V O L 2 6 I S S U E 5 / 1 7 O k t o b e r / N o v e m b e r 2 0 1 7 T H E E U R O P E A N F O R U M F O R T H O S E I N T H E B U S I N E S S O F M A K I N G H E A L T H C A R E W O R K RADIOLOGY & ULTRASOUND 8-26 Focus on prenatal ultrasound techniques PET/MRI leads hybrid imaging Imaging’s role in CRC liver metastases LAB & POCT CRISPR system embeds 28-34 images in DNA Simplified mass spectrometry for bioanalysis MicroRNA supports testicular cancer detection We have impact on value! The movement to Value-Based Healthcare gives no value to diagnostic processes, including Radiology. ESR aims to establish a more holistic approach to help Europe’s single-payer systems shift to a new economic model. John Brosky reports The organisers behind Value-Based Healthcare (VBH) are gaining ground in an effort to transition public and private payers toward value-based reimbursement. To date, International Consortium for Health Outcomes Measurement (ICHOM) has pub- lished 21 sets of standards covering almost half of what it defines as the global disease burden. the Some European health care groups have experimented with this approach with mixed results, notably the Karolinska University Hospital in Sweden. VBH started in the United States as a response to ineffective models introduced by payers to manage costs of healthcare services, such as fee-for-service or capitated payment approaches. Incredibly, VBH does not include diagnostic processes, focusing instead on therapeutic outcomes. Value is defined by treatment with- out considering the multi-discipli- nary evaluation of the patient that in the first instance determines the patient’s pathway for care. ‘It’s still early days,’ said Professor Lorenzo Derchi, who is chair of the Value-Based Imaging Working Group of the European Society of Radiology (ESR) and the ESR’s First Vice-President. ‘Value-Based Healthcare is an economic approach that is interesting, but not the only possible approach. The initiators of this movement come from the Harvard School of Economics, not the medical school,’ he told European Hospital during our recent interview. ‘It does not consider the whole spectrum of care, a holistic approach to the patient. With this model, radiology is not considered for its role in providing guidance for the therapy, nor for following up the treatment to fine-tune and adapt that treatment. ‘Radiology adds impact, more than what is being called value, which is only a calculation of out- come versus cost. ‘It’s not easy to value the impact of diagnosis,’ he pointed out. ‘It becomes easier for calculations if the diagnosis is taken for granted. It’s not clear if ICHOM did not con- sider diagnostics, or if they consid- ered it but found it too difficult to measure as a value.’ In September the ESR published a Concept Paper On Value-Based Radiology in the Society’s journal, Insights into Imaging, seeking to contribute to the discussion on this critical issue and to move it to the next level by asserting that a correct diagnosis is the first outcome that matters to patients. European governments are fac- ing difficulties in managing their national health systems, just as the American private payer systems. And the ESR paper points out that short-term cost-cutting solutions, and austerity measures that have been the first reaction, have already reached their limit and are now negatively affecting the quality of healthcare, creating a vicious circle of increased demands on healthcare and a need for greater spending. ‘It’s like low-cost airline compa- nies,’ Derchi compared. ‘They work for a while, then low-cost risks becoming a low-value service.’ After publishing the paper, he has taken to the podium at national radiology congresses to increase awareness of this issue, and to start a dialogue that ESR can bring to all involved stakeholders. ‘As radiologists we have a long tradition of measuring and assess- ing our chain of work from the request of the referring physician to the report, to measure each step,’ he said. ‘Yet VBH sees these as processes and not as outcomes. What we need to do is define that the endpoint of these processes (the final diagnosis) is an outcome. And we need to ask how we can fit this intermediate outcome into the Value-Based Health Care frame- work.’ Metrics to measure radiologists’ impact on patient outcomes become a key step to take the discussion to the next level, to demonstrate whether the diagnosis is correct and actionable, that it is relevant and useful to the episode of care. ‘I use the term impact rather than the word value here, because this is the main problem in the ICHOM framework, where value means outcome versus cost,’ said Derchi. ‘They calculate cost and outcomes starting only at the moment when the patient comes to therapy. The impact of the imaging process, or of the other diagnostic methodolo- gies, such as lab tests, biopsies and even the pathology report, needs to be considered not only as a cost but also as something that’s key to the subsequent outcome, affecting what will be done in the treatment process.’ The ESR Concept Paper On Value- Based Radiology sets out five key factors in determining appropriate metrics for what it defines as Value- Based Radiology (VBR). • Appropriateness of requests • Attention to radiation protection • Characteristics of the reports, measures whether they are correct, com- plete, understandable, structured and properly used • Relationships between patients • Continuous professional educa- and radiology personnel tion, research and innovation. Professor Lorenzo Derchi heads Emergency Radiology at San Martino Hospital at University Hospital Genoa in Italy. He also chairs the Value-Based Imaging Working Group of the European Society of Radiology (ESR) and is the ESR’s First Vice-President. and for communicating the report. There is no longer time to discuss the findings with the referring phy- sician, to be sure they are under- stood, and how they may change the opinion on how to treat.’ ‘There are two perspectives,’ Derchi concluded. ‘One is econom- ic, and if we are to be measured, we want to be able to show that we have impact on value. The other is an opportunity to discuss this topic, to create a moment for rethinking how we can achieve acknowledge- ment of our efforts for the quality in our work.’ VBR creates an opportunity to shift from volume-based calcula- tions to a value-based practice of radiology that puts more emphasis on the relation between quality and outcomes. ‘We are doctors in medi- cine. We are neither photographers, nor operators running machines and pushing buttons. We interpret what is coming from the machines to integrate this information into the clinical picture of the patient to develop the diagnosis. It is our medical knowledge that gives these images significance,’ he emphasised. ‘If you measure only volume, then time is squeezed, the time for the examination is tight, cutting the time for reading and interpreting www.healthcare-in-europe.com CONTENTS NEWS & MANAGEMENT 1-4 IT & TELEMEDICINE SURGERY ULTRASOUND RADIOLOGY CARDIOLOGY LABORATORY & 5 6-7 8-15 16-26 27 INFECTION CONTROL 28-34 DIGITAL PATHOLOGY 35

N E W S & M A NAG E M E N T 3 Curbing patients who demand A&E attention unnecessarily in accident and emergency (A&E) departments, is inappropriate use of service. Unfortunately, A&E is still inundated with patients suffering minor or chronic ailments, in the hope of gaining a faster transit to neces- sary investigations and treatment. The senior nurse stresses the importance of educating patients in the correct use of facilities and triaging systems linked with a more efficient set-up between hospital and community net- works as a means of counteracting unnecessary pile-ups in a unit where lack of efficiency can easily result in loss of life. Overcrowding, both in A&E and other departments, also results in chaos, decreased efficiency, increased risk of infections and a great challenge to the nurse/patient ratio. Overcrowding rises as winter looms Luckily in Malta, this is still at 1:5 and 1:8 during the night. In fact the most recent Eurostat update (January 2017) reported that Malta boasted ‘by far the largest increase in nursing profession- als... (with) 180 more professionally active nurses per 100,000 inhabitants in 2014 than five years earlier’, in con- trast to Poland, Ireland and Slovakia which manifested a decline. The senior nurse believes that a functional set-up between hospital and community networks can also render discharge of patients in the community more efficient, taking into account not only the condition at hand but also their general physical, mental and social well-being. Thus supported, the patient, especially in the elderly bracket, is less prone to be re-admitted, at times in a worse state of health. At the hospital this role is currently being carried out by the Discharge Facilitation Team with Discharge Liaison Nurses, where the latter also cater for intravenous antibi- otics at the patient’s home, thus avoid- ing the need of hospital admission. Other measures taken by the hospi- tal in supporting decentralisation of Continued on page 4 Report: Moira Mizzi Overcrowding in healthcare systems has become a worldwide phenomenon with regional influences related to the different healthcare structures in dif- ferent countries. A recent BBC analy- sis (February 2017) showed that over- crowding afflicted 9 out of 10 NHS hospitals this winter, with 23 declaring ‘black alerts’, as other European hospi- tals face similar ‘care crises’, especially member states such as Greece, with their ever declining health budgets. (Euronews, January 2017) The Maltese Islands have not been spared the deluge: overcrowding is among main challenges and priorities to the local health sector. A senior nurse manager of the hospitals maps out the factors she believes are the main culprits for this phenomenon. She claims that, although we have long been aware of the rising age of the population, com- pounded with the sociocultural shift featuring more working women and smaller nuclear families, not enough has been and is being done to coun- teract the state of affairs. As a result of this drastic decline in the availability of support from extended family, mainly due to life- style pressures, neglect or debilitating disease, most elderly citizens depend heavily on healthcare systems with acute care wards being blocked by social cases especially since, at pre- sent, the hospital administration has no jurisdiction to impose care on fam- ily members. Another factor that greatly influ- ences turnover of patients, especially Nurse/midwife Annette Kennedy MA BNS gained her bachelor’s degree in Nursing at University College Dublin and received diplomas in Management and HR, and a Master’s in Public Sector Analysis from Trinity College Dublin, Ireland. From 1999-2004 she was an Executive Board Member for the European Federation of Nurses (EFN) and became its President in 2005 until 2007. From 2013-2017 Kennedy was Vice President of the ICN before becoming the present ICN’s President this May. Currently, Kennedy is also Chairperson of the Bray Homeless Forum. She is also a Director on the Citizens Information Service Board. The Education, Research and Resource Centre for the Irish Nurses and Midwives Organisation (INMO) was established by Kennedy, aiming to shift nursing and midwifery into mainstream university life. Last year, the Royal College of Surgeons Ireland awarded her an honorary fellowship in nursing. medication advice, we speak out when infection control practices are not adhered to and we advocate for our patients on issues of medication side effects. Armed with education and information on antibiotic use and AMR, we will be better able to fight its growth. www.healthcare-in-europe.com Experience the power of the Atellica Solution Now available! Atellica™ Solution:* Flexible, scalable, automation-ready immunoassay and chemistry analyzers engineered to deliver control and simplicity so you can drive better outcomes. A bi-directional magnetic sample transport that is 10 times faster than conventional sample conveyors The new standard in sample management—revolutionary technology that gives independent control over every sample An immunoassay analyzer that runs up to 440 tests per hour,† the industry’s highest productivity per square meter‡ Unprecedented flexibility with more than 300 customizable configurations including L and U shapes *Product availability will vary by country. †Dependent on test mix. ‡Versus leading IVD companies. Atellica is a trademark of Siemens Healthcare Diagnostics Inc. 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I T & T E L E M E D I C I N E The potential insights are invaluable; we should not waste this source Medical data mining aiting to be explored in German hospitals is immense and could hat about data security and privacy? Andreas Klüter, CTO of a new business entry in healthcare IT, spoke with European t mining and the need for ethics discussion. es, and we need to discuss how we are going to deal with the new insights and which approach we will choose. It’s a long process for a society to agree on a path, but this consensus is necessary and we have to embark on this journey now. To do nothing, I’m 5 s i l o p m E f o y s e t r u o C sure, is the wrong decision. ‘The archives of German hospitals are full of text and image data wait- ing to be used, data that might really advance clinical research. The tech- nological obstacles are surmountable today, the potential insights are invalu- able. We should not waste this source.’ For over 20 years, Andreas Klüter, CTO of Empolis Information Management GmbH, has focused on developing systems for intelligent information processing. From 1994 on he was instrumental in realising the “Verbmobil”, the worldwide first research prototype for fully automated translation of spoken language at the German Research Centre for Artificial Intelligence. During his tenure as Head of Development at ORBIS, he gathered profound knowledge of healthcare IT. As CTO of Empolis Information Management GmbH Andreas Klüter is in charge of the company‘s product portfolio and the business division eHealth. step. In addition we want to analyse the results of other imaging modalities such as MR scans.’ ‘Data security and privacy are immensely important issues. Therefore only the study principals receive the results and they decide how the data will be used,’ he explained. ‘We can show trends, but it is not for us to decide whether a trend indicates a problem.’ ‘We need this debate on artificial intelligence from the very beginning. However: In my opinion the computer cannot do everything better and it won’t be able to do everything better, even though it can perform increas- ingly complex tasks. ‘There was a very telling experi- ment recently where artificial intelli- gence was used to “train” a computer in Shakespearean language and then the computer was asked to write a book. The result: The machine’s choice of words was indeed rather “Shakespearean” but the text was completely devoid of meaning. That clearly shows the current stage of AI. ‘Having said that, there are advanc- t a t s o r u E : e c r u o S Experience the power of Atellica Atellica™ Solution* Flexible, scalable, automation-ready immunoassay and chemistry analyzers. Atellica Solution now available! A new diagnostics portfolio engineered to deliver control and simplicity so you can drive better outcomes. Atellica™ COAG 360 System† Atellica™ PM 1.0 Software* Fully automated high-volume specialty coagulation system that unifies five testing methodologies. Process management software to optimize lab operations through data analytics and visualization. Atellica™ 1500 Automated Urinalysis System† Fully automated, streamlined urine chemistry and sediment analyzers. Atellica™ NEPH 630 System † Atellica™ MDX 160 Molecular System‡ Mid-volume, dedicated nephelometric system to further simplify specialty protein testing. Flexible, automated molecular system with maximum productivity for multiple sample types. *Product availability will vary by country. †Not available for sale in the U.S. Product availability will vary by country. ‡Under development. Not available for sale. Product availability will vary by country. Atellica is a trademark of Siemens Healthcare Diagnostics Inc. A91DX-9563-A2-4A00. © Siemens Healthcare Diagnostics Inc., 2017 siemens.com/atellica www.healthcare-in-europe.com

S U RG E RY 7 Virtual fracture clinic boosts patient care A fracture clinic model being pioneered by a UK hospital is improv- ing patient care and delivering significant cost savings for the NHS, Mark Nicholls reports The Virtual Fracture Clinic (VFC) established by the Brighton and Sussex University Hospitals NHS Trust sees patients with broken bones or soft tissue injury sup- ported through video links and self- management methods, rather than make additional journeys to hospital for face-to-face appointments with orthopaedic consultants. The trust says the initiative also makes better use of consultant time by allowing specialists to focus more on their own areas of expertise. The clinic was originally set up after orthopaedic consultant James Gibb became concerned that the existing model of care – where patients emergency departments with fractures were assessed and then booked in for a further appointment with an on-call orthopaedic consultant - was inef- ficient. attending However, that meant they did not necessarily see the best person for their specific injury – a spinal spe- cialist may be seeing someone with a broken toe, for example. ‘It was a bit of a lottery,’ said Lucy Cassidy, the trust’s VFC project lead. ‘Now, when a patient attends A&E, instead of being put on a list to see some- one face to face, they are referred for a virtual consultation. ‘This consultation involves an orthopaedic consultant looking through each case, and depending on the type of injury, the patient is placed on a self-management path- way and supported with rehab vid- eos online. Or if they had an injury that needed to be seen, they would be booked into an appointment with the right specialist and receive the appropriate management.’ Patients have access to a rehab adviser within 72 hours of their injury, saving them having to come in to hospital with a generic frac- ture clinic consultant before being referred on. The model is based on a vir- tual clinic in Glasgow, but has been taken a significant step further in Brighton by adding the physiother- apy component. ‘Our service is now more stream- lined and we find a large percent- age of our patients can be self- managed, where they do not even need to come in for an appoint- ment, ‘ Cassidy added. ‘We decided to design with a physiotherapy-led service because we found patients were not being given much informa- tion to self-manage injuries.’ The VFC has 27 rehab videos hosted on YouTube, presenting patients with six weeks’ worth of rehab across various injuries. Giving patients the correct information at the outset of their treatment jour- ney is helping to reduce long-term problems. Brighton has 4,500 adult general fracture clinic cases and 3,000 wrist and hand injury patients a year with plans to expand to paediatric cases next year. The hospital has been collecting data to help manage referrals and ultimately to measure outcomes by coding every injury hospital consultants can be rede- ployed to maximise their skills,’ Cassidy pointed out. Within the trust, this has meant additional ward rounds for neck or femur fracture patients, while other hospitals have held additional clinics or helped increase theatre capacity. ‘We are basically using the workforce to maximise their skills set rather than using them in a generic fracture clinic way.’ While there are clear staff resource benefits, putting figures on internal savings is more difficult, but it does mean less imaging, fewer registrars using clinics, reception staff time saved, and patient journeys down with carbon footprint reduced. Current figures show that 57% of patients referred to the VFCs are dis- charged or placed on SOS appoint- ments - where they are on self- management but can regain contact for support - after first referral from A&E, compared to a previous dis- charge rate of approximately 40% in the traditional model. The initiative has reduced out- patient appointments by 57%, sav- ing the NHS more than £750,000 (€850,000), with 2,000 fewer patients having to visit the hospital a year. Mrs Cassidy said patient satisfac- tion is up and, since January, the hospital has been collecting data to help manage referrals and ulti- mately to measure outcomes by cod- ing every injury, to enable clinicians to look at the functional outcome for each injury and assess patient progress. Lucy Cassidy is an advanced practice physiotherapist and leader of the Brighton and Sussex NHS Trust’s Virtual Fracture Clinic project. With the virtual appointment half the price of a £150 (170 euro) face-to-face appointment, there are significant cost savings for the NHS from the project, for which Microsoft supplies software and part-funds the initiative. ‘It also means that our The VFC has 27 rehab videos hosted on Youtube, helping patients to self- manage injuries ersal lighting www.healthcare-in-europe.com ADLINK Medical Computers Enabling Top-Level OR Patient CareVisit us at Hall 10, Stand F40ADLINK TECHNOLOGY GmbHTel: +49-621-43214-0 -Germany@adlinktech.com -www.adlinktech.comOptimum Image ViewingEnhanced Patient SafetyEasy Cleaning and MaintenanceSuperior Product Longevity

