V O L 2 8 I S S U E 2 / 1 9 A p r / M a y 2 0 1 9 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 PATHOLOGY & RADIOLOGY 13-23 Multiple viewing improves consultation across professions Disease processes by pixel analysis Inside a refined Belgian prostate unit h o t n e k / k c o t s r e t t u h S © LABORATORY We need a special senior laboratory Rapid myocardial infarction 6-11 verification Sequencing technologies increase © Shutterstock/Ollyy patient safety AI? We shouldn’t worry about it – yet Humanity is not doomed to submit to machines as in the Terminator movies – or at least not yet. Artificial intelligence (AI) systems are still far from capable to imitate the human brain in all its complexity. Yet there is no doubt that AI will have a global and huge impact, particularly for professionals such as radiologists, who should look at AI critically and focus on the many new opportunities that will arise, advises Australian AI expert Professor Toby Walsh. Report: Mélisande Rouger ‘People have woken up to the idea that AI is going to be interesting and transformative because it will impact on every aspect of our lives,’ explained Toby Walsh, a profes- sor of AI at the University of New South Wales, speaking at the AI Premium meeting organised by the European Society of Radiology and the European School of Radiology in Barcelona. AI will have a major impact on global economy, according to audit giant PwC, which predicted it could generate 15.7 trillion USD and account for 26.1% of GDP in China, 14.5% in North America and 10% in Europe by 2030. ‘That’s an inflation just in terms,’ said Walsh, who is dubbed ‘the rock star of the digital revolution’ and has published many books on the topic. ‘16 trillion USD is China and India’s GDP put together. It’s like we’ve discovered a whole new con- tinent. Last time that happened, it had big ramifications for the world’s economy.’ Walsh’s last work, ‘2062: The World that AI made’, is an opti- mistic vision of how to help man- kind benefit from AI, rather than helplessly suffer the consequences ‘Every profession and particularly data intensive professions, such as radiology, will be affected,’ he said. Four exponentials Walsh shared a brief history of AI, which was boosted by four exponentials, including Moore’s law, according to which the number of transistors in computers dou- ble almost every two years. This observation has accurately guided www.healthcare-in-europe.com things for us are often surprisingly hard for computers. What’s more, we have made almost no progress in artificial general intelligence that matches humans in their full capa- bilities.’ Computers can do narrow tasks, but nothing approaches the human brain yet. Machines are not going to take over anytime soon. ‘We have 50, 100 or maybe 200 more years before it can match the human brain, if ever. So, we should not worry about it,’ he said. Instead, people should look into the exciting new opportunities and just learn about the field. This starts with differentiating between AI and machine learning. ‘People often mix up these terms. But there’s a lot more to your intelligence than learning.’ Other intelligence include, for instance, perception, speech and speech recognition, NLP, vision and reasoning. A lot of AI research focuses on machine learn- ing, but much more could be done in workflow, image optimisation, etc. All these fields are interesting to explore for medical imaging. types of Will machines be taking over? No – at least not in the foreseeable future, according to AI expert Toby Walsh. While certain algorithms today come close to, or even surpass, humans in narrowly defined tasks, it should be another 50, 100, maybe even 200 years before artificial intelligence will match the complexity of the human brain. projection rates and technological developments for the past 50 years, all of which have led to immense computing power. ‘Things that we dreamed about doing, we just do now because we have more computing power. We have more computing power in our smartphones than was once used to fly a man to the moon,’ he observed. Moore’s law is now officially dead and scientists need to design new architecture to increase computing power. One trend is to design speci- fied chips to do AI and do more on the device energy, he says. Along the doubling of transistors count, there has been a doubling in data. ‘We’re collecting more and more data, and have the ability to store more and more data. This continues to help expand AI,’ Walsh pointed out. The third exponential was a dou- bling in performance of algorithms to recognise objects and limits. Back in 2010, one in 10 objects were clas- sified properly. Since then perfor- mance has been doubled every two years, and now it recognises objects better than the average human does. Last but not least, investment has doubled every two years over the past decade, allowing skyrocketing advances in AI. The impact on radiology AI started to make headlines in 2015, when humans lost against machines in a Go competition. Nonetheless, and despite all the progress made, it is remarkable how slowly the machine learns compared to humans, even with unlimited resources of time, Walsh underlined. ‘There are still many things that machines can’t do as well as humans, some of which are plain trivial. A robot developed by a col- league at Berkley University takes 25 minutes to fold a towel. Easy Provocation for attention The rule of thumb is that AI can now do most things a radiologist can do in a moment’s thought. ‘You can see an image and recognise it. The computer has been trained to do this. It can now also label images – i.e. a man dances dressed in black; a girl plays the violin, etc. – and that works pretty well. So, we can also start labelling X-rays,’ he explained. In 2017, AI researcher Andrew Y Ng, from Stanford University, claimed he and his team had devel- oped an algorithm that could diag- nose pneumonia at a level exceeding practicing radiologists. Such claims need to be taken with precaution, Walsh insisted, because studies may show some limitations. ‘In this case researchers trained on 6,351 images and reported results on 420, but they only used frontal images and no patient his- tory. Although the machine was more accurate on average than four human radiologists, one of them had only been working for four years. That brought down the human performance. Actually, there was one experienced radiologist l / s d a o p u / p p a / g r o . r s e y m . i a / / : s p t t h : e c r u o S g n p . e i p o K - y b o T - h s l a W World-renowned artificial intelligence professor at the University of South Wales and Data61, Toby Walsh was named by the media as a ‘rock star’ of the digital revolution and has been included on a list of the 100 most important digital innovators in Australia. He is the author of the books ‘IT’s Alive’, ‘Android Dreams’ and the soon to be published release ‘Machines That Think’ and ‘2062: The World that AI Made’. The professor is a sought-after keynote speaker on how AI influences business, education, warfare, personal development, and finance, and more. Together with Pope Francis, he was voted runner up in the Person of the Year Award by the Arms Control Association, recognising his work in ensuring the safe use of AI in warfare. who did better than the machine,’ he said. People should read through stud- ies carefully, because obviously some authors might be looking for funding. Caution should also prevail upon hearing provocative quotes, such as Geoffrey Hinton’s famous line about stopping radiologists’ train- ing. ‘Geoffrey is extremely bright, but he is also famous for saying pro- vocative things to get people’s atten- tion. He also said that you couldn’t predict more than five years out. I agree. There is still some distance to go,’ Walsh concluded, ‘before you can get much faith and confidence in equalling humans.’ www.healthcare-in-europe.com CONTENTS NEWS & MANAGEMENT 1-5 LABORATORY 6-11 INFECTION CONTROL 12 DIGITAL PATHOLOGY 13-15 RADIOLOGY ONCOLOGY 14-23 24

