2 H E A LT H I T Webcams in neonatology offer clinical value Baby on-screen 24/7 True or false: Webcams have only recently been introduced in neo- natology and are a patient-side component of the Digital Health Portfolio. False! Already in 1989, Professor Dr Roland Wauer at Charité Berlin built his DIY sys- tem to transmit images from the neonatology ward. Today, there is only one such com- mercial webcam system available in Europe despite the market being huge: in 2020, in Germany alone 60,682 babies were born prema- turely. The technology is not only used in neonatology but also in paediatric ICUs and mother-child units. In additions, since the Covid- 19 pandemic it is also monitoring ventilated patients. How does BabyWatch work? The specialized webcam allows parents to see their child on a smartphone, tablet or desktop around the clock and in real-time. Thus, digitalization can contri- bute significantly to the bon- ding process between child and parents, siblings or grandparents. This might sound counterintuitive since in this crucial phase physical proximity, heartbeat and the smell of the baby are the foundation of a tight bond. However, successful bonding is also possible when the baby’s status upon delivery and immediately afterwards does not allow physical contact. Several factors can positively influence bonding at a later stage, e.g. stress- free and enjoyable observation of facial expressions, gestures or min- ute movements of baby. The web- cam complements and strength- ens bonding, explains Professor Dr Andreas Holzinger, medical director of the paediatric clinic at Diakoneo Klinikum, where in November 2021 twelve “baby TV” cameras were installed: ‘Studies, for example those conducted by Professor Dr Hans Proquitté at the University of Jena, have shown that for the milk production it is important for the mother to see the baby.’ The system in clinical routine The fairly small camera, which is mounted on a flexible arm above the incubator, transmits live imag- es. Using a password-protected access parents can see their baby in a livestream from anywhere – either mobile or from home. The data is transmitted with 256 bit SSL encryption; data storage complies with GDPR requirements regard- ing user and camera management during data transfer and is handled by the admin server in a German high-performance computer cen- tre. Images are transmitted in real- time, albeit without sound from the ward – which is an important aspect in a clinical environment. During the day, the livestream is in colour, at night in black and white. The parents and relatives see the baby’s head and upper body. A control light indicates to the nur- sing staff whether the camera is turned off or whether the parents are “babywatching”. Advantages and drawbacks While in theory the baby TV idea sounded great, in reality ‘it was not met with undivided enthusi- asm’, remembers Dr Holzinger and explains that ‘there were concerns that the baby TV would introduce a form of control and that the staff would have to deal with an R ö d K o e n o k a i D © Thanks to the Babycam, the Wunderlich family can always keep an eye on their second child in the clinic. R ö d K o e n o k a i D © increased number of phone calls from anxious parents. