2 N E W S & R E S E A RC H Discovered: what make us humans Continued from page 1 Hebrew University of Jerusalem, Israel, said that, to really understand the human brain and what makes us human, ‘it is essential to study the human brain at the detailed level of cells and the synaptic connections’. He explained that this can be challenging because of the complex- ity of the human brain and because of ethical and technical limitations. ‘To overcome these limitations, we built 3-D computer models of human neocortical pyramidal cells. We chose cortical pyramidal neurons because they are the most abundant cell in the cortex,’ he explained. ‘Ramon y Cajal, the researcher who discovered pyramidal neurons, called them “the psychic cell”.’ ‘The pyramidal neurons are larger in humans than in rodents and they also have more dendritic branch- es, which potentially makes them a more sophisticated computing device. As such, “what makes us human” also implies that, even at the single-cell level, we are more computationally-sophisticated,’ Segev observed. Their detailed digital model for human cortical pyramidal neurons is the first to integrate these dis- tinct anatomical and physiological features, thus enabling the team to identify several new proper- ties of human neurons and ana- lyse their functional implications using advanced computational tools. Pointing to the difficulties of this research, he said it was a chal- lenge to obtain the neuronal tis- sue from the hospital, recording and reconstructing the neurons and then making sure that the computer model was accurate. The team used Model predicts that HL2/L3–HL2/L3 excitatory synapses are formed at proximal dendritic sites. (A) Pair recording from HL2/ L3 PCs. A presynaptic spike was initiated in a cell (lower left trace) and the postsynaptic EPSP was measured in another cell (lower right trace). The shape index of this EPSP is defined by its rise time and half-width (bottom right). (B) Top: Theoretical shape-index curve for the modelled cell shown in (C), as a function of distance from the soma. Colours code for the physical distance from the soma; colour circles for apical inputs and colour diamonds for basal inputs. Bottom: Zoom-in into the square demarcated at the top frame. Black circles are from 10 experimental somatic EPSPs. The large filled colour circles with radius of one ms are centred around the loci of the respective four experimental EPSPs shown in (D). (C) Modelled cell used in (B), with dots depicting the predicted synaptic locations that give rise to somatic EPSPs whose shape indices fall within the corresponding large coloured circles in (B). For example, red points are all synaptic contacts that yield rise-time and half-width that are within the red circle in (B). (D) Four experimental EPSPs (black traces) from four connected pairs of HL2/L3-HL2/L3 pyramidal cells and the theoretical EPSPs (100 model fits, per experimental EPSP, in colour traces, with their mean depicted by the dashed white line) corresponding to the respective colour dots in (C). The peak synaptic conductance, for each of the putative dendritic synapses, was obtained by fitting the theoretical to the experimental transients. The recordings in (A) were taken from a pair of cells that were not reconstructed, and the HL2/L3 morphologies are shown here only for illustration of the method. a cluster of computers to ensure the model fitted their experimental requirements as well as to speed up the computations. They also devel- oped new algorithms to help this fit. Their computer models revealed how human pyramidal neurons effi- ciently process a larger number of more powerful synaptic inputs, assisted by their lower membrane capacitance, compared to rodents’ neurons. ‘Human cortical cells have Early preparation pays off, but hurdles remain Software gains highest- risk MDR certification Medtech companies operating in Europe are preparing for a busy year, with the end of the transition period for the European Union’s Medical Device Regulation (MDR) fast approaching. After the May 2020 deadline, all new medical devices must meet MDR require- ments in order to be placed on the European market. Meanwhile, exist- ing devices that have already been certified under previous legislation will have to be recertified under the MDR by 2024. In September, Berlin-based Biotronik achieved the industry’s first MDR certification for a device in the highest-risk Class III cat- egory, after obtaining approval for its Renamic Programmer software. The company says the achievement comes down to a preparation effort dating back three years, but that challenges still remain to meeting MDR requirements in time. The MDR replaced both the previ- ous Medical Device Directive and the Active Implantable Medical Device Directive with a single regu- lation governing product certifica- tion across the EU. Although com- panies have until 2024 to recertify existing products, parts of the MDR remain open to wide interpretation, says Roman Borkowski, Biotronik’s Senior Vice President, Quality Management and Regulatory Affairs, Biotronik Renamic Programmer. The Renamic’s software was the first Class III (highest-risk) product worldwide to achieve certification under the new MDR. Cardiac Rhythm Management. This leaves open the question of how firms might have to adapt while the regulatory ambiguities are gradually clarified over the next few years. ‘The “MDR journey” has only just begun and there’s still a long way to go,’ he says and points out that while Biotronik agreed on a transi- tion plan with its notified bodies earlier this year to recertify exist- ing products, the firm anticipates it will have to use almost the full length of the transition period for legacy products that ends in 2024. ‘Although manufacturers are prepar- ing themselves as best as possible, complete guidance has not yet been published, many standards have not been harmonised, the majority of necessary implementation acts have not been adopted, and common specifications do not exist yet.’ With the number of products that must be recertified, in addition to the new technologies companies will seek to launch on the European market, Borkowski predicts regula- tory bodies may be heavily back- logged – especially towards the end of the transition period. So, what can organisations do? Some are expected to pull certain existing products rather than recer- tify them. on this, Borkowski recom- mends that companies do whatever they can do to prepare now with the information currently available. ‘The faster a manufacturer starts with the practical implementation of the known interpretations of the MDR, the easier it will be to adapt later and ultimately imple- ment the necessary changes suc- cessfully in order to comply with unique membrane properties, with more efficacious excitatory synapses that compensate for their highly- branched and elongated dendritic tree. ‘Combined, these properties boost their computational power,’ Segev explained. ‘This suggests that human neurons, compared to rodents’ neurons, are fundamentally more powerful in their ability to integrate, process and store infor- mation. These cells support nearly double the number of simultane- ous, independent synaptic inputs to be conveyed from the dendrite to the cell body, which explains the enhanced computational capability of these cells. Unlike biopsy mate- rial, their computer model can inte- grate plastic processes at the syn- aptic level – thus the neuron model and its synapses may change due to the cell’s activity in the computer model. ‘We were quite surprised by our findings,’ he added. ‘We weren’t aware of the enhanced complex- ity of human neurons compared to rodents.’ Segev, looking at what lies ahead with this research, said: ‘We have made significant advances model- ling human hippocampal neurons – the “memory region” of the brain. ‘In the next decade we will see a growing effort, worldwide, to under- stand the human brain at the local circuit level. Next, we want to build a whole human cortical circuit – like we did for the mouse under the “Blue Brain Project”.’ Sources: Frontiers in Cellular Neuroscience:; Blue Brain Project:; Frontiers Science News. Roman Borkowski, Senior Vice- President for Quality Management and Regulatory Affairs, Cardiac Rhythm Management at Biotronik the MDR,’ Borkowski points out. Biotronik began with a cross-depart- ment project in 2016 to first recer- tify its programmer software. The firm also focused on collaborating with numerous industry associa- tion working groups across Europe, to gain a sense of how the MDR was likely to work in practice. This helped to prioritise products, like the Renamic Programmer software, that are widely used but required less expert panel involvement to achieve certification. Borkowski argues it is a harder result to duplicate in other products, ‘but we are prepared to fulfil the conditions required for recertifica- tion until 2024,’ he points out. ‘Many changes to legacy products will be limited during this time because any such changes, for example ones involving component availability, would require immediate certifica- tion under the MDR. But we are confident that the steps we’re taking will allow us to ensure a seamless continuity of supply during a chal- lenging time for how we handle regulatory compliance.’ EUROPEAN HOSPITAL Vol 28 Issue 6/19

4 N E W S & R E S E A RC H TAITRA at Medica 2019 A vision of Taiwan innovation A popular proverb in Mandarin goes ‘Hearing something a hundred times is not as good as seeing it once’ ( Taiwan pavilion at this year’s Medica, it’s clear to see that the Bureau of Foreign Trade (MOEA) from Taiwan, together with the Taiwan External Trade Development Council (TAITRA) and its foster companies, have taken this sentiment to heart. Seeing virtual and augment- ed realities through a VR headset, watching AI in digital pathology through the eyepiece of a microscope – the power of images was clearly on the exhibitors’ side. They showed their guests some of the innovations that have propelled Taiwan from former manufacturer nation to one of the leading developers in medical technology and healthcare solutions. ). Visiting the Report: Wolfgang Behrends ‘We are looking at a new wave of Taiwan innovations to transform the medical world’, announced Karen Pai during the ‘Taiwan Excellence’ press conference. As Deputy Executive Director she underlined the ambi- tious expansion of med-tech TAITRA promotes as ‘Best Made in Taiwan’ with its impressive growth rate of 10.73 percent in 2018. It is hard to deny the nation’s global impact. 253 Taiwanese companies presented their products at Medica 2019. Every year, 20 of this country’s manu- facturers are awarded the ‘Taiwan Excellence’ accolade to acknow- ledge their outstanding approaches to VR/AR, 5G, AI and robotics in medical applications. At Medica, manufacturer HTC DeepQ presented the latest refine- ment of their virtual reality set, the Vive Pro Eye, as well as a 5G hub. Whilst both products may be geared towards entertainment, their use in healthcare is also apparent. With new eye-tracking features, the Vive Pro Eye analyses the wear- er’s attention and focus areas. ‘This creates a whole new level of immer- sion, for example in augmented reality surgery training’, explained Lewis Chang, Product Development Manager at HTC DeepQ. At this point Richard Vincent, CEO of FundamentalVR joined the conver- sation. The company’s software – a ‘flight simulator for surgeons’, as Vincent put it – now supports the advanced features of the Vive Pro Eye. This is complemented by the HTC 5G hub, which provides the high-speed mobile data infrastruc- Five winners received the coveted Taiwan Excellence award Visitors were keen to connect with the ‘Taiwan Excellence’ winners during Medica 2019 Robots might soon guide patients and families through hospital visits – some Taiwanese hospitals have already begun to deploy these mechanised helpers The potential of VR for surgery was explored by HTC subsidiary DeepQ ture for advanced wireless medical equipment, VR and telemedicine. Virtual realities are also the domain of Taiwan Main Orthopaedic Biotechnology, another ‘Taiwan excellence’ winner. The firm’s CEO, Min-Liang Wang PhD, brought improved versions of the company’s smart surgical glasses and virtual anatomy table. The new editions expand the application areas from medical education and intricate procedures like spinal surgery to minimally-invasive techniques. A new 3-D endoscopy system, cou- pled with smart glasses, provides detailed insight into a patient’s body via augmented reality, with critical anatomical structures and instrument position superimposed on the viewer’s glasses. ‘The addi- tional information shortens proce- dure duration, improves the overall outcome and puts less strain on the surgeon’, Wang PhD explained. Counting on AI counting Artificial intelligence in medicine is a definitive mainstay at Medica, so aetherAI presented a cell counting algorithm for leukaemia differentiation the great enthusiasm for aetherAI’s digital pathology solution was hard- ly surprising. Their AI model, named Hema, specialises in the automatic differential cell counting of a bone marrow smear – a vital task to dis- cern specific forms of leukaemia. ‘Five years ago, this was an impos- sible challenge for imaging solu- tions’, aetherAI CEO and co-founder Joe Yeh. ‘With the help of AI, we now can.’ Trained with a dataset of 300,000 annotated bone marrow cells, the Hema AI can perform in five seconds what might otherwise take up to half an hour – even for a well-trained haematologist. The spread of knowledge is the driving force behind the wire- less medical camera developed by Taiwanese manufacturer Faspro. This head-mounted device can record up to 24 hours of video footage and enables live stream- ing. This is more than just a GoPro for doctors, company representative Adam Horng stressed. ‘Instead of providing a wide “fish-eye” perspec- tive, our camera features a narrow field-of-view – 10 to 28 degrees – and autofocus with low minimum distance, to accommodate for sur- gery and dentistry settings.’ Other than sharing videos for educational purposes, the system is designed to reduce the burden of procedure documentation. Accessories for the camera system include an advanced light source and foot pedals for hands-free recording control. An advanced video streaming solution was presented at Medica by Advantech. Based on the com- pany’s expertise as a provider of integrated computing systems, the system, named AVAS, manages video inputs from multiple 4K sources. This allows for combination and simultaneous display of up to four different camera feeds, vital moni- tors, radiology images, virtual 3-D patient models and more, while integration into the hospital infor- mation system (HIS) ensures com- patibility of many different formats. Strengthening relations In addition to the five ‘Taiwan Excellence’ winners highlighted at the Taiwan Excellence press con- ference, the Taiwanese pavilion at Medica presented an impres- sive range of novel and improved healthcare products, from robotic clinical assistants and rehabilitation helpers to point-of-care and moni- toring solutions. ‘The relationship between Taiwan and Germany is growing stronger’, concluded Juan Carmona-Schneider, senior consult- ant for healthcare at the European enterprise networking organisation ZENIT. With the continued support of their respective governments and increasing number of innovative products, it is just a matter of time until Taiwanese healthcare solutions gain a strong foothold in European hospitals and doctor’s practices. EUROPEAN HOSPITAL Vol 28 Issue 6/19

