clinical use, biomarkers would need to be validated in different clinical care jurisdictions, and meaningful cut-off values would need to be derived through large studies in representative populations with isolated RHF.

Practical considerations

References: Jabagi H, Ruel M, Sun LY. (2019). Can Biomarkers Provide Right VentricularSpecific Prognostication after Cardiac Surgery? Journal of Cardiac Failure.

S1071-9164(19): 30516.

The advent of point of care ST2, sST2 and Gal-3 assays bring these biomarkers closer to the bedside. Indeed, biomarkers offer rapid, non-invasive molecular level insight that may be used to inform prompt

Jagabi H, Mielniczuk LM, Liu PP, Ruel M, Sun LY. (2019). Role of Biomarkers in the Diagnosis, Management, and Prognostication of Perioperative Right Ventricular Failure after Cardiac Surgery.

J Clin Med, 8(4), 559

AUTHOR BIO

Right Heart Failure is especially deadly when occurring in combination with Left Heart Failure.

venous congestion) and after load (i.e., pulmonary hypertension) in patients with isolated right-sided heart disease. In practice, sST2 is unaffected by age, sex, body habitus, rhythm, kidney function, and interferences by contaminants. It is therefore more specific than natriuretic peptides in providing right heart-specific information in the complex cardiac surgical population.

Gal-3 is a macrophage product of the lectins family, which has been implicated in contractile regulation of the heart as well as inflammation and injury. It was incidentally found in a general heart failure study to be a better predictor of mortality and hospitalisation in patients with preserved left heart function. It also correlates well with many aspects of right heart size and function in patients with isolated pulmonary hypertension without left heart impairment. In the LVAD population, Gal-3 was associated with major sequelae of RHF.

IS S UE - 52, 2021

Louise Sun is an Associate Professor of Anesthesiology and Epidemiology and Director of Big Data and Health Bioinformatics Research at the University of Ottawa Heart Institute, Canada. Her team applies machine learning, advanced statistical methodology and modern technology in the field of cardiovascular epidemiology and biomarker discovery, integrating perspectives from population and precision health and patient engagement.

INSIDE A GLOBAL LEADER IN MEDICAL IMAGING SOLUTIONS What’s behind the success of Guerbet?

An exclusive interview with Mathieu Elie, Chief Commercial Officer, Asia Pacific, Member of Guerbet's Executive Committee.

Can you share with us the history of Guerbet and your vision for Asia-Pacific?

Guerbet is known as a leader in medical imaging worldwide, offering a broad range of pharmaceutical products, medical devices, digital and AI solutions for diagnostic and interventional imaging, that improve the diagnosis and treatment of patients.

Our headquarters are in Villepinte near Paris, and the company was established there by André Guerbet in 1926, to expand production and distribution of the first iodinated contrast medium discovered by his father Marcel Guerbet in 1901.

At Guerbet, we build lasting relationships, to enable people to live MATHIEU joined Guerbet in 2007 as Financial and better. This is our Purpose and it is the Administrative Director of Guerbet in Korea, then took over driving force for our actions and a source as the Head of Business Operations in Korea, Asia-Pacific of inspiration for all our new initiatives and Latin America before becoming Vice President of and innovations. It is a shared energy the APAC region in 2015. He was appointed as the Chief Commercial Officer for APAC in September 2020. which supports the sustainable growth of our company.

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Today, we are a global company specialising in medical imaging solutions and want to be recognised as the best partner for diagnostic and interventional imaging.

Guerbet has a broad range of products, a long history of innovation and a strong reputation, especially in Europe and the US after the acquisition of the imaging business of Mallinckrodt in 2015. Our core products have been established over many decades.

Asia-Pacific now significantly contributes to Guerbet global business.

Having first established a strong base in Korea in 1998 followed by Japan, we have been growing our reach in Asia-Pacific, opening offices in many countries and key markets. We opened in India last year to be in close proximity to the doctors there, which is an important part of our strategy. We have also been significantly reinforcing our presence in China.

The Asia-Pacific region is an important clinical development platform for Guerbet. We run numerous clinical trials here and have realised advantages in terms of quality and speed.

Having started small with only five people in 1998, we decided to invest in Asia-Pacific and now have over 200 employees in nine countries. We continue to invest in our people with development programs to help them grow together with the company.

With such a long and rich history, what are your thoughts on innovation?

Patient safety is our first priority. At Guerbet, we care for all patients at every touch point of their journey to recovery.

We are keen to keep investing in and exploring new techniques and methods to deliver state-of-the art technology. Originally, our focus was on diagnostics, but we have expanded into interventional radiology to support increased use of minimally invasive guided procedures, and digital/AI solutions that improve operational efficiency

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and diagnostic confidence. Our objective is to bring value ‘now and in the future’ for our stakeholders.

Indeed, we have invested significantly in interventional radiology, based on our strong foundation product ‘Lipiodol’, and we are building a full range of interventional radiology products that are best-in-class across many product lines.

In diagnostic imaging, we strongly believe in integrated delivery solutions combining contrast medium, injectors, consumables, software and services.

Advanced data analytics allows us to improve the workflow in the radiology centre by reducing the reporting and compliance burden via automation while providing meaningful insights.

This common ecosystem of interconnected products allows noticeable productivity gains, we call this ecosystem “UNIK”.

In this data-driven era, we have decided to invest massively in Artificial Intelligence (AI) to accompany physicians in their clinical decisions: AI to help detect, characterise and stage lesions on imaging findings, and eventually AI to help quantify risk. We believe in proven and reliable outcomes, and we spend a lot of time and effort to clinically validate our algorithms.

Guerbet also focuses on delivering a range of best-in-class education programmes, which are shifting from physical to online models with webinars, videos and social media.

We play an important role in linking medical communities with exchange programmes between countries in Asia-Pacific and France that provide a catalyst for knowledge transfer, sharing of best clinical practices, network cultivation and relationship among the healthcare community.

What are the healthcare needs that Guerbet addresses?

We see many healthcare challenges.

Diagnostics have become central to many medical decisions, including biopsy, pathology, in vitro and in vivo

IS S UE - 52, 2021

A world leader in medical imaging, Guerbet is a publicly traded company on the Paris Stock Exchange, headquartered in France with offices and production facilities in Europe, the Americas and Asia-Pacific. It has a longstanding reputation as a pioneer in the research and development of contrast media for radiology. In 2015, Guerbet doubled in size with the acquisition of Mallinckrodt’s contrast media and delivery systems’ business unit. It also expanded its portfolio in the interventional imaging business with the acquisition of Accurate Medical Therapeutics in 2018.