N E W S & M A NAG E M E N T 3 Data and information can off-set physician burnout Digitisation pushes and prevents burnout tored the time patients spent with each clinician and the wait before they were seen, the backlog of let- ters to be managed, the number and waits associated checking lab results, and the number of visits awaiting completion. ‘This gave us a view of how well each individual was managing with the workload,’ he continued. ‘When we noted deteriorations in perfor- mance, we immediately instituted a process where we offered extra sup- port – such as reduced workload till they caught up. This both identified impending problems very early and put in remediation immediately. We did not have a single episode of burnout in the years that followed, despite increasing workload and throughput as well as serial intro- ductions of new EHR processes.’ He suggests the EHR can be used as a ‘clinical extender’ in this con- text; as the vehicle to communicate with the patient, with the impor- tant issue being to try to keep that connection as personal as possible between patient and clinician, such as using a named person to com- municate.’ However, he stressed the impor- tance of thinking carefully before deployment of new systems and taking the perspective of the clinical staff into account as well as that of the administrative staff and patients. Evidence remains that EHRs con- tribute to physician burnout, such as from a 2017 study published in the Annals of Family Medicine (AFM) which found that primary care physicians spend more than 50% of their time working on tasks associated with EHRs instead of car- ing directly for patients. A similar 2016 study published in the Annals of Internal Medicine (AIM) found that ‘for every hour physicians provide direct clinical face time to patients, nearly two additional hours are spent on EHR and desk work within the clinic day’ with further tasks performed out- Dr Charles Alessi is Chief Clinical Officer for the Healthcare Information and Management Systems Society (HIMSS); senior advisor to Public Health England and lead around dementia and ageing. He is also a former Chair of the National Association of Primary Care in England (the national body representing the hospital sector including primary care). The HIMSS is a global advisor and thought leader supporting the transformation of health through information and technology. side office hours. In a recent Mayo Clinic update – based on extensive research on phy- sician burnout – findings suggest physician well-being is improving, but physicians remain at high risk for burnout, depression and dep- ersonalisation, compared to other professionals. Researchers from Mayo Clinic, the American Medical Association and Stanford University collaborated in the national survey of physicians across more than 20 specialties to assess any changes between the pre- vious study in 2014 and the original survey in 2011. While burnout var- ies by specialist, overall reported levels of burnout and satisfaction with work-life integration improved between 2014 and 2017 – but only to 2011 levels. More than 30,000 physicians were invited to participate in the electron- ic survey; just over 5,000 responded. Researchers say the reason for the change may be due to physicians adapting to the new work environ- ments over the three-year period. Also, much progress may be attrib- uted to interventional programs to stem burnout in hospitals and other facilities. Acticor & Rivacor Family More Life. Made Simpler. www.biotronik.com Report: Mark Nicholls (EHR) are Deployment of electronic health records increasing- ly cited as a factor in physician burnout. However, a senior figure with the Healthcare Information and Management Systems Society (HIMSS) – which supports the trans- formation of health through infor- mation and technology – believes defined use of data and information can help off-set the impact of burn- out among health professionals. ‘Physician burnout is often said to be caused by digital transformation,’ HIMSS Chief Clinical Officer Dr Charles Alessi said. ‘If the deploy- ment of an EHR is badly handled, this can be the case, but there are plenty of other reasons why burn- out is a problem.’ His lecture ‘Managing Physician Burnout: Using the EHR as a Clinical Extender’ delivered dur- ing the HIMSS Global congress in Orlando, Florida last February, focused on causes and solutions whilst acknowledging the issue of physician burnout – which encom- passes emotional exhaustion, deper- sonalisation, distress and depression – remains serious. The session came as new data emerged from Mayo Clinic that physician well-being was improv- ing, though he pointed to broader research that still suggests 50% of physicians, in practice across all dis- ciplines or in training, are affected, along with nursing cadres and other o t o h p h o k z t u w / k c o t s r e t t u h S © health and care workers. Causes, he said, range from ‘doing more with less’, increased thought output and manpower issues. They include changes brought about by the democratisation of information allied with the consumer revolu- tion; the requirements of clinicians to both manage and exclude clini- cal risk at the same time and with the same patient; and the increased administrative burden associated with payments and assurance, as well as ‘less than optimal’ EHR deployments. measures can be taken and that the EHR has a part to play in helping to address the issue of physician burnout. ‘The data and information can play a significant role in managing burnout if applied correctly. A use case is one I introduced personally into my general practice in England, where we had teams of people look- ing after populations. This meant we had doctors and nurses working in a way where the continuity of care was delivered via the clinical records.’ While there are ‘no simplistic solutions’, Alessi said mitigating He outlined how his practice insti- tuted a system whereby they moni- How a strong complementary merger pays off ards multi-organ support The next step: multi-organ support ‘By entering the treatment of cardiac and pulmonary diseases via Xenios, FME is expanding and strengthen- ing its leading position in the area of extracorporeal organ support,’ the firm continues. ‘Treating heart and lung diseases with extracor- poreal therapy systems is closely tied, of course, to dialysis – both in technical terms and in the clinical process. ‘Together with Fresenius Medical Care we are creating a perfect syn- ergy between FME’s expertise in renal support and Xenios’ expertise in heart and lung support. We are taking the next step towards multi- organ support,’ Dr Andreas Terpin, CEO of Xenios AG, added. ‘Xenios and FME already imple- mented their technological collabo- ration by connecting the Xenios console via the iLA active iLA kit IPS to the MultiFiltratePro from FME. ‘During dialysis, a CO2 removal for lung support can be carried out simultaneously, combining renal and lung therapies,’ the FME report continues. ‘Consistently pursuing a holistic multi-organ approach, FME aims to establish worldwide market leadership from renal to heart and lung assist. Supplying this technology to cardiac surgeons and perfusionists, Medos was one of the leading German companies in this field since 1987. This acquisition enabled the com- pany to expand its overall product portfolio to offer both heart and lung support on one single plat- form: the Xenios console.’ ‘Xenios’ dedication applies to the welfare of patients. Especially Novalung therapies provide fun- damental advantages to patients: physicians and caregivers can keep them awake, mobile and self-deter- mined which facilitates improved outcomes. ‘The combination of Xenios and FME therapies empowers clinicians with the tools required to practice true interdisciplinary care in the ICU for the benefit of seriously ill patients. Many are already receiving renal therapy prior to the need for heart and lung assistance.’ www.healthcare-in-europe.com BIOshape. Ultraslim 10mm ICD and CRT-D. Up to 15 years longevity.2 Up to 10 years warranty. Full 3T MRI. Autodetected. 90% fewer inappropriate shocks1 Continuous CRT optimization More than 60% mortality reduction3 1 Guédon-Moreau L et al. Decreased delivery of inappropriate shocks achieved by remote monitoring of ICD: a substudy of the ECOST trial. J Cardiovasc Electrophysiol, 25 (2014). 2 Single-chamber ICD standard conditions. Data on fi le (service time calculation]. 3 Hindricks G at al. lmplant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial. The Lancet (2014).

