news & management continued from page 1 brexit: uncertainty in every question of policy confusion there. one thing is clear: the uk will struggle to play any significant role in these global debates, which is a pity.’ brand: ‘i totally agree. momentarily, we obviously live in times of so called post-truth-politics, where eve- ryone can spread untruths in politics online via social media and offline, and people do believe it. the best example is the claim about these £350 million that were transferred to the eu on a weekly basis and which was the very first thing politicians backed up on directly after brexit.’ after brexit is completely con- cluded, what will happen to all the physicians working abroad in common projects at universities and clinics? mckee: ‘first, who can tell wheth- er brexit ever will be concluded? second, this is a very good point. universities in the uk were unani- mously opposed to brexit, recognis- ing that the consequences would be devastating. the same is true for the nhs, which depends on eu citizens in so many areas. ‘some british politicians talk about giving eu citizens already here the right to remain, but that simply reveals their ignorance of the issues involved. these workers have many rights, as eu citizens, including enti- tlement to healthcare should they retire to other member states after retirement or when they travel home while employed in the uk, as well as portability of pensions etc. i see no evidence that these issues are being addressed.’ brand: ‘the most important thing is that there exists a date for the exit. now, the european commission has to deal with the question of where the european institutions will move and what to do next. several good people are already leaving, return- ing to their home countries. ‘i personally know neurologists who are concerned about the fact that they might have to leave horizon 2020, which is not a question of financials in first place, but a ques- tion of the existing and established networks. big projects cannot be stemmed solely. if britain leaves such projects because of brexit an important partner will be lost. this is definitely something both sides will suffer from.’ what’s next? mckee: ‘it really is impossible to predict. the scottish first minister was asked, after she met theresa may, whether she was undermining the government’s plans. she pointed out that there was nothing to under- mine. ‘i can only conclude that the british government is lost, with no idea where it is, or where it wants to go. there are many options, from no brexit, through soft brexit, and hard brexit. all are, for one reason or another, “impossible”. the challenge is to find the least impossible solu- tion, which may just be remaining a member of the eu.’ brand: ‘i think that an important question for the healthcare sector will be how to deal with standards. we do have standards for drug approvals, in medical technology, regulations for treatment and thera- pies, there exists a joined procure- ment for ordering vaccines, and all these are european standards. ‘the question is, what will britain do? will it stay with these established standards or, for example, draw near the usa. the second could lead to a lot of problems. these are questions that have to be faced.’ helmut brand is jean monnet professor of european public health and head of the department of international health at maastricht university, the netherlands. the professor studied medicine in düsseldorf and zürich and holds a master’s degree in community medicine from the london school of hygiene and tropical medicine and london school of economics. he is president of the european health forum gastein (ehfg) and co-chair of the european alliance for personalised medicine (eapm). professor martin mckee qualified in medicine in belfast, northern ireland, with subsequent training in internal medicine and public health. as professor of european public health at the london school of hygiene and tropical medicine he was founding director of the european centre on health of societies in transition. he is author of over 900 scientific papers and 44 books and is fellow of the royal colleges of physicians of london, edinburgh, and ireland and the uk faculty of public health and a former chair of the uk society for social medicine. norbert nowotny phd is a professor at the institute of virology in the university of veterinary medicine, vienna, and professor for virology at the mohammed bin rashid university of medicine and health sciences in dubai, united arab emirates. the virologist researches all aspects of infectious diseases (particularly viral related) in humans plus domestic, zoo and wild animals. he also specialises in medical and veterinary medical entomology, viral infections spread by mosquitoes and ticks, emerging infectious diseases and zoonoses. his work as local scientific organiser and member of the scientific committee at the imed 2016 is a role he has held at five previous imed congresses. global warming causes vectors for emerging diseases to spread further and further north science can only react hospital d infections caused by the zika virus present a very broad clinical pic- ture. in 2015, when problems in the unborn babies of infected pregnant women were first observed, the car- dinal symptom was microcephaly. the document from the royal college of physicians (rcp), enti- tled ‘underfunded, under-doctored, overstretched – the nhs in 2016’, highlights challenges facing the health service across the united kingdom. the report depicts the nhs strug- gling to cope under the increasing pressure of rising demand and inad- equate funding, with resulting work- force pressures threatening patient safety. drawing on views ranging from senior consultants to trainee physi- cians, combined with on-going evi- dence of the scenario facing the nhs, the report outlines key areas of concern, yet also offers recom- mendations for government action. it comes as health trusts are facing financial shortfalls with recorded hospital deficits hitting £2.45 billion and as junior doctors have contin- however, it has since been discov- ered that the typical cerebral anom- alies (reduced volume, calcifications or malformations of the cortex) can also occur in children whose heads are of normal size. the clinical picture has also been significantly extended, with malpo- sition of the hands and legs now also frequently diagnosed. furthermore, there are indications that an infection with the zika virus can also lead to severe clinical symptoms in adults. ‘the diagnosis of the zika virus, along with all other types of flavivirus, is still a big prob- lem,’ nowotny points out. with flaviviruses, the time span in which the virus itself, or its molecular foot- prints (e.g. via polymerase chain reaction) can be detected is relatively short, and the serological tests avail- able (zika virus immunoglobulin-g and m) cause massive cross reac- tions with other flaviviruses, such as with the pathogens causing dengue fever, yellow fever or west nile fever. considerable research is still needed, nowotny explains. global warming causes the vec- tors for emerging diseases to spread further and further north. although aedes aegypti, the transmitter of dengue fever and chikungunya fever, has not yet managed a break- through into europe, aedes albop- ictus, a type of mosquito and close relative, has now spread across the entire mediterranean, and can also function as a transmitter for both those diseases. spread via infected holidaymak- ers bitten by this species of mos- quito, there has already been a local dengue fever outbreak in dubrovnik, croatia, and around 200 people developed chikungunya fever in ravenna, italy. these out- breaks were only contained with the help of a massive chemical fight against the transmitters. ‘this shows how important monitoring systems are,’ nowotny emphasises. this is not only important in the mediterranean countries: ‘aedes albopictus is on the brink of cross- ing the alps,’ the virologist warns. ‘for hospitals, mers-cov is a big problem,’ he stresses. there has been an unusual increase in hospital infections through this viral agent, which originates in the arabian peninsula. only 5% of those infected had direct contact with dromedar- ies, which act as vectors for this infection, and the remaining 95% of infections were transmitted from human to human – within the fam- ily, in the community and frequently also in hospitals. the hospital acquired infections were initially limited to saudi arabia but, in mid-2015, at least 186 people became infected in south korea (of whom 36 died) after an infected traveller who had returned home from a trip to the arabian peninsula had sought help in several hospitals. ‘there is not yet sufficient research into the problem of why there are so many hospital-acquired infections from mers-cov,’ nowotny reports. although travellers have now spread the virus throughout many countries there have not yet been any cases of hospital acquired infections involving the mers coronavirus outside the arabian peninsula and .korea. the ‘transmission, prevention, and reporting of emerging infectious diseases’ programme for the international conference imed 2016 in vienna, this november, reflected events in the field of emerging diseases that have occurred over the last two years. therefore, key congress topics included the zika virus, the effects of global warming and the unusually high number of hospital-acquired infections (hais) caused by mers-cov. ‘with all emerging diseases, sci- ence can only ever react to them,’ emphasised austrian virologist professor norbert nowotny, a local scientific organiser and member of the scientific com- mittee at imed, who spoke with european hospital at the event. a leading british medical organi- sation has issued a hard-hitting report that paints ‘a grim picture’ of the national health service (nhs), mark nicholls reports to replicate, a virus needs to hijack mechanisms within our cells © dr. kateryna – fotolia.com 2 european hospital vol 25 issue 6/16