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.

diagnostics. The right diagnostics at the right time are increasingly important in enabling clinicians to make data-driven decisions. The 2020s is the decade for data and at Guerbet we see ourselves moving from being a contrast medium provider to also becoming an informatics data provider in diagnostic imaging.

The global population will reach 10 billion by 2050 with roughly two billion people aged over 60. Half of us will be living in Asia-Pacific (APAC), giving the region a significant share of the ageing population. Given the advances in oncology treatment, there will be increased survival times for patients with chronic diseases and a greater need for imaging, which is likely to create immense pressure on healthcare.

This demand for imaging procedures is likely to skyrocket in the next decades not only because of demographics and better chronic disease survival time, but also because of the extensive use of imaging modalities in health check-ups.

Adding a new MRI machine or a new CT scanner is not always possible or wanted in hospitals.

Enhancing the imaging workflow in the hospital is our answer to this challenge. We are uniquely positioned as the only player with a strong foundation in contrast, injection systems, advanced informatics and AI algorithms.

How did you overcome challenges as Chief Commercial Officer (APAC) under the COVID-19 situation?

COVID-19 has been a difficult time for everyone. We adapted really fast as a company because we knew early on that imaging diagnostics were important for COVID-19 patient management.

We knew we couldn’t fail; our first priority was ensuring our employees were safe and our factories were up and running to produce contrast, which is essential in the diagnosis of COVID-19.

We also managed to source PPE kits for our employees worldwide and to produce thousands of litres of hydroal-

coholic solutions in our factories that were given to the medical community.

We took extra precautions in our factories to ensure seamless operations and no factories have been closed because of COVID-19. This crisis demonstrated there is great solidarity and resilience within Guerbet, with staff actively committed to ensure continuity in production and distribution activities.

Many hospitals required support for diagnostic imaging, and we continued to deliver and install injectors in hospitals including in Wuhan, China, where Guerbet APAC delivered an OptiVantage Dual Head injector to a newly built hospital at the end of January 2020. To make sure diagnostic centres could still operate during COVID-19, we quickly trained field service technicians so that they could fix and service injectors in a safe manner. We created guidelines on the disinfection of injectors, to help technicians and nurses in hospitals prevent the spread of COVID-19.

Although we had to overcome disruption in logistics, we managed to sustain supply to our consumers and are proud that we were able to help in the battle against COVID-19 by meeting government demands for immediate shipment of injectors to allow thoracic imaging.

COVID-19 made us rethink how we share our expertise with the medical community. We created Guerbet APAC TV, Medical Imaging Institute, and are considering expanding the Guerbet APAC Preceptorship Program (GAPP) training centre. Throughout this period, we contributed to educating communities on how to tackle the pandemic.

What is your view on the use of AI for the future of medical imaging?

We are expanding very fast, with a focus on new markets and geographies, creating more educational programs and investing in research to develop new products, such as our new MRI contrast medium, which is at the last stage of its development.

Artificial Intelligence (AI) is transforming the imaging field. New data analytic methods can augment clinicians’ ability to interpret and act on large and complex data sets. As an innovator in medical imaging, Guerbet has identified AI partners with validated software technology to expand its portfolio of augmented intelligence solutions with the same aim of helping radiologists diagnose better and faster than ever before.

Today, we partner with icometrix for the exclusive distribution* of icobrain, an AI software that extracts clinically meaningful information from brain CTs or MRI scans of patients with multiple sclerosis, dementia or brain injury.

And in the US, we are starting to distribute IBM Watson Imaging Patient Synopsis**, a radiologist-trained AI tool that extracts patient information and summarises that data in a dashboard tailored to help clinicians make better decisions faster and more efficiently.

With IBM Watson Health we are developing two AI solutions to help clinicians diagnose and monitor patients with liver or prostate cancer.

The liver solution is a diagnostic support tool that will use AI to automate the detection, staging, tracking, monitoring, and eventually therapy prediction and therapy response of primary and secondary liver cancer for clinicians.

In the prostate program, we are developing a tool using AI with the goal of helping to detect, segment, characterise and monitor lesions over time. This AI approach may allow for faster and more informed diagnosis of prostate cancer.

AI is obviously a major trend and Guerbet is determined to be at the forefront of its application. It showcases our continued contribution to building the future of medical imaging, just as we have done since our foundation some 95 years ago. * in Brazil, Italy and France ** in the United States

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DIAGNOSTICS

RADIOLOGY IN THE NEW NORMAL In this interview, Per discusses how the radiology practice has changed during COVID-19 and how innovation can better support radiologists and the healthcare industry in the new normal. He also emphasises on the importance of continued education and collaboration to develop scientific exchange and bolster the capabilities of radiology professionals.

Per Edlund, Head of Radiology Commercial Operations Asia Pacific, Bayer Pharmaceuticals Division

How has the practice of radiology changed since COVID-19?

Many aspects have certainly changed.

For one, many procedures were postponed by healthcare professionals in line with medical guidelines and society recommendations. This can delay critical diagnosis and treatment for severe diseases.

In addition, the workflow is impacted, because radiology suites need to have more stringent hygiene protocols in place e.g. for the stratification of patients of different risks, isolation areas set up for suspected

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COVID-19 patients etc. Healthcare workers and hospital infrastructure have also been strained due to the pandemic. These trends will lead to a growing demand for digital solutions that help radiology departments be more efficient and meet the increasing workload, while still imaging patients safely and accurately.

Safety, speed and accuracy are key needs in radiology – and our highest priority – especially here in the APAC region. Even before COVID-19, the pressure to diagnose many patients speedily and accurately in the APAC

IS S UE - 52, 2021

region was increasing, and now more than ever radiology clinics and departments need to be able to effectively handle a high number of patients. With the Asia-Pacific accounting for half of the world's population and will have nearly 5 billion people by 2050, and given its rapidly ageing population, this will drive a strong demand for diagnosis of chronic conditions like cancer and cardiovascular diseases.

Speeding up the diagnostic process helps patients receive treatment earlier; clearer images lead to more accurate diagnosis and better treatment decisions; and maximising hygiene and minimising radiation exposure enhances patient safety.

In what ways can innovation in radiology support healthcare professionals to navigate the outbreak better?

The radiology industry can support healthcare professionals by putting patients first, and taking the time and effort to understand the common concerns and challenges faced by radiology clinics and professionals,

and tailoring solutions to meet these needs.

Especially in these times of strained healthcare workers and systems, we know there is a keen need for timesaving, efficient diagnostic solutions.

Many new and established solutions are already specifically designed to improve and automate workflow and hygienic safety, freeing radiology professionals to focus more on their patients, and keeping staff and patients safe.