6 L A B O R AT O RY Screening for the use of 5-FU anti-cancer drug Fully-automated DPD deficiency testing Each year almost 80,000 new patients in France alone receive fluoropyrimidines, a group of anti-cancer drugs including 5-FU which is normally administered intravenously to treat digestive, breast and head and neck cancer. Interview: Daniela Zimmermann However, fluoropyrimidines-based chemotherapies can cause severe toxicities (incidence at around 20%) and sometimes lethal toxicity (inci- dence between 0.1 and 1%) with part of these toxicities possibly related to deficiency in the activity of the main enzyme enabling elimi- nation of 5-FU, dihydropyrimidine dehydrogenase deficiency (DPD). Because of this risk, routine screening for DPD deficiency before treatment with fluoropyrimidine is now necessary. EH asked Stéphane Moreau, who is responsible for LC/MS in Europe for the Japanese instruments and medical equipment manufacturer Shimadzu Corporation, to outline what is available for this kind of screening and any new develop- ments. Two methods currently exists to diagnose DPD deficien- cy, he said, but under- lined that each involves a significant amount of manual work. One is genotyping, though key to that is in knowing the different variants to detect. ‘It‘s not 100 percent accu- rate,’ Moreau observed, ‘because you detect only what you know.’ The second technology is LC-MS/ MS, which has the advantage that the ratio of uracil and Dihydrouracil is measured directly. ‘As uracil is metabolised to UH2 by DPD, the ratio UH2/U reflects the DPD activ- ity, thus indicating a risk for the use of 5-FU drugs. In this way, you can identify the DPD deficiency, even if you don’t know the different genes influencing the DPD deficiency. ‘In genotyping,’ Moreau added, ‘you are looking for the genes that are the cause of the deficiency while, with LC-MS/MS, you estimate the activity of DPD by measuring the ratio of compounds UH2 and uracil. In one case you look at the cause, in the other, you look at the result. ‘The advantage of measuring the deficiency in DPD via the ratio U/UH2 is that you will take care of all deficiency cases, thus eliminating the risk of toxicity. In that way, this is safer.’ However, he did acknowledge that the problem with LC-MS/MS is that sample preparation is ‘quite tedious, with a lot of manual steps’ and has been limiting penetration of LC-MS/MS. The fully-automated LC-MS/ MS method Potentially leading to toxicity and bone loss by reduction of 5-FU metabolism, DPD has a big impact on the use of the cancer drug 5-FU (5-fluorouracil). Thus DPD identi- fication is key to identifying those patients who may be susceptible to a negative reaction to 5-FU and help to avoid that serious reaction. Additionally, with the ever- increasing number of tests need- ed, automating this process has grown in importance. Fortunately, Shimadzu Corporation has now developed a process that prom- ises to speed up testing and also deliver greater accuracy, safety and standardi- sation. The answer has been to develop a fully-automated LC-MS/MS method for uracil and dihy- drouracil in human plasma, known as indirect phenotyp- ing. Previous LC-MS/ MS methods encountered prob- lems with com- plex liquid/liquid or solid-phase extraction procedures. However, Moreau explained that Shimadzu has developed a method in which the extraction is carried out by a programable liquid handler directly coupled to a liquid chromatograph (LC) MS/MS system. Specifically, the extraction proce- dure is performed by a CLAM-2030 coupled with a LCMS-8060 triple quadrupole mass spectrometer. Now, with the increasing num- ber of tests required – and the new French guidelines introduced in December 2018 that state that all patients treated by 5-FU should be checked for DPD enzyme deficiency – coping with demand and through- put is a challenge, due mainly to the long sample prep process. Due to the complexity of liquid extraction and the manual steps, Shimadzu received a request from a customer using its CLAM robot to develop a method to automate the preparation process prior to LC-MS/ MS. ‘That completely automated this,’ Moreau said, ‘and reduced the analysis time with a solution for the customer to increase the throughput in their lab.’ France has now installed its first systems Recently validated at a hospital in Limoges, the first systems in France are being installed. Moreau believes this will attract wide- spread interest in other countries. He points to a presentation, last June at the European Association of Pharmacology and Toxicology in Sweden, from scientists in Leiden regarding their systematic genotyp- ing process with a profile for each patient, but also showing that, with this, there are still cases of toxicity Critical lack of skilled lab workers Addressing the lab technician shortage The UK and Europe are facing a serious lab skills shortage over the next decade with medical laboratories among the worst affected, Mark Nicholls reports. An ageing population and skilled operators retiring without being replaced by a new generation of lab technicians is at the core of a criti- cal lack of skilled lab workers, with it taking 5-10 years for a technician to become fully competent and an expert in their field. The current challenges facing the technical community were outlined at the Lab Innovations 2019 confer- ence Birmingham, UK, by National Technical Development Centre (NTDC) Director Natalie Kennerley, who pointed to the lack of recog- nition, career pathways and train- ing as major issues to overcome in ensuring ‘a sustainable technical workforce for the future’. ‘The skills shortage within the UK and Europe is very serious,’ she said. ‘Not only are laboratory skills in short supply, but also increas- ing numbers of creative arts-based skills are also vulnerable. We have an ageing population who have an extensive knowledge formed over many years within their roles, which will be lost if we cannot find ways to address this problem.’ Research carried out by the Gatsby Foundation has indicated that, by 2030, the UK will require a further 700,000 technicians to support the economy. Kennerley suggested that today’s graduates are often not ‘work-ready’ in terms of understanding how hands-on prac- tical processes work and lack the practical experience to do the job and solve the problems that techni- cal staff work on every day. ‘In the UK, technical roles status is not where it should be. By contrast, in Germany the technician is a highly regarded and respected individual.’ All areas of research could suf- fer but, she pointed out that this could be particularly acute in the medical arena. ‘If we cannot recruit the right people to do the job, then those areas are at serious risk of col- lapse,’ Kennerley added. ‘Histology n i e Z r a i t h k a B / k c o t s r e t t u h S : e c r u o S technicians working with hospitals and research institutions are key to ensuring that valuable experimen- tal and/or patient tissue samples are tested/treated correctly and the results produced are accurate and meaningful. Learning to fine tune methods and techniques is a skill built up over many years and can- not simply be learned quickly from textbooks but requires hands-on practical experience.’ The NTDC has developed tools to enable organisations to address these issues, with close links to the Technician Commitment initiative launched in the UK in 2017 to raise the profile of technical staff. With work required to promote technical careers to the next gen- eration of technicians, steps being taken by the NTDC and other bodies to avert the crisis include promotion of secondments, work shadowing opportunities, apprenticeships and working with schools and colleges to promote careers within the tech- nical community. The NTDC also provides bespoke tools to support organisations in ensuring they have an engaged, moti- vated and skilled workforce which is future fit. These include the tech- nician Roles, Responsibilities and In 1994 Stéphane Moreau obtained his diploma from INSA in fine chemistry and engineering with a specialisation in chemical process engineering. He then began his professional career in labo- ratory equipment distribution before joining the brand new Shimadzu France subsidiary in 2002. Since then, he has held various positions to develop the MS range business. Since September 2013, he is product manager for the MS range with Shimadzu Europe. because they do not know all the variants that cause this problem. ‘So, I’m sure LC-MS/MS is the best solution and that automated sample prep will help a lot of people.’ The automated process is time-saving, improves workflow and offers stan- dardisation. The Shimadzu LC-MS/ MS approach has cut manual sample prep time from 30 to 10 minutes or less, but a major benefit is that the next sample is being prepared while the existing sample is being run on the system, increasing throughput. Sample analysis is also reduced to 15 minutes. After the sample is placed on the robot there is no need for human manipulation and, as the robot han- dles every sample in exactly the same way, standardisation is high. With so many cancer patients receiving 5-FU-based chemotherapy, Moreau stressed that the importance of finding out quickly about DPD deficiency is now widely recognised and he believes the Shimadzu solu- tion of automating sample prep and a LC-MS/MS method to measure ura- cil and dihydrouracil with no human intervention once the sample tube is positioned, is set to play a key role in speeding up this process, and offer better and quicker outcomes for patients. Skills audit; the Higher Education Career Pathway tool; the technician development framework. The NTDC has also launched a new online por- tal designed to capture continuing professional development, and has gathered data to identify high risk areas and help to influence national policy. ‘Training and development of technical staff is also fundamental to the delivery of new and cutting- edge technologies and organisations need to be encouraged to find resources to support staff training and development,’ Kennerley added. This approach can also lead to a much more engaged and motivated sector as they see the value their organisation places on them and their willingness to invest in their development.’ While Artificial Intelligence (AI) also has a role to play in areas such as auto analysers and robotic sam- plers, she stressed that additional appropriate training is essential to optimise AI advances. ‘Employers will try to introduce this technology as a way of effi- ciency savings (staff costs reduction) but will need to realise specialist highly trained and skilled techni- cians will still be needed (and at a EUROPEAN HOSPITAL Vol 28 Issue 6/19

8 L A B O R AT O RY Therapeutic proteins at peak among pharmaceuticals Sports drug testing gains powerful aids Due to the scientific and technical developments in recombinant DNA technology and protein engineer- ing since the early 1980s, therapeutic proteins have emerged as one of the most important classes of new pharmaceuticals. Currently, more than 200 protein and peptide based drugs have gained approval by the USA’s Food and Drug Administration (FDA) and many more are under preclinical or clinical investigation. Report: Katja Walpurgis & Mario Thevis These comprise recombinant versions of natural proteins (e.g. growth fac- tors, enzymes, anticoagulants) as well as engineered proteins, protein conjugates, Fc fusion proteins, and recombinant therapeutic antibodies. Both protein re-design and chemical modifications such as glycosylation and PEGylation are strategies that can be employed to extend the serum half-life and improve the effector functions of a protein drug. Moreover, the construction of Fc fusion proteins through the attachment of an immu- noglobulin G1 (IgG1) Fc domain to a protein or peptide can provide IgG- like properties, such as a long serum half-life, due to recycling through the neonatal Fc receptor (FcRn) and a slower renal clearance. Therapeutic antibodies are comparably stable mol- ecules, which bind their targets with high affinity and specificity. Therefore, they constitute the largest and fastest growing class of protein drugs. At pre- sent, more than 50 chimeric (approx. 70% human sequences), humanised (85-90% human sequences), and fully human antibodies are approved for the treatment of autoimmune diseas- es, cancer, and other disorders. Both the approved and investi- gational protein/peptide therapeutics Indirect vs. direct Western blats for the detection of therapeutic proteins in sports drug testing. In indirect assays (A), a protein drug is detected on the basis of its properties (e. g. affinity for a TGF-ß cytokine and presence of a human Fc domain. In direct assays (B), the compound is bound by a highly specific primary antibody, which can subsequently be detected by a species-directed secondary antibody. Dr Katja Walpurgis studied Biology at the University of Bonn. Since gaining her PhD in 2013, she works as a postdoctoral researcher at the Centre for Preventive Doping Research/Institute of Biochemistry of the German Sport University Cologne. Her work focuses on the development of novel detection methods for performance- enhancing protein drugs by using different proteomics techniques, such as gel electro- phoresis, western blotting, and high resolu- tion accurate mass LC-MS. Dr Mario Thevis graduated in organic chemistry and sports sciences in 1998. He gained his PhD in Biochemistry in 2001 and did post-doctoral research at the Department of Chemistry and Biochemistry at the University of California Los Angeles (UCLA) in 2002. After being a senior researcher (2003- 2005) he became Professor for Preventive Doping Research at the German Sport University Cologne in 2006. In August 2017, he accepted the position of Director of the Institute of Biochemistry of the German Sport University in Cologne. comprise several drug candidates with potential performance-enhanc- ing properties, whose misuse in sports is restricted under the terms of the World Anti-Doping Code (WADC). While protein drugs such as eryth- ropoietin and its derivatives, human growth hormone (hGH), and human chorionic gonadotropin (hCG) can be detected by using immunological approaches such as Western blot- ting and luminescent immunoassays (LIAs), liquid chromatography and high-resolution mass spectrometry (LC-HRMS) are routinely used to test doping control samples for the pres- ence of peptidic compounds such as insulins and growth hormone releas- ing peptides (GHRPs). The proactive development of spe- cific and sensitive detection methods for emerging protein/peptide thera- peutics still missing clinical approval is the main task of preventive doping research. Many of the protein-based drugs currently undergoing clinical investigation have the same thera- peutic target: TGF- cytokines such as myostatin, activin A, and GDF-11. While myostatin is considered as the key negative regulator of skel- etal muscle mass, both GDF-11 and activin A were found to inhibit late- stage erythropoiesis. Additionally, activin A is involved in the regulation of bone formation and recent studies suggest that the cytokine could also play a role in muscle growth inhibi- tion. TGF- cytokines exert their bio- The Heraeus Symposium at DKOU The challenge of Periprosthetic infection Report: Beate Wagner joint infection (PJI) Periprosthetic is on the increase internationally. In Germany, for example, around 14,500 cases of PJI in hip and knee replacements occur annually. 