editor-in-chief: brenda marsh art director: olaf skrober managing editor: sylvia schulz editorial team: sascha keutel, marcel rasch senior writer: john brosky executive director: daniela zimmermann founded by heinz-jürgen witzke issn 0942-9085 correspondents austria: michael kraßnitzer, christian pruszinsky. china: nat whitney france: jane macdougall. germany: anja behringer, annette bus, walter depner, cornelia wels- maug, holger zorn. great britain: brenda marsh, mark nicholls. malta: moira mizzi. spain: mélisande rouger, eduardo de la sota. the netherlands: madeleine van de wouw. usa: cynthia e. keen, i.t. communications, lisa chamoff. subscriptions liane kaiser, theodor-althoff-str. 45, 45133 essen, germany subscription rate 6 issues: 42 euro, single copy: 7 euro. send order and cheque to: european hospital subscription dept management report: mélisande rouger the visc+ project was intend- ed to collect all patient data in catalonia. the health minister’s administration dropped this last summer. what will happen now? comín i oliveres: ‘it’s important to remember that big data generates a lot of concern, especially regarding data confidentiality and information security. there are also concerns as to who will benefit from that infor- mation, i.e. public entities to improve healthcare or private companies for their own interests. many questions remain open. ‘big data is fundamental to pursue health investigation, so it’s crucial for any project to be consensual both at the political and social level. we couldn’t have such a controversial programme as visc+. we couldn’t have any plan that caused suspi- cion and defiance in politicians and among the public. ‘we held participative meetings with scientists, experts, research- ers and social and political repre- sentatives, to let everyone explain in today’s digit- ised world, hos- pitals are already embracing the ben- efits which tech- nology brings to improve efficiency and reduce costs. against a backdrop of stretched resourc- es and operational scrutiny hospi- tal managers are able to address the needs of multiple stakeholders through hospital-wide digitisation. improving communication using digital signage for way finding, check-in, queue management and info/entertainment helps to enhance the patient and visitor experience and alleviate potential frustration. in clinical practice, collaboration is essential to maximise productiv- ity and synergy of talent requiring visual access to patient information to ensure best patient outcomes. to assist in the challenges of hospital-wide digitalisation, nec is the only manufacturer able to offer such a wide portfolio of display products, including desktop and large format displays and projection, as well as fine pitch led modules. this unique position means that nec can recommend the best fit solution to virtually any application scenario with a customer oriented consultative approach. trusted nec quality is the benchmark for per- their views on big data. all parties also signed a common resolution in parliament ‘our new plan is called padris (programme for health research and innovation analysis) and will be implemented by the end of 2016. it will enable massive data analy- sis for research purposes using our seven million patients database and the database of the health catalan institute. this is the second biggest big data plan in europe after the united kingdom. ‘only research centres accredited by government will be able to use that information. these include non- profit private research groups such as the puigvert foundation or the sant joan de déu hospital. ‘this will guarantee no one can make business with the citizens’ clinical history.’ a lot of controversy also sur- rounds your decision to buy back the activity of clínica del vallès in sabadell from the quirónsalud group… ‘this is creating a lot of political formance and longevity with a long heritage serving the special needs of the healthcare sector. ready access to up-to-the minute information will help to improve the patient and visitor experi- ence. touch screens allow visitors to check-in and receive directions for their onward journey through the hospital building. video walls and large format displays provide debate, but really it is quite sim- ple. we are following the provision model defined in the catalan health law in 1990, according to which the government must employ public hospitals first, and only if necessary privately run institutions – and then the government should work with non-profit private groups first. we are following this principle of pref- erence. ‘the hospital activity purchase sys- tem had become messy over the years and we tied it up. providers are very influential, but our mission is to guarantee maximum quality, equity and efficiency. ‘the activity at clínica del vallès could be done by two public hos- pitals: the parc taulí, also located in sabadell, and the consorci sanitari, in nearby terrassa. we have relocat- ed two thirds of the activity in taulí and a third in terassa. we also save €1 million in the process. ‘you don’t need to be left wing to do this. adam smith said that private companies needed to compete in the market and criticised monopolies. however, a hospital consortium is way finding information and can be instantly updated to provide emergency messaging, should the need arise. delivering excellence in patient care demands effective multi-dis- cipline collaboration. the multi- disciplinary team (mdt) facility is critical in assembling healthcare practitioners to collaborate with full access to patient data and multiple pacs images, side by side, viewable by large numbers of people, both in one room and via remote conferenc- ing. nec’s large screen uhd dis- plays deliver images equivalent to 8mp presenting unprecedented rich- ness of detail and pixel-free viewing on a huge scale with controlled colour reproduction and consistent images viewable from all angles. projection solutions, also available in 4k resolution provide additional options for break out rooms and training centres. where performance and accu- racy are vital, the nec medical grade dicom pre-set colour display series exceeds the highest reviewing expectations for departments like radiology, nuclear medicine, ortho- paedics, pneumology and intensive care. designed with both reliable quality and affordability in mind, the review displays with unique built-in firmware features can be calibrated to the dicom grayscale display function using nec’s gammacompmd qa software. besides medical specialty monitors, nec offers a wide range of com- mercial and professional desktop displays offering a dicom pre-set plus large format screens to support surgeons in the or. in a caring profession, there is no substitute for the personal touch, but with nec as your part- ner, hospitals can benefit from state of the art visual technology to improve patient confidence and deliver an excep- tional health- care service. * source: nec display solutions like a small monopoly, limited in time and space. how can a company be competitive inside a monopoly?’ are you then planning to buy other hospitals from private com- panies? ‘we are in talks with quirónsalud concerning the purchase of the hospital general de cataluña (hgc), located in sant cugat. in 2005, the administration had planned to build two hospitals in rubi and cerdanyola, which are very close to sant cugat. ‘experts have estimated the pur- chase would cost us €55 million. it’s actually cheaper to buy the hgc than to build two new hospitals. that’s a lengthy and costly process and, right now, there’s no money for that. ‘in addition, we could transfer basic healthcare activity to nearby hospitals in terrassa and taulí, and let the hgc do all the specialised work. right now it’s the other way around and basic care hospitals pro- vide specialised care, while the hgc provides basic care. it’s the world upside down.’ how will you tackle waiting lists, one of catalonia’s major prob- lems? ‘last june, there were 161,730 people waiting for surgery, 3.1% more than a year ago. there were also 4.7% less patients waiting for diagnostic exam- inations. about 100% cancer patients had received surgery in less than 45 days and almost every heart surgery patient had waited less than 90 days. ‘our plan is to reduce the waiting list for surgery and diagnosis by 50%, by improving information access, empowering primary care, increas- ing the proactivity of our health- care system and augmenting activ- ity. we need €100 million to do it. ‘to reduce the list to nought, we would need €1,000 million!’ how does catalan healthcare com- pare to the rest of europe? ‘i’d like to have an ocde pisa report for catalonia; i think we’d rank very high. we have a very good, high quality model, which is very linked with research and uses a large diver- sity of providers. ‘however, we have three major problems: waiting lists, wages and the fact that our foundations haven’t received a cent in years because of the crisis. some hospitals are also ageing pretty fast. all of these issues are solvable with money and that is why we want to cancel our annual €16,000 million deficit – the biggest in the eu. we’re the only region in the eu with an 8% budget deficit. for us, the only way to do so is to become independent.‘ at the heart of catalan health minister’s strategy from desktop display to large formats, projection and led modules big data, de-privatisation and independence opt for state-of-the-art visual technology antoni comín i oliveres (toni comín) is the catalan health minister under carles puigdemont’s administration, composed of junts pal si (‘together for yes’), the pro independence coalition formed by convergència (right wing) and esquerra republicana (left wing) in 2015. comín, a professor of social sciences and a philosopher, became a socialist deputy in june 2004. proposed by esquerra republicana, he was appointed health minister. catalonia, spain’s richest region, is launching one of the largest big data healthcare projects in europe, after scrapping a polemic plan that would have enabled patient data to be shared with private for-profit companies. as the region confirms its leading role in healthcare technology, it is also de-privatising key hospitals to improve efficiency in a context of low funding, a decision that has received considerable attention in spain. antoni comín i oliveres, the catalan health minister, came back on these highly dis- cussed issues and explained what other challenges lie ahead for his region in our exclusive interview. digitised information signage systems – a visible profit for everybody 4 european hospital vol 25 issue 6/16

color display megapixel it & radiology a workshop held before this year’s conhit and attended by representa- tives from the german parliament, medical insurers and health infor- matics firms, tried to open up an international perspective and to answer the question if germany’s current position regarding xhealth. participants compared patients’ access to digital services within the health service and access to their own data. the question: are patients par- ticipants in the digitisation or is it only affecting service providers? the country-specific ehealth strategy was also scrutinised. ‘unfortunately the result shows that germany is in last position compared to other countries,’ böckmann says. to a large extent this is due to the number of different players work- ing on the subject of digitisation. however, she does not believe it would be possible to implement a centralised system in germany such as the one introduced in denmark. ‘our health system, with its federal structure, cannot support this. self- administration, with different associ- ations representing the service pro- viders and funding bodies, makes this centralisation impossible.’ whilst austria is automatically introducing the electronic patient file (epa) for everyone via the e-card, the plan in germany is that citizens must act. ‘people themselves will have to apply for the use of ser- vices such as the epa per electronic health pass. however, this plan has an inherent danger of a silent, large majority developing who will do nothing and therefore will not have access to these modern, digital ser- vices, in the same way as this was discussed around the topic of organ donation. therefore, the switch from analogue to digital for routine processes in doctors’ surgeries, for example, will only happen very slowly. from a systems and health informatics point of view a centrally since jvckenwood corp acquired the display manufacturer totoku three years ago the expected synergies in the development and distribution of common solutions and products have been set, according to marcel herrmann, marketing manager for medical displays at totoku: ‘we wanted to combine our expertise and gradually develop new areas and applications – and we’ve suc- ceeded.’ their first product was a display for endoscopy. ‘our mother brought her expertise from the broadcasting sector, and we have the knowl- edge for specific requirements in healthcare facilities,’ he pointed out. during the european congress of radiology in march this year, the company first launched its video solution based on a 4k video-capa- ble camera from the broadcasting field. the next screen, jointly devel- oped by jvckenwood and totuku, is the gd-w213l. this high-reso- lution 16:9 widescreen lcd / led monitor with a size of 21.5 inches is reported to be particularly suitable for reviewing. ‘it has a high contrast ratio of 1,000:1 with 1920 x 1080 pixels and, thanks to an anti-reflec- tive screen, a wide viewing angle. for high quality, bright and sharp images, the led backlight has a brightness of 250cd / m²,’ herrmann explains. besides this, the gd-w213l offers an integrated power supply, audio inputs for hdmi, dvi and rgb and a multilingual menu that allows oper- ation in german, english, french, spanish and japanese, the manu- facturer reports. ‘the aspect ratio is adjusted automatically. a dicom preset ensures realistic reproduction of all xray images.’ controlled approach taking interna- tional standards into account and making digitisation part of routine care would obviously be wonderful,’ böckmann believes. more focus on the patient the introduction of an electronic health card would shift the inter- ests of the patient to the fore. the ehealth law states that gematik (the company in charge of the elec- tronic health card development) will have to develop certain specifica- tions, such as the electronic patient record, by 2018. ‘unfortunately, the actual plans are oblivious to cur- rent technologies and possibilities because they hold on to principles developed at a time when there were neither smartphones nor apps,’ the professor points out. one example of this is the medi- cation plan. conceived initially on paper, in the second step it is to be introduced in electronic form and stored on the patient card. ‘however, the patient will have to carry it around as a paper version because they will not be able to access their own data stored on the card beyond the surgery, i.e. without a health professional card (hpc), due to the legally prescribed two- key principle. in my view, this is completely the wrong approach and will reduce public acceptance of this card even further,’ böckmann states. ‘an increasing number of health insurers now offer their patients apps. there are also numerous tel- emedicine projects, and the technol- ogy is developing at a rapid pace, but the way things are now this could lead to a two-class society. whether a diabetic patient will have an app financed will depend on their insurer. whether or not heart failure is treated telemedically, of whether a patient is even told about this option, depends on whether the combination of the doctor in charge of treatment, the location of the patient and who they are insured with, happens to be covered by one of the pilot projects. but surely it shouldn’t be like that,’ she says, dis- playing anger. a clear mandate for the future there was a clear call for a consist- ent ehealth strategy for germany that was also discussed during the workshop: ‘the law on ehealth only covers certain aspects and main- ly introduces the infrastructure. it consists of a collection of regula- tions which, although meaningful in parts, does not follow any overall strategy,’ böckmann complains. ‘the interoperability register is only a collection and evaluation of exist- ing projects which utilise certain standards instead of clear rules as to which standard is to be used in which cases and settings, which would be the only way for manufac- turers and users to adhere to them. diversity is the enemy of interoper- ability here.’ there is also the financing issue. böckmann: ‘xhealth services, being inter-sectoral building blocks, often fall into the gap between out- and in-patient treatment, as telemedical care concepts often have in-patient as well as out-patient aspects. we’ve been practising telemedicine for 20 years, but there are only two reim- bursable items in the billing cata- logue. on the other hand, the post- age for a doctor’s letter is very easy to reimburse.’ however, böckmann does point to evidence of progress in the medi- cal fraternity. ‘the state medical association in baden-wurttemberg is now accepting applications for, and evaluations of, telemedical pro- jects involving remote treatment. this means that the ban on remote treatment is finally put under scruti- ny, and it is the first time that things are moving on the part of the medi- cal associations, with other federal german states watching this devel- opment with a lot of curiosity.’ diversity is the enemy x-health: demands for real interoperability introducing the dicom preset monitor britta böckmann has been professor for health informatics at the technical university of dortmund since 2006. her focus is on telemedicine and telematics, digital care management for integrated care, trans-sectoral treatment and information systems in healthcare. böckmann also heads the scientific advisory board at dgtelemed, the german association for medical informatics, biometry and epidemiology (gmds) telemedicine working group and the working group on health informatics at the institute for medical informatics, epidemiology and biometrics at the university of duisburg-essen. britta böckmann, professor for health informatics at the technical university of dortmund summarises the lack of feeling for terms such as ehealth, mhealth and telehealth with the description xhealth. however, xhealth also stands for exchange, ‘that is interoperable solutions, meaning actual interoperabil- ity and data exchange not seen in previous approaches,’ böckmann explains. she views the current direc- tion with scepticism and calls for a consensus-based ehealth strategy for germany. expertise of jvckenwood and totoku joined for another display product overview of the formats used: systems with a medication plan for patients can, for instance, directly print a paper version for the patient (1). the plan is stored electronically in cda format or fhir format/ultra short format (2). cda and fhir/ultra short format can simply be transformed into one another, both ways, with generally available tools (bijectivity, a). paper versions can be produced from cda (3) as well as fhir/ultra short format (4). the short format is also suitable for the barcode (5) or the egk (6). the fhir base format is available for mobile apps (7). 6 european hospital vol 25 issue 6/16

color display megapixel radiology installing a complete diagnostic radiol- ogy solution to network six sites of a hospital group, to process, man- age and archive image data acquired across all modalities, is a ‘chal- lenge’, acknowledged by professor dr peter landwehr, medical director of the clinic for diagnostic and interventional radiology of dikovere henriettenstift, hanover, germany. in 2010, he and his team over- came that challenge and they are extremely happy with the results. ‘why didn’t we do this sooner?’ asked those involved in sourcing and implementing the solution. how it all began a complex tender procedure to pur- chase diagnostic radiology viewer, enterprise archive and an enter- prise viewer solution resulted in six manufacturers being short-listed. for the final decision, comprehen- sive requirements documents and detailed specifications were drafted and systematically evaluated by a fifteen-strong committee represent- ing all user groups and the it department. understanding how the technol- ogy is supported in a real-life clini- cal setting is just as important as the technology itself. an experienced consultant familiar with the market supported the committee. ‘it was crucial for us to have professional expertise on board because this was our very first diagnostic radiology solution.’ the hanover-based hos- developments. from analogue to digital ‘before we could put the new solu- tion into operation we had to get rid of a few analogue standalone solu- tions,’ landwehr points out, add- ing that several cr systems had to be purchased and some ultrasound systems had to be made dicom- compatible. ‘at the same time we worked well with carestream’s drx1,’ he says. above all the radiographers liked the wireless cassette-based x-ray solution because it offers mobility and good image quality. solution roll-out issue of the purchase order kicked off an intensive six-months’ plan- ning and implementation phase, culminating in the hardware instal- lation: core it components, local workstations with modern screens and reconfiguring certain modali- ties. at the same time several work- flows were redesigned. after ten months everything was set up. in june 2010 the count- down arrived: overnight x-ray was switched from analogue to digital. no exception allowed? only one: a complete solution breakdown, for example, caused by network or server failure, was considered the only situation when films can be printed out. this tough stance paid off. after only a year film usage had pital group was a ‘digital radiology late-adopter’ due to a drawn-out process when the legal structure of the local hospitals was turned into a holding. ‘since we were lagging behind, we wanted full adoption from day one,’ landwehr recalls. a precise needs assessment and an operational plan were established aiming to optimise the cost-ben- efit ratio while avoiding common deployment mistakes. the winner is… finally, the selection committee unanimously opted for the pro- vider they considered offered superior functionality and sup- port: carestream. the firm’s solu- tion scored with ease-of-use inside and outside of radiology, a slew of innovative functions, a convinc- ing value-for-money ratio and an innovative team focused on future decreased to one percent. ‘for a dig- itisation project this is an extraor- dinary result, since it takes us to profitability sooner than we had anticipated,’ landwehr points out. positive feedback all around despite the staff’s positive attitude towards the new digital solution, there were traces of scepticism. this is normal when a new technology is introduced that disrupts and forces changes upon well-oiled processes. “but when it ran without a hitch and everybody was comfortable with operating it the entire team was happy and we received positive feedback, not only here in radiol- ogy, but also from the non-radiology clinics we work with,’ landwehr concludes. a system scales with the users six years have now passed. quantity and quality of the requirements have been increasing constantly mainly due to images in ct and mri, with rising expectations with regard to fast access to the image data. the internal technology land- scapes, as well as the provider’s system, have continuously devel- oped high-performance processors and huge data storage space at hospitals, new releases with new functionality at the provider’s. ‘we are not interested in the dernier cri when it comes to our diagnostic platform – what we do expect are intelligent and feasible solutions to optimize our workflow day in day out,’ the radiologist emphasises. ‘so far, the provider has met the expec- tations with flying colours – a fact that confirms the committee’s initial decision. however, in these rapidly changing times none can rest on the laurels. current highlights so far, the provider has provided fully-integrated 3d-/mpr-/mip func- tionality. ‘other manufacturers can’t offer comparable quality,’ landwehr believes. he underlines the excellent work- flow support, e.g. in mammogra- phy, contrast-enhanced ultrasound, functional imaging in colour duplex ultrasound and hybrid imaging. today the system also offers sup- port by semi-automated assessment of oncological studies. for lesion management and size comparison current and historic images can be viewed side-by-side in mip or 3-d and images acquired in different planes can be automatically corre- lated in anatomy. ‘that even works across modalities with ct and mri,’ says landwehr. outlook in radiology there will be ever more data to be evaluated; ever more high-performing tools are needed to support radiologists due to scarcity in the profession. landwehr believes radiologists with professional exper- tise in diagnostics and intervention will still be here in 30 years’ time ‘but they’ll need more technological backup to meet clinical require- ments’. a system cannot simply store images and ensure access. the major task will be to provide advanced post-processing workflow such as semi-automated protocols to screen lesions, cross-referencing different clinical and imaging data sources, such as from endoscopy and pathol- ogy for clinical decision support, or an intelligent worklist assignment to optimise sub-specialty reading, thus freeing time and capacity for a radi- ologist to deal with complex clinical imaging questions. ‘equipped with such tools for structured reading, we will be able to meet the challenges of tomor- row and the day after,’ landwehr predicts. responsible radiology while the technological support and innovative approaches by the manufacturers are indispensable, landwehr urges radiology, as a dis- cipline, to spearhead the develop- ment of enterprise imaging systems. why? dealing with huge volumes of imaging data has to be organised first and foremost with an appropri- ate clinical context, then to make available for clinical and scientific purposes. ‘this is not something we can leave to the it experts and industry. ‘as clinically focused radi- ologists, we’re in the best position to decide where more data will indeed translate into added value for the patient and where it won’t.’ a gung-ho ‘big data will solve all problems’ approach is wrong, warns landwehr, because it will lead to ‘apple, google and other usual sus- pects knocking on our doors and defining health and disease based on what’s good for them. collecting data just for the purpose of collect- ing does not make sense.’ far rather, landwehr is convinced, radiology, both in diagnostics and intervention, must be even more innovative, more clinically effec- tive. ‘technological tools, such as a modern enterprise imaging solution, help us to become just that.’ success for a complete diagnostic radiology solution going fully digital in a single key stroke professor peter landwehr, who grew up in remscheid, birthplace of wilhelm conrad röntgen, worked for 14 years in the radiology departments of universities in bonn, würzburg and cologne. his seven years spent as senior physician at the institute and polyclinic for radiological diagnostics at the university hospital, cologne, including three and a half years as managing senior physician, increased his leadership skills. in january 2001 he was appointed medical director of the clinic for diagnostic and interventional radiology at diakovere henriettenstift hospital, hanover. in october 2015 he gained a professorship from hanover university’s medical school and, in 2016, became president of the 97th german radiology congress in leipzig. in 2017 landwehr will serve as a member of the advisory board of röntgen’s birthplace foundation in remscheid-lennep ct and mri imaging have brought increasing expectation of faster access to image data the analogue world contained large folders of x-ray and other scans and notes all needing transportation 8 european hospital vol 25 issue 6/16

laboratory medication testing in real life conditions becomes possible when misdirected antibodies the birth of the amazing organoids no case for a psychiatrist’s following medical studies at the university of lübeck professor klaus- peter wandinger md became a researcher in the neuroimmunology department at the national institute of neurological disorders and stroke (ninds) in bethesda/usa. in 2000 he became a researcher under professor einhäupl in the neurology department at the charité clinic. three years later he wrote his habilitation on a neuroimmunology topic. he was involved in the development of laboratory procedures at euroimmun and, since 2013, has been deputy director of the institute of clinical chemistry, campus lübeck, university hospital schleswig- holstein (uksh). professor hans clevers, researcher and group leader at the hubrecht institute in utrecht, the netherlands, invented the organoids, a ground-breaking new technique to grow new ‘organs’ and to test medication. this year, his work was rewarded in the form of the prestigious korber european science prize*, presented in hamburg. at the heinrich f c behr-symposium he dis- cussed organoids and the individual therapy for colon cancer made pos- sible by this significant development. for years, clevers has studied how cancer develops and what goes wrong at the dna level. ‘until 2007 it was thought that bowels do not contain stem cells. we discovered that they do, and even more, that they divide themselves every day. to make that visible, we added the dna of fireflies in the stem cells of mice. and what happens in mice, also works for peo- ple. this discovery was a real break- through and it was a race against time to be the first to come out with this study. we – mostly – won this race, but it was also worth a lot to see that other researchers, who were on the same track, confirmed our research.’ the development of organoids the discovery of stem cells in the intestines led to further investigation and, within two years, clevers and up to ten years ago only a handful of antibodies that could be detected in the blood were known to neu- rology. patients had inflammatory changes in the brain or spinal cord and also malignant tumours. when an antibody was detected this auto- matically triggered the search for a tumour. usually, patients’ neurologi- cal symptoms improved once the tumour was removed. in 2005, the catalan neurolo- gist dr josep dalmau, working at the university of pennsylvania in philadelphia, was the first research- er to describe new antibodies found in liquor from young women suf- fering encephalitis, but not neces- sarily also from uncontrolled tissue growth. this was the starting signal for the discovery of new antibodies, a process that is still not complete. in germany the institute for clinical chemistry at the university hospital schleswig holstein is pur- suing the diagnosis of, and research into, these antibodies. in our european hospital interview with professor klaus-peter wandinger and pd dr frank leypoldt, neurolo- gists and trained/trainee laboratory medics, we asked how dalmau dis- covered the new antibodies. wandinger: ‘professor dalmau car- ried out research in the field of neuro-oncology in the us for a long time and collected and examined a lot of liquor and serum. he found n-methyl-d-aspartate-receptor (nmdar) antibodies in around 100 patients, who all had similar clinical symptoms and responded to immu- nosuppressive treatment. these were mainly young women aged between 20 and 40, who initially displayed psychiatric symptoms. ‘the clinical picture usually start- ed with the patients hearing voices or experiencing hallucinations, simi- lar to schizophrenia. they then also suffered from epileptic fits, which were so severe that their breathing was affected to such an extent that they had to be treated in intensive care. it was a severe clinical pic- ture, which was life threatening in around 20% of patients but which, up to that point, could not be diag- nosed.’ what are nmdar antibodies and how do they trigger these symp- toms? leypoldt: the nmdar antibodies are a subspecies of glutamate recep- tors. glutamate is a messenger sub- stance in the brain that transmits impulses from receptor to receptor. the antibodies that normally fight team managed to grow a small intes- tine in a petri dish from a stem cell. the result is a new standard for the unlimited reproduction of adult stem cells, from which organs can grow in mini-size. moreover, these ‘organoids’ contain all the cells that behave just as they do in the intestines, meaning that medication can be tested in real- life conditions. personal treatment method using organoids also leads to answers to questions such as how do cells work together; what they need from each other; what goes wrong to cause a particular disease, and especially how it can be solved. ‘with these so-called ‘tumoroid’ stud- ies, research is carried out on the patient’s disease. you harvest a few cells from the patient, out of which the organoids can grow. ‘this is far less stressful than several physical examinations. the result is that you can prove which medication will be most effective for this patient in order to provide him with personal treatment.’ cystic fibrosis variants clevers, in close cooperation with kors van der ent and jeffrey beekman, from the wilhelmina children’s hospital, proved the benefits of this technique. a dutch patient named fabian, aged 18 years, suffers a rare form of cystic fibrosis. ‘the medicine ivacaftor was tested for people with cystic fibrosis who had emerged from the same dna error. fabian was not eligible for the drug because it was not tested for the gene that causes his form of cf. with organoids, we showed that ivacaftor would also work in him. so he was given the medicine after all and is now doing great.’ dilemma and global training however, the use of organoids also leads to a dilemma. ‘the cost of medications is high,’ clevers point- ed out. ‘you can still say “yes” if you can prove that medication will indeed help, but we can also predict with certainty when it does not. so do we have to refuse a medicine that people are entitled to have?’ additionally, current regulations regarding the authorisation of new drugs are not yet adapted to the recent developments. ‘therefore, we unfortunately cannot make any state- ments yet for colon cancer,’ clevers explained. ‘the regulations also demand more testing on animals, whilst the use of organoids can dimin- ish the use of animals in laboratories.’ clevers is training lab staff world- wide in growing organoids. ‘in hong kong, for instance, influenza virus- es were tested on pieces of lung removed during lung surgery. they needed to work very fast, because those pieces only remain good for four days. we have trained research- ers from hong kong in our lab in utrecht and now the technique is being applied there. the future clevers has not finished his studies. ‘the heart is still a virgin territory when it comes to the question of whether that organ has stem cells. in addition, the research into the application of organoids is still in progress. yes, we can grow miniature organs and implant them in animals, but is that safe? suppose you grow mini organ stem cells from a donor bank. will you give the patient a new liver, but also perhaps a disease? another step is the development of tailor-made drugs by pharmaceutical companies.’ his big dream, however, is the emergence of a liver bank, contain- ing ‘freezers with pieces of liver together with the royal academy of sciences, hans clevers founded the hub to test the operation and effectiveness of drugs on a large scale, using organoids. ‘we need human material to grow organoids,’ he explained. ‘because of this non-profit organisation, people find it less difficult to donate cells for research.’ example of neuronal autoantibodies, in this case directed against neurofascin 155. immunohistochemistry with specially prepared rat brain tissue samples. areas marked in brown are identified by human igg from patient serum. the hippocampal formation is visible in the central part. 2.5 x magnification immunohistochemistry with visualisation of anti-neuronal antibodies against the cerebellum on specially fixed rat brain tissue samples, in this case directed against glutamate receptors type ampa. areas marked in brown are identified by human igg from the patient serum. from outside to inside: molecular cell layer, purkinje cell layer, granular cell layer, medullary layer of the cerebellum. 10 x magnification. indirect immunofluorescence with patient liquor on specially prepared, non-fixed, non-permeabilised, embryonic hippocampal primary culture neurons. the binding of human igg to the surface is marked in green. green dots correspond with synaptic clusters of the target antigen iglon5. blue corresponds with dapi nuclear staining. 63 x magnification generate – german network for research on autoimmune encephalitis founded in 2014, the network is entirely initiated by ‘investigators’ and is supported by 63 centres in germany, aiming to help patients. next to information from patients and doctors the main objective is to create a register; so far, this contains 570 pseudo­ nymised sets of data. they facilitate internationally comparable research into the disease. http://www.generate-net.de/ 10 european hospital vol 25 issue 6/16