Innovation in radiology should simplify and automate workflows for busy radiology departments, for instance by personalising injection protocols to specific patients, so that radiologists can focus more on patients.

We see radiology innovations bringing value to radiologists by allowing clinics to serve more patients without compromising on patient safety and diagnostic accuracy.

Innovation can also help to cut down on unnecessary invasive surgeries. For example, it can be challenging to identify smaller liver lesions or differentiate between benign and malignant

How do you see continued education and collaboration supporting healthcare professionals manage the new realities of radiology practice?

As a scientific partner, we know that continuing professional education is critical in the dynamic field of radiology, and will contribute to better patient care by advancing medical practice.

In the new normal, supporting healthcare professionals with relevant, timely and targeted informative programmes and materials is crucial.

Such ongoing education can help radiology professionals to prepare their patients better for imaging procedures and improve the standard of care.

We strongly believe in fostering scientific exchange—last year, we connected our Centers of Excellences in China with Latin American radiology

clinics, for an exchange of experiences on how to handle the pandemic situation.

The value of collaboration is higher than ever to deliver breakthrough science, as evident in the accelerated development of novel vaccines during the pandemic. Open innovation and collaboration are major focus points, and we see digitalisation and artificial intelligence as the way forward, to help radiology suites become quicker and more efficient. For example, collaborations to deliver centralised access to a toolbox of digital and AI-powered applications can support the medical imaging workflow holistically.

Such applications can assist with the complex decision-making processes of radiologists and their teams, which will potentially result in enhancing diagnostic confidence and enabling earlier disease interventions for patients. To illustrate, we have always embraced different forms of collaboration – from traditional licensing partnerships and strategic research alliances with companies and academia to new models of open innovation involving entrepreneurs, start-ups and young researchers. Through our global G4A (formerly known as Grants4Apps) open innovation platform, we promote and support digital and technological innovation in healthcare across the world, in areas including cardiology, oncology and women’s health.

Our partners benefit from our global presence and business acumen to grow their healthcare business startup ideas, while we drive towards transforming healthcare through collaboration.

Per Edlund has about 20 years of experience leading multi-cultural teams to drive innovation, growth and patientcentricity, to meet unmet needs in the field of diagnostic radiology. He currently heads a diverse business featuring a portfolio that includes Contrast Agents, Medical Devices, Services, and Informatics.

AUTHOR BIO

lesions before a surgery, and innovation in contrast agents can help make this possible, in some cases saving the need for surgery. This is especially relevant given that 70 per cent of the liver cancer incidence is in Asia, with a majority occurring in China.

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DIAGNOSTICS

T

he global cancer burden is raising an alarm for healthcare leaders worldwide. Cancer claimed 10 million lives in 2020 1. The International Agency for Research on Cancer (IARC) estimates that 1 in 5 people develop cancer in their lifetime and these new estimates suggest that more than 50 million people are living within five years of a past cancer diagnosis2. With more new patients being diagnosed each year, the number of active cancer patients is increasing rapidly.

The rising population of cancer patients has presented a new set of 1 https://www.who.int/news-room/fact-sheets/detail/cancer 2 https://www.uicc.org/news/globocan-2020-new-globalcancer-data.

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AMBULATORY CANCER CARE Quicker expansion to bring more value and accessibility to patients Cancer is said to be on rise and is one of the leading cause of deaths. With the increase in cases, the call to accommodate to the cancer patients needs and care rises as well. This article highlights the expansion of ambulatory care centres and how it benefits cancer patients.

Phoebe Ho, Chief Executive Officer, Integrated Oncology Centres (IOC).

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DIAGNOSTICS

challenges for all countries. Healthcare administrators have to speed up the establishment of health care facilities.

Universities and colleges have to expand their training capabilities to train health care professionals, with the aim of catching up with the service capability and the ever-growing demand of cancer services.

In this context, integrated cancer care in an ambulatory setting can be a beacon of hope. Ambulatory cancer care, which is also known as cancer care given through outpatient settings, is well-recognised to be cost effective, deliver better clinical outcomes and has a relatively scalable model.

Over the course of the last decade and a half, ambulatory cancer care has seen tremendous growth due regulatory, legal, and economic reasons. Most importantly, studies show that to stay out of the hospital environment and in a smaller, more comforting and familiar setting is often linked with higher patient satisfaction.

Seeing this growing trend, this article seeks to share the benefits of ambulatory cancer care for patients.

Single specialty networks and ambulatory care centres can help fill the gap

With the rise of cancer cases worldwide, the need to support a growing population of cancer patients is frequently being discussed at various medical forums and roundtables. It is clear that there is a gap between the number of cancer facilities available in Asia versus the number of projected cancer patients.

However, establishing a hospital can be a daunting task and this is not just from a financial point of view. This has given rise to the birth of single specialty centres that provide ambulatory cancer care which have successfully navigated the complexities of a large hospital set-up and yet bring together competent medical professionals to provide patients with the best-fitted

facilities, quality treatments, diagnostics and advanced technology. Single specialty cancer centres as such are also less capital-intensive compared to traditional multi-specialty healthcare, making them more scalable and faster to set up.

One such example in the AsiaPacific region would be Integrated Oncology Centres (IOC) which is led by CEO, Ms Phoebe Ho and her team of healthcare professionals. In Asia, there is still a limited number of centres providing ambulatory care and this clear shortage of the available number of facilities led the organisation to believe that they needed to roll out more treatment centres at a quicker rate to keep up with demand of ambulatory cancer care.

Besides providing ambulatory cancer care, IOC’s approach provides doctors the opportunity to be partners in managing these centres, thus providing them with the chance to have greater involvement in management

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DIAGNOSTICS

and administrative functions.

With the expertise of the doctors, clinical workflow can be designed in the most efficient way. This model enables the doctors to serve the patients in a more direct and effective way and the process is leaner with the whole centre serving patients with the same disease. This appeal has enabled many more cancer centres to be rolled out quicker than other networks with the geographically advantage by engaging local doctors.

Access to multiple specialisations

A recent article published in the Journal of Healthcare Contracting showed that 80% of the cancer care can now be delivered in an outpatient setting3. With the advances in the technology in drug treatment, for example oral targeted therapy, cancer treatment has become more sophisticated. Inpatient admissions are no longer necessary for most of the clinical situations.

In the past, a cancer patient would have to admit themselves to a hospital to receive cancer treatment which would most likely lead them to missing out of valuable family time while staying on an inpatient bed. When a cancer patient is diagnosed with cancer, their loved ones mean the most to them for support and for them to make the most out of their lives.