N E W S & M A NAG E M E N T 5 Speeding up assessment of clinical risks The digital early warning system Staff shortages are among the most urgent healthcare problems. While digitisation might offer relief, unfortunately many hospitals lag behind in transforming their processes. As pressure mounts, the chorus is heard: ‘It’s high time for bold changes’. Indeed, this was the motto of the 2019 Western German Health Congress held in Cologne, an event that focuses on health policy and health economy in this area. There was also a focus on how to inject energy into the sluggish approach to digitisation. Report: Beate Schenk According to estimates by the German Hospital Federation the country’s healthcare system could save a whopping €34 billion annu- ally, half of this in hospitals, if the potential of digitisation were to be fully realised. Non-digitisation not only means loss of income, but also possible loss of lives, particularly in emergency care. ‘Unexpected events and the deterioration of the patient’s status must be recognised early – one of the core life-saving tasks on any hospital ward. We have many multimorbid patients. On average, 20% of them suffer a severe incident,’ said Bernd W Böttiger, Director of Anaesthesiology and Surgical Intensive Medicine at University Hospital Cologne. ‘To avoid such incidents emergency care guidelines explicitly demand monitoring vital signs and responding to emergency calls quickly. an 2019 – this June nose masks widely used in Asian countries outside healthcare. CSD offers masks not only in the usual hospital colours of white and turquoise, but many other hues, and even popular denim. A famous Taiwanese pop singer wore one of the masks in her most recent music video. The manufac- turer, who also produces surgical gowns, medical-grade gauze and disinfection swipes, has even part- nered with fashion magazine Elle to issue a special ‘Parisian’ edition of products with Eiffel tower prints. While in Europe these products are still few and far between, Asian exhibition visitors will most likely be delighted by the fancy masks. The Keeogo exoskeleton augments everyday movements such as walking, sitting or getting up www.healthcare-in-europe.com Professor Axel R Heller is Director of the Department of Anaesthesiology and Intensive Care Medicine at the University Hospital Augsburg. Previously, he chaired the Department of Emergency Medicine at the Technical University Dresden. He is an expert on the practical implementation of clinical research, including digital solutions for anaesthesiology and the ICU. cantly improve the quality of care. The vital signs of all patients in the 34-bed department of general and abdominal surgery are meas- ured and recorded digitally twice a day. ‘The procedure takes about one minute per patient,’ said Ivonne Lemke, interim head of nursing. ‘The team records many more parameters than before,’ she added. Digital cost reduction The Clinic of Anaesthesiology and Surgical Intensive Medicine at University Hospital Augsburg also uses an IT-supported early warn- ing system. Wireless measurement devices, mostly cuffs, record vital parameters at individually set inter- vals and continuously transmit val- ues to a central monitor in the nurs- es’ station – entirely independent of a patient’s location – even if moni- tored in their home. Frequently, cer- tain vital parameters start to dete- riorate 48 hours before the actual clinical deterioration. Depending on the type of values recorded, and the given risk pattern, the physicians or an emergency team is automatically notified. Whenever the early warn- ing system indicates deterioration of vital signs, the nurses monitor the Professor Bernd W Böttiger is Director of the Department of Anaesthesiology and Intensive Care Medicine at the University of Cologne. His work focuses on emergency medicine and promoting knowledge of resuscitation basics among the general public. He is also Director of Science and Research at the European Resuscitation Council (ERC), CEO of the German Resuscitation Council (GRC) and a board member of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI). patient more closely and can initiate measures proactively. treatment, When the ward cannot provide a recommended the patient can be moved to the ICU. Unnecessary moves, on the other hand, can be avoided – which reduc- es costs. ‘Per one thousand patients we see a significant decrease in emergency calls and circulatory arrests. Thanks to clearly defined early warning criteria the absolute number of necessary reanimations is on a low level – despite increasing severity and increasing number of patients,’ explained Professor Axel R Heller, Director of the Clinic of Anaesthesiology and Surgical Intensive Medicine at University Hospital Augsburg. Heller plans to use digital meas- urements systems more often in research: ‘With Smart Data, meaning the intelligent use of large data vol- umes, we can make real progress in anaesthesia and intensive medicine, in research as well as patient care, above all regarding early detection of patient risks.’ Philips IntelliVue Guardian with Early Warning Scoring is a customisable patient monitoring system combining software, clinical decision support algorithms and mobile connectivity. Used in a general ward, this helps to identify subtle signs of deterioration in a patient’s condition hours before a potential adverse event occurs Early warning, quick response To recognise, or even better, avoid signs of a patient’s clinical instability despite tight staffing, Sana Klinikum Lichtenberg in Berlin introduced IT-supported Early Warning Scoring (EWS) to its abdominal surgery department. After successful com- pletion of the pilot phase, EWS is now in regular operational mode. EWS is based on the vital signs: blood pressure, pulse/heart rate, body temperature, oxygenation and assessment of consciousness level. These parameters are regularly recorded by the nurses. When the score deviates, which might indicate a change in patient status the medi- cal team are alerted via smartphone in a cascading alarm system, ena- bling immediate response. Wireless sensors can be set to individually configurable time inter- vals, which allows tighter and site- independent monitoring and control of the vital signs without putting an additional burden on the nurses. Early warning systems that alert the medical team to problems signifi- Progressing with a strong partner Shaping the future of multi-organ support Since the end of 2016, Xenios with its subbrands Novalung and Medos has become part of Fresenius Medical Care, the world’s leading provider of products and services for people with chronic kidney failure. Fresenius Medical Care Deutschland GmbH 61346 Bad Homburg . Germany . www.freseniusmedicalcare.com Check out our new website www.xenios-ag.com

L A B O R AT O RY 7 research use only, there is a broad choice of platforms and solutions that meet the needs of individual applications, analysts, and organisa- tions. Expansive databases, methods and workflows that facilitate and add value to research, as well as intuitive software solutions that can be seamlessly integrated with exist- ing laboratory information manage- ment systems, are helping laborato- ries reach their goals in the shortest possible timeframe. With prompt support and effective training from instrument and con- sumables vendors, clinics and other organisations use their resources more efficiently and gain more from their teams. For clinical laboratori- ans and researchers to be confident of the integrity of the technologies they buy and use, and the data they obtain from them, it is imperative that vendors of LC-MS devices and consuma- bles meet the needs for routine clinical, lab developed tests as well as research apps. The Thermo Scientific™ Cascadion™ SM Clinical Analyser is an easy-to-use system designed for specialty testing in clinical laboratories or easy-to-use platforms or clinical labs Moreover, the choice of LC columns and eluent profile is also critical for the separation of the analyte of interest from isobaric or non- specific interferences, and avoiding ion suppression. Improving accessibility and support for users The operational nuances of LC-MS technologies, workflows and appli- cations, together with the expect- ed future analytical demands, all point towards the need for smart and easy-to-use platforms that help users overcome their analytical chal- lenges and achieve their scientific and business goals. Thermo Fisher Scientific is ena- bling implementation of LC-MS tech- nology in multiple environments with an optimal combination of analytical instruments meeting a range of regulatory requirements (Research use only [RUO] to Class I and Class II – product availability in each country depends on local regu- latory marketing authorisation sta- tus), easy to use software, and supe- rior application and service support,’ says Bradley Hart, Senior Director, Clinical Research, Chromatography and Mass Spectrometry Division at Thermo Fisher Scientific. ‘This pro- vides customers choice and flexibil- ity for solutions to cover the broad range of analysis for a variety of clinical applications.’ From Class I medical devices and Class II clinical analysers through to novel sample preparation options and for instruments designed In 1998, a year after physician Rainer Blasczyk completed his aggregate in transfusion medicine at the Charité, Humboldt-University Berlin, he was appointed university professor and director of the Institute for Transfusion Medicine at the Medical College in Hanover. In 2009 he became a member of the Scientific Committee of the European Federation for Immunogenetics and, from 2014 he has been a member of the management board of the Integrierten Forschungs- und Behandlungszentrums Transplantation (IFB-Tx) of the MHH, which receives funding from the Federal Ministry for Education and Research (BMBF). For the past four years Blasczyk has been active in the ‘Blood’ working group at the Robert Koch Institute, German Federal Health Ministry. ly increase the number of available organs by making re-transplantation less frequent. Until now the basic idea for avoiding a rejection has always been to modify the recipient’s immune system to attain an immunological blindness towards the transplanted organ, usually at the expense of life- long immunosuppression. Now the research objective has been complete- ly reversed – to make the donor organ immunologically invisible. www.healthcare-in-europe.com For in-vitro diagnostic use. Specifications subject to change. Cascadion SM Clinical Analyzer is CE marked but not 510(k)-cleared and not yet available for sale in the U.S. Availability of product in each country depends on local regulatory marketing authorization status. © 2019 Thermo Fisher Scientific Inc. All rights reserved. All trademarks are the property of Thermo Fisher Scientific and its subsidiaries unless otherwise specified. AD72925-EN0119SWith so much riding on something so small, why would you choose anything else?Be sure. Liquid Chromatography Mass Spectrometry for Clinical LaboratoriesContact your local Thermo Fisher Scientific representative for more informationEvery sample analyzed in your clinical lab carries the weight of doctors and patients waiting for the direction your results provide. Hence, leveraging the best analytical instruments allows you to BE SURE of the quality and timing of your results. Our new family of liquid chromatography mass spectrometry instruments for in vitro diagnostics are designed to provide clinical labs with consistent reliable results, faster.