U LT R A S OU N D 9 New transducer delivers best resolution in first trimester exams Ultrasound is indispensable in prenatal exams The sagittal plane has to be set manu- ally,’ Hoopmann explains, In prenatal ultrasound diagnostics, ‘at no point is a human body, from the little finger to the mitral valve, examined more thoroughly and in its entirety as in the first trimester. ‘No machine can handle this com- plexity. But maybe I’m just not as utopia-inclined as other people.’ 3-D ultrasound is another issue where Hoopmann’s feet are firmly on the ground: ‘So far all endeavours to establish 3-D prenatal ultrasound Continued on page 10 Hypoplastic nasal bone in pregnancy week 16 ‘In prenatal diagnostics, particularly in the first trimester, ultrasound con- tinues to be the modality of choice when looking for malformations,’ says Professor Markus Hoopmann, deputy director of prenatal medicine and gynaecological ultrasound at the Women’s Health Clinic in Tübingen University Hospital. This case for ultrasound is significant because today fetal DNA that circulates in the maternal blood, can be screened for trisomy 21, or Down’s syndrome. ‘When this blood test was introduced, many experts predicted the demise of prenatal screening, particularly in the first trimester.’ He strongly rejects a swansong. The trisomy 21 blood test offers 99 percent sensitivity. A success rate, Hoopmann concedes, ultrasound first trimester screening will never achieve. Nevertheless, he adds, ‘many people forget that the cell-free fetal DNA test is a screening test, not a diagnostic test. For a full diagnostic work-up representative fetal cells are needed that can only be obtained by punction.’ However, an even more important misconception is the widely held view that trisomy 21 screening equals prenatal diagnostics. ‘Chromosomal anomalies account for a mere 10 percent of all malformations – and of those 10 percent only half are trisomy 21,’ he explains. Far more frequent are structural anomalies, such as congenital malformations of the heart, anenzephaly or holopros- encephaly. ‘50 percent are clearly visible in ultrasound during the first trimester. Today, even spina bifida can be detected much better due to specific changes in the posterior fossa: Modern ultrasound systems offer increasing resolution which means that more and more anatomi- cal detail is visible.’ Another alleged or real innovation in ultrasound that he is not keen on, especially in prenatal diagnostics, is artificial intelligence, inter alia in automated nuchal translucency measurement: ‘Automated measuring processes by no means replace qual- ity assurance.’ The positioning of the measuring points to measure fluid in the neck at 11-13 weeks pregnancy is not crucial but correct setting of the planes on the ultrasound system. ‘Deviating only a few degrees can sig- nificantly compromise your results. Since 2006, gynaecologist/obstetrician Markus Hoopmann MD has focused on specialised obstetrics and perinatal medicine and chaired the working group Ultrasound Diagnostics in Gynaecology/ Obstetrics (ARGUS). In 2009, he became deputy director of prenatal medicine and gynaecological ultrasound at the Women’s Health Clinic, University Hospital Tübingen, Germany. This April he was appointed extraordinary professor at Eberhard Karl University Tübingen. www.healthcare-in-europe.com

U LT R A S OU N D 1 1 Fusion imaging could improve detection Advancing cervical and endometrial cancer diagnosis cases reported worldwide in 2012. In France – where the trial is being conducted – 3028 new cases and 1102 deaths were reported in 2012. The American Cancer Society says 12,820 new cases of invasive cervi- cal cancer were diagnosed in the USA in 2016, and more than 4,200 women died from cervical cancer in that year. Fusion is generally imaging conducted after biopsy, as Claire Theodore stressed the importance of conducting biopsy at the earli- est opportunity, with imaging per- formed for all patients who have a suspicion of cervical or endometrial cancer. However, she also stressed that fusion imaging is still at an early stage, with further studies need- ed to assess its full potential and added that it was purely a diagnos- tic model. The first study about cervical can- cer recognised that ultrasound was very accurate for malignant diagno- sis and MRI was the more efficient for the parametrial and bladder infiltration, whereas fusion imaging was accurate also for vaginal and bladder infiltration. The team emphasise that fusion imaging should not be considered as an additional examination… ‘but as a complementary technique eas- ily performed when ultrasound and MRI are not efficient enough. ‘Fusion imaging is a combination of ultrasound and MR data that can enhance and improve the diagnosis in some difficult cases.’ Hitachi’s Fusion imaging combining MRI and Real-time Virtual Sonography (RVS) showing a cervix lesion with color Doppler diagnosis, real-time fusion imaging could improve in such difficult cases the patient care’s management.’ Claire Theodore, from the Hôpital Intercommunal de Créteil, said the aim is to improve diagnosis through fusion imaging. ‘Looking at the extension of the disease is very important to determine the stage of the disease and will improve differ- ent care managements – whether surgery, or concomitant radiother- apy and chemotherapy – and it will also help to advise more com- plex surgery if the disease is more spread.’ From the results, the team devel- oped a fusion imaging protocol for cervical cancer including axial T-2 MRI sequence to evaluate the para- metrium. The technique, she explained, is user-friendly and patient friendly and involves using the MRI sequenc- es to focus on specific areas and then use the ultrasound on the same plain as a second view on a differ- ent axis. ‘The aim is to improve diagnostic performance because there is some discrepancy in MRI for extension of the disease, and it can be more diffi- cult to assess, so fusion imaging can provide more information by adding ultrasound information and in real time we can compare the two exams and have more information.’ Figures show that cervical cancer is responsible for more than 266,000 deaths annually, with 528,000 new Claire Theodore started her medical studies in Toulouse and finished her medical residency of gynaecology and obstetrics in Paris. In 2017 she received her M.D. in gynecology and obstetrics after completing her master 2 research degree focusing on the use of MRI and ultrasound fusion imaging for cervical cancer. www.healthcare-in-europe.com The Next Evolution in Ultrasound,designed for high expectations Pure Image to fit your sight Seamless workflow to fit your touch Your application to fit your processThis high-end ultrasound platform makes use of refined fundamental perfomance to provide diagnostic imaging without compromise, flexibly responding to your individual needs across all clinical disciplines.Hitachi Medical Systems Europe Holding AG, Switzerlandwww.hitachi-medical-systems.comFEATURING 4G CMUTThe innovative MATRIX linear transducer and one-probe solution for whole body imaging

1 3 n o s s a r a M e k i M t h g i r y p o C U LT R A S OU N D How microbubbles cross the blood-brain barrier A transducer halts abdominal bleeding 60 frames per second during a dynamic study, new algorithms and different trans- mission and reception settings may well increase this number to 6,000 frames per second to significantly enhance image resolution. ‘The researchers in Chicago,’ Clevert confirmed, ‘demonstrated that bubbles can handle the stress created by such high frame rates.’ If bubbles could be packed with pharmaceuticals, in the way we pack our car boot, substances could be transported into brain tissues in a targeted way Stopping abdominal wall bleeding with contrast-enhanced ultrasound was just one of the exciting developments in CEUS presented at the Bubble Conference 2017 in Chicago contrast-enhanced ultrasound. Last but not least, technological devel- opments were presented at the Bubbles Conference. Whilst a conventional ultra- sound system produces a maximum of When you cut your finger you apply pres- sure to the wound until the bleeding stops. Professor Dirk-André Clevert from the Institute for Clinical Radiology at the Ludwig Maximilian University Hospital, Munich, Germany, remembered this sim- ple remedy when seeking a non-invasive method to stop abdominal wall bleeding. In a first step, the radiologist precisely locates the bleeding site with the help of fusion imaging, i.e. computed tomog- raphy and contrast-enhanced ultrasound (CEUS). Then, using the transducer, he applies pressure to the damaged vessel. Intermittent contrast medium injections enable him to check whether the bleed- ing continues. ‘In most cases, it stops within 30 minutes,’ Clevert underlines, adding, ‘The procedure was born out of necessity. The fact that vessels involved in abdomi- nal wall bleedings tend to be very small, turning endovascular therapy into quite a challenge, and that access via the groin can be difficult in older and obese patients triggered the search for a new method to manage the bleeding. Clevert had used a similar pressure approach with false aneurysm in the groin post catheterisation. While the bleeding can indeed be stopped by applying constant pressure on the lesion, ‘the aneurysm procedure is more difficult since the groin vessel is much larger. The abdomi- nal wall with its weaker perfusion pre- sents itself for this technique.’ Penetration, however, is the limiting factor: ‘The closer the bleeding is to the surface the easier it is to stop. Deeper than five or six centimetres, it becomes rather difficult.’ Also, obviously if the bleeding is located behind a bone, the pressure technique won’t work either. ‘With soft tissue, it’s a very helpful proce- dure,’ Clevert reports. Since substantial physical strength is required the radiologist recommends upright standing during pressure appli- cation rather than sitting down: ‘Ideally, the patient couch is lowered so the trans- ducer can be placed on the relevant site with arms outstretched.’ Professor Clevert presented this tech- nique at the recent Bubble Conference 2017 in Chicago, the largest annual event in North America dedicated to new developments in contrast-enhanced ultra- sound. The ‘bubble’ refers to gas-filled microbubbles used for contrast in CEUS. While the system has shown its value as a non-invasive, cost-efficient and radi- ation-free diagnostic imaging procedure, more recently CEUS has also revealed its treatment potential. In addition to Clevert’s new method to manage abdomi- nal wall bleeding, a procedure was pre- sented at the conference to briefly open the blood-brain barrier using contrast- enhanced ultrasound. The oscillation of the microbubbles widens vessels just long enough to allow the bubbles to cross the blood-brain bar- rier. ‘If we manage to pack these bubbles with pharmaceuticals, the way we pack the trunk of our car, we can transport substances into the brain tissues in a targeted fashion,’ Clevert explains. In addition, the bubbles can be loaded with specific markers that inter alia dock onto VGF-2 receptors that are expressed dur- ing tumour angiogenesis – thus a high level of VGF-2 receptors is often associ- ated with tumour growth. Myocardial imaging Myocardial imaging was another exciting feature at the conference. CEUS detects an infarction very early and enables a more precise prognosis of the extent of the cardiac event than catheterisation. Wall motion disorders and myocardial perfusion can be visualised better with www.healthcare-in-europe.com