However, ambulatory care centres of today have evolved and thankfully, medical professionals can provide a very broad range of treatments to patients ranging from tomotherapy, immunotherapy to targeted therapy and chemotherapy without them being in an inpatient setting. The rapid advancement of ambulatory cancer care has seen a surge in a variety of specialty treatment modalities, from palliative clinics, physiotherapy to survivorship programmes. Most ambulatory cancer centres now also provide ancillary patient services, from nutritional guidance to psychological services and even financial counselling for some cases.

3 https://www.jhconline.com/cancer-care-migrates-tooutpatient-setting-2.html 44

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Studies show that to stay out of the hospital environment and in a smaller, more comforting and familiar setting is often linked with higher patient satisfaction.

Providing the best possible care to cancer patients is most important for medical professionals. With ambulatory cancer centres, medical professionals and doctors work as a team to ensure smooth service delivery as well as effective communication for clinical decisions.

With medical care professionals making most decisions in an ambulatory care centre, there is more ownership, accountability and overall better decision in cancer care. Ultimately, a cost-effective cancer centre can be built to serve cancer patients in the best way.

Faster turnaround

Ambulatory care centres are also free from lengthy inpatient care pathways.

When it comes to patient care, experienced doctors in ambulatory care centres can make clinical decisions swiftly and make arrangement immediately with the facilities set up around their practice, thus helping patients to save time and hassle. Ambulatory cancer care allows patients to have direct access quickly to a team of doctors and medical professionals without hospitalisation.

According to Voice Ons (2019), ambulatory cancer care provides cancer patients with a better quality of life. In ambulatory care, patients limit their IS S UE - 52, 2021

time in the health care facilities to active treatment time4. Contrast to inpatient admissions, patients do not have to queue up at the admission office, receive their treatment on a hospital bed for a couple of days and have their meals in the wards. They can instead spend the rest of their time with their loved ones, have dinner at home and sleep on their own beds. Some patients might even be able to continue to work in the office.

These routines might seem like trivial requests, but they mean a lot to cancer patients.

As a result, patients can quickly get their treatments and go back to their loved ones to enjoy their quality time with them instead of going through long administrative procedures. In addition to that, the dynamic culture and flat structure of such ambulatory cancer care networks means faster turnarounds and quicker roll outs of new services to patients. This then translates into timely and accessible care for patients as the main focus of ambulatory cancer care centres is the wellbeing of cancer patients.

Enhanced psychological well-being of patients

When cancer patients first learn that they have been diagnosed with cancer, a lot goes through their minds as they have many questions and most of the time they are worried of what their future holds. Most of the time, the cancer diagnosis on a patient can take both a mental and physical toll on the patients and their loved ones.

The journey taken by cancer patients can be long, daunting, and arduous.

Understanding the psychological burden of cancer patients and their care givers takes years of experience in oncology.

The ability to provide a solution to this particular patient need takes a team with a clear focus. With the help of doctors, nurses and medical social workers specialised in cancer care, the 4 https://voice.ons.org/news-and-views/the-vital-role-ofoncology-nursing-in-ambulatory-care

DIAGNOSTICS

psychological issues can be of the patient can be resolved.

Patients are already undergoing a great degree of stress and suffering and the aim of these ambulatory cancer centres is to lessen as much of their burdens as possible by putting emphasis on giving cancer patients the treatment they need through a faster and more convenient channel. Besides, Ambulatory cancer care centres have had a positive impact on cancer patient as a study published in the International Journal of Environmental Research and Public Health mentioned that breast cancer patients who receive ambulatory care are less likely to experience negative health effects, like hospitalisation and emergency department visits5.

Cost benefits for patients

PHOEBE is a pharmacist by training and has over 20 years of experience in healthcare. She also served in various senior executive positions with Fortune 500 pharmaceutical companies. Formerly Vice President & General Manager of GlaxoSmithKline Ltd, Phoebe was instrumental in establishing new businesses that covered vaccines and dermatology for GSK in China and Hong Kong.

Focusing on one key specialty such as cancer is a key differentiator for ambulatory cancer care centres. By focusing on key treatments and developing talent that are specific to cancer, the centre’s resources are very customised and specific to one particular specialty. As a result, this contributes to cost effective operations for the healthcare provider with a key focus on maximising value for cancer patients and improving efficiency.

For the patient, the advantage of ambulatory cancer care means that they need not spend extra costs for hospitalisation. Patients can receive their treatment and often go home that same day. Besides experiencing the comfort of receiving treatment in a safe and familiar setting, ambulatory cancer care can also translate to real and measurable cost savings.

In conclusion, more ambulatory cancer care centres ought to be set up.

Patients should be surrounded by a supportive environment with a team of professionals knowing their needs deeply.

They should walk their cancer journeys with the healing hands and caring hearts, eventually to the way of recovery.

5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6747467/

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INFORMATION TECHNOLOGY

Technology in Telehealth There is an erroneous perception that widespread adoption, upscaling and deployment of Telehealth is a function of technology. ‘Customer delight’ in telehealth interaction will occur only when body language of the Health Care Provider conveys sympathy, understanding and total involvement. This alone will make one ‘hooked on’ to experience virtual remote healthcare.

K Ganapathy, Director, Apollo Telemedicine Networking Foundation; Director, Apollo Tele Health Services

T

here is an erroneous perception that widespread adoption, upscaling, and deployment of telehealth is solely related to availability of cost-effective, affordable, accessible, and user friendly technology. There is no doubt that technology acceptance and behavioural modification, which we are witnessing particularly after the onset of Covid-19, has a major role to play. ‘Customer delight’ is what every e-Commerce platform aims for. The Amazons and Flipkarts and Googles of the world package their products in such a way that even octogenarians from rural backgrounds get hooked to the incredible experience. Whom are we selling telehealth to? Who needs to get ‘hooked on’ to experience virtual remote health care? How do you convince a worried or sick patient tens, hundreds thousands of kilometers away that the specialist on the screen can do as good a job or even better than if he is holding

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INFORMATION TECHNOLOGY

your hands directly. How do you excite every individual doctor to evangelise telehealth? This will happen only when his/her patient is convinced that telehealth is as good or better than a face to face consultation 5G, bandwidth of 100 Mbps, a 55” hi -resolution screen, a future ready voice activated EMR where images uploaded with ease at the remote end can be digitally manipulated by the consultant, playing videos, a wide choice of highly secured payment gateways etc etc – the list can be never ending. All this hi-tech no doubt will help, but are we not missing the wood for the trees?

What does a patient using telemedicine even today really want?