L A B O R AT O RY 9 atory believes, should be better aligned with this group. However, why strive for the early detection of diseases that cannot be cured anyway – such as Alzheimer’s? Even in those cases, Gutensohn says, lab tests are beneficial for patients: ‘Today lab diagnostics for dementia might be ahead of ther- apy, but it may well be that in a few years an effective therapy will be available.’ Such progress – driven also by high-throughput pro- cedures, multiparametric analyses and big data-based algorithms – is very real, he points out. Moreover, today many diseases might not be curable but nonetheless early detec- tion can increase the quality of life, Gutensohn underlines. ‘Take anae- mia – the most frequent lab diag- nosis in older patients. If detected early on, a few simple measures, such as prescribing iron or vitamins as long as there is no significant further underlying disease, can do a lot of good and enable the patient to live a long and autonomous life.’ Professor Kai Gutensohn is Managing Director and Medical Director of AescuLabor Hamburg as well as Managing Director of Laboratory Group North of amedes GmbH. He has a board degree in laboratory medicine, transfusion medicine, haemostaseology, is health economist and professor at the Medical School of Hamburg University. He is also a member of several medical societies and associations, such as the German Association of Laboratory Medicine (BDL); the Society for Thrombosis and Haemostasis Research (GTH); the German Society for Clinical Chemistry and Laboratory Medicine (DGKL) and the German Society for Haematology and Oncology (DGHO) and the IGLD, Germany’s largest group for laboratory medicine. Small effort, huge benefit ‘Lab tests in geriatric medicine are invaluable, since they offer varied input that helps to ascertain the diseases of the 65+ cohort and thus to determine adequate treatment,’ Gutensohn points out. Rather sim- ple lab tests can show asymptomatic diabetes, which could cause severe damage. The individual patient, as well as the healthcare system at large, thus profit from such tests, he emphasises. ‘Lab diagnostics is the foundation – with €8.5 billion per year, it only accounts for 2.5 percent of the annual healthcare spend, but affects 60 to 70 percent of all diag- nostic and therapy cases.’ Since a major share of healthcare resources are used for older people, the diag- nostic and treatment options, he a sex specific 99th percentile. ‘That’s important because, in the past, the myocardial damage in women was not well detected and managed because we used to have just one 99th percentile for both male and females.’ Siemen’s reports: ‘High-Sensitivity Troponin I is the latest addition to Siemens Healthineers’ cardiac menu to assist clinicians with diagnosis/ treatment of chest pain patients, through the quantitative measure- ment of cardiac troponin I in serum or plasma. It allows clinicians to measure slight changes between serial troponin I values, giving con- fidence in patient results at the low end of the assay range. ‘Compared to traditional troponin assays, the Siemens Healthineers Continued on page 11 www.healthcare-in-europe.com www.gbo.com/preanalyticsGreiner Bio-One GmbH | Bad Haller Straße 32 | A-4550 KremsmünsterPhone: (+43) 75 83 67 91-0 | Fax: (+43) 75 83 63 18 | E-mail: office@at.gbo.com Wide product range for different vein conditions Reliable protection for user and patient Innovative safety technology combined with unique handling comfort Practical combination products with pre-attached needle save timeMake Needlestick Injuries HistoryVACUETTE® SAFETY Products

L A B O R AT O RY 1 1 Administrators should recognise the diagnostics revolution Sequencing technologies increase patient safety safety. Moreover, they can drive down costs, as the microbiologist explained. ‘Take two infections with the same organism in a certain ward. Usually, such cases are unre- lated but that is something you have to prove very quickly. If you can- not exclude a connection, the ward might need to be shut down.’ ongoing revolution in diagnostics. Sometimes they think microbiolo- gists just want some fancy new toys.’ Nothing could be further from the truth: sequencing technologies are important tools to increase patient For hospitals that also perform income-generating procedures the temporary closure of a whole ward obviously can result in a financial disaster. n g i s e d s t k / k c o t s r e t t u h S © another problem. Especially when it comes to metagenomics, there are limitations. To obtain high-quality genetic material recovered directly from environmental samples for research purposes is very difficult – hence having validated meth- ods to qualify a sample is all the more important. ‘We should invest more in quality control, training and standardising of methods to pave the way for integrating these tech- nologies,’ Moran-Gilad believes. Emerging diseases would benefit immensely from the new generation of sequencing methods. State-of-the- art sequencing can provide crucial information on infectious diseases that are either entirely new or have emerged in regions where previ- ously unknown. The pathogen itself or its genetic information can be isolated from a blood sample of an infected person. Depending on the vector, food or water samples can also be tested for the pathogen. In a next step, the results are compared to epidemiological data, Moran-Gilad said. ‘We want to understand the story: Where did this infection come from? Who infected whom?’ In a local outbreak, the regional hospital can most likely handle it. If the outbreak affects a wider area, a reference lab will be involved. These reference labs, in most cases affiliated to public health agencies, are in charge of diag- nostics for certain predefined infections. National reference labs cooperate on an international level. Surveillance networks collect data from different countries or regions. The European Centre for Disease Prevention and Control (ECDC) operates several such networks. One of the most successful accord- ing to Moran-Gilad is the European Legionnaires’ Disease Surveillance Network (ELDSNet). Legionella thrives in complex aquatic systems, such as the water infrastructure of large buildings – including hospitals and nursing homes. This is the vicious circle, says Moran-Gilad: ‘My general impres- sion is that hospital administra- tors don’t always acknowledge the Report: Michael Krassnitzer Gene sequencing has progressed in leaps and bounds over recent years. The process of determining the order of nucleotides in DNA is now faster and more precise. Moreover, both microbial DNA and host DNA can be identified in a patient’s infected blood sample, and isolated and sequence d. ‘We are facing a technological revolution, but we still struggle with actually implementing these new technologies in healthcare institu- tions,’ observed Professor Jacob Moran-Gilad, MD, MPH, Associate Professor at Ben-Gurion University of the Negev in Israel. At IMED 2018, in Vienna, the microbiologist and public health expert spoke with our European Hospital rep- resentative about the gap between the potential of the new generation sequencing methods and the clinical reality – meaning these technologies have not yet arrived – although they could be very useful, for example, for infection control. ‘Money,’ Moran-Gilad emphasised, ‘is not the main problem.’ A few years ago, these innovative meth- ods were indeed too expensive for clinical use, but they are increas- ingly affordable. The problem is rather a methodological one. While Microbiologist Jacob Moran-Gilad MD MPH is Associate Professor of clinical microbiology at the Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel. He is also senior advisor for Public Health Microbiology, Public Health Services, in the Israeli Ministry of Health and Chairperson of the ESCMID Study Group for Genomic and Molecular Diagnostics (ESGMD). generating masses of data with these sequencing-based technolo- gies, there is a lack of standardised methods to analyse the data rapidly and sufficiently to produce clini- cally actionable information. A lot of promising assays are not yet vali- dated, he pointed out. The lack of correlation between genomic findings and phenotype is Rapid myocardial infarction verification Continued from page 9 derful because it is very precise, you can compare the results day by day, and they are more or less the same.’ A next step is to conduct an eco- nomic evaluation on the use of the assays compared to the number of troponins previously requested by the clinicians from the laboratory. ‘We think there is less troponin now performed by the laboratory. We would also like to know whether the patients who can go home safely experience a shorter period in the emergency department, which is important for an institution.’ (MN) Atellica IM, ADVIA Centaur, Dimension EXL and Dimension Vista TNIH assays can detect lower levels of troponin and smaller changes to a patient’s troponin levels. ‘Both Troponin I and Troponin T are released into the circulation at the time of injury following the same release pattern in the sys- tem. However, cardiac Troponin I is slightly more differentiated from skeletal Troponin I than cardiac Troponin T is different from skel- etal Troponin T. Fasano is delighted with the performance of the Siemens High- Sensitivity Troponin I assay: ‘From a laboratory point of view, it’s won- www.healthcare-in-europe.com