5,100 of those are caused by multidrug resistant pathogens. ‘Eighty-seven percent of those affected die with- in five years,’ orthopaedic surgeon Professor Rudolf Ascherl MD pointed out during the Heraeus Symposium held at the German Congress of Orthopaedics and Traumatology (DKOU) held in Berlin, this October. Life expectancy is lower than for those affected by prostate cancer, breast cancer and melanoma, and quality of life is severely impaired. ‘The condition has chronic, almost oncological characteristics and patients suffer both physically and mentally for years,’ he added. ‘Twelve in 100 patients even state that they would rather die. We need a better understanding of who the high-risk patients actually are to get a better handle on PJI’, Ascherl believes. According to British studies, over- weight, multimorbid patients with heart, kidney or liver problems, and often further implants along with knee or hip endoprostheses, are at particular risk. ‘The present classification of PJI The experts gathered at the Heraeus Medical Satellite Symposium. From left: Professors Andrej Trampuz, Rudolf Ascherl, Klaus-Dieter Kühn and Volker Alt into acute or chronic stages does not sufficiently reflect the complex individual situation,’ according to Professor Volker Alt, from the Clinic and Polyclinic for Trauma Surgery at Regensburg University Hospital. A new classification of PJI devel- oped by Volker Alt and team now offers the prospect of improvement. This is to provide a clearer indica- tion if a patient is still suitable for an intervention, from which type of intervention they could benefit and if, like many of those affected, they have already undergone one or several revisions. ‘Like other clas- sification systems, PJI classification must consider all key factors, such as implant, pathogen and morbidi- ties. The condition of the soft tissue, concomitant diseases and whether or not the patient can be anaesthe- tised are also important. ‘The new classification may sound complicated,’ Alt observed, ‘but it’s basically designed to clarify every- thing that needs to be addressed in a structured manner, before any kind of treatment. ‘In future, all treatment options are to be based on this,’ Ascherl said. PJI is one of the main reasons for around 72,000 revisions of hip and knee joint replacements. These often complex interventions carry a risk of their own. Amputation is not uncommon. ‘If patients wear unsuitable spacers for too long, for instance, or if foreign bodies are not completely removed, we should talk about the option of amputation,’ Ascherl explained. He recommends this in cases where sep- sis and three relapses have already occurred. In each case, weighing up exarticulation and amputation must be on an individual basis. According to experts, the chal- lenge of PJI can only be met in a multidisciplinary, professional set- ting – with a consistently stand- ardised treatment algorithm, for instance – as implemented at the Centre for Musculoskeletal Surgery (CMSC) at the Charité University Hospital in Berlin. ‘Our multidis- ciplinary concept factors in spe- cifics such as nosocomial patho- gens, the condition of the bones and soft tissue, as well as the sta- bility of the endoprosthesis,’ said Professor Andrej Trampuz, Specialist in Infectious Diseases and Head of the Department of Septic Surgery at the Charité Berlin. The standardised procedure has reduced the occur- rence of relapses from 10.4% to 3.1%. ‘However, the increasing use of local antibiotics, implant coating and bacteriophages is new.’ Trampuz emphasised the impor- tance of treating PJI as early as possible. ‘If the implant is to be preserved, the infection must not be older than a maximum of four the weeks,’ infection specialist advised. During this acute phase, sufficient surgical debridement, the administration of systemic and local antibiotics and, if applicable, the exchange of the mobile prosthetic components, have priority. Once this early phase has passed, the persistent biofilms can no longer be eradicated even with biofilm- active antibiotics. ‘The objective is always the least invasive treatment option, with the best functional result without negative impact on the cure rate,’ Trampuz explained. ‘The importance of preserving the implant has increased considerably over recent years.’ After four weeks, PJI is regarded as chronic. There are around 6,500 of these late-stage infections every year, 4,000 in hip replacements and 2,500 in knee replacements. At this stage, those affected have now most definitely become high-risk patients. ‘If nosocomial pathogens are involved, when bones and soft tissue are in bad condition, and where the endoprosthesis is unsta- ble, the only options are complete revision or lifelong suppression,’ said Trampuz. The objective is always a one- stage exchange with a short inter- val. A Berlin study confirms the advantages. ‘Combined with local and systemic antibiotics this demon- strably reduces recurrences,’ he added. ‘During this late phase it’s important that the antibiotics are biofilm-active. Examples of this are rifampicin, ciprofloxacin, penicillin and fosfomycin. The combination of several anti- biotics in the bone cement is advo- cated to prevent resistance. The different active agents attack the bacterial metabolism in different EUROPEAN HOSPITAL Vol 28 Issue 6/19

1 0 R O B OT I C S The future of endovascular interventions Robotic angioplasty An exciting development from an innovative French company is poised for a major breakthrough in European markets, Jane MacDougall reports. As is now well-known, coronary angioplasty is a procedure that wid- ens and/or unblocks the arteries to the heart by the insertion and infla- tion of a balloon and/or stent into the vessel lumen. In modern prac- tice, a stent is normally left in place to ensure the blood flow remains unhindered. Known collectively as percutaneous coronary intervention, PCI, angioplasty with stenting is one of the most widely performed procedures worldwide. Driven by the burden of cardio- vascular disease on human health, the specialty of PCI is characterised by continuous growth and rapid advances in technology in the quest for better results. While innova- tions in stents, guidewires, cathe- ters, suturing and of course imaging have facilitated outcomes over many years, it is only relatively recently that robotic assistance for PCI has been considered with the CorPath robotic system from Corindus (USA) being the most advanced to date. Close collaboration with interventional cardiologists A French company, Robocath, based in Rouen, was set up in 2009 by Dr Philippe Bencteux to design, develop and commercialise robotic systems to help treat cardiovascu- lar diseases. Robocath, which now has more than 25 employees, has received financial support from regional and national investment Professors Durand and Sabatier using the robot at Rouen University Hospital Preparing the R-One for an intervention Dr Fajadet, from the Clinique Pasteur in Toulouse, at the R-One control panel cardiologists funds. Its business model involves close collaboration with European interventional to achieve a robotic system fit for purpose. By so doing, their robotic platform, R-One, has become the first European robotic solution to obtain the CE mark for use in inter- ventional cardiology. Obtained in February 2019, the CE mark means that the system can now be commercialised in Europe and the Middle East. Dr Bencteux explains that the potential for the system in Europe alone is enor- mous, with the possibility to install it in more than 3,000 procedure rooms and perform around 1.6 mil- lion interventions annually. The company is currently work- ing to finalise a number of strategic distribution partnerships in geo- graphic areas with high potential. The R-One is expected to launch throughout Europe and the Middle East in 2020. Thanks to the practical approach to its design, R-One integrates seam- lessly into cath lab protocols with- out introducing additional steps. The robot, which suits femoral or Hospital in Wesel is a Senhance Reference Centre radial access, provides reliable and precise assistance to enhance the cardiologist’s movements for a bet- ter clinical outcome. The possibility of remote delivery and manipula- tion of guidewires and stent/balloon devices during PCI has the added advantage of protecting the opera- tor from radiation exposure. Clearly, ionising radiation is a constant in the work life of cath lab teams, potentially subjecting them to long- term health issues. R-One consists of two core ele- ments, a radio-protected control sta- tion from which, protected by a mobile radiation screen, the physi- cian can remotely control the instru- ments by joysticks, and the robot with its articulated support arm. The robot is compatible with all leading manufacturers’ devices: guidewires, stents, balloons and imaging sys- tems, and is very easy to install. specific Although the learning curve is first minimal, operators should obtain from Robocath on the use of the system before attempting