They want Tender Loving Care (TLC).

“Listen, listen, listen, he is telling you the diagnosis” said Sir William Osler 150 years ago. When I give a teleconsult I still listen! Patients do not care how much you know. They want to know how much you care. Healthcare is personal — it is very hard to feel your experience was excellent, when those treating you don’t introduce themselves, or make eye contact, or say what they are doing to you and why. The doctor’s body language says it all. No Artificial Intelligence (AI), no technology will ever substitute for a doctor who empathises, sympathises with his far away patient, wiping the patient's tears albeit virtually.

Alas the powers that be, including teleconsultants, forget that providing remote healthcare is not like selling / buying a pizza online or booking a train ticket. Technology in healthcare should only be a tool, a means to achieve an end, not an end by itself. Technology helps in producing remarkable solutions.

Sometimes after this we go in search of problems! Lars Leksell the inventor of the Gamma Knife famously remarked half a century ago, “ A fool with a tool, is still a fool”. I belong to the BC era – not before covid but, before computers.

Yes, I am a technology buff. I even brought out a special edition for the journal Neurology India on “Extra Terrestrial Neurosciences”- the ultimate

Technology in healthcare should only be a tool, a means to achieve an end, not an end by itself. Technology helps in producing remarkable solutions. in technology. Over the last 21 years when I first started telemedicine, it has been my privilege to see the radical transformation and the exponential growth of remote care. I am optimistic that soon telehealth will be centre-stage in the core of the healthcare delivery system. This phenomenal growth is no doubt a direct byproduct of technological advances. An app a day may keep the doctor far far away, but I would still like my tech savvy doctor to be commiserating, to understand what I want so that he will prescribe the

right apps for me. 'Customer delight’ is the only way that telehealth will truly come centre-stage and be integrated into the core of the healthcare delivery system. Worldwide remote healthcare is driven by technologists, software/ hardware entrepreneurs, communication engineers, mobile network operators, CEO’s of startups. Manufacturers of peripheral medical devices, wearables etc . During the last 21 years 95 per cent of the numerous talks I have given have been organised by the telemedicine ecosystem! Medical colleges, medical associations, clinical societies do not include telehealth in any CME programme. It is extremely unusual to find a clinician giving up a medical or surgical career to embrace telehealth.

The clinician should be the first among equals if patients are to get excited about telehealth and take the initiative requesting his/her doctor to appear on the screen. Circumstances and necessity will make doctors understand that this tool for connecting, ensuring a continuum of care will no longer be a choice but will become the writing is on the wall!

AUTHOR BIO

K Ganapathy Past President, Telemedicine Society of India, Neurological Society of India & Indian Society for Stereotactic & Functional Neurosurgery.

Former Secretary General Asian Australasian Society of Neurological Surgery. Hon Distinguished Professor The Tamilnadu Dr MGR Medical University, Chennai Formerly Adjunct Professor IITM and Anna University Chennai, India. Digital Health Expert WHO Director Apollo Telemedicine Networking Foundation & Apollo Tele Health Services, India.

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BOOKS

Multiple Perspectives on Artificial Intelligence in Healthcare: Opportunities and Challenges Author(s): Mowafa Househ, Elizabeth Borycki, Andre Kushniruk

Healthcare Informatics for Fighting COVID-19 and Future Epidemics Author(s): Lalit Garg, Chinmay Chakraborty, Said Mahmoudi, Victor S. Sohmen No of Pages: 658

No of Pages: 135

Year of Publishing: 2021

Year of Publishing: 2021

Description: This book presents innovative solutions utilising informatics to deal with various issues related to the COVID-19 outbreak. The book offers a collection of contemporary research and development on the management of Covid19&nbsp;using health data analytics, information exchange, knowledge sharing, the Internet of Things (IoT), and the Internet of Everything (IoE)-based solutions. The book also analyses the implementation, assessment, adoption, and management of these healthcare informatics solutions to manage the pandemic and future epidemics. The book is relevant to researchers, professors, students, and professionals in informatics and related topics.

Description: This book offers a comprehensive yet concise overview of the challenges and opportunities presented by the use of artificial intelligence in healthcare.

It does so by approaching the topic from multiple perspectives, e.g. the nursing, consumer, medical practitioner, healthcare manager, and data analyst perspective. It covers human factors research, discusses patient safety issues, and addresses ethical challenges, as well as important policy issues. By reporting on cutting-edge research and hands-on experience, the book offers an insightful reference guide for health information technology professionals, healthcare managers, healthcare practitioners, and patients alike, aiding them in their decisionmaking processes. It will also benefit students and researchers whose work involves artificial intelligence-related research issues in healthcare.

• Reveals solutions employing informatics for battling COVID-19 and other coronaviruses; • Discusses health data analytics, knowledge sharing, and IoT in relation to informatics and COVID-19; • Pertinent to researchers, professionals, and professors in informatics and related fields.

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Comprehensive Healthcare Simulation: Improving Healthcare Systems Author(s): Ellen S. Deutsch, Shawna J. Perry, Harshad G. Gurnaney No of Pages: 279 Year of Publishing: 2021 Description: This book presents simulation as an essential, powerful tool to develop the best possible healthcare system for patients. It provides vital insights into the necessary steps for supporting and enhancing medical care through the simulation methodology.

Organized into four sections, the book begins with a discussion on the overarching principles of simulation and systems. Section two then delves into the practical applications of simulation, including developing new workflows, utilizing new technology, building teamwork, and promoting resilience.

Following this, section three examines the transition of ideas and initiatives into everyday practices. Chapters in this section analyze complex interpersonal topics such as how healthcare clinical stakeholders, simulationists, and experts who are non-clinicians can collaborate. The closing section explores the potential future directions of healthcare simulation, as well as leadership engagement.

Evaluation of Health Care Quality for DNPs, Third Edition: A Practical Guide for Health Care Professionals Author(s): FCCM Hickey, Joanne V., PhD, RN, FAAN (Editor), FNP-BC Giardino, Eileen Riviello, Dr., PhD, RN, APRN, ANP-BC (Editor)

Do No Harm: Protecting Connected Medical Devices, Healthcare, and Data from Hackers and Adversarial Nation States Author(s): Matthew Webster No of Pages: 336

No of Pages: 388

Year of Publishing: 2021

Year of Publishing: 2021

Description: Protecting Connected Medical Devices, Healthcare, and Data from Hackers and Adversarial Nation States, cybersecurity expert Matthew Webster delivers an insightful synthesis of the health benefits of the Internet of Medical Things (IoMT), the evolution of security risks that have accompanied the growth of those devices, and practical steps we can take to protect ourselves, our data, and our hospitals from harm.