laboratory report: mélisande rouger predicting disease development and anticipating adequate treatment may appear to be as uncertain as gazing into a crystal ball. but, what if there was a way to sort out and classify the myriad available genetic infor- mation to help doctors to do so? a multidisciplinary team from oviedo university is beginning to demonstrate that possibility by using biomedical robots that can adapt and improve predictions as they unravel phenotype – how genetic information expresses itself in a given environment. ‘searching for classifications that can optimally explain gene expres- sion is a little bit like trying to open a safe deposit box with multiple combinations. we are working with 50,000 genetic probes in cohorts of 100 or 200 patients at a time; this means we are dealing with an extremely high level of indetermi- nation. ‘we need tools that take into account the degree of uncertainty contained in phenotype predic- tion and understand that genetic networks have their own struc- ture,’ explained professor juan luis fernández-martinez, head of inverted problems at the mathematics department in oviedo university. combining knowledge from applied mathematics, statistics and computational science, since 2010 fernández-martinez and team have been designing biomedical robots with biomodels, a company headed by dr steve sonis from harvard university and brigham and women hospital in boston. their robots are able to learn from complex data sets and help doctors make decisions and plan personalised treatment according to a patient’s needs; in a word, they enable personalised medicine. the principle behind design- ing such machines is simpler than one might have thought. ‘people believed they needed highly com- plex computers to treat so much data, but we actually did it with a pretty simple model. basically, we applied the concept of parsimony. uncertainty comes from ambigu- ity in knowledge, so it’s interest- ing to look at things through that angle and simplify what is complex,’ fernández added. the engineer and his colleagues believe the machines will not only help in the study of rare and neu- rodegenerative disease and cancer, but also in designing orphan drugs and new treatments, and tailoring therapy to each patient. the team has just published a study in the journal of computational biology, in which they show robotic poten- tial in chronic lymphocytic leukae- mia, inclusion body myositis and amyotrophic lateral sclerosis. in leukaemia, the researchers have highlighted the relevance of lipoprotein lipase, an enzyme that decomposes triglycerides in free fatty acids and glycerol. the team has also discovered the importance of certain genes and how viruses and bacteria influence the genesis of myositis, an autoimmune disease affecting the muscular system, by showing how the immune system mistakes the organism’s proteins with those of the invader. biomedical robots have also been able to underline the importance of caspases, a group of proteins controlling programmed cell death and which have been related to mutations in gene sod1, a cause for amyotrophic lateral sclerosis. all these findings still need clini- cal validation, fernández-martinez stressed. meanwhile, the oviedo team has developed tools that can help dif- ferentiate between genes called headers, which are responsible for most of the phenotype, and helpers, adjuvant genes that bring further detailed information on discrimina- tion. researchers have applied this method to a toxicity study and will publish results soon on parkinson and alzheimer’s disease from the so-called finisterrae project (http:// www.slideshare.net/ifalberti/effec- tive-analysis-of-biomedical-big-data- for-the-optimisation-of-drugs-for- rare-and-neurodegenerative-diseas- es-and-cancer). the oviedo researchers also recently published a paper ques- tioning most of what has been said so far on microarray pre- processing techniques by show- ing their impact in biological pathways (impact of microarray pre-processing techniques in unravelling biological pathways, journal of computational biology, http://online.liebertpub.com/doi/ abs/10.1089/cmb.2016.0042). ‘genetics is still an understudied field and gene function is often mis- understood. our long-term goal is to make a genetic test as common as a blood test,’ fernández-martinez said. ‘we will multiply cooperation pro- jects with the medical field to do so.’ identified, many of those by josep dalmau, but also by angela vincent, in oxford, who heads up the sec- ond largest working group on this topic. neurologists can indicate a suspected anti-immune disease and also any clinical details on our test request form. we then use the pro- cedures we’ve developed to test for the known neuronal antibodies, and also for antibodies as yet unknown, using further tests from our research laboratory that were developed in close cooperation with professor dalmau and which are not available to buy. ‘we not only do this for hospi- tals in all of the german speaking countries but we also work with laboratories in spain, the usa and australia. our dual qualification is unique. i am already a qualified spe- cialist for laboratory medicine and dr leypoldt will soon qualify. when a positive result is confirmed we are well qualified to advise doctors on treatment. ‘the clinical pictures of autoim- mune diseases are not that well known outside of centres for maxi- mum care, and colleagues are grate- ful for our guidance.’ might more antibodies be discovered? leypoldt: ‘it is to be assumed that continued from page 11 no case for a psychiatrist’s couch more will be found as there is a vast number of potential target proteins within the nervous system. theoretically, each protein can trig- ger an auto immune reaction in the body, especially when it’s located on the cell surfaces where antibod- ies have good access. some people most probably have a genetic pre- disposition. ‘for now, the large groups, the most common autoantibodies, have been described with the laboratory procedures currently available. but the research continues for seronega- tive, i.e. antibody negative autoim- mune encephalitides, for example. if no antibodies can be detected it doesn’t necessarily mean that they don’t exist. ‘one of dalmau’s most important findings was the development of new laboratory procedures that can be used to identify a whole group of diseases through defined antibodies, i.e. patients who we had previously only perceived as suffering from encephalitis. ‘there are biomarkers for spe- cific groups of diseases that are very similar and treatable. following this advance into new dimensions it is likely that further steps will be made to identify and treat diseases not yet classified.’ “parsimony is the key in genetic data study” simplifying what is complex genetics stepping ahead as spain-based researchers develop biomedi- cal robots that can help in the study of rare diseases, neurodegenera- tive disorders and cancer, as well as the creation of orphan drugs trained as a petroleum engineer in paris (1988) and london (1989), and after years as an it software engineer in france, in 1994 juan luis fernández- martínez gained a phd in mining engineering from the university of oviedo, in spain. he joined the university’s mathematics department and became professor of applied mathematics. during 2008-2010 he was a visiting and research professor at uc berkeley-lawrence berkeley laboratories and stanford university. his expertise includes cooperative global optimisation methods, with applications in oil and gas, biometry, finance and biomedicine – in which he aims to design biomedical robots in translational medicine for diagnosis, prognosis, and treatment optimisation. the finisterrae project particularly aims to find effective solutions for rare and neurodegenerative diseases, as well as various types of cancer. professor fernández-martinez (left) with dr enrique j andrés galiana outside the geology department at oviedo university. the minicollect capillary blood collection system refined capillary blood collection and others, including the youngest patients. all need a gentle approach. to that end, austrian firm greiner bio-one has developed and opti- mised its minicollect system. no more tubes and funnels the cumbersome process of trans- ferring the drop of blood using capillary tubes or funnels is in the past, thanks to this system because the blood collection scoop is inte- grated into the wide tube opening. ‘the sample comes into contact with the additive immediately,’ the manufacturer reports. ‘the caps are completely sealed, meet the highest standards and can easily be sent via pneumatic dispatch or other trans- port systems without losing any sample material.’ carrier tubes and combined filling volumes simplify use ‘for centrifugation, the minicollect tubes can be inserted into a premi- um carrier tube using a simple rota- tional movement. when combined, the dimensions correspond to a standard 13 x 75 mm tube format and can easily be placed in a stand- ard rack or standard centrifuge.’ two easily visible filling marks on the tube provide greater flexibility for use. the new minicollect capillary blood collection system went on show at medica 2016 the capillary blood collection system not only benefits geriatric patients, or those who need regular blood sampling, but also burns victims small tubes, great impact 12 european hospital vol 25 issue 6/16