to perform any intervention. Training sessions are provided on a frequent basis. training First two coronary angio- plasties with R-One This September, the first two coro- nary angioplasties were performed with assistance of the R-One robotic platform. These successful proce- dures were undertaken at the Rouen University Hospital by Professors Durand and Sabatier, and at the Clinique Pasteur in Toulouse by Doctor Fajadet. The participating teams are very encouraged by these initial results and highly positive Dr Philippe Bencteux is president and founder of Robocath. He has an MD from Caen University and special- ist qualifications in radiology, medical imaging and business strategy. He also works as a radiologist in a private clinic in Rouen while maintaining his active involvement in the evolution and devel- opment of the R-One platform. about the outcomes from the forth- coming trial they are also involved in. The safety and efficacy of the R-One platform in coronary angio- plasty will be investigated in a prospective clinical trial. The first of its kind in Europe, the study will enrol 60 patients from six different centres, three of which are based in France (Rouen University Hospital, Caen University Hospital, Clinique Pasteur in Toulouse) and the other three in the Benelux countries. Judging by Siemens’ planned acquisition of Corindus for a pur- chase price of US$1.1 billion at the end of this year, robotic assistance is now very much recognised as the future of endovascular interven- tions. Robocath intends to be part of this. Among its R&D efforts, the group is exploring the possibility of robotic assistance in stroke and other vascular emergencies to guar- antee all cardio-vascular patients benefit from the best care pathway available. A new era in minimally invasive robotic surgery Report: Sonja Buske The Protestant Hospital Wesel (EVK Wesel) is one of two reference centres in Germany and one of 25 worldwide for the Senhance® Surgical Robotic System from Transenterix. ‘We wanted to be the first in the Lower Rhine region to go to market with a robotic sys- tem as we believe that this type of digital surgical assistance represents the future,’ explains Rainer Rabsahl, CEO of the 356-bed hospital. ‘We have been a very innovative healthcare institution ever since our foundation,’ says Rabsahl. The EVK Wesel was one of the first hospi- tals in the Lower Rhine region to set up an Oncology Department, a Stroke Centre and a Nephrology Department. The EVK Wesel is also amongst the pioneers in hip and knee endoprosthetics. ‘For a hospi- tal of our size and especially in a rural region, this is not a matter of course. Luckily, we have always had a good feel for which innovations are likely to become established,’ explains the CEO. The Senhance Surgical Robotic System for minimally invasive pro- cedures in general and visceral sur- gery was introduced in Wesel at the beginning of August. It provides the surgeon, who sits next to the patient in a comfortable position at an open console during the opera- tion, with pin sharp, high resolution images enlarged up to six times. The camera is controlled with the sur- geon’s eye movements, the instru- ments inside the patient’s abdomen are controlled via the hands. An integrated tremor filter eliminates the slight jitters experienced by eve- ryone. This facilitates working with a level of precision not otherwise possible with human hands. It is this precision which has already attracted a lot of attention and is very sought after. ‘We have patients who come to us and explic- itly state that they want this device to be used for their surgery,’ reports Rabsahl. ‘We have not seen any fear of, or scepticism towards robotically assisted surgery.’ 40 operations were carried out between August and October, with a target of 240 per year. Says Rabsahl: ‘However, I must emphasise that we will not oper- ate on patients who do not require surgery. We do not carry out more operations just because we have a new system. The patient obviously always comes first.’ The advantages for the patient are obvious though: Surgery is less invasive due to smaller incisions and therefore smaller scars, with less wound pain. The system in Wesel is used for hernia operations, gall bladder removal and oncologi- cal, abdominal interventions. Cancer patients benefit particularly from the new technology. It is planned to extend the use of the system to gynaecological interventions as well. ‘We are taking this step by step, as stipulated in the training plan for surgeons,’ explains Rabsahl. ‘Training with the new robot takes a certain amount of time, and at the moment each intervention is super- vised by an external doctor experi- enced in using the robotic system. We can also draw on constant sup- Rainer Rabsahl is CEO of EVK Wesel GmbH since 2004. The qualified busi- ness economist is also responsible for several health centres and care facilities that are predominantly located on the large campus area. port from a Transenterix technician. Safety is our main priority.” Rabsahl reports that his staff are proud to work in a hospital which can afford such modern equipment. ‘This investment was certainly a financial challenge for our hospital, but we look at this as a means of safeguarding the future.’ The hospital specifically aims to attract the attention of young doc- tors in this way and hopes that the robotics system will provide a competitive advantage which will also have an impact on economic viability in the long run. The EVK Wesel is not only a reference centre but also an obser- vation and practice centre: inter- ested surgeons and students can gain an insight into surgical proce- dures of the new generation – and may become motivated to return as employees at a later stage. EUROPEAN HOSPITAL Vol 28 Issue 6/19

1 2 R A D I O LO G Y Reference institution thoroughly tests CT system and potential New Incisive CT is ‘outstanding’ A new CT scanner created by Philips and installed in Berlin’s Zehlendorf district in October, is Germany’s first Incisive CT. The machine is now demonstrating its outstanding capabilities of modern computed tomography at the Diagnostic Department of Theodor-Wenzel-Werk e. V. (TWW), a reference institution which is part of a network operated by the Protestant Church. The Incisive CT scanner supports fast, non-invasive diagnostics of arterial pathologies s p i l i h P : e c r u o S TWW includes a clinic, three in-patient care facilities, two assisted living facilities and an out-patient depart- ment. It is also among the top institutions for mental health. ‘We have expert teams that treat medical conditions that continue to stigma- tise patients, their families and even the care staff. We are proud that we were able to strengthen our profile with innovative medical technol- ogy, particularly in radiology,’ says Managing Director Bernd Jakobs. In addition to psychiatry and psy- chotherapy, the TWW clinics offer psychosomatic-psychotherapy care with a focus on internal medicine and neurology. Being a fast and robust procedure, computed tomo- graphy is used primarily for head, spine and vessels exams. Efficient, intuitive and close to the patient ‘The Incisive CT provides an intui- tive workflow with a self-explanato- ry user interface that requires little training. OnPlan patient-side gantry controls allow the radiographer to work right at the scanner – which saves time and movement. However, more importantly, the radiographer is also right next to the patient which is a major quality feature above all in the care of vulnerable patient groups. Not only coopera- tion-impaired patients benefit from reduced exam times. A study by the Oz Radiology Group has indi- cated that the system can potentially reduce scan times by almost 20 per- cent,’ Philips points out. ‘The shorter the time in the gantry, the less likely are spontaneous movements and thus the need for sedation or repeat scans.’ High image quality, low dose Modern medical technology aims at reducing the physical and mental patient stress connected with a CT scan. This entails protecting the patient from the harmful effects of ionised radiation. Incisive CT features DoseWise Portal, a web- based dose monitoring solution that collects, measures, analyses and reports radiation exposure in line with applicable law, and helps to optimise dose, while maintaining high image quality. Since artefacts impair diagnos- tic conclusivity, iDose4, an iterative reconstruction technology, ensures noise-free images with high spatial resolution even at low dose. In view of demographic chang- es, more and more patients with endoprostheses will need to be scanned. Incisive CT is equipped with O-MAR, a technology that reduces artefacts caused by large orthopaedic implants. At TWW‘s neurological depart- ment, many patients suffer from spinal pathologies. Here, O-MAR is helpful in follow-up imaging after stabilisation surgery. Moreover, the 70 kV scanning protocol enhances contrast resolution at low dose. With this system, radiology at TWW ‘made major progress,’ says Bernd Jakobs and adds that ‘the system achieves significantly better image quality in shorter scan times and with lower radiation exposure, which means we can offer our patients a faster and more precise diagnostic work-up.’ Future-oriented platform: designed to grow alongside needs Being a scalable platform, the Incisive CT flexibly adapts to the user‘s specific needs and require- Bernd Jakobs, Managing Director of TWW E.V. ments. To provide the entire range, from routine applications to highly complex cardiac and Dual Energy scans, TWW‘s Diagnostic Department is equipped with the full system. Interested radiologists and radiology technicians have the opportunity to familiarise them- selves with the new scanner in regu- lar operating mode. TWW is looking forward to the benefits of the new system.‘ As a reference institution,’ adds Jakobs, ‘we could thoroughly test the systems and the potential it holds for patients and users before a final investment decision was taken.’ Another benefit: TWW will become an attractive cooperation partner for office-based radiologists who can use the new system to offer their patients a broader array of CT exams than with their current equipment. OnPlan patient-side gantry controls on both sides of the gantry allow the user to stay close to the patient s p i l i h P : e c r u o S Accu-Gold TOUCH for X-ray QA and Service Accu-Gold TOUCH for X-ray QA and Service Get in TOUCH with Radcal ! Stand-Alone Diagnostic Radiation Test Instrument • Easy to read 5 inch touchscreen for the X-ray service industry • Access to the full lineup of Radcal Accu-Gold sensors • Simple to use - accurate, reliable, economical • Wired or wireless computer interfaces Visit us at ECR, Booth X1-129 Call Us 626-357-7921 sales@radcal.com • www.radcal.com Malta: Moira Mizzi Spain: Mélisande Rouger, Eduardo de la Sota The Netherlands: Madeleine van de Wouw. USA: Cynthia E. Keen, i.t. 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EUROPEAN HOSPITAL Vol 28 Issue 6/19

1 4 R A D I O LO G Y Anaesthetic trainee trains trainees in administer Portable POCUS impresses Zambian medics Consultant and trainee anaesthetists from Surrey, in the United Kingdom, have travelled to Lusaka with a Fujifilm SonoSite point-of-care ultrasound (POCUS) system, to train Zambian colleagues in ultrasound- guided regional anaesthesia. Here, Dr Madankumar Narayanan describes the educational objectives of the visit and the enthusiastic response from doctors there, as the team demonstrated the benefits of ultra- sound-guided interventions in classroom workshops and on real patients. Anaesthetic trainees in the UK often undertake an “out-of-programme” fellowship to developing countries to expand their clinical and profes- sional experiences. One such train- ee visited the University Teaching Hospital in Lusaka for his fellowship and saw the challenges and limita- tions of managing patients’ pain without the use of ultrasound-guid- ed nerve blocks. On his return he decided to rally the support of his UK colleagues and arrange a train- ing visit, to show Zambian anaes- The team at the University Hospital using POCUS to assess a patient thetists how using ultrasound for vascular access and administering nerve blocks could transform care for their patients; he knew POCUS would significantly improve the pain management currently being offered. Three consultants and one trainee could commit to this pro- ject and linked up with two British trainees already in Zambia on fel- lowships at the time. Well-equipped to introduce ultrasound The University Teaching Hospital in Lusaka is the largest, most advanced hospital in Zambia and was a logical starting place for the training initia- tive. A seven day visit was planned – two days of classroom teaching, four days practical training in theatre and a day of consolidation. The team from the UK was equipped with a portable, robust SonoSite point-of- care ultrasound machine, donated for the training exercise, as well as for the Lusaka hospital to use in the future. Anaesthetists at the University Teaching Hospital in Lusaka were unfamiliar with POCUS and did not have access to any machines. While their knowledge of anatomy was good, the process for choosing vas- cular access sites was based purely on clinical landmarks and they had used very little ultrasound in their diagnostic evaluations or manage- ment of pain – most of the theatre anaesthetists had never even seen nerve blocks performed. There is also very poor availability of pain- relief medication in Zambia; post- operative patients were having to tolerate significant levels of pain, Anaesthetists from Surrey successfully ran POCUS workshops in Lusaka to train Zambian colleagues in ultrasound-guided regional anaesthesia which often increased their length of stay in hospital. This presented huge scope to train the theatre anaesthetists to perform ultrasound-guided nerve blocks and introduce a culture of making a real difference in the quality of care they could provide their patients. Delivering training The UK team carried out a prelimi- nary workshop for 20 anaesthetists from across Zambia; comprehen- sive reading material was provided beforehand to outline the context of ultrasound-guided regional anaes- thesia and cover the theoretical basics. Although the workshop was in a classroom setting, its content was very practical, concentrating on demonstrations of how to use the machine, how to hold the nee- dles, how to scan and most impor- tantly, how to guide vascular access and identify individual nerves. Four theatre anaesthetists from the work- shop were then selected, all of whom worked at the University Hospital, and provided with hands- on training on real patients in their theatres. This initially focused on simple, low-risk nerve blocks – fem- oral, fascia iliac, axillary and pop- liteal – to help them improve their confidence, and then moved on to some more advanced blocks. They Mobile hybrid solution for cardiovascular procedures Fast forward for C-arm users ‘Since 1972 Ziehm Imaging has been a company of firsts. Our forward thinking has allowed us to be the mobile C-arm expert worldwide. As an innovation leader, we were the first manufacturer to show a Digital Subtraction Angiography (DSA) on a mobile C-arm, the first with a touchscreen user interface, the first with a flat-panel detector on a mobile C-arm, the first to launch a 3-D C-arm with flat-panel detector on the market and the first to intro- duce a mobile full-size C-arm with a CMOS detector.’ Thus Ziehm Imaging is proud to report the firm’s past and continu- ing advances. ‘We pursue new tech- nologies long before they are estab- lished on the market. Our constant curiosity and forward thinking pay off. As an innovation leader, we are committed to our mission of setting new technology standards. We are always ahead in helping you meet your individual goals. ‘Our portfolio offers answers to current challenges in the field of mobile imaging, such as new areas of clinical application, optimal workflows, patient safety, and cost- effectiveness. Reducing overall expendi- tures ‘Thanks to the intraoperative use of our advanced systems, the accu- racy of clinical outcomes can be improved, revision surgery rates sig- nificantly lowered and overall health during highly demanding interven- tional cardiovascular procedures,’ the company reports. ‘To ensure consistent system temperature and prevent system failure due to over- heating it is ideally equipped with Advanced Active Cooling (AAC). expenditures reduced. The innova- tive use of our C-arms opens new clinical pathways and offers lower purchase and installation costs as well as a faster return on investment than fixed installed systems.’ The Ziehm Vision RFD Hybrid Edition represents a group of optional hardware and software that creates an option package on the device named Ziehm Vision RFD. ‘The powerful 25kW mobile C-arm is designed to successfully perform Advanced cardiac interventions able for minimally invasive cardiac procedures, such as percutaneous transluminal coronary angioplasty (PTCA), heart valve implantations and pacemaker interventions. With its small footprint, it supports effi- cient room utilisation and exact results at manageable personnel costs.’ ‘Unique to the market, Ziehm con- tinues, ‘the system offers motorisa- tion of all four axes for easy control directly from the sterile field. With its small footprint compared to a fixed installed system, this mobile solution delivers reliable results for complex applications, such as TAVI angioplasties and EVAR. ‘Besides supporting clinicians in the daily routine, the Ziehm Vision RFD Hybrid Edition prevents revi- sion surgeries resulting in shorter hospital stays and cost savings.’ This system can instantly convert a conventional operating room into a hybrid room, the firm points out. ‘It requires no modifications to the OR and is up and run- ning in no time.’ Extended vascular surgical capabilities ‘Specialised vascular work- flows and innovative software features meet the needs of com- plex vascular procedures and consequently save precious time in the OR,’ Ziehm adds. ‘Combined with excel- image lent CMOS quality, the system is a valuable contri- bution to any clin- ic’s competitiveness and financial performance.’ The high-end system is also suit- Extended vascular surgocal capabilities EUROPEAN HOSPITAL Vol 28 Issue 6/19 Comprehensive mobile hybrid solution: Ziehm Vision RFD Hybrid Edition

1 6 R A D I O LO G Y Personalised imaging with standardised results Scanner protocols go automatic Against a backdrop of staff shortages, the ever-increasing demand for CT scans, and a need for lower doses for patients, Daniela Zimmermann reports on the new Siemens Healthineers Somatom X.cite single- source CT scanner and innovative myExam Companion user guiding system With patient-friendly features that also improve workflow and diag- nostic accuracy, the new launch is coupled with the innovative myEx- am Companion – an intelligent user guidance system, which automati- cally adapts scanner protocols in line with patient data. Clinically approved and available this month, the system has been tested by radiologists at several European hospitals, among them the University Hospital Zurich (UHZ), where it was unveiled at the end of November. Professor Hatem Alkadhi, Consultant Radiologist at UHZ, described the Somatom X.cite as the ‘one-fits-all’ scanner in the way it unites first class image qual- ity through high-end features; con- ducts complex examinations with- out problems; personalises imaging with standardised results and deliv- ers workflow improvements. Investing in the future Unveiling the product, André Hartung, President (Diagnostic Imaging), Siemens Healthineers, stressed that investing in the future was of utmost to Siemens Healthineers in a market where demand is soaring for high level healthcare solutions and the number of procedures rises. importance ‘Digitisation is at the core of addressing this challenge and, while more diagnostic data and informa- tion is being collected, we must Low kV imaging with high power reserves makes low kV possible even for bigger patients ed image quality in the single- source segment combined with maximum patient comfort, Siemens Healthineers reports. Radiographers can prepare and perform the scan using removable tablets that are attached to the scanner using mag- nets, enabling them to remain along- side the patients until immediately before the scan, and then keep their patients in view via a 2-D camera integrated in the housing of the gantry while an optional 3-D cam- era gathers more information on a patient’s anatomy and automatically positions them in the isocentre. Dr Philipp Fischer, Head of Computed Tomography at Siemens Healthineers, said the healthcare sector was having to cope with a shortage of radiology staff with clin- icians and technicians dealing with greater technical complexity under time pressures and often rotating between different modalities and systems, coupled with a demand for precision medicine with low dose and high image quality. s r e e n i h t l a e H s n e m e i S : t h g i r y p o C myExam Companion user guidance system, underpinned by AI, guides the user through the workflow using specific questions, making use of available patient data and combines these with additional patient-spe- cific information gathered by ask- ing specific questions, for example the presence of metal implants or a patient’s ability to hold a breath. Accordingly, the scanner optimises the scan parameters. With its 82cm gantry, Somatom X.cite can offer unprecedent- He explained how myExam Companion was an important step Somatom X.cite ensure it is patient specific,’ he said. This will see Siemens Healthineers invest in more software-based solu- tions with artificial intelligence (AI) and a high degree of automation at the heart of expanding the diagnos- tic offering. He underlined how Somatom X.cite and myExam Companion are a big step in Siemens Healthineers’ imaging portfolio toward the world of intelligent user support. The l n i a p S , a n o p m a P , a r r a v a N e d d a d i s r e v i n U a c i n í l C : t h g i r y p o C d n a l r e z t i w S , h c i r u Z l a t i p s o H y t i s r e v i n U : t h g i r y p o C Stroke assessment Flex 4D Spiral in helping offset some of that pres- sure and workload in the way it gathers data relevant to the exam with neither user interaction nor additional work steps. ‘Before,’ Fischer added, ‘there were so many things that a technologist must do by himself to obtain data from dif- ferent data sources. Now, this work will completely disappear.’ Unique tools Professor Christoph Stippich, Chairman of the UZH Department of Neuroradiology, outlined how his department had been test- ing Somatom X.cite with the new software platform with successful results. Giving examples of imaging of the temporal bone and stroke and bleeding, he said the system had enabled reductions in radiation exposure and improved workflow and that the large gantry facili- tates the examination of seriously ill patients. Professor Alkadhi highlighted three features he felt added real benefits for patients and radiolo- gists: Fast 3-D camera, Tin Filtration and myExam Companion. ‘The 3-D camera is an important feature in placing patients in the right posi- tion,’ he said. ‘Studies have shown that 95% of patients were not posi- tioned correctly, which is a problem and there are consequences as off centring affects dose.’ Research conducted in Zurich showed that off centring by 2cm can result in a 7% dose difference, while off centring by 4cm can result in a 20% dose difference. ‘This is too much unnecessary dose,’ he said, ‘so we are very happy with the 3-D camera. We can show how the chest CT patient position is much more accurate when we use the 3-D camera, compared to manual patient positions.’ Topogram with Tin filtration, he pointed out, was also a way osef saving radiation dose and also highlighted the value of myExam Companion in workflow improve- ment and delivering standardised results. EUROPEAN HOSPITAL Vol 28 Issue 6/19