asound implementation U LT R A S OU N D 1 5 Supporting the next generation of doctors Fujifilm SonoSite maintains its strong focus on supporting medical train- ing and education, and recently supplied instruments for a series of ultrasound workshops at the Doctors Academy International Medical Summer School. Doctors Academy is one of the world’s largest providers of inde- pendent medical education. Ultrasound workshops prove very popular among delegates, since the opportunity to gain hands-on expe- rience in this area is necessary to fully understand the basics of the technique. Professor Stuart Enoch, a surgeon by training and now the CEO of Doctors Academy, explained: ‘We focus on responding to the aca- demic needs of medical students and junior doctors by delivering specialised knowledge advancement and skills courses that are not avail- able via traditional routes. ‘Medical students and junior doc- tors are seldom given the chance to perform and interpret ultrasound scans during their education or training. The workshop covers the fundamental principles of ultra- sound, including the interpretation of core organs and choosing the most appropriate probes to use in different situations. Our tutors focus on a series of real-life scenarios, and discuss whether MRI, CT or ultrasound is the most appropri- ate investigative technique. This is followed by a demonstration and a practical session, enabling del- egates to perform ultrasound scans for themselves, which explains the popularity of the workshop.’ Professor Giancarlo Bizzarri is the Head of the Interventional and Diagnostic Radiology Department at Regina Apostolorum Hospital – Albano Laziale (Rome, Italy) easy matching and precise real-time tracking. These new 2-D mapping techniques may provide tremendous support in the accurate diagnosis and proper planning of surgery and interventional procedures such as core biopsies and FNA procedures.’ ‘Because BodyMap 2-D naviga- tion, 3-D Fusion Imaging, and Virtual Biopsy techniques can increase the diagnostic confidence of the opera- tor, in different parts of the body, there are countless possible applica- tions. ‘Simplified and automatic fusion technologies and customised proto- cols will reduce the learning curve for the operator, and will help to make all these techniques more widespread. New developments and future impact ‘The main efforts in medical imaging are now directed towards preven- tion, diagnosis, selection of optimal (personalised) therapy (local/sys- temic), guidance of local treatments, assessment of therapy results (local/ systemic) and disease follow-up. All these objectives require information to be not only archived and com- municated, but also co-registered and processed by fusion and virtual reality software algorithms. ‘In the near future, these new technologies will be integrated into all imaging and diagnostic modali- ties, PACS, Oncology Information Systems, and HIS, going beyond the simple radiological environment and spreading throughout all diag- nostic and therapeutic fields.’ Real-time image fusion techniques allow ultrasound to be spatially co-registered with multiple volumetric image diagnostic modalities, such as those from MRI, CT, PET, and even with 2-D Dicom images. www.healthcare-in-europe.com Bibliography 1. Laurent S, Elst LV, Muller RN. Comparative study of the physicochemical properties of six clinical low molecular weight gadolinium contrast agents. Contrast Media Mol Imaging. 2006;1(3):128-37 2. Lohrke J, Frisk AL, Frenzel T, et al. Histology and gadolinium distribution in the rodent brain after the administration of cumulative high doses of linear and macrocyclic gadolinium-based contrast agents. Invest Radiol. 2017;52(6):324-33 3. Bussi S, Tedoldi F, Maisano F, et al. Differences in gadolinium retention after repeated injections of macrocyclic contrast agents to rats. J Magn Res Imaging. 2017. DOI:10.1002/jmri.25822 4. Maravilla K, Smith MP, Vymazal J, et al. Are there differences between macrocyclic gadolinium contrast agents for brain tumor imaging? Results of a multicenter intraindividual crossover comparison of gadobutrol with gadoteridol (the TRUTH study). AJNR Am J Neuroradiol. 2015;36(1):14-23 5. Gutierrez JE, Rosenberg M, Seemann J, et al. Safety and Efficacy of Gadobutrol for Contrast-enhanced Magnetic Resonance Imaging of the Central Nervous System: Results from a Multicenter, Double-blind, Randomized, Comparator Study. Magn Reson Insights. 2015;8:1-10 6. Yoshikawa K, Davies A. Safety of ProHance in special populations Eur Radiol 1997;7 Suppl 5:246-50 7. Runge VM, Parker JR. Worldwide clinical safety assessment of gadoteridol injection: an update. Eur Radiol. 1997;7 Suppl 5:243-45 8. Morgan DE, Spann JS, Lockhart ME, et al. Assessment of adverse reaction rates during gadoteridol-enhanced MR imaging in 28,078 patients. Radiology. 2011;259(1):109-16 9. Murata N, Gonzalez-Cuyar LF, Murata K, et al. Macrocyclic and Other Non-Group 1 Gadolinium Contrast Agents Deposit Low Levels of Gadolinium in Brain and Bone Tissue: Preliminary Results From 9 Patients With Normal Renal Function. Invest Radiol. 2016;51(7):447-53 10. McDonald RJ, McDonald JS, Dai D, Schroeder D, Jentoft ME, Murray DL, Kadirvel R, Eckel LJ, Kallmes DF. Radiology. 2017 Jun 19:161594. doi: 10.1148/radiol.2017161594. [Epub ahead of print].11. Questions and answers on the review of gadolinium-containing contrast agents. Doc. ref. EMEA/727399/2009 rev. EMEA/H/A-31/1097, July 1 2010. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/gadolinium_31/WC500015635.pdf 12. ACR Manual on Contrast Media – Version 10.2, 2016. Nephrogenic systemic fibrosis. Available at: https://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast-Manual/2016_Contrast_Media.pdf/#page=89 13. Bellin MF, Van Der Molen AJ. Extracellular gadolinium-based contrast media: an overview. Eur J Radiol. 2008;66(2):160-7 14. Bracco data on file 15. Sardanelli F, Giuseppetti GM, Panizza P, et al. Sensitivity of MRI Versus Mammography for Detecting Foci of Multifocal, Multicentric Breast Cancer in Fatty and Dense Breasts Using the Whole-Breast Pathologic Examination as a Gold Standard. AJR Am J Roentgenol. 2004;183(4):1149-57 16. Deurloo EE, Peterse JL, Rutgers E, et al. Additional breast lesions in patients eligible for breast-conserving therapy by MRI: Impact on preoperative management and potential benefit of computerised analysis. Eur J Cancer. 2005;41(10):1393-401 17. Le Y, Kipfer HD, Nickel DM, et al. Initial Experience of Applying TWIST-Dixon With Flexible View Sharing in Breast DCE- MRI, Clin Breast Cancer, Vol.16, N.3, 202-6 2015 18. Loo CE, Teertstra HJ, Rodenhuis S, et al. Dynamic Contrast-Enhanced MRI for Prediction of Breast Cancer Response to Neoadjuvant Chemotherapy: Initial Results, AJR:191, November 2008 19. Ishibashi M, Fujii S, Kawamoto K, et al. Capsule of parotid gland tumor: evaluation by 3.0 T magnetic resonance imaging using surface coils. Acta Radiol. 2010;51(10):1103-10 20. Akai T, Taniguchi D, Oda R, et al. Prediction of radiographic progression in synovitis-positive joints on maximum intensity projection of magnetic resonance imaging in rheumatoid arthritis. Clin Rheumatol. 2016;35(4):873-8 21. Liu PT, Chivers FS, Roberts CC, et al. Imaging of Osteoid Osteoma with Dynamic Gadolinium enhanced MR Imaging. Radiology 2003;227:691-700 SUMMARY OF PRODUCT CHARACTERISTICS For prescribing information please refer to the approved SPC in your country. ProHance, 0.5 M solution for injection Composition 1 ml of solution for injection contains: gadoteridol 279.3 mg/ml (0.5 M) Excipients Calteridol Calcium, Tromethamine USP, Hydrochloric Acid Ph Eur, Sodium Hydroxide Ph Eur, Water for Injections Ph Eur Therapeutic indications Using Magnetic Resonance Imaging (MRI), ProHance provides contrast enhancement of the brain, spine and surrounding tissues resulting in improved visualization (compared with unenhanced MRI) of lesions with abnormal vascularity or those thought to cause a disruption of the normal blood-brain barrier. ProHance can also be used for whole body MRI including the head, neck, liver, breast, muscoloskeletal system and soft tissue pathologies. Contra-indications Hypersensitivity to the active substance, or to any of the excipients or to other gadolinium-based contrast. ProHance is contraindicated in children under 66 months of age. Special warnings and special precaution for use Patients with a history of allergy, drug reactions, or other hypersensitivity-like disorders should be closely observed during the procedure and the contrast medium administration, as well as for the time the physician deems useful given the patient condition. As with other gadolinium chelates, there have been reports of anaphylactic/anaphylactoid/ hypersensitivity reactions with gadoteridol. These reactions manifested with various degrees of severity, including anaphylactic shock or death. They involved one or more body systems, mostly respiratory, cardiovascular and/or mucocutaneous systems. Anaphylac-tic shock has been very rarely been reported with the use of gadoteridol. Appropriate drugs and instruments for emergency measures must be readily available. In patients suffering from epilepsy or brain lesions the likelihood of convulsions during the examination may be increased. Precautions are necessary when examining these patients (e.g. monitoring of the patient) and the equipment and medicinal products needed for the rapid treatment of possible convulsions should be available. Transitory changes in serum iron (within normal range in the majority of cases) have been observed in some patients after administration of ProHance and these changes were shown not to be clinically significant. Since Gadoteridol is renally cleared from the body, caution should be exercised in patients with severely impaired renal function. Undesirable Effects The accepted safety considerations and procedures that are required for Magnetic Resonance Imaging are applicable when ProHance is used for contrast enhancement. The following adverse reactions have been reported with ProHance. Adverse reactions from clinical trials have been included with an indication of the frequency. Adverse reactions from spontaneous reporting are included with the frequency “not known”. There were no adverse reactions with an incidence greater than 2%. Common (≥ 1/100, < 1/10): Gastrointestinal