Description: Now in its third edition, this awardwinning text work is the only advanced practice nursing text to present effective, systematic, and in-depth evaluations of all aspects of health care quality. Comprehensive in scope, it distills best practice information from numerous sources to facilitate utmost competency for APN and DNP graduates. The third edition keeps pace with the rapidly evolving healthcare market by presenting a more comprehensive range of evaluation strategies for analyzing quality, safety, and value in healthcare practice and programs. It provides a completely new chapter on evaluation of simulation programs to improve clinician competency and patient care technology.

Big Data and Artificial Intelligence for Healthcare Applications (Big Data for Industry 4.0) Author(s): Ankur Saxena, Nicolas Brault, Shazia Rashid No of Pages: 286 Year of Publishing: 2021 Description: This book covers a wide range of topics on the role of Artificial Intelligence, Machine Learning, and Big Data for healthcare applications and deals with the ethical issues and concerns associated with it. This book explores the applications in different areas of healthcare and highlights the current research.

The book covers healthcare big data analytics, mobile health and personalized medicine, clinical trial data management and presents how Artificial Intelligence can be used for early disease diagnosis prediction and prognosis. It also offers some case studies that describes the application of Artificial Intelligence and Machine Learning in healthcare.

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RESEARCH INSIGHTS Social determinants of mortality from COVID-19: A simulation study using NHANES Benjamin Seligman, Maddalena Ferranna, David E. Bloom Published: January 11, 2021 https://doi.org/10.1371/journal.pmed.1003490

cerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents.

Background

Conclusions

The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level.

Methods and findings

We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID19 deaths and correlations among these variables in the general population from the 2017–2018 National Health and Nutrition Examination Survey (NHANES).

We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% nonHispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%–59.6%, p < 0.001), individuals with income below the median (67.5%, 95% CI 63.4%–71.5%, p < 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% –27.9%, p < 0.001), and veterans (19.5%, 95% CI 15.8%–23.4%, p < 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression.

Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incar-

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Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.

Author summary Why was this study done?

• The COVID-19 epidemic in the United States of America (US) has been found to disproportionally affect racial/ethnic minorities and areas with higher concentrations of poverty.

• Few data on COVID-19 deaths with respect to individual-level social determinants of health other than race/ethnicity are available.

What did the researchers do and find?

• We used the 2017–2018 National Health and Nutrition Examination Survey (NHANES) and publicly reported data on COVID-19 deaths from the public health agencies of the US, China, the United Kingdom, Spain, Italy, and France to simulate COVID-19 deaths among noninstitutionalized (e.g., not residing in a prison or nursing home) adults aged 20 years or older in the US. • We found large social gradients in COVID-19 mortality. Adults from households earning less than the median income made up two-thirds of COVID19 deaths, while those with less than a high school education accounted for approximately 1 in 4 deaths.

Veterans also accounted for nearly 1 in 5 deaths, despite representing less than one-tenth of the population.

• Our simulation reproduced known racial/ethnic disparities in COVID-19 mortality.

What do these findings mean?

• The associations between social determinants of health and COVID-19 mortality are similar in scale to those between hypertension and diabetes and COVID-19 mortality.

• COVID-19 mitigation will require measures to support people from low-income, low-education communities and the healthcare systems that serve them.

• Citation: Seligman B, Ferranna M, Bloom DE (2021) Social determinants of mortality from COVID-19: A simulation study using NHANES. PLoS Med 18(1): e1003490. https:// doi.org/10.1371/journal.pmed.1003490 • Academic Editor: Mirjam E. E. Kretzschmar, Universitair Medisch Centrum Utrecht, NETHERLANDS • Received: May 27, 2020; Accepted: December 3, 2020; Published: January 11, 2021 • This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

• Data Availability: All relevant data are within the manuscript and its Supporting Information files.

• Funding: We received financial support from the Bill & Melinda Gates Foundation. BS is supported by the US Department of Veterans Affairs. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

• Competing interests: The authors have declared that no competing interests exist.

• Abbreviations: CDC, US Centers for Disease Control and Prevention; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; IHD, ischemic heart disease; NHANES, National Health and Nutrition Examination Survey

Introduction

The SARS-CoV-2 pandemic is a profound challenge to healthcare systems and societies. While no segment of society is unaffected, some groups face disproportionate burdens of illness. Multiple studies have established the increased risks of severe illness and mortality with age and comorbidity [1–6]. Within the United States of America (US), geographic differences in the prevalence and incidence of COVID-19 morbidity and mortality are known [4]. However, data on social determinants of health and the associated risks of infection with SARS-CoV-2 and death from COVID-19 are less available. US Centers for Disease Control and Prevention (CDC) surveillance has demonstrated the overrepresentation of African Americans among people hospitalized with COVID-19, but more detailed information is lacking in disease statistics [7,8]. Other major sources of COVID-19 statistics likewise lack information on social determinants of health [9,10].

Social determinants of health play an important role in the spread of and mortality from epidemics, from influenza in 1918 to Ebola in 2014 and others, including the first severe acute respiratory syndrome (SARS) epidemic [11–16]. They affect susceptibility to acquiring infection, due to differences in social contacts and differences in living circumstances [15,17–19]. They

affect severity of illness, in part through concentration of comorbidity in susceptible groups [20–22]. Finally, they also affect outcomes through differential access to healthcare, which may in turn limit opportunities to identify and contain local outbreaks [17,23–25].

Understanding the COVID-19 burden in terms of social determinants of health is important for policymaking and targeting both public health and clinical interventions. Ecological-level data show that areas with higher poverty rates and larger proportions of individuals who identify as racial/ethnic minorities have higher COVID19 mortality [26]. However, few analyses to date consider social determinants at the individual level.

Here, we use simulation to investigate the distribution of COVID-19 mortality with respect to social determinants of health at an individual level.

Methods

Because data on social determinants of health among COVID-19 deaths are limited, we simulated mortality. We started with univariate distributions of COVID19 deaths by age, sex, race/ethnicity, and comorbid conditions—as reported by multiple public health agencies from the spring to summer of 2020—and the correlations among these variables from the

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RESEARCH INSIGHTS 2017–2018 National Health and Nutrition Examination Survey (NHANES). Using these data, we estimated the joint distribution of deaths by these variables. The probabilities obtained from this joint distribution were used as weights for simulating COVID-19 deaths in the NHANES cohort. This provided a sample with which we could investigate social determinants of health in COVID-19 mortality.