D I G I TA L PAT H O LO G Y 1 3 The Lean concept in digital pathology We talked to Dr Annika Blank, Consultant and Lean green belt, about eight-year experience with the concept and optimisation of processes, the implementation of digital pathology and a voice recognition system for patient management. Interview: Walter Depner EH: In autumn 2014, Professor Alessandro Lugli reported on the first successful years the Lean concept use in pathology. Originally used in the automo- bile industry, this was designed to increase effectiveness, improve quality, processes, workflows and customer-orientation and much more. The system also impacts on the premises, staff (e.g. to avoid overtime), and added value. To what extent can you vouch for these improvements eight years on, and what else should be men- tioned? Annika Blank: The biggest and most cost intensive step taken to optimise workflows was the refurbishment of our laboratory, which was com- pleted in 2016. This allowed us to adapt our premises to the workflow defined by the Lean principles. The design of the laboratory with indi- vidual work stations is now based on the processing steps for the samples. A very open-plan design has helped to make the path of the samples through the laboratory vis- ible, to cut down on legwork and facilitate flexibility for innovations and communication. The increase in value-added time has freed up more time resourc- es for other responsibilities. This includes quality control and assur- ance, staff training and academic obligations, lectures and courses. Measures implemented so far have been very successful with regards to processing times. Now we are at the point where we need to opti- mise the defined processes further to avoid stagnation. We are facing two major challenges: actively fight- ing against ‘operational blindness’ by constantly scrutinising ourselves and our processes, and redefining processes to make them as simple as possible. Finding simple solu- tions for problems and ensuring that they can be implemented with ease often poses a great challenge. Pathology depends on coopera- tion with colleagues in many dif- ferent departments/wards inter- nally, as well as with those who send samples from outside the hospital. How has this coopera- tion developed in the context of Lean? One of the most important prin- ciples of Lean is the focus on the customer. The needs of the patient and of our clinical colleagues are at the centre of our work. We are constantly asking our senders for their opinions and suggestions for improvements through surveys and personal conversations, so that we can adapt our work to this as best possible. We see our task as simpli- fying the work of individual doctors. One process where this was implemented successfully was the introduction of standardised reports for malignant tumours. The stand- ardised reports make it easier to achieve a diagnosis as they contain all relevant information and contrib- ute to the completeness of the diag- nosis. The structure of the report has led to more clarity and compre- hension. Monitoring our processing times makes the release of reports and their availability to those who send in the samples more predict- able, which in turn makes it easier to plan the next appointments with patients to discuss the results. Close cooperation with clinical colleagues is also very important for the quality of the diagnosis as the interpretation of the histological results often depends on the respec- tive clinical context. What impact has Lean had on the case numbers and staff numbers The future holds workforce challenges compared to 2011? The number of staff members has increased by 7.5% since 2011, and the number of samples received has grown by 40%. The reduc- tion of legwork, waiting times and unnecessary work stages results in more efficient handling, making it possible to process more samples in the same amount of time, without increasing the workload of indi- vidual staff members per time unit. Digitisation of pathology has become an important topic over the last few years. One of the largest institutes in Switzerland, and one of the most important in Europe, must surely be part of this development. What progress have you made in Bern? At our institute, we integrated digital pathology into the workflows step by step in those areas where we see its implementation creating added value. Digital pathology has been an integral part of our research projects since 2012. Scanned histological sections can be used in many ways. They facilitate access to sections for international cooperation, can be evaluated with the help of image analysis procedures or used as the basis of annotations to develop so- called tissue micro arrays. Since 2016, we have been using an online platform to exchange information on certain cases with external assessors. Since 2017 this platform has also been used to display sections during case discus- sions with clinical colleagues and for tumour boards. Cost-benefit considerations are of essential importance in daily, rou- tine diagnostics. Digital pathology delivers added value for the evalua- tion of complex parameters, such as the proliferation fraction of tumours based on immunohistochemical markers. We are currently working on the development of robust algo- rithms for the evaluation of such parameters and will integrate these into diagnostic routine in spring 2019. Something that used to be laboriously counted by hand can now be analysed via automation, as long as it passes the pathologist’s plausibility check. Dr Annika Blank is Consultant at the Institute of Pathology at the University of Bern, Switzerland, where the Lean concept was introduced in 2011. Thus it became one of the first European pathology institutes to do so. Five years have now passed since a Lean audit in 2014, in which the institute scored very well. The period was used to gather considerable experience, to think about further innovations and continued improvements. Does the Lean concept impact digital pathology, and if so, how? As digital pathology will soon become part of routine diagnostics, it is integrated into our workflow of laboratory processes and must adhere to the Lean principles to keep up with the pace of our case processing. Lean principles can not only be implemented in the design of workflows but will also be used for the appropriate utilisation of our resources and for quality control, particularly for quality of scans. The institute’s annual report mentions that the introduction of voice recognition for the patient management system is an impor- tant component. How far have you progressed in this field? The introduction of voice recogni- tion in diagnostic routine was one of our main objectives for 2019, on a medical level. It was implemented in March and has proved itself for the drafting of short reports of find- ings. Voice recognition will continue to be adapted to our needs and requirements throughout the year until it is also suitable for complex reports of findings. Pathologists will hold a pivotal role Amid ever-growing demand for services, significant chal- lenges face the pathology workforce in the years ahead but – there are also good opportunities. in technology and With advances the advent of artificial intelligence as a decision-making support tool, Professor Jo Martin, President Royal College of Pathologists (RCPath) in the UK, believes there remain oppor- tunities for pathology to play a pivotal role in a new era of healthcare deliv- ery. After the latest National Health Service (NHS) long-term plan unveiled late last year, Martin pointed out that pathology can help address some of its issues and goals. Her views were outlined in her pres- entation ‘The workforce pressures fac- ing pathology and what are the poten- tial solutions’ during the Frontiers in Laboratory Medicine (FiLM) confer- ence in Birmingham, England, at the end of January, where workforce pres- sures and plans to address the chal- lenges were a key aspect. Speaking with European Hospital ahead of her presentation, the professor detailed the current workforce position within the UK, referencing new RCPath data www.healthcare-in-europe.com gathered from clinical biochemistry and histopathology colleagues, and also suggesting how the sector can support the National Health Service future more broadly. ‘Some of the NHS long-term plan objectives are only possible with the support of the pathology community and with investment and support for our workforce.’ Headline elements in the NHS 10-year plan include genetic tests for all children with cancer; putting the health service on a digital first foot- ing; giving patients personal budgets to fund their own choice of treatment; cutting back on bureaucracy; increas- ing spending on mental health; a i u j n u N m o o p k a P / k c o t s r e t t u h S © greater focus on prevention, genetics and more out-of-hospital care. One area where pathology has a role is also around the commitment in the plan to out-patient re-design and reducing the number of unneces- sary appointments by up to a third (in 2017-18, there were 119.4 million out-patient appointments, of which 93.5 million were attended), perhaps moving to a condition where a sig- nificant amount of patient follow-ups can be run from and by colleagues in pathology. ‘With good algorithms and systems designed by our clinical scientists and medics, we have models that would be very helpful, and take the pressure off our primary care and acute colleagues,’ Martin added. Other areas of the plan where pathology is essential are in rapid diagnostic centres, early diagnosis of cancer, and around mental health and prevention. ‘It’s about ensuring we have enough people in training, that people want to stay in work and Professor Jo Martin is President of the Royal College of Pathologists and a practicing histopathologist, specialising in renal pathology and gastro-intestinal neuro-muscular disease at the Royal London Hospital. She also directs Academic Health Sciences, Barts Health NHS Trust, and is Professor of Pathology at Queen Mary University of London. Her research interests lie in gastro- intestinal and neuro-muscular disease of the gut as well as drug development. enjoy what they are doing,’ she said. ‘Recruitment and retention are abso- lutely key, along with a commitment for continuing professional develop- ment, and improved interoperabil- ity with more robust IT to make the pathologists’ work easier.’ RCPath has conducted workforce surveys among clinical biochemistry and histopathology disciplines, with Continued on page 15