disorders; Nausea Uncommon (≥ 1/1,000, < 1/100): Nervous system disorders; headache, paraesthesia, dizziness, taste disturbance. Eye disorders; increased lacrimation. Vascular disorders; flushing, hypotension. Gastrointestinal disorders; dry mouth, vomiting. Skin and subcutaneous tissue disorders; pruritus, rash, urticaria. General disorders and administration site conditions; injection site pain, asthenia. Investigations; heart rate increased. Rare (1/10,000, < 1/1,000): Immune system disorders; Anaphylactic/anaphylactoid reactions. Psychiatric disorders; anxiety. Nervous system disorders; mental impairment, abnormal coordination, convulsion. Ear and labyrinth disorders; tinnitus. Cardiac disorders; nodal arrhythmia. Respiratory, thoracic and mediastinal disorders; laryngospasm, dyspnoea, rhinitis, cough, apnea, wheezing. Gastrointestinal disorders; abdominal pain, tongue oedema, oral pruritus, gingivitis, loose stools. Skin and subcutaneous tissue disorders; oedema face. Musculoskeletal and connective tissue disorders; musculoskeletal stiffness. General disorders and administration site conditions; chest pain, pyrexia. Not known (cannot be estimated from the available clinical trial data): Nervous system disorders; loss of consciousness, coma, vasovagal reactions. Cardiac disorders; cardiac arrest. Renal and urinary system; acute renal failure; Respiratory, thoracic and mediastinal disorders; respiratory arrest, pulmonary oedema. Additional Safety Information Isolated cases of nephrogenic systemic fibrosis (NSF) have been reported with ProHance, most of which were in patients co-administered other gadolinium-containing contrast agents (see below). Impaired renal function Prior to administration of ProHance, it is recommended that all patients are screened for renal dysfunction by obtaining laboratory tests. There have been reports of nephrogenic systemic fibrosis (NSF) associated with use of some gadolinium-containing contrast agents in patients with acute or chronic severe renal impairment (GFR < 30 ml/min/1.73 m2). Patients undergoing liver transplantation are at particular risk since the incidence of acute renal failure is high in this group. As there is a possibility that NSF may occur with ProHance, it should therefore only be used in patients with severe renal impairment and in patients in the perioperative liver transplantation period after careful risk/benefit assessment and if the diagnostic information is essential and not available with non-contrast enhanced MRI. Haemodialysis shortly after ProHance administration may be useful at removing ProHance from the body. There is no evidence to support the initiation of haemodialysis for prevention or treatment of NSF in patients not already undergoing haemodialysis. Infants from 6 months to 1 year of age Due to immature renal function in infants up to 1 year of age, ProHance should only be used in patients 6 to 12 months of age after careful consideration at a dose not exceeding 0.1 mmol/kg body weight. More than one dose should not be used during a scan. Because of the lack of information on repeated administration, ProHance injections should not be repeated unless the interval between injections is at least 7 days. Use of ProHance is not recommended in children less than 6 months of age. Use for whole body MRI is not recommended in children less than 18 years of age. Elderly (aged 65 years and above) As the renal clearance of gadoteridol may be impaired in the elderly, it is particularly important to screen patients aged 65 years and older for renal dysfunction. Please note The peel-off tracking label on the vials should be stuck onto the patient records to enable accurate recording of the gadolinium contrast agent used (EU). The dose used should also be recorded (EU). Consult the locally approved package insert. The Marketing Authorisation Holder, the Marketing Authorisation number and the date of approval may be different in different countries. For current prescribing information refer to the package insert and/or contact your local BRACCO organisation. Date of revision of this text September 2016.Proven efficacy4,5,15-21Large worldwide experience with over 25 million doses administered14Low risk of nephrogenic systemic fibrosis (NSF)11,12Established safety profile4-10Macrocyclic GBCA with very high in vivo stability1-3Low viscosity and osmolality13

R A D I O LO G Y 2 1 ‘This project will clearly contribute to more accurate risk estimations for radi- ation-induced cardiovascular events and thus support primary and second- ary prevention’, says Prof. Guy Frija from the University Paris Descartes (FR) and Clinical Coordinator of the project. The project’s overall goal is to enhance the scientific bases and practice of radiation protection in medicine Enhancing radiation protection cancer treatment and cancer risks following CT scanning in children and adolescents • to develop science-based consen- sus policy recommendations for the effective protection of patients, workers and the general public To achieve this, MEDIRAD has three major operational objectives: • to improve organ dose estimation • to evaluate and understand the and registration mechanisms of the effects of medical exposures, focusing on two outcomes of public health relevance, namely cardiovascular effects of radiotherapy in breast A new project funded by the European Commission calls together medical and radiation scientists, physicists and clinicians to enhance the radiation protection of patients and medical professionals. The four-year MEDIRAD project, which kicked off in June 2017, is led by the European Institute for Biomedical Imaging Research and comprises a consortium of 33 part- ners from 14 European countries. ‘The strength of MEDIRAD is the unique multidisciplinary approach involving research groups focusing on radiol- ogy, nuclear medicine, radiotherapy, dosimetry, epidemiology, biology, bioinformatics, modelling, radiation protection and public health’, says Prof. Elisabeth Cardis from ISGlobal (ES) and Scientific Coordinator of the project. The use of ionising radiation in medicine has been steadily increasing, and this trend is set to continue, with obvious health benefits for the popu- lation thanks to improved diagnostic and therapy technologies. However, this increase in radiation exposure levels also raises a number of safety concerns: the potential health effects among patients and medical workers need to be evaluated, dose evaluation tools for clinical practice need to be developed, and practices need to be optimised in order to reduce exposure doses and ensure adequate radiation protection. MEDIRAD’s overall goal is to address these needs by enhanc- ing the scientific bases and practice of radiation protection in medicine. A Turkish study compared PET/MRI and non-contrast enhanced PET in the assessment of gastrointestinal tumours and found PET/MRI to be more effective in detecting lesions and metastases ocedures s r e e n i h t l a e H s n e m e i S f o y s e t r u o C www.healthcare-in-europe.com Hitachi Medical Systems Europe Holding AG, Switzerlandwww.hitachi-medical-systems.comQUALITYSPEEDCOMFORTECOSPACESMARTThe Enlightened Choice for High-field MRIThis smart 1.5T MRI concept features ‘SmartQUALITY’ for superb clinical images and sophisticated applications, ‘SmartSPEED’ for reduced examination time, ‘SmartCOMFORT’ for an extraordinary quiet patient experience, ‘SmartECO’ for low running costs and ‘SmartSPACE’ to offer the smallest possible installation footprint.

The best just got better—every way you look at it.ADS-01949-EUR-EN Rev 001 © 2017 Hologic, Inc. All rights reserved. Hologic, 3D, 3Dimensions, 3D Mammography, Dimensions, Selenia, The Science of Sure, and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the US and/or other countries. All other trademarks, registered trademarks, and product names are the property of their respective owners.Introducing the Hologic 3Dimensions™ Mammography System• Sharper: THE fastest and highest resolution 3D™ images in the industry.1 And, it’s the ONLY tomosynthesis exam clinically proven to detect up to 65% more invasive breast cancer than 2D alone.2• Smarter: Clinically proven comfort3 without compromise in image quality due to advanced processing software that takes the curved compression geometry into account. • Simpler: Enhanced workflow for both the technologist and radiologist, without compromising on speed, dose or accuracy.Also available in 2DLearn more at 3DimensionsSystem.com1. Data on file and from public sources, 2017. 2. Results from Friedewald, SM, et al. “Breast cancer screening using tomosynthesis in combination with digital mammography.” JAMA 311.24 (2014): 2499-2507; a multi-site (13), non-randomized, historical control study of 454,000 screening mammograms investigating the initial impact of the introduction of the Hologic Selenia® Dimensions® on screening outcomes. Individual results may vary. The study found an average 41% increase and that 1.2 (95% CI: 0.8-1.6) additional invasive breast cancers per 1000 screening exams were found in women receiving combined 2D FFDM and 3D™ mammograms acquired with the Hologic 3D™ Mammography System versus women receiving 2D FFDM mammograms only. 3. In an internal study comparing Hologic’s standard compression technology to the SmartCurve™ system (18 x 24cm).NEW

Lead or follow?The chotce ts cleartn mammoqraphy.Take the lead with Hologic XNot all breast tomosynthests systems are created equal. XWhen you partner wtth Holoqtc, tt means proof—not promtses. The Holoqtc 3D Mammoqraphy™ exam has proven results backed by more than 200 cltntcal studtes. XOnly Holoqtc 3D Mammoqraphy™ exams detect up to 65% more tnvastve breast cancers compared to 2D alone.1 Contact your Hologic representative for updates on the latest innovations in mammography.1. Results from Frtedewald, SM, et al. “Breast cancer screentnq ustnq tomosynthests tn combtnatton wtth dtqttal mammoqraphy.” JAMA 311.24 (2014): 2499-2507; a multt-stte (13), non-randomtzed, htstortcal control study of 454,000 screentnq mammoqrams tnvesttqattnq the tntttal tmpact of the tntroductton of the Holoqtc Selenta® Dtmenstons® on screentnq outcomes. Indtvtdual results may vary. The study found an averaqe 41% (95% CI: 20-65%) tncrease and that 1.2 (95% CI: 0.8-1.6) addtttonal tnvastve breast cancers per 1000 screentnq exams were found tn women recetvtnq combtned 2D FFDM and 3D™ mammoqrams acqutred wtth the Holoqtc 3D Mammoqraphy™ System versus wom-en recetvtnq 2D FFDM mammoqrams only. ADS-01940-EUR-EN Rev 002 © 2017 Holoqtc, Inc. All rtqhts reserved. Holoqtc, 3D, 3D Mammoqraphy, Dtmenstons, Selenta, The Sctence of Sure, and assoctated loqos are trademarks and/or reqtstered trademarks of Holoqtc, Inc. and/or tts substdtartes tn the US and/or other countrtes. All other trademarks, reqtstered trademarks, and product names are the property of thetr respecttve owners.