NHANES sample

Data on individuals aged 20 years or older in the general population were taken from the 2017–2018 cycle of NHANES (n = 5,265), a nationally representative study of the health of noninstitutionalized Americans [27]. This study comprised a questionnaire, a physical exam, and selected laboratory studies. Questions asked addressed health status, including comorbidities; demographic information; and social determinants of health, such as income and education.

To code the presence of certain comorbidities we used definitions incorporating both questionnaire and examination or laboratory findings. Hypertension was defined as the presence of either self-reported hypertension in the health questionnaire or an average blood pressure greater than 140/90 mm Hg on examination; we did not incorporate use of antihypertensives due to missingness [28,29]. Diabetes was defined as self-report or a hemoglobin A1C greater than 6.5% [30]. Chronic kidney disease (CKD) was defined as self-report of either kidney failure or dialysis or an estimated glomerular filtration rate less than 60 ml/min/1.73 m2 using CKD-EPI [31,32]. Ischemic heart disease (IHD) was defined as self-report of coronary heart disease, angina, or heart attack. Chronic obstructive pulmonary disease (COPD) was defined as self-report of emphysema, chronic bronchitis, or COPD. Additionally, we created a comorbidity index based on the number of comorbidities each participant had, including the presence of hypertension, diabetes, CKD, IHD, COPD, and self-reported asthma, congestive heart failure, stroke, liver disease, and cancer.

For social determinants of health, we considered race/ ethnicity, income, education, and veteran status based on their availability in NHANES. We specifically considered veterans because they are disproportionately older compared with the general population and frequently face service-related health conditions [33,34]. Cases with missing data or with responses of “don’t know”

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or “refused” were dropped from the final analysis. For race/ethnicity, the categories “Mexican American” and “Other Hispanic” were combined into “Hispanic.” For income, we used household income, limited analysis to responses within specific income ranges, and did not include the answers “under $20,000” and “$20,000 and over.” In the NHANES data, age was top-coded at 80 years, and income was top-coded at $100,000 per year.

Simulation of COVID-19 deaths

Simulating COVID-19 deaths involved 3 steps, with the last 2 repeated in each simulation run. This was necessary given the absence of cross-tabulations of COVID19 deaths by age, sex, and comorbidity, with only univariate distributions consistently available. In the first step, marginal distributions of age, sex, and comorbidity were taken from multiple public health agencies and used to estimate prior distributions. In the second step, the marginal distributions of age, sex, and comorbidity were randomly drawn from the priors. Using the correlations among these variables from NHANES, we then approximated their joint distribution. In the third step, the joint distribution was used to reweight the NHANES sample to represent COVID-19 deaths. We give more detail on each step in the following.

As joint distributions of characteristics of COVID19 deaths were unavailable, we first obtained their marginal distributions. We considered the marginal distributions of deaths by age, sex, the absence of comorbidity, and presence of each of hypertension, diabetes, CKD, IHD, COPD, and cancer. These were obtained from the CDC, the United Kingdom’s Office for National Statistics, Santé Publique France, Istituto Superiore di Sanità in Italy, Instituto de Salud Carlos III in Spain, and the China Center for Disease Control and Prevention [35–41]; S1 Text provides further details. Comorbidity data from the CDC, the Office for National Statistics, and Santé Publique France were excluded from fitting the model due to their reliance on death certificate data, which underestimate the prevalence of comorbidities compared with reported data from US hospitals and from systematically collected data from Italy, Spain, and China [42,43].

We then fit maximum-likelihood beta or Dirichlet (for age) priors to each marginal distribution. To estimate a joint distribution, race was set as an indicator variable for non-Hispanic white and fixed to the proportion reported by the CDC, as this was the only agency that reported race/ethnicity.

The second step was to approximate the joint distributions of the aforementioned characteristics. To do this, we used marginal distributions for age, sex, and each of the comorbidities drawn from their respective priors, the fixed marginal distribution of non-Hispanic white individuals, and the correlations of these variables from NHANES to estimate a joint distribution using a Gaussian copula [44]. We then assigned the joint probabilities as weights to each NHANES participant such that the participants would, in total, represent 200,000 deaths.

We repeated step 2 1,000 times. We checked calibration against CDC-published distributions of deaths by age, by sex, and by race/ethnicity. We report our results and data in terms of gender, which is reported in NHANES. However, data from public health agencies are given in terms of sex.

pattern of disproportionate deaths among the elderly holds in the simulation, although the simulation indicates a higher proportion of deaths at younger ages than is observed in CDC data. The results for gender show close calibration with observed data and follow the pattern of a greater proportion of deaths among males.

Analytic approach

With the simulated data we produced distributions across variables of interest. Differences in proportions were assessed by a bootstrap chi-squared test compared to a null distribution of 1,000 replicates randomly sampled from NHANES. To assess the independent contributions of these variables, we also analyzed the data as a case–control study using multivariable logistic regression. In this instance, the NHANES sample was weighted to represent the general population to serve as controls, and to represent COVID-19 deaths to serve as cases. Confidence intervals were bootstrapped from the 1,000 simulation runs, while p-values were bootstrapped through 1,000 replicates of a null. We did not have a prespecified analytic plan.

Neither individually identifiable information nor patient health information was used in this study; all data are publicly available and are described in S1 Text. Analysis was conducted by author BS in R version 4.0.2 using the package GenOrd version 1.4.0 [45,46]. Code used for the simulation is available from https://www. hsph.harvard.edu/pgda/data/.

Results

Table 1 shows the distributions of characteristics of the simulated COVID-19 deaths and the characteristics of their comparison population from NHANES 2017–2018. Fig 1 shows the results of model calibration against age and gender, indicating acceptable calibration of the simulation against the observed age and gender distributions in the US. Clearly, the general

Fig 1. Calibration of simulated distributions of deaths by age and gender against reported distributions from the CDC. Age (top); gender (bottom). Gray bars and whiskers show mean and 2.5th–97.5th percentile range for simulated proportions, the blue circles show the CDC-reported proportions, and the red triangles show the NHANES-estimated proportions for the general population.

CDC, US Centers for Disease Control and Prevention; NHANES, National Health and Nutrition Examination Survey.

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Table 1. Characteristics of simulated COVID-19 deaths and the weighted NHANES sample.

Fig 2 and Table 1 show the distributions of social determinants of health among COVID-19 deaths and in the general population. When we divide the population between non-Hispanic white and all races/ethnicities, the simulation shows that all others are overrepresented among COVID-19 deaths compared with

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their proportion in the general population (54.8% of deaths, 95% CI 49.0%–59.6%, p < 0.001). When data are broken out by specific race/ethnicity (S1 Fig), we see that the simulation captures some disparities, but understates others, particularly among African Americans.