D I G I TA L PAT H O LO G Y 1 5 and colon cancer. Mitoses counting in breast can- cer usually takes pathologists 10-15 minutes. An AI algorithm could be used as a pre-screener that finds candidate mitoses to expedite the process. ‘We could click on the ones we like and don’t like and end up with a number of mitoses for a dif- ferent area, of typically two square millimetre.’ In nuclear segmentation in breast cancer, pathologists could segment the nuclei with image analysis algo- rithms without having to estimate in a subjective way. AI algorithms are also particu- larly helpful in immune infiltrate quantification, an important prog- nostic feature that proves more dif- ficult to assess in colon cancer than in breast. ‘You have more tissues, muscle, fat, etc.,’ he said, ‘and you only need to count a number of infiltrating inflammatory cells in a tumour area, so all areas must be recognised,’ Finding metastases in breast can- cer is a tedious task in which pathol- ogists typically have to put under and look at 50 slides, a process that can take up to 20 minutes. The missed rate is high. Van Diest and colleagues, who recently revised the original material from a big breast study, found that pathologists missed 23% of central node patholo- gies. ‘We need something to do a better job. AI did get better results than very experienced pathologists at detecting lymph node metastasis in breast cancer,’ he pointed out. The problem remains that, so far, very few AI algorithms have been implemented in clinical cases. ‘We are not there yet.’ Van Diest con- cluded. ‘Workflow needs to be com- pletely integrated and we need fully integrated image analysis, but we need to do this step by step.’ of staining, quality assurance of per- formance, implementation controls, and accreditation. A key advance would be for the elements to come together to pro- vide algorithms that are truly inter- operable and perform on different platforms, he said. ‘Digital pathol- ogy is progressing without these algorithms at the moment, but adop- tion will be speeded up when really useful algorithms come along.’ (MN) TMAs could be a vital screening tool for radiology Infusing tissue micro- arrays with new life Report: Mark Nicholls The advent of digital pathology is help- ing to address some of the chal- lenges surrounding tissue microarrays as they are integrated into the digital workflow, in some ways giving them ‘a new lease of life’, according to Professor Inti Zlobec, who spoke at the Digital Pathology and AI Congress in London last December. As Head of the Translational Research Unit at the Institute of Pathology, University of Bern, she pointed out the challenges surrounding next-generation Tissue Microarray (ngTMA) and explored the benefits of coupling with digital pathology in translational research. A long work history with tissue microarrays indicates that digital pathology is now ‘vital to the whole process’ of how TMAs are constructed. Reflecting on the early days of TMAs from 1998 and the combination of different spots on one block, Zlobec said the idea uses less resources and material and, by adding associated pathological data, a research tool can be created that can last 5-10 years. It was clear for some time that TMAs might be a valuable screening tool, and her team, which has a focus on colorectal cancer, was interested in tumour budding but the challenge was how to get budding on a TMA. ‘One solution was to incorporate digital pathology into the microarray workflow,’ she said. ‘The digital slide could be used to annotate exactly the region or multiple regions you wanted. By increasing the resolution, you could really see what you were putting on the TMAs.’ The next-generation Tissue Microarray approach, which utilises slide scanning and digital annotation Snapshot of an H&E stained next- generation Tissue Microarray as a basis for TMA construction, has been used in her lab since 2012. ‘The beauty of that is that you have fully annotated – and documented – spots and images. There was also the ability for every single spot to have clini- cal and pathological information and the clinical outcome for every single patient.’ Her Bern group created 720 TMA blocks with about 150,000 punches thumped physically into the blocks. While colorectal cancer was the main focus – about 30% of the blocks – the team also created tissue blocks for lung, pancreas, oesophagus, pros- tate and other areas. Ultimately the process led to more than one million images in the TMA archive from different tumour entities (after TMA cutting and staining) and all with the associated pathological annotation, histological information and clinical outcome… and poten- tially available for image analysis. ‘Now the problem is how to manage that number of TMA slides,’ she said. ‘A solution is with machine learning tools and having the TMA spots linked back to patients, whole slide images, annotative infor- mation and image analysis results, though this is still work in progress.’ Another question Zlobec posed was whether, with the ever-advancing technology, TMAs are still relevant and, she noted, the num- ber of annual publications on the sub- ject had plateaued in recent years at about 600. The original aim of TMAs of screening and resource efficiency, she said, was still relevant and, they can be used to study heterogene- ity, biomarkers, and to capture the tumour environment. More recently, the Bern group has developed a tool (Scorenado) that provides an inter- mediate solution to image analysis, Professor Inti Zlobec heads the Translational Research Unit at the Institute of Pathology, University of Bern. Her interests lie in inter- disciplinary translational research to improve the clinical management of patients with colorectal cancer and in histomorphological biomarkers as prognostic and predictive features of tumour response to therapies. Single spot from a next-generation tissue microarray of colorectal cancer stained with pan-cytokeratin facilitating user-friendly visual assess- ment on digital slides. Today, TMAs are a resource in the machine learning era for classification or prognosis and prediction for patient outcomes and also for translation into clinics. ‘They also combine technology with molecular applications – we can take the punch we put on a TMA and then put it into a tube to do the sequencing, giving us the kind of documentation we really need,’ Zlobec explained, also pointing out that digi- tal pathology also can complement mass spectrometry, identifying and validating new biomarkers. As digital pathology evolves, its added value to TMA use becomes clear. It improves, she pointed out, the quality of bio- marker studies with precise ngTMAs that quickly capture ROIs; uses digital image analysis; improves documenta- tion; aids biobanking and the accredi- tation process; it also offers high quality pathology standard annotation of images, and can be combined with molecular applications. Additionally, using the image as a biomarker adds a huge wealth of morphology infor- mation. Pathologists will hold a pivotal role Continued from page 13 In 1997, NHS consultant pathologist Professor David Snead works at the University Hospital of Coventry and Warwickshire, where he is clinical lead for Cellular Pathology at Coventry and Warwickshire Pathology Services. Having led the implementation of digital pathology at the centre, his main research interests lie in extending the capability of digital pathology for routine diagnostic use and the advancement and deployment of computer assisted diagnostic algorithms. the haematology survey in progress. Data from the clinical biochemistry survey is currently being analysed with results imminent, but findings from the histopathology report have been described by Martin as ‘grue- some’. ‘The survey showed that 97% of laboratories do not have enough histopathologists, and it’s going to get worse. 2021, we are expecting somewhere around 25-28% gap in the histopathology workforce. ‘RCPath is making the case for more pathologists, with support from a range of charities and other organisa- tions, in its efforts to get investment in the laboratory and diagnostic work- force. This data means we can show exactly what the issue is.’ Pressure has grown in recent years because of increased workload, not enough trainees, with a lower pro- file in medical schools and limited opportunities to meet pathologists. Additionally, an ageing workforce exists with a quarter of histopatholo- gists aged 55 years or over, as well as the risks of stressed practitioners opt- ing for early retirement. ‘We need to de-stress the system to take the heat off current people so that they are prepared to stay,’ Martin emphasized. Digital pathology and AI support will help, she believes. With high levels of pathology expertise in the NHS, she remains optimistic about the future for pathology with the various disciplines poised to play a pivotal within future diagnosis and care delivery. (MN) Lluís Donoso-Bach gained his medical degree from the School of Medicine of the Autonomous University of Barcelona in 1981. He completed his residency in radiology at the Hospital de Sant Pau in Barcelona, in 1992, and in that year was appointed Chairman of the Radiology Department at the UDIAT Diagnostic Centre. In 1998 he became its Executive Director. Since 2006 he has led the Diagnostic Imaging Department at the Hospital Clínic of Barcelona and been Professor of Radiology at the University of Barcelona. gration of image analysis and deep learning. During diagnostic work, we often use completely subjective features to make a diagnosis. For example, we diagnose cancer when we see, within the tissue, big nuclei, variation of shape or size between the nuclei, or when the chromatic pattern of nuclei are irregular, etc. But these are all subjective, and we’re easily tricked in our visual system in assessing size, so we’re going to measure it,’ he explained. Ideally pathologists could use AI and image analysis in several appli- cations, e.g. mitoses, nuclear area, degree of tubule formation and metastases finder, ‘a tedious task, where we might miss things.’ Integration would also make sense in immune infiltrate quantifi- cation; IHC membrane scoring and positive nuclei scoring; and tumour vs. stroma quantification, which is becoming quite popular in breast el analysis efits in tumour cell morphometrics to predict survival in lung adeno- carcinoma. Similar work is being conducted for prostate cancer and breast carcinoma, he said. In several tests/challenges Snead acknowledged how the computer is at least as good as the pathologist and sometimes probably better, e.g. to predict which lung cancers har- bour mutations in the EGFR gene. The UK government is funding five centres to advance AI in image diagnostics. Digital pathology is central to three of these centres including the Coventry PathLAKE centre, of which Snead is director. This initiative is designed to con- nect the UK’s excellence in AI, its strength in real world NHS clinical data and the innovative SME start biotech sector, to encourage innova- tive ideas and solutions. However, he warned, ‘Such solutions will only get into the clinic if we can validate these tools and get them approved through our regulatory framework.’ He remains confident that this can be achieved by working with regula- tors and helping to align processes with the FDA, and across the EU. Digital image analytics is mov- ing into practice, he said, but there are many challenges that remain including interoperability across platforms, variability of sections and www.healthcare-in-europe.com

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R A D I O LO G Y 1 9 Dr Irene Burger at the Nuclear Medicine Dept, University Hospital Zürich She pointed out that PSMA is ‘not a prostate specific tracer’, but also over-expressed in neovasculature and therefore positive on various solid tumours, before briefly com- paring its performance with Choline and GRPR (gastrin releasing peptide receptor) PET, noting the latter had the advantage of being more spe- cific within the prostate. She said choline PET/CT was not useful for the primary tumour but has a higher sensitivity and speci- ficity for lymph node metastasis or distant metastasis than CT, MR or bone scan. It is useful, she added, to detect disease in biochemical recurrence, but only after a PSA of 2 ng/ml, and pointed out that salvage radiotherapy should be performed before PSA of 1.5 ng/ml. Therefore, whenever available, the PSMA-PET is now used for bio- chemical recurrence, given the sig- nificantly superior detection rate for PSA values as low as 0.2-0.5 ng/ml. This led to a significant change in the radio oncologic approach for those patients, Burger explained, since early biochemical recurrence does not receive a ‘blind’ salvage radiotherapy to the prostate bed anymore, but can be targeted to the PSMA-positive lesion, often not localised in the prostate bed. Burger added that, for staging high risk prostate cancer, PSMA-PET has a superior sensitivity compared to MRI or Choline PET for lymph nodes and distant metastasis. Prostate cancer heterogeneity negates one perfect method WB-MRI improves disease evaluation Frederic Lecouvet, from the Catholic University of Louvain in Brussels, Belgium In one step, whole body MRI including anatomic T1 (left) and functional diffusion weighted imaging (DWI) sequences (right) shows bone (red circles) and lymph node metastases (yellow circles), providing a one-step staging of prostate cancer, non- irradiating and with no need of contrast material or radiotracer responded. ‘WB-MRI will inform about response and progression early and detail early disease and relapse - it is indeed a very comprehensive technique.’ Early identification of treatment failure, she added, not only spares futile treatment but also potential toxicity and reduces the cost of ineffective treatments as well as decreases the time to the next line of potentially effective treatment. In conclusion, Tunariu pointed to the imaging response to prostate cancer on WB-MRI: it offers early detection of response, especially in bone lesions; early detection of local relapse; accurate assessment of visceral metastases and of any complications. Dr from Irene Burger the Department of Nuclear Medicine at University Hospital Zürich, looked at PET and PET/MRI in prostate cancer, and the role of PSMA in prostate cancer. tive information. Dr Nina Tunariu, consultant radiologist at the Royal Marsden Hospital, London, concen- trated on ‘WB-MRI Response and Assessment’ and told the congress session that imaging approaches to prostate cancer had changed signifi- cantly over the last decade, primar- ily driven by patient and clinician expectations. She said bone scans are still requested by clinicians but are no longer necessarily an essential part of the process because they offered late detection and poor accuracy. Another issue, she said, is that active disease depends on the image you use. ‘Prostate cancer is very heterogenous, so there will not be a perfect single technique,’ she pointed out. ‘Diffusion MRI as part of WB-MRI will help you see more lesions when other imaging tech- niques are letting you down, while WB-MRI can show a response to treatment whereas CT and a bone scan will not tell how a patient has Whole-body magnetic resonance imaging (WB-MRI) is championed as offering significant benefits, such as improving disease evaluation for prostate cancer patients. ment. ‘It’s an intrinsically hybrid technique,’ Lecouvet pointed out. He demonstrated that WB-MRI provides an all organ approach and looks beyond the skeleton to the nodes, liver and lung. From there, its indications are extending beyond prostate cancer to renal, testicular, ovarian, breast, lung cancers, and to haematological malignancies. Lecouvet also outlined the MET- RADS-P reporting template for pros- tate cancer. The recommendations are designed to promote standardi- sation in the acquisition, interpre- tation, and reporting of WB-MRI prostate cancer. Used at different time points during the disease, it allows the evaluation of patients for response to treatment of the bone, node and visceral lesions that are recorded and followed-up using morphological and quantita- Report: Mark Nicholls During an intense session in genito- urinary cancer at the ECR 2019, three key speakers focused on the advantages over conventional imag ing modalities – including bone and CT scans – as well as discuss- ing new PET (Positron Emission Tomography) tracers, and raising concerns about the relevance of the current Prostate Cancer Working Group (PCWG) guidelines within the evolving diagnosis and treat- ment landscape. The ‘Whole body imaging in metastatic urinary tract and pros- tate cancer’ session was chaired by Professor Anwar Padhani, consult- ant clinical radiologist at Mount Vernon Cancer Centre in London, who initially posed questions about which techniques to use and when. He suggested that conventional imaging can lead to poor confi- dence for assigning clinical states and assessing therapy benefits for bone disease. Limited imaging tools cannot accurately predict metastatic disease presence and extent, or are unable to identify who is not benefiting early after starting treatment; they also are limited in depicting het- erogeneity of biologic behaviour of bone disease, Padhani pointed out. Professor Frederic Lecouvet, from the Catholic University of Louvain in Brussels, Belgium, explained that metastases from prostate cancer mainly involve the skeleton and lymph nodes, and that two ‘modern imaging modalities’, WB-MRI and PET, are the current best options, with significant advantages from WB-MRI. ‘Whole body MRI – covering the body ‘from eyes-to-thighs’ – can detect metastatic infiltration of the bone marrow; it also plays a role in detecting lymph node infiltration and, most importantly, it can assess response to treatment,’ Lecouvet told delegates. He compared WB-MRI with PSMA PET-CT in several examples. WB-MRI examinations should include both T1 and STIR ‘anatomical’ sequences, and ‘functional’ diffusion sequences, providing a PET-like image. ‘The combination details the anatomy and characterises the lesions, yet offers functional information on tis- sue viability and response to treat- www.healthcare-in-europe.com

R A D I O LO G Y 2 1 iver that enhances patient welfare ventricle surfaces no longer need to be added up manually. The comput- ers do the drudgery. At the same time the different brain regions are labelled automatically, which is very helpful in the diagnosis of neurode- generative diseases.’ When these and other results, let’s say of liquid biopsy, are linked – or, to be precise, if a computer is asked to link them – a full picture of the patient is generated. This is an immense added value for therapy but also for prevention purposes. No doubt there are obstacles to overcome, for example non-stand- ardised procedures, such as MRI, where every radiologist uses the sequences and protocols he or she considers most appropriate in any given case. Since there are no ref- erence values, such as Hounsfield units in CT, data integration poses a challenge. ‘Consensus is virtu- ally impossible to reach, since an image that is considered good by a radiologist in the USA, might be viewed sceptically in Asia and Europe,’ Zindel says, but he adds a way out ‘might be MR fingerprint- ing, which, for the first time, offers quantifiable data.’ A new and crucial role While Zindel, unlike many others in the industry, does not consider artificial intelligence (AI) to be a panacea, he is convinced that it will drive progress in several areas of healthcare: ‘Smartly used, AI has enormous potential, above all when ing options in an abdominal emergency Based on MR images and ECG measurements, digital twin technology simulates the physiological processes of a patient’s organ. Virtual planning is used to visualise responses to treatment before the intervention. Siemens Healthineers is developing algorithms that generate digital models of organs based on vast amounts of data. Source: Siemens Healthineers it comes to simplifying and accel- erating processes – which in turn will improve productivity.’ While the machine takes on the role of supporter, humans will continue to make the final decisions – a sce- nario which will not change any time soon, says Zindel. The algo- rithm for image data analysis can already discard irrelevant images; Illustration of acute, ongoing arterial bleeding in the liver with added value of virtual non- contrast series: On the left picture from the arterial series a huge hyper-attenuating zone (arrow) is visible above a moderately hyperattenuating mass (asterisk). On the right, on the virtual non-contrast reconstructed series, the acute bleeding zone is removed, due to the presence of a high percentage of iodine (active extravasation). The moderate hyper- attenuated mass did not change because of the absence of iodine there is diffuse abdominal pain, its low sensitivity for free intraperito- neal gas and for non-obstructive renal stones, as well as a lower spa- tial resolution than CT. Millet explained ways to optimise MRI protocols, such as by limiting the number of sequences and multi- planar acquisitions as well as using compressed sensing technologies that allow a decrease in acquisition time and would permit T1 weighted images acquisition in free breathing with very low temporal resolution. In future, she hopes MRI will replace CT as a first line imag- ing modality for appendicitis/diver- ticulitis and also to investigate bowel Illustration of added value of lower keV reconstructed images when the vascular phase is of poor quality, like in this case of suspicion for an acute aortic dissection obstruction and diagnose bowel per- foration, and accurately assess uro- logic emergencies. However, for now, ‘There is a need for standardisation of MRI protocols, assessment of enhanced sequences added-value, and for further radiolo- gist training and education to be at ease with MRI images and their inter- pretation,’ she pointed out. One area that has proved effective to diagnose A renal abscess with typical arterial rim enhancement (left) and washout (right) is nicely depicted in the CEUS images of this young woman in high fever The CEUS image (left) shows a partially liquefied abscess (arrow), which is less conspicuous in the basal ultrasound image (right) www.healthcare-in-europe.com thus the radiologist has to deal with a much smaller number of images than before. Drudge work, such as the manual counting of lesions, is history since AI performs this task faster and better. In differential diagnostics, in par- ticular, Zindel expects AT, combined with Big Data and radiogenomics, will trigger quality leaps: ‘Going for- ward we may well have a troika of physician, patient and AI that jointly stratifies the patient. Not only the cooperation between radiology and pathology will profit from increased standardisation, the patients will also benefit because AI-processed data will provide information the patient can understand.’ In this scenario, Zindel says, the radiologist will assume a new, but still crucial role as a guide navigat- ing the sea of patient data. ‘The important issue about Big Data is not the fact that we need more data, but that we must be able to cull the relevant information from the sheer mass of data.’ In the long run, this development will render proprietary data silos obsolete, since going it alone is not an option with huge data volumes. ‘The future belongs to collaboration; it is the driver that enhances patient welfare.’ Thus, collaboration will be the starting point of future-proof business models – models that are no longer based on services ren- dered but on value generated. abdominal conditions in an emer- gency setting is contrast enhanced ultrasound. ‘Adding contrast increas- es the efficiencies of ultrasound in the emergency setting, and CEUS is also very useful in follow-up,’ said Dr Teresa Fontanilla, from the Hospital Universitario Puerta de Hierro- Majadahonda in Madrid, Spain. Fontanilla has looked at the CEUS role in abdominal inflammatory and infectious conditions, highlight- ing the use of contrast when view- ing hepatic abscess. ‘CEUS can help when there is an indeterminate sus- picious mass and to determine the degree of liquefication to decide on drainage and antibiotics, or just anti- biotic treatment.’ In addition, she suggested CEUS is a valid tool for gastrointestinal tract and gynaecologic inflammatory lesions and at times for cholecystitis and prostatitis, offering delegates vis- ible examples. CEUS can identify inflammatory bowel disease complications, appen- dicitis and diverticulitis complica- tions and differentiate abscesses from phlegmon and measure abscess size, she added. There are limitations to CEUS, e.g. a poor window and difficulty in detection of very small lesions, but, she said, ‘CEUS is an efficient, case-solving tool in selected cases in the emergency setting and has a general-purpose role in any abdomi- nal inflammatory condition. It can also be used if there is a suspicion of drainage catheter obstruction or fis- tula and for follow-up away from the emergency setting. ‘It offers real-time, quick, assessment without radiation and nephrotoxicity.’ However, she added, the big advantage with CEUS is in direct patient contact,often at the bedside. (MN) PET and MRI provide complementary information on several clinical applications, including cancer. While MRI offers high-resolution imaging of anatomical structures with high soft-tissue contrast, PET visualises metabolic processes inside the body. The combination of these modalities has great potential for improved detection and therapy monitoring in oncology. Source: mMR Munich (TUM/LMU) Professor Etienne Danse, from St Luc University Hospital, at Louvain’s Catholic University, Belgium Professor Ingrid Millet works in the University of Montpellier, France Teresa Fontanilla is from Hospital Universitario Puerta de Hierro- Majadahonda in Madrid, Spain

R A D I O LO G Y 2 3 WHO: ‘Refugees do not bring diseases to western shores’ Detecting migrant health risks legal barriers, health service capac- ity and continuity of care,’ he said. of Diagnostic and Interventional Radiology in Heidelberg. ‘TB is the most common infectious disease in the migrant population. There’s a difference between TB in the migrant population, which affects mainly young people, and TB in the host population, where it’s typically a disease of the elderly.’ The main challenge for radiolo- gists in pulmonary TB is to differen- tiate between active and inactive TB. TB or not TB The most common migration diseas- es relevant to radiology are pulmo- nary and extrapulmonary tubercu- losis (TB), according to Tim Weber, senior physician at the Institute Tim Weber MD is a senior physician at the Institute of Diagnostic and Interventional Radiology, in Heidelberg University Hospital, Germany. Continued on page 24 early detection and correct treat- ment of diseases is key. ‘The links between migration and radiology are worth exploring, espe- cially regarding access to services, Ultrasound The migrant population is fast growing and heterogeneous. Experts at a session held dur- ing the European Congress of Radiology (ECR 2019) concluded that radiologists can play a key role in detecting and differentiat- ing related diseases. Migration is a growing phenome- non and has an impact on health, according to Jozef Bartovic from the World Health Organisation (WHO) in Copenhagen, Denmark. ‘We’ve seen a huge increase in migration over the last few decades, and about 10% of global population today are international migrants. There is a huge heterogeneity of resources, backgrounds, exposure to risks, which are all important to consider in healthcare. Refugees are just 7% of all migrants,’ he said. Key migration factors can lead to health problems before, during and after migration. War impacts on mental health before and after migration. Violence during migra- tion, for instance smuggling, burns or drowning, has consequences on a migrant’s health. Discrimination and low levels of integration in the host country can also trigger health problems. The WHO refugees and migrants’ health in Europe report states: Migrants do not bring diseases with them to their country of destination. ‘Refugees and migrants are general- ly in good health, but can be at risk of falling ill during the transit period and in the receiving countries, due to poor living conditions and adjust- ment to their new lifestyle,’ Bartovic pointed out. Considering the incubation period of most bacterial and viral infections, most migrants will be either cured or dead by the time they arrive in the destination country. Living in a refugee camp, for instance, can pro- voke a number of diseases that can be fatal and take up considerable healthcare funds if untreated. Very Technical officer Jozef Bartovic at WHO/ Euro, contributes to the PHAME project, the Knowledge Hub and the Migration and Health Knowledge Management Project. Previously, working for the Regional Commission for Western Asia of the UN Secretariat in Beirut, Lebanon, he covered migration and displacement issues in the Arab region. Originally from Slovakia, after com- pleting political studies he worked in the UK for the Ministry of Health, Public Health England (Health Protection Agency) and the NHS on screening programs, sexual and reproductive health and primary care access. www.healthcare-in-europe.com Next-generation ultrasound. Elevated performance. The Philips EPIQ Elite for general imaging ultrasound system brings an exceptional level of performance, workfl ow and advanced intelligence for today’s most demanding practices. Expect fast, consistent, easier exams across all clinical segments. EPIQ Elite enhances diagnostic confi dence, helping you deliver a new class of care to your patients. There is always a way to make life better. See the EPIQ Elite video at www.philips.com/epiq