CA R D I O LO G Y 2 7 Interactive mobile application provides continuous surveillance Smartphone monitors cardiac rhythm KEY FACTS ABOUT ATRIAL FIBRILLATION (AF) In Europe, more than 10 million people suffer from AF and by 2050 this figure is predicted to have multiplied by five due mainly to our ageing population. In AF, the heart rate becomes rapid and irregular due to the atria beating so fast that they tremble. Untreated AF can lead to stroke if preventive treatment is not introduced. Northern France, from the Heart and Lung Institute of the CHU has recently used a new genera- tion of ICM, which can automati- cally record the heart rhythm via an application that can be down- loaded to a Smartphone. The Lille hospital group has a 20-year history in the use of telemedicine, having first developed Tel Urge, a net- work designed to treat neurosurgi- cal emergencies at a distance. Today, the group’s healthcare teams have seven different networks for telemedicine in use for consul- tations, advice and monitoring of medical devices, therefore this new application fits well with the group’s established way of working. The ICM that has been implanted in Lille is the Confirm Rx, which although originally provided by St Jude Medical, is now available from Abbott and is the world’s first smart- phone compatible ICM. Equipped with Bluetooth low- energy wireless technology, patients can connect using their own mobile devices; telephones, tablets etc. The ICM continuously monitors the heart rhythm and automatically records The user-friendly interface allows patients to record symptomatic events easily and reminds users of upcoming transmissions events of interest via the myMerlin app, as configured by the attending cardiologist. Transmission of data via the app is secure and proactive. The doctor has access to the data at the secure web platform Merlin.net and, in the case of an incident, also receives alerts in real time. The app has an intuitive user- friendly interface that allows patients to record symptomatic events, view past and upcoming transmissions and ensures that they stay con- nected with the doctor. Monitoring of the heart’s rhythm becomes easy, effective and discreet. Insertable cardiac monitors are very comfortable and this innovative yet simple method of data collection does not interfere with patients’ daily activities, or their mobility. Close interaction with their health via the app has been shown to allow greater involvement in their condi- tion and its management. It has also been demonstrated to be particularly useful in helping patients to recognise triggers for their arrhythmia and, if possible, how to avoid them. The hope is that uptake of the app will improve patient compli- ance with their treatment and help reduce the burden of the disease on healthcare usage. Report: Jane MacDougall Insertable cardiac monitors (ICM) are designed for long-term use. Unlike external heart monitoring devices, an insertable monitor, smaller than a key, is placed under the skin of the upper chest, with no sticky pads or protruding wires, meaning that the patient can live as normal a life as possible. ICMs can record the heart’s rhythm for up to three years either automatically or onto a patient held device. The information generated helps the treating physician to understand clinical symptoms and, in many cases, such as cryptogenic stroke, find the underlying cause to be atrial fibrillation (AF). A series of recent clinical trials has attested to the value of ICM in detecting AF which would otherwise have gone undetected in most patients had monitoring been limited to 30 days. However data acquisition has remained cumbersome and unlike the ICM itself, does impact on the patient’s comfort and way of life. A Cardiology team in Lille, Catheter ablation reduces mortality and hospitalisation in HF patients The CASTLE-AF Study k i n o r t o B i f o Forthcoming CASTLE-AF study results indicate a 38 percent reduction in composite risk for all-cause mortality and worsening heart failure (HF) hos- pitalisation in patients with coexisting HF and atrial fibrillation (AF) treated with catheter ablation—when com- pared with patients receiving pharma- cological therapies that current guide- lines recommend. First presented at a late-breaking tri- als session at the 2017 ESC Congress, CASTLE-AF found a 47 percent reduc- tion in mortality and a decrease of 44 percent in hospitalisation for worsen- ing HF, when the endpoints were measured separately. Due to lack of data, the most appropriate treat- ment for patients with coexisting HF and AF has been frequently debated amongst physicians. Lead investiga- tors Dr Johannes Brachmann and Dr Nassir Marrouche say that this makes www.healthcare-in-europe.com y s e t r u o C CASTLE-AF a potentially guideline- changing study with a considerably positive impact on patient outcomes. ‘The results of this trial underscore the importance of catheter ablation as a mode of treatment, indicating that the procedure should be performed as early as possible and as a first-line therapy in this group of patients,’ Marrouche believes. Brachmann expects the study to have a considerable impact on how HF patients with coexisting AF are treated in the future. ‘The indicative results from CASTLE-AF could pave the way for wider adoption of catheter ablation and may prompt changes in current guidelines for treatment.’ Marrouche and Brachmann led what is, so far, the world’s largest ran- domised clinical trial to compare the efficacy of catheter ablation against the current guideline recommenda- tion for HF patients being treated with an ICD or CRT-D and suffering from atrial fibrillation. The study, sponsored by Biotronik, enrolled 398 patients in 33 centres in the USA, Europe, and Australia between 2008 and 2016. Investigators measured the primary composite end- point with a mean follow-up of more than three years—making CASTLE-AF the first catheter ablation study to fol- low this patient population for that length of time. Mortality and morbidity reduction through AF ablation? CASTLE-AF has the answer! Learn more: www.castle-af.org

L A B O R AT O RY & I N F E C T I O N 2 9 Seth Shipman PhD is a neuroscientist and postdoctoral fellow in Genetics at Harvard Medical School and a member of a team at the Wyss Institute for Biologically Inspired Engineering. He gained his doctorate, focused on Neuroscience, at the University of California, San Francisco. His key interests lie in genetics and the advancing understanding of brain function. population of bacteria, which, using Cas1/Cas2 activity, added them to the CRISPR arrays in their genomes. After retrieving all arrays again from the bacterial population by DNA sequencing, we finally could recon- struct all frames of the galloping horse movie and the order in which they appeared.’ Effectively, to read the information back, the researchers sequenced the bacterial DNA and used a computer code to unscramble the genetic information. ‘We took on this research because we see the potential for cells to gather information about their own biology and their environment,’ Shipman said. ‘For that to happen, we need a way to capture and store information within a cell while it’s still alive – that’s what we are test- ing.’ It took researchers three to four years to go from the idea of cells encoding information using the CRISPR-Cas adaptation system to this latest work and it took several days to do the recordings. ‘Going forward,’ Shipman contin- ued, ‘we’d like to see this work used as the basis for building living bio- logical recording devices that might function as a research or medical diagnostic tool.’ 19th century horse gallops through bacterial DNA CRISPR system embeds images in DNA images because they represent con- strained and clearly defined data sets. The film also gave the bacteria a chance to acquire information frame by frame. The breakthrough follows work in 2016 when the HMS team built the first molecular recorder based on the CRISPR system. The recorder allows cells to acquire elements of chronologically provided, DNA-encoded information that generate a memory in a bac- terium’s genome. The information is stored as an array of sequences in the CRISPR locus and can be recalled and used to reconstruct a timeline of events. The latest breakthrough con- firmed the scientists’ ability to engi- neer CRISPR system-based technol- ogy that enables the chronological recording of digital information in living bacteria. For the research, the HMS group inserted a gif of a horse galloping into the DNA of bacteria and then sequenced the bacterial DNA to retrieve the gif and the image The CRISPR system helps bacteria develop immunity against viruses in their environments. Capturing viral DNA molecules Dr Seth Shipman, a postdoctoral fel- low in Genetics at HMS, explained that, as a memory of survived infec- tions, it captures viral DNA mol- ecules and generates short ‘spacer’ sequences from them, which it then adds as new elements upstream of previous elements in a grow- ing array located in the bacterial genomes’ CRISPR locus. The CRISPR-Cas9 protein – a widely used genome-engineering tool – uses this memory to destroy the same viruses when they return, but other parts of the CRISPR sys- tem have not so far been much exploited. In this study, the scientists showed that two proteins of the CRISPR sys- tem, Cas1 and Cas2, which they had engineered into a molecular record- ing tool, together with new under- standing of the sequence require- ments for optimal spacers, enables a significantly scaled-up potential for acquiring memories and depositing them in the genome as information. that essentially translate the digital infor- mation contained in each pixel of an image or frame into a DNA code that, with additional sequences, is incorporated into spacers,’ Shipman explained. ‘Each frame thus becomes a collection of spacers. We then provided spacer collections for con- secutive frames chronologically to a ‘We designed strategies Report: By Mark Nicholls A research team in the United States has developed a revolutionary tech- nique that has encoded an image and short film in living cells. Scientists at the Wyss Institute for Biologically Inspired Engineering and Harvard Medical School (HMS) used CRISPR gene editing to encode the image and film in DNA, using this as a medium to store infor- mation and produce a code that relates to the individual pixels of each image. The team hopes to use the technique to create ‘molecular recorders’, an approach ultimately to lead to better methods to gener- ate cells for regenerative therapy, disease modelling and drug testing. For the research, the HMS group inserted a gif – five frames of a horse galloping - into the DNA of bacteria and then sequenced the bacterial DNA to retrieve the gif and the image, verifying that the microbes had incorporated the data as intended. The images chosen were of a human hand (because it has the type of intricate data the researchers hope to use in future experiments) and a galloping horse by 19th cen- tury British photography pioneer Eadweard Muybridge, because it has a timing component that could help to understand better how a cell and its environment may change over time. The team used still and moving As Senior Director and General Manager of SCIEX Diagnostics Dr Aaron Hudson leads the company’s clinical diagnostics strategy and execution. A Sciex director since 2010, he has had roles in the firm’s global marketing strategy, plus academic and omics business. Previous work includes European sales and marketing for Waters and Applied Biosystems, from which Sciex later formed as a separate company. Along with his Molecular Genetics PhD, he holds a BSc in Biochemistry from the University of Sheffield, UK. System is intended to be used in conjunction with other clinical or laboratory data to assist the clini- cian in making individual patient management decisions in an adult population in the assessment of Vitamin D sufficiency. in Europe, ‘For the European market, Sciex is currently working closely with partners including Chromsystems, to validate clinical assays for the Topaz System. Using a turnkey assay will give clinical labs return of investment in a very short period of time, and adding lab-developed tests to the repertoire will make it even more efficient,’ Hudson summed up. www.healthcare-in-europe.com Your new flagship of coagulation analysis has finally arrived. Meet the new member of our Coatron family.Downloads/Information:www.teco-medical.com/coatron-a6plusTECO Medical Instruments, Dieselstr. 1, 84088 Neufahrn, Germany, Tel.: +49 (0) 8773 70780-0, E-mail: info@teco-gmbh.comDon‘t miss to see us atMEDICA, Hall 3 / C65Double the speed (compared to Coatron A6)2 pipette needle system with high-precision XYZ location, sensitive level sensor and optimized work flowComplete high quality optical analysis. 6 optic channels at 405nm with auto light sensing and maximallight elimination to reduce interferences such like bilirubin orsunlight.Full functionality included35 heated and cooled reagent positions for reagents, controls, buffersHigh precision syringe pumpEconomical rinse/clean consumptionEasy maintenance proceduresAutomatic self control of all instrument functionsProven and improved usability.Intuitive TECO familiar graphical user interface.PLUSMADE INGERMANY