Fig 2. Simulated proportions of deaths by race/ethnicity, income, veteran status, and education level.

Panels show mean and 2.5th–97.5th percentile range for the simulations (gray bars and whiskers), the CDC-reported proportions (blue circles, only for race/ethnicity), and the NHANES-estimated proportions for the general population (red triangles). AA, associate’s degree; GED, General Educational Development; NHANES, National Health and Nutrition Examination Survey.

With respect to income, COVID-19 deaths are disproportionately among middle- and lower-income people.

Those making below the median income, which is the $55,000–$64,999 category, make up 67.5% of deaths (95% CI 63.4%–71.5%, p < 0.001). Similarly, disparities exist regarding level of education: Individuals who have less than a high school level of education are overrepresented among COVID-19 deaths (25.6%, 95% CI 23.4%–27.9%, p < 0.001). Disparities with

respect to being a veteran are smaller on an absolute scale; however, veterans make up almost 20% of deaths in the simulation (19.5%, 95% CI 15.8%– 23.4%, p < 0.001) versus 9% of the population.

Table 2 shows the results of the multivariable logistic regression of COVID-19 mortality against age, gender, and the social determinants of health studied. The coefficients show increasing odds of mortal-

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Table 2. Odds ratios of death from COVID-19 based on age, gender, race/ ethnicity, income, education, and veteran status.

ity with age, while female gender is associated with lower odds. These data also show increasing odds of mortality for Hispanics, African Americans, and Asian Americans/Pacific Islanders. For income and education, as the level of either one declines, the odds of mortality rise, except for the “some college” category.

In this group, relative to high school graduates, the odds of mortality are increased. Being a veteran was not significantly associated with increased odds of death from COVID-19 independent of the other variables considered.

Discussion

Our simulation provides evidence of the scale of social and economic disparities in the COVID-19 epidemic in the US. Mortality from infection disproportionately strikes individuals from low- or middleincome families, individuals with less education, individuals who are of racial/ethnic minorities, and individuals who have served in the military. The disparities identified here are likely underestimates of their true scope. As the simulation only consid-

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ers age, gender, race/ethnicity, and comorbidity as drivers of death, direct effects of social determinants of health on vulnerability to infection and mortality are not explicitly modeled. These effects include crowded living conditions, limited access to care, and economic hardship that may force people to continue to risk exposure by working. This analysis also does not consider the low wages of many essential jobs that place workers at increased risk of infection, including healthcare workers such as environmental services staff and patient care attendants [47]. Even with these limitations, however, the associations of COVID-19 mortality with social adversity in our study are comparable to the associations of COVID-19 mortality with diabetes (odds ratio 1.75–1.90) and hypertension (relative risk 2.21) [48–51]. Our findings differ from a study that found no difference in income among persons who died or had critical illness during hospitalization for COVID19 versus those who survived hospitalization without critical illness [52]. This is likely due to our consideration of the general population, versus those who are hospitalized.

Our findings provide further evidence that efforts to reduce COVID-19 mortality should involve prioritizing the needs of disadvantaged communities. This could involve greater assistance for healthcare systems that disproportionately care for low-income or low-education people, such as many public and rural hospital systems, the Veterans Health Administration, and the Indian Health Service. This would also need to involve public health measures, such as paid sick leave, income support, and expansion of health insurance access, to make social distancing more feasible and make care accessible. This may also involve messaging around social distancing and other health behaviors targeted to groups facing social disadvantage.

Further, it is crucial that we systematically collect data on social determinants among COVID-19 cases and deaths. These are key data for understanding and controlling the epidemic [53,54].

Our approach has several limitations in addition to not explicitly modeling the effects of social determinants of health. We assume that the correlations among age, gender, race/ethnicity, and comorbidity in the population of individuals who have died from COVID-19 are the same as those in the general population. This is not true in the case of the correlation between gender and age, as males are disproportionately represented in all age groups among COVID19 deaths, whereas females predominate at older ages in the general population. NHANES data do not include nursing home residents, who make up a large fraction of COVID-19 deaths. This likely contributes to differences between the simulated and observed age distribution of deaths. The other model parameters are based on data from multiple countries, which may affect representativeness for the epidemic in the US, especially with regard to comorbidities, where CDC data could not be used for calibration.

Finally, we depend on reliable reporting of deaths, and there is concern that not all COVID-19 deaths are being registered [55,56]. We recommend that further work systematically collect and report data on social determinants of health among individuals affected by COVID-19.

As the Introduction notes, social determinants of health have been associated with disease burden in past epidemics. They have potentially facilitated increased transmission as well, suggesting that control may depend in part on addressing the epidemic specifically among individuals who are poor, have less education, or live in poor conditions [12,14]. As more

data become available, we may better understand the roles of particular social determinants and be able to design more effective interventions. By protecting the health of the most vulnerable, such measures could mitigate the toll of the COVID-19 pandemic and protect all Americans.

Supporting information

Acknowledgments

We would like to thank Prof. Marcello Pagano at the Harvard T.H. Chan School of Public Health for his helpful comments on our model.

The work of DEB and MF on this paper was supported by the Value of Vaccination Research Network (VoVRN) through a grant from the Bill & Melinda Gates Foundation (Grant OPP1158136). The content is solely the responsibility of the authors and does not necessarily reflect the views of the VoVRN or the foundation.

This material is the result of work supported with resources and the use of facilities at the VA Boston Healthcare System. The contents do not represent the views of the US Department of Veterans Affairs or the United States government.

S1 Fig. Simulated proportions of deaths by race/ethnicity.

Figure shows mean and 2.5th–97.5th percentile range for the simulations (gray bars and whiskers), the CDC-reported proportions (blue circles), and the NHANES-estimated proportions for the general population (red triangles). AA, African American; AAPI, Asian American/Pacific Islander; NHW, non-Hispanic white.

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Combining the power of the industry’s highest performance Er:YAG and Nd:YAG lasers for applications in aesthetics and dermatology, as well as an additional surgical QCW Nd:YAG laser.

87048/14

www.fotona.com

Committed to designing, manufacturing and delivering:

The Highest Performance, Best Made Laser Systems in the World www.asianhhm.com

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NEEDLESTICK INJURIES ARE HISTORY

WE TAKE CARE OF YOUR SAFETY VACUETTE® Safety Products Greiner Bio-One offers a wide range of innovative safety products, which can be selected according to your requirements and application.

Greiner Bio-One GmbH / Kremsmünster, Austria / E-MAIL office@gbo.com We are a global player / Find the contact details of your local partner on our website. www.asianhhm.com

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