| visit us on follow us on european hospital verlags gmbh | theodor-althoff-straße 45 | 45133 essen www.healthcare-in-europe.com trends & innovations in healthcare. 25 years of european healthcare communication: print & online. online portal | newspaper | product guides | newsletter stay tuned on all channels. the european forum for those in the business of making healthcare work v o l 2 6 i s s u e 3 / 1 6 • j u ly / a u g u s t 2 0 1 6 laboratory 4-6/19-20 • biobank develops research standards • testosterone and male heart problems • in reprocessing qualifications are vital surgery 21-23 • reconstruction or amputation? • gaining a suite for 3-d printing • procedures in your pocket contents news & management 1-3 lab & pathology 4-6/19-20 cardiology special 7-18 surgery 21-23 events 24 www.healthcare-in -europe.com exuding the aroma of hi-octane fuel, the glamour of multi- coloured racing leathers, flashy sponsored brands and the glitz of the circuits, motorcycle racing can be an irresistible fast-action sport. amid the roar of engines, the world’s leading motorcycle aces, such as marc marquez, valentino rossi or jonathan rea, hit around 300kmh on tracks across the globe. interview: daniela zimmermann high-speed duals thrill the crowds, but clearly the risk of accident and injury remain high, despite improve- ments over the last three decades in equipment, machines, safety fea- tures and medical facilities. at the core of these is the renowned clinica mobile, a fully equipped medical and physiother- apy centre ‘on wheels’ to treat riders and the wider motor- cycle racing entourage. since the 1970s, clinica mobile has grown from a group of car- ing and enthusiastic practitioners carrying medi- cal boxes to race circuits into a mobile diagnostic and treatment facility with 50 employees attending superbike world championship and motogp races. in 2015, for example, the facility performed 2,966 interventions for motogp alone, of which about 1,245 their own permanent medical facili- ties, but clinica mobile is still a critical resource for care and treat- ment. the unit constantly upgrades its equipment, the latest being an additional carestream drx-1 flat panel from medical imaging systems and it solution specialist carestream health. installed at the back of the truck this produces immediate radiographic images; the console captures images and a detector forwards exposures wire- lessly to the console for processing and display, and then onward to printing and archiving systems. the digital detector reduces expo- sure to x-rays compared to conven- tional systems and the light weight of the system makes this a versatile tool to conduct a range of tradi- tional tests, e.g. general and trauma radiography and orthopaedics. ‘carestream’s drx-1 is a high-tech w e r e for driv- ers and 1,721 for paddock staff. ‘very often it helps diagnose and treat minor injuries, but sometimes - 359 times in 2015 - an x-ray is required. all this must be carried out within our 65-metre square facility, which can treat up to eight patients simultane- ously,’ medical director dr michele zasa explains. circuits now have continued on page 2 ace motorcyclists gain instant radiographic imaging from a flat panel system clinica mobile’s drx-1 delivers high-speed care system, able to meet the diagnostic needs of the specialisms that we serve, allowing us to provide more timely and accurate support,’ zasa points out. ‘it’s a very important and extremely reliable tool, useful in case of falls and ascertained frac- tures. in diagnostics, you need to have good machines that produce excellent diagnostic images. i need to provide a good quality service to the top riders, so the quality of all our equipment is very impor- tant. in terms of diagnostics the carestream drx-1, is a very good system. for traumatology, we can diagnose more and more fractures and it’s important to see, if the rid- ers are in pain, whether there are minor fractures. dr michele zasa is the medical director of the clinica mobile, a fully equipped medical and physiotherapy centre ‘on wheels’, and sometimes riders’ refuge. checking for minor fractures is important – they will race anyway, but they can relax knowing what the pain is the european forum for those in the business of making healthcare work 7-18 esc special reports and more laboratory diagnosing zika virus infection the society for virology (gfv) which promotes virology through the increase and exchange of research within german speaking countries, as well as via cooperation with other scientific societies, announced this year that a new test can unam- biguously confirm the diagnosis of a zika virus infection – leading to fast diagnosis and identification of an infection. the diagnosis of pregnant travellers worried a zika infection upon their return home was cited as one example. waiting for a diagno- sis is just a few hours. commercial blood test researchers at the university hospital, freiburg and at the bernhard nocht institute for tropical medicine have now substantiated the use of a commercial blood test for antibodies. ‘this test detects zika virus antibodies reliably and, unlike other procedures, shows no cross reactivity with other, related virus- es,” confirmed dr daniela huzly, head of diagnostics at the institute of virology in freiburg. professor thomas mertens, president of the society for virology, added: ‘the availability of a reliable and fast test for the specific and sensitive detection of zika virus antibodies is a great relief for those who may be infected as well as for doctors.’ a small window of time in a patient with an acute infection the zika virus has generally been confirmed via direct virus detection, a so-called pcr test. however, diag- nosis is only possible during a small window of time and only works during the first few days of an infec- tion. most patients therefore require a serological examination, i.e. a test for antibodies. one problem with this is that the antibodies developed by the body against the zika virus show a dis- tinct cross reactivity with antibodies against related viruses in most of the previously used blood tests. thus a test reacts positive when antibodies against other viruses circulate in the blood, such as those against fsme, yellow fever or dengue fever. this is a problem not only for those already infected but also those previously vaccinated against one of these viruses. ascertaining whether a patient really is infected with the zika virus therefore required further, extensive tests that can only be carried out in a few specialist laboratories. the new test, however, does not require extensive diagnostics and can be carried out in any laboratory that routinely tests for antibodies. also test men with pregnant wives the society for virology and the bernhard nocht institute for tropical medicine recommend con- firming a potential zika virus infec- tion not only for pregnant travellers returning from locations where the zika virus has spread, but also for men who have spent time in those areas and have pregnant partners. in both cases testing is also recom- mended when no symptoms or ill- ness are present. returning travellers who had symptoms typical of a zika virus infection, such as fever, headache, lethargy, muscle and joint pains, rash, conjunctivitis, can also be tested to check whether they are infected, even when symptoms may have been mild. source: society for virology, http://g-f-v-org/ newsletter commercial blood test proves reliable moving through the r&d pipeline a pan-cancer screening test cancer blood tests might become available in the near future. last january illumina, inc., a usa-based firm, announced the creation of grail, a new firm aiming to enable cancer screening from a simple test measuring nucleic acids circulating in blood. the earliest cancer detection increases long-term survival. the successful development of a pan- cancer screening test for asympto- matic individuals could, effectively, diminish global cancer mortality. grail, now as a separate company, with majority owned by illumina, is initially funded by over $100 million from illumina and arch venture partners, with participating invest- ments from bezos expeditions, bill gates and sutter hill ventures. ‘the holy grail in oncology has been the search for biomarkers that could reliably signal the pres- ence of cancer at an early stage,’ said richard klausner md, formerly illumina chief medical officer and nci director, and a grail director. ‘illumina’s sequencing technology now allows the detection of circu- lating nucleic acids originating in the cancer cells themselves, a supe- rior approach that provides a direct rather than surrogate measurement.’ grail has secured the counsel of a world-class set of industry and cancer experts for the com- pany’s advisory board, including klausner, dr jose baselga, physician in chief at memorial sloan kettering and president of the american association of cancer research; dr brian druker, director, ohsu knight cancer institute; mostafa ronaghi, chief technology officer at illumina; don berry, professor at md anderson cancer center; timothy church, professor at the university of minnesota school of public health and charles swanton, group leader at the francis crick institute. the company will initially have a five-member board of directors, including jay flatley, william rastetter (chairman of illumina), richard klausner, robert nelsen, and the ceo – former senior google executive jeff huber. huber, who has now led grail since last february said, in a us magazine interview for forbes at the time of his appointment, that he took on this role largely due to the death of his wife, laura, from colon cancer in late 2015. © kalamurzing www.shutterstock.com 14 european hospital vol 25 issue 6/16 v o l 26 i s s u e 3 / 16 • j u ly / a u g u s t 2016

laboratory & infections direct-to-consumer testing (dct), or direct access testing (dat), are laboratory tests with results that go straight to the end customer or patient, explained professor matthias orth. ‘this includes tests ordered by a physician for medi- cal purposes and clearly evidence- based tests, such as glucose moni- toring or blood glucose sticks for diabetes patients. these exams are also pocts – point-of-care tests. furthermore, dtc tests encompass test strips, for example urine preg- nancy tests or lactate tests in your gym. ‘however, more recently a new generation of dct tests has emerged: tests where the customer samples blood or dna at home, mails the sample to the lab and then calls up results over the inter- net. according to the test providers, each sample is individually ana- lysed, with the test pretending to be a medical lab service.’ are these tests a problem for lab specialists and other healthcare professionals? ‘in most countries the healthcare sector is highly regulated to protect the patient. in the usa, for exam- ple, the tests need fda approval and labs must be certified by the clinical laboratory improvement amendments (clia). in germany, we have a guideline issued by the german physicians’ association for quality assurance of lab medical exams. according to this, tests must offer a medical benefit; moreover only adequately qualified people can perform tests. ‘there are also many more rules and regulations to protect the patient, such as privacy laws, regu- lations applying to healthcare pro- fessionals, the genetic diagnostics law and rules that govern physicians fees for services. ‘all these – undoubtedly neces- sary and useful – laws and rules do not apply to lifestyle testing. therefore we must now somehow define when the line between life- style and healthcare is crossed and when legal action is required. that is very difficult, as we saw recently when the business model of theranos, the worldwide largest provider of dtc testing, turned out to be a complete fraud. scientists and physicians alike had relied on theranos methods. it was claimed that there is a conflict of interest, because they themselves provide diagnostic services and there were attempts to force them to cease and desist from using the theranos methods. ‘it is also highly problematic when physicians use results from lifestyle dtc tests since this basi- cally means that lifestyle test results are jazzed up to be healthcare diag- nostic results – but these lifestyle tests follow no legal and technical standards whatsoever. if the patient suffers damages, the physician who accepted the dtc results is liable even though he probably was not involved in the generation of the results at all.’ do these tests impact on work in the lab? ‘one important danger i see is the nosocomial infections are danger- ous – sometimes having grave con- sequences. the german company schmitz u. söhn points out that manufacturers of medical equip- ment and furniture are challenged to keep germs under control and it increasingly focuses on the hygienic aspects of new and further product developments in its closed design of operating tables and antimicrobial coatings. the firm uses such coatings on all frequently touched surfaces, includ- ing side guards and push bars of its stretchers. these coatings are based on innovative silver ion technol- ogy that effectively and permanently fights mildew, fungi and even resist- ant strains of bacteria. studies show that 80 percent of harmful bacteria on the coating can be removed in just 15 minutes and even 99 percent of germs are eliminated after two hours, the company reports. pads attached by adhesive gel removable pads are generally attached to couches and transport vehicles using velcro fasteners, which, due to their uneven struc- ture, are extremely difficult to clean. schmitz u. söhne use an adhesive gel to attach pads. this is resistant to disinfectants, features an even surface and makes it possible to thoroughly clean the underside of the pad, the firm adds. design and construction of or tables the design and construction of the company’s or tables and attach- ments also have smooth surfaces and a closed design to ensure maxi- mum ease of cleaning. even critical areas, such as screw heads, are closed or completely covered and, the firm reports, there are virtually no nooks or crannies in which bac- teria can multiply undisturbed. new cleaning shuttle ‘a prime example of a new product exclusively developed for hygiene is the schmitz u. söhne cleaning shuttle, which for the first time cleans operating tables easily and thoroughly from the bottom,’ the firm adds. ‘the shuttle consists of a separate, movable frame into which the operating table is placed at maximum height. the supports of the shuttle are positioned directly under the seat section of the table. afterwards, the staff lowers the operating table again. the chassis lifts off the floor, allowing for thor- ough cleaning of the underside of the table as well. hygiene constantly challenges manufacturers ‘we consider hygiene in hospitals to be one of the most pressing current careless handling of medical data in dtc testing. there is high potential for abuse, particularly with molecu- lar exams. it defeats me how people can thoughtlessly allow 23andme, a genetic testing company with close links to google, the use of their genetic and other highly sensitive data. ‘another problem is the waste of healthcare resources through dtc testing: the business model of dtc testing often entails the fabrication of conspicuous findings in order to sell, for example, dietary supple- ments, or expensive monitoring ser- vices. thus lifestyle tests often lead to complex diagnostic procedures of a perfectly healthy person – with the general public footing the bill. ‘a third issue is the media hype surrounding dtc testing, something we have never seen in evidence- based medicine: dtc testing servic- es are regularly promoted in blogs, user groups and the social media. the promotional texts, even though they might be labelled as “advertise- ment” somewhere, convey images of a certain lifestyle and make claims regarding dtc testing that are in no way supported by evidence. however, we find it impossible to counter these internet trolls with reasoned arguments.’ should dtc be more strongly reg- ulated? ‘the definitions of dtc testing are indeed very complicated and we do see efforts of dtc testing providers to circumvent the healthcare rules and regulations that are in place and necessary to ensure patient safety. think of the over-the-counter sale of lab tests in pharmacies, or the call for tenders for genetic testing under section 140a of the german social code, book v regarding spe- cial services. ‘moreover, internet offerings and mail order pharmacies cross nation- al boundaries and thus turn many reasonable regulations into blunt instruments. in addition, dtc test- ing providers legitimise their servic- es by referring to the eu consumer rights directive 2011/83/eu, which is meant to promote free movement of goods and services. ‘in my opinion that is dangerous and very naïve: today, even small forensic dna specimens provide information on features as such ethnic background, size, hair col- our, etc. it is naïve to assume that complete genome sequencing in a lifestyle test done for genealogical purposes does not provide medi- cal data that need to be protected. consumer protection in dtc testing is marginal. the limitations of the methods are hidden in the small how can some people thoughtlessly allow a genetic testing firm to use their genetic data? new and improved equipment strengthens hospital hygiene the dangers of commercial direct-to-consumer tests coatings defeat patho lifestyle tests that pretend to be medical procedures are inherently problematic in terms of clinical, medical and privacy issues. professor matthias orth, medical director of the institute of laboratory medicine at marienhospital stuttgart, discussed ‘direct-to-consumer testing: the business of lifestyle tests’ at a september congress in copenhagen that focused on ‘the benefits and challenges of point-of- care testing across the clinical spectrum’. on offer to the public: testing for a fee integration of dtc testing 16 european hospital vol 25 issue 6/16

laboratory & infections report: brigitte dinkloh recommendations on the current- ly valid prevention of intravascular catheter-related infections from the commission for hospital hygiene and infection prevention at the robert koch-institute (krinko) are now 14 years old and therefore out-dat- ed. much has happened since their first publication in 2002, making an update essential to include the latest developments in medical sciences. we interviewed dr christine geffers, consultant at the institute for hygiene and environmental medicine at the charité berlin and co-author of a new recommendation to be issued in the new year. ‘this recommendation was overdue for a revision, and such an important guideline should, in fact, be updated in much shorter intervals of five to six years,’ geffers points out. ‘this cannot always be assured due to the large number of recommendations that need to be issued,’ geffers, who is a colleague of professor petra gastmeier at the national reference centre for the surveillance of nosocomial infections, first mentioned data sourc- es. recommendations currently in place are based on 219 sources; the new recommendations quote more than 600 sources. ‘what was assumed or believed back in 2002 can now be safely confirmed by the number of studies carried out since.’ not only the quantity but also the quality of the underlying data has report: beate wagner the implantation of knee and hip joints is considered one of the suc- cess stories of recent years. but periprosthetic joint infections (pji) are one of the severe complica- tions, with an infection rate of 2%. the probability of revision surgery increases with concomitant diseases such as rheumatoid arthritis, with fracture prosthesis or after previous surgery. the challenges in diagnosis include low-grade infections, small colony variants, contamination of samples, mixed-species colonisa- tion and increasing development of resistance: apart from mrsa the other problematic pathogens include gram-negative bacteria (mrgn) and vancomycin-resistant enterococci (vre). treatment is impacted by old age and multimorbidity. ‘often, high concentrated antibiotics cannot be administered,’ says professor georg matziolis md, senior consultant at the clinic for orthopaedics and emergency surgery at the eisenberg waldkrankenhaus. ‘topical treat- ment with antibiotics is becoming increasingly important.’ ‘firstly, it is important to establish whether a ppi or aseptic loosen- improved. ‘studies carried out prior to 2000 are now considered out-dated,’ geffers confirmed. ‘these days, the expectations of quality with regards to ethics, for instance, are very differ- ent to what they were 15 years ago, when everyone had the freedom to carry out studies based on their own ideas. therefore, the objective now is to draw on more recent studies that comply with current quality stand- ards.’ the new recommendations cover non-tunnelled central venous cath- eters (cvc), peripheral venous cath- eters and arterial catheters. port sys- tems, partially implanted intravascular catheters and intravascular catheters for newborns are no longer covered, with the latter now being covered by a separate krinko recommendation. there is also a lack of recommenda- tions on how to deal with large bore vascular access required for extracor- poreal oxygenation or decarboxyla- ing is present,’ explains professor johannes holinka md, from the medical university of vienna. in 25% of cases a pji is the reason for revision and, in 16%, it’s mechani- cal loosening.’ the anamnesis, fol- lowed by radiological and clinical examination along with laboratory diagnosis of blood, synovial fluid, tissue and histology provide the indications required. microbial detection as the pri- mary objective of the diagnosis of low-grade infections often proves difficult. ‘in up to 30% of cases no micro-organism can be cultivated,’ holinka points out. the specificity of microbiological cultures increases tion (the artificial lung), because there are hardly any studies available on this topic. as it is not possible to introduce all innovations here, geffers lists some examples. the preferred access point for a cvc in the subclavian vein is no longer recommended, with no recommendation being made either for or against this access. ‘the only recommendation here is not to use the jugular vein for patients with a tracheostomy who need a cvc. it would be too complex to list all the changes in detail,’ says the specialist for infection prevention and control and environmental medicine. another new recommendation is that peripherally inserted cvcs should no longer be preferred. regular, daily monitoring and documentation of the diagnosis during ward rounds is another significant change. going forward, doctors will have to moni- tor on a daily basis whether the cvc with the number of samples. ‘three to six intraoperative samples are ideal, and in cases of low virulence organisms or after previous admin- istration of antibiotics we require up to ten.’ sonification is more significant than a tissue culture. as a biomark- er, alpha-defensin facilitates the detection of a pji because it is not impacted by antibiotics. quantitative measurements have shown a sensi- tivity and specificity of 96% and 97% respectively. the procedure only has one disadvantage: ‘although the diagnosis is as good as cer- tain it does not provide microbial detection,’ holinka says. on the should remain in place or not. there is also a change regarding access to the system. the new recommendation stipulates that the connections, such as the three-way tap, must be disin- fected after every use. however, there is no change to the recommended time in situ for the catheter. ‘the objective is still to remove it as soon as possible, which is also why daily monitoring is advised, to see if the indication for leaving the catheter in place is still valid,’ geffers explains. ‘there were no maximum time limits for leaving cvcs in situ in the 2002 recommendations, and there won’t be any in the 2017 recom- mendations, either. the current rec- ommendations advise against chang- ing catheters regularly, and this will continue to apply. the infusion tubes were supposed to be changed every three days, but the new recommenda- tions advise at least four day intervals between changes.’ a large part of the recommenda- tions revolves around staff training. this should ideally be carried out in small groups and should include a lot of practical exercise. in future, impor- tant preventative measures are to be focused on with the help of specific campaigns. the fitting of peripheral cannulas was discussed in the context of using specialist catheter teams – as seen in the us – but the new recom- mendations stipulate that it is prefer- able to ensure that all team members are capable of changing catheters, and to check that this is the case. ‘the new recommendation aims to mini- mise the risk of infections further still. however, regardless of the numerous new recommendations, up till now, not everything that has been practiced on the wards has, in fact, been wrong,’ she concedes. the recommendation will certainly contribute towards increased patient other hand, multiplex-pcr (mpcr) of synovial fluid with unyvero iti for instance is often decisive for treatment. ‘the analysis can be carried out with minimal effort and with no need for specialist staff trained in molecular biology or a special infra- structure,’ he adds. ‘microbial detec- tion including resistance markers is available after five hours, even for low virulence organisms that normally take 14 days to cultivate.’ combined with the culture grown, the sensitivity is around 90%. treatment of a pji is carried out via one- or two-stage revision and high- dose antibiotics. with an eradication rate of 89.2% and 90.6% respectively the effectiveness of both procedures is very close. ‘successful one-stage exchange requires microbial con- firmation, radical debridement and effective antibiosis with systemically and locally applied antibiotics,’ says dr akos zahar, orthopaedic special- ist at the helios endo-klinik, in hamburg. the key to success for the one-stage procedure lies in the close multidisciplinary cooperation between surgery, microbiology and infectiology.‘for one-stage exchange the use of industrially manufactured, antibiotic-loaded bone cement (such as copal g+c or copal g+v) is recommended to achieve the high concentrations required for local antibiotics therapy without actually having to add antibiotics yourself. safety. the prevention of nosocomial infections by the management of med- ical institutions as required by para- graph 23(3) of the law on infection prevention and control is usually ensured through the implementation of the krinko recommendations. ‘as these are supposed to reflect the lat- est findings of medical sciences many medical institutions adhere to them,’ geffers points out. ‘the recommenda- tions are therefore essentially binding, particularly when litigation is con- cerned. in these cases it is important to prove that the recommendations were implemented, or to substantiate why they were not adhered to.’ ‘this avoids turning the doctor into a manufacturer of medical products,’ the expert underlines. with cement- ed one-stage exchange, antibiotical treatment can be cut from several weeks to 14 days. two-stage exchange is the gold standard worldwide. this is indi- cated in cases of negative bacterial culture, difficult-to-treat pathogens as well as in the case of soft tissue defects that require a step-by-step approach. antibiotic-loaded bone cement is used as a spacer during the prosthetic-free interval and for the re-implantation during the sec- ond operation. ‘dynamic spacers (such as those made from copal knee moulds) are more effective than static ones,’ zahar points out. ‘they offer more patient com- fort, are easier to re-implant and the functionality is better,’ adds matziolis. the abrasion of cement and ceramics particles appears clinically irrelevant. there is currently lit- tle evidence available for mobile spacers compared to static spacers. however, the advantages of mobile spacers for dead space manage- ment and local antibiotics treatment prevail. two meta-analyses show that the range of motion (rom) for a mobile spacer is better by +8 degrees, and superior in lowering re-infection rates, reducing bone loss and easing re-implantation. matziolis talked about the superi- ority of spacers made from industri- ally manufactured, antibiotic-loaded bone cement compared to alterna- changes to intravascular catheter systems in 2017 the heraeus lunch symposium ousting out-dated recommendations painful knee prosthesis: loose, infected or both? in 1996, dr christine geffers began her career as a research assistant at the institute for hygiene and environmental medicine, then part of the free university berlin and now part of the charité university medicine berlin. after qualifying as a specialist for hygiene and environmental medicine she became a consultant at the institute for hygiene at the charité in 2001. in 2003/2004 a grant from the walter marget foundation for the advancement of the study of infectious diseases facilitated a research stay with professor barry farr at the university of virginia, usa. in 2015, geffers wrote her habilitation in infection prevention and control. her focus is on the surveillance of nosocomial infections, nosocomial infections in newborns and the prevention of catheter-related sepsis. from left: ákos zahár, assistant professor johannes holinka and professor georg matziolis to prevent intravascular catheter-related infections further, the new recommendations cover non-tunnelled central venous catheters (cvc), peripheral venous catheters and arterial catheters 18 european hospital vol 25 issue 6/16

join - learn - care the xenios e-learning platform xenios campus offers a large selection of teaching programs on applications, certifications, professional publications and learning assessments, as well as detailed information on our xenios products. but the xenios campus has much more to offer! create your own learning environment with content totally tailored to your needs. contact our xenios mentors for an exciting exchange of experience and opinions. become part of the xenios campus and benefit from the community’s concentrated expert knowledge! www.xenios-campus.com xenios ag i im zukunftspark 1 i 74076 heilbronn, germany i +49 7131 2706 0 l u n g a n d h e a r t t h e r a p i e s the therapy leader in lung and heart assist. emergency management assessing the performance of emergency departments many units themselves need emergency care according to thomas fleischmann, specialist in the reorganisation of emergency departments, care for emergency patients rakes up a loss of about one billion euros every year. comparing apples and oranges ‘the loss generated in emergency departments is primarily caused by a significant increase in out-patients – who today account for two thirds of all patients presenting to the emergency room. the major prob- lem is the reimbursement system via the german physicians’ associations, the kassenärztliche vereinigung. to be more precise: physicians in the emergency room are reimbursed exactly like office-based physicians. however, the emergency room is open 24/7, 365 days a year, whilst a doctor’s office is open 30 hours a week.’ a second difference, fleischmann points out, ‘are the provision costs of an emergency department, be it for physicians or nurses, for ct, cardiac cath lab or intensive care. the moment you subtract these provision costs from the total costs and add comparable costs for 24/7 care to the profit and loss account of a doctor’s office the difference between hospital emergency room and doctor’s office is not that big any more. currently, costs in very different infrastructures are reim- bursed identically – but whilst this reimbursement might be sufficient for a doctor’s office it will never even come close to covering the additional staff and operating costs a hospital’s emergency room incurs with its around-the-clock service.’ internal considerations ‘when we look at internal factors, our emergency departments don’t look too bad. overall, we provide good healthcare. however, there is room for improvement. unlike other industrialised countries, in germany it’s mostly the junior physicians rather than specialists who staff the emergency room.’ specialists are in short supply ‘germany is one of the few coun- tries – not just in europe, but also among high-income countries worldwide – that does not provide regulated training for emergency room staff. the result is that inexpe- rienced junior physicians, trying not to make mistakes in the emergency room, tend to do too many exams of patients with low-degree conditions and to admit too many people as in-patients. this issue can only be solved with adequate and defined training in clinical emergency medi- cine.’ going forward ‘most importantly, emergency care must be financed; we must not allow it to starve to death. secondly, the quality of care has to be raised to specialist physician level for each patient to receive exactly the type and level of care he or she needs – not more, not less. ‘let’s look at the triage categories: red, orange and yellow – these are patients with medium to severe con- ditions. green and blue are patients with minor problems and injuries. patients with medium to severe con- ditions account for about 60 percent of cases; the remaining 40 percent are greens and blues. it’s the latter category that is rapidly increasing. in my opinion, care for patients in the triage categories red and orange is very good, but we do offer too much medicine to the others.’ light at the end of the tunnel ‘the problem of under-financed emergency rooms is not a german problem, but a problem that’s pre- sent in many high-income countries, such as the usa. in germany we cannot – and must not – wait for an international solution; we must find our own direction. to be fair, we are witnessing a historic change: the coalition contract between the german government two parties mentions emergency departments – for the first time ever! emergency care is recognised as one of the four pillars in the hospital structure law. that is new. while modifications to the hospital structure law are not sufficient, they are a clear step in the right direction. they show that german politicians have recognised the problem.’ conclusion ‘beyond the fundamental and politi- cally necessary changes, there are no simple solutions for the individ- ual emergency room. optimisation of emergency care will not result from one single measure but rather from the result of the package of measures to increase efficiency, lower costs and improve financ- ing. germany has to overcome two major challenges: the extreme shortage of emergency profession- als – both in the medical and in the nursing sector – must be addressed. and secondly, no matter how we look at it, we must not allow emer- gency care to be atrophied for busi- ness reasons.’ germany’s hospital emergency departments run up a loss of more than one billion euros every year. eh correspondent ralf mateblowski asked dr thomas fleischmann, medical director of the department of interdisciplinary emergency medicine at westküstenkliniken in schleswig-holstein, about the fragile state of the emergency department. thomas fleischmann, md was among the first german physicians to pass the european board examination in emergency medicine (ebeem) and, in 2014, he completed his master of health business administration (mhba) course – top of the year’s class. having formerly successfully reorganised emergency departments in salzgitter, frankfurt-höchst, sanderbusch and hirslanden (zurich, switzerland), he was appointed medical director of the emergency medicine department of westküstenklinikum heide, this summer. a specialist physician for general medicine, emergency medicine and clinical emergency medicine, and fellow of the royal college of emergency medicine (frcem, uk) and of the european society for emergency medicine (fesem), he has received many awards for his dedicated work. he has also edited several textbooks on emergency medicine and co-authored the european curriculum for this specialty. dedicated to improve emergency flow, thomas fleischmann says: ‘modifications to the hospital structure law are insufficient, but are a clear step in the right direction.’ congress on emergency medicine the 11th european congress of emergency medicine will be held from 23 to 27 september 2017 in athens, greece. congress presi- dent is dr roberta petrino. for the first time, there will be a new congress format in a move to transform this event into an opportunity for learning and teaching, to integrate the differ- ent professionals in emergency medicine – doctors, nurses and trainees. further information: www.eusemcongress.org 20 european hospital vol 25 issue 6/16 xenios ag i im zukunftspark 1 i 74076 heilbronn, germany i +49713127060