L A B O R AT O RY & I N F E C T I O N 3 1 Plans, patience and a lot of persuading are necessary Integrating three laboratories For POCT, point-of-care testing, a lab has to purchase new equipment, perform new measurements and handle new parameters – right? Right! However, more importantly, POCT requires the adaptation and integration of the existing lab organisation, with all its consequences, from additional quality control down to new areas of responsibility. Dr Herbert Stekel is currently integrating three previously external lab operations, including POCT, into one central lab at his 1,000-bed hospital in Linz, Austria. In conversa- tion with EH correspondent Walter Depner, he outlines the regulations and complexities. k c o t s r e t t u h S / y i l i s a V v e h s u k r e M : e c r u o S Asked what exactly ISO 22870 means for POCT, GP Dr Herbert Stekel pointed out that, like any other standard, ISO 22870 offers recom- mendations. ‘It defines technical, management and quality require- ments. A crucial aspect is the fact that the standard places responsibility for POCT firmly in the lab – this includes the selection of equipment and meth- ods, staff training and quality control during operations.’ Depner: Another more general question: ISO, the Inter national Organisation for Standardi- sation, has currently more than 160 member states covering the majority of the global population. Is any standard that was adopted by ISO automatically binding in all member states? Stekel: ‘It’s applicable – but not bind- ing. Standards organisations have no legislative powers. Thus a standard needs to be adopted by the legisla- When organic structures are about to be changed, plans, patience and a lot of persuading are needed to get buy-in from the team. However, Herbert Stekel is certain that the synergies from including POCT are worth the effort ture in order to become legally bind- ing, for example through integration in the medical device law, or a similar act. However, beyond this legal issue standards reflect current knowledge and provide a basis for expert opin- ions. Therefore, healthcare facilities are well-advised to adopt the recom- mendations defined in a standard.’ POCT affects many hospital IT areas, from the lab information system (LIS) to the hospital infor- mation system (HIS). The inte- gration of POCT in these systems involves software as well as hard- ware issues. How complex is this integration? ‘POCT is an organisational structure to provide lab services. To be able to establish proper documentation, a link to a LIS or HIS is recom- mended. This link is an important selection criterion: modern systems offer easy integration; some include even remote device monitoring.’ What does the standard adoption imply for staff – be it training, quality control, technical support or responsibilities? Can current lab members (or staff in other areas) handle additional tasks created by POCT, or are more tech- nicians needed? ‘As far as I can tell from our 1,000- bed facility, 1.5 full-time equivalent of a medical-technical assistant is required. This will also cover on- site support for blood gas analys- ers, training, internal testing and a hotline.’ POCT is performed in ambu- lances, cars, helicopters, at traf- fic accidents, in hospital depart- ments, lab satellites, and there are patient self-measurements. The lab must carry the greater part of this burden. How can it cope with this additional work? ‘To be precise, according to ISO 22870, patient self-measurement is not POCT. I mentioned the additional staff requirements above – no doubt POCT cannot be implemented en passant if all aspects, particularly training, are taken seriously. In terms of professional knowledge, POCT is not challenging for a lab team. The hospital and lab teams consider the closer and personal contact between labs and departments is a positive As a specialist in medical-chemical laboratory diagnostics, general practitioner Herbert Stekel MD, heads the Institute for Medical and Chemical Laboratory Diagnostics at Kepeler University Hospital Linz, Austria. His professional focus is on lab organisation, lab economics, POCT, pre- analytics and lab IT. side effect of POCT.’ It won’t suffice to follow ISO guid- ance. Quality obligations include mandatory ring trials. How does your lab handle those, and how is that handled among interna- tional labs? ‘In addition to purchased ring trials for blood gases, we use controls and ring trials we designed ourselves. Some systems that integrate inter alia glucose measuring devices support control measurements on different levels.’ In your lab, you are in the process of integrating three different lab sites. Does POCT make your task easier or more difficult? ‘In our current situation harmonising the POCT environments is an addi- tional task. As always, when organic structures are about to be changed, plans, patience and a lot of persuad- ing are needed to get buy-in from the team. Processes need to be adjusted and even re-designed. But in the end you will also find many synergies. It’s really worth the effort.’ urement to determine endurance performance. However, many other parameters that allow precise meas- uring of body functions are often also determined with the help of POCT, although some of these do not belong in the realm of traditional medicine. One decisive reason for POCT in sports is that it can be used without the need for medical and laboratory staff, and with capillary blood samples and mobile devices. However, proper utilisation of the existing medical potential of this new type of POCT measurement requires the necessary technical and organisa- tional prerequisites, such as standard- ised blood sample collection (fasting blood sample for instance) and the combined evaluation of many differ- ent measurement data etc. Under appropriate conditions, a single POCT measurement can cer- tainly become part of a diagnostic system. A ‘normal’ laboratory diag- nosis is usually based on a measure- ment; the diagnosis of a competitive athlete can be based on many dif- ferent measurement results obtained not only in a sports-scientific context. Apart from the analytes examined, this also depends on the questions involved. POCT is a topic that continues to have much potential, but which equally throws up a lot of questions that need answers. Biochemist Roman Fried PhD MBA, from the Institute of Clinical Chemistry, University Hospital Zurich, heads the Medi- cal Laboratories of Switzerland (FAMH) and is Managing Director of the Association for Medical Quality Control in Switzerland. for wet chemical equipment in larger laboratories. All these points some- times lead to POCT devices actually being superior to equipment used in large laboratories. Larger laboratories only achieve better results with cardiac markers. External quality control works effectively with POCT analytics. The four ring trials per year regularly remind users that quality assurance measures are an essential part of test- ing. Quality control centres can also utilise these evaluations to inform participants about innovations. This is important as the compe- tence of the people performing the tests ultimately decides quality. Medical practice assistants (MPA), trained to deal with all relevant POCT devices in a three-year course, per- form testing in GP practice labs. In a hospital, mostly nurses carry out POCT testing; their training level can vary a lot. In many hospitals a POCT coordinator monitors all aspects of POCT and ensures users are continuously trained. One positive side effect of regular training is that it improves the overall understanding of laboratory analysis. If users gain more experience in pre- analytics as a result of Point-of-care- testing this will ultimately also benefit central laboratories or contract labo- ratories. www.healthcare-in-europe.com The gold standard in point-of-care HbA1c testingQuo-Test A1c analyzerFind out more at ekfdiagnostics.com

L A B O R AT O RY & I N F E C T I O N 3 3 Infection management in bone surgery The benefits of antibiotic-loaded cement The use of antibiotic-loaded bone cement (ALBC) is an effective sup- porting option to prevent and cure infections in bone surgery as well as in arthroplasty. This is the quin- tessence of the Satellite Symposium ‘Defect - Infect - Regeneration – Infection Management with ALBC in Bone Surgery’, hosted by Heraeus Medical GmbH during the 36th Annual Meeting of the European Bone and Joint Infection Society (EBJIS) held in Nantes, France, this September. Olivier Borens, orthopaedic sur- geon at the University Hospital Lausanne, Switzerland, discussed the benefits and specifics of local antibiotic treatment via antibiotic- loaded bone cement (ALBC) in his talk on ‘Surgical management - What are the options to fill a bone defect?’ ‘First, the antibiotics are being elut- ed locally to the important site. Second, there is no systemic toxic- ity. Third, the protection allows for the induction of a good membrane, and fourth, it brings antibiotics to a usually devascularised area,’ he explained. In large bone defects, dead space management becomes important. ‘This can also be done with PMMA enriched with antibiotics.’ However, ALBC should always be combined with systemic antibiotics to avoid an infected space. ‘PMMA is available pre-loaded with one or two antibiot- ics but, if needed, can also be mixed with other antibiotics after compre- hensive diagnosis,’ states Borens. Tristan Ferry, infectious disease specialist from the Hospices Civils de Lyon, explained in his presenta- tion the ‘Rationale for the use of Active compound concentration of systemic (left) and locally (right) administered antibiotics in the body local antibiotics in patients with sep- tic pseudarthrosis.’ A septic pseudar- throsis always requires personalised treatment, depending on the loca- tion, the size of the bone gap and the type of pathogen, he said. ‘Usually, a multi-disciplinary team will perform a two-stage Masquelet approach - a mechanical manage- ment of the bone gap and manage- ment of the infection.’ According to Ferry, the first goal should be infection treatment at the time of the bone resection. ‘Staphylococci are the most important pathogens, but one third of patients were also infected with Gram-negative bacilli.’ Therefore, he recommended using a combination of two antibiotics. The second goal is to prevent super infection at the time of bone grafting: ‘Increase the dose of gentamicin locally, and second, combine two antibiotics acting on staphylococci,’ he advised, and also recommended combining local and systemic antibiotic therapy. Mike Reed, Consultant Orthopaedic Surgeon and Professor from the University of York Northumbria (UK), described the application of ‘High Dose Dual Antibiotic Bone Cement in Hip Hemiarthroplasty.’ He found that ABLC eluting two antibiotics was very effective in preventing biofilm formation after hip hemiarthroplasty. ‘Therefore, we can use ALBC not only to treat, but also to prevent infections,’ he said. Another reason for using cement is to support the implant: ‘ALBCs such as COPAL have the same physical properties of other cements.’ Based on a randomised trial involving more than 800 hip hemi- arthroplasty patients receiving either PALACOS R+G (Single AB) or COPAL G+C (dual ABs) Reed pointed out that the deep infection rate had been dramatically reduced to one third (from 3.5 to 1.1) with COPAL G+C. ‘If you look at deep and super- ficial surgical side infections (SSI) combined, the use of COPAL G+C is even more potent, reducing the rate from 5.3 to 1.7.’ The reason is the high concentration of antibiotics well above the minimum inhibitory concentration. ‘We also examined whether pre- ventive ALBC use is driving the development of antibiotic resist- ances,’ Professor Reed pointed out. ‘But’ he added, ‘based on obser- vations and tests of nearly 2,000 patients, there is no sign of resist- ance development.’ ansportable equipment is a ey factor for the Laboratory n o i r O f o y s e t r u o C atory ywhere program Martin Myers MBE is a Consultant Clinical Biochemist and Associate Divisional Medical Director for Pathology at Lancashire Teaching Hospitals, where he continuously addresses pathology re-design, using advanced automation and point of care testing (POCT). His scientific interests include the use of automation, POC testing and informatics in improving the quality of the diagnostic process, while his clinical interests include the use of laboratory testing to improve patient pathways. Scientific Officer of NHS England, Myers is leading a national pilot for the National Health Service (NHS) to deliver the Laboratory Anywhere model to these patient groups, with HbA1c, Total Cholesterol and HDL cholesterol measured. The hope is that the Laboratory Anywhere concept will be adopted throughout the UK and beyond, to diagnose and monitor diabetes and cardiovascular disease in hard-to- access groups in developing coun- tries, where socio-economic and political issues have resulted in lack of laboratory services, Myers added. Laboratory Anywhere uses port- able Lab-in-a-bag or Lab-in-a-Box technology to take to the patient. The devices vary depending on the purpose; for diabetes and car- diovascular disease, simple devices to measure HbA1c, glucose, cho- lesterol and HDL cholesterol on a finger prick blood sample are used, whilst for more complicated questions, such as assessing renal function, blood gases, and calcium, cartridge-based devices can measure up to 20 analytes at the same time from one blood sample. In a Health Mela, his team screens more than 200 people in six hours. However, he acknowledges that whilst measuring HbA1c and lipids in 4-8 minutes is good and glucose meters take seconds, he is keen to see developments where the analyti- cal time can come down to less than a minute for some tests. Into outreach services The Laboratory Anywhere model is also being used by outreach services (Sepsis and Acute Kidney Injury teams) with Myers’ team now about to implement the Laboratory Anywhere for frailty units, care homes, urgent care centres and GP surgeries, with results captured on the patient record. Overall, the impact of Laboratory Anywhere has been ‘remarkable’, Myers said. ‘Patients enjoy the concept, and support what we are doing. As well as diagnosing some patients with diabetes and elevated lipids, many patients are identified as at risk and therefore we can intervene before disease develops. ‘Advances in technology,’ he con- cluded, ‘mean healthcare scientists can bring the laboratory wherever it’s needed and no longer can lack of access be used as an excuse for not reaching out to patients’. www.healthcare-in-europe.com

D I G I TA L PAT H O LO G Y 3 5 Time to speed up the adoption of digital pathology Deep learning and AI progress n e n a t u o P i s k e l A : e c r u o S To profit from the implementation of digital pathology, it is vital to add image analytical tools and machine learning and artificial intelligence to analyse and pre- process samples t s i v q d n i L i a K : e c r u o S t s i v q d n i L i a K : e c r u o S Another important factor is providing the pathologists with better interfaces to view and handle the samples digitally. The web microscope developed by the company Finmic, where Lundin is a consultant, is an example for such an interface Professor Johan Lundin is Research Director at the Institute for Molecular Medicine Finland (FIMM), hosted by the University of Helsinki, and Guest Professor in Medical Technology at the Karolinska Institute in Stockholm. He is also Associate Professor for Biomedical Informatics at the University of Helsinki. His key research aims to fully utilise development within information and communication technologies to improve diagnostics and care of the individual patient. He is also a consultant for Finmic, an academic spin-off company that is commercialising the web microscope developed within his group. ers and clinical pathologists, one which Professor Lundin hopes the 14th European Congress of Digital Pathology – Helsinki. May 29 to 1 June 2018 – will help address. As joint President of the confer- ence – which will also incorporate the Nordic Symposium on Digital Pathology – he said: ‘The whole topic of the conference is digital diagnostics and augmented intel- ligence. ‘I hope to gather together researchers from the technical field and the clinical pathologists to build a bridge between algorithm devel- opment and the users of these methods. ise and develop the actual digitisa- tion process to be much more effi- cient and also to develop the work- flow and way pathologists interact with images and with the results from the automated analysis.’ Cost, in terms of hardware, scan- ners and instrumentation, remains an issue, but Lundin is convinced that the addition of analytical tools, such as automated analysis, will translate into improvements in effi- ciency and speed. He notes that several institutions are introducing digital pathology on a step-by-step basis, initially by acquiring a scanner, and then dig- itising archival material for teach- ing and seminars before leaning towards clinical samples. A key challenge is to bridge the gap between technical research- ‘It will give the opportunity to dis- cuss and see examples from current applications and the most recent advances in deep learning and arti- ficial intelligence that shows the complex things you can now clas- sify and analyse with the machine tools,’ added Lundin, who is also involved in the European Congress of Pathology in Amsterdam (2-6 September). Image analysis of the thyroid gland more convenient to view and handle the samples digitally.’ An area where there is room for advancement, he said, is in the development of more sophisticat- ed instrumentation with almost all instruments currently available still based on conventional technolo- gies and typically centralised rather than located where the samples are prepared. Professor Lundin believes there are a number of steps to take to help overcome these hurdles. ‘When you see the huge advances in artificial intelligence applied to pathology in the 1-2 last years, you realise there is no going back from that progress. It will definitely come, but the question is when and how fast? ‘We have seen from other parts of medicine - like diagnosing a mela- noma from a photograph of a skin lesion, or looking at the diabetic changes in the fundus of the eye – that the algorithms have reached expert levels of performance, so that means the same will of happen in pathology. Of course,’ he continued, ‘it will not replace pathologists, but it will provide a number of really efficient tools to add to the clinical workflow. ‘What is really needed is to organ- Report: Mark Nicholls Early adoption of image analytical tools and artificial intelligence (AI) are crucial if health systems across Europe are to see the full poten- tial of digital pathology, according to leading expert Professor Johan Lundin, Research Director at the Institute for Molecular Medicine Finland (FIMM) at the University of Helsinki. Although European institu- tions increasingly embrace digital pathology, he remains concerned that progress is slow and several organisations have not yet moved onto the next level of introducing analytical tools. Speaking from his experience in Finland and Sweden, he pointed out that, during the last two years, major university institutions where pathology is part of the operation have acquired microscopy scanners that are the basis for going digital and the instruments for digitising a sample. However, he said that the pattern in some parts of Europe was slow- er than he would have expected. ‘There are many reasons for this,’ he said. ‘One of the most important is that, so far, digital microscopy and pathology have mainly been limited to viewing. If you compare viewing a sample under a microscope, or viewing it on screen, there is not much difference or much to gain - maybe only in speed and access to the sample archives. For the every- day work of the pathologist, I do not think they experience it as a clear improvement.’ Critical to changing this, and exacerbating the implementation of digital pathology, is the addition of image analytical tools and machine learning and artificial intelligence to analyse and pre-process the sam- ples. ‘With these you have a clear reason why you should go digital but without going digital you will not be able to use those tools,’ he pointed out. ‘Another driver is to create better interfaces, where it is of the product Emam explains. ‘We have integrated a number of func- tions that cannot be found in this form in conventional products. For example, SensoClean has an inte- grated warm white LED light that points towards the hands and is switched on automatically with the water. What’s more, the temperature can be easily adjusted whilst wash- ing your hands, touchless of course.’ The flow of water is also acti- vated touchless by sensors, as is the operation of the dispensers. If necessary, the SensoClean from Integromed can also be fitted with an integrated UV lamp that is also switched on by simply holding your hands beneath it. ‘But this is only used during training, where a disinfectant containing a fluores- cent concentrate is used to check how successfully the hands have been disinfected,’ Emam explains. ‘We decided to include this option because a sustainable improvement of compliance is dear to our hearts. And regular training is indispensa- ble to guarantee sustainability.’ Integromed (www.integromed.de) will present SensoClean at MEDICA 2017 in Dusseldorf this November. www.healthcare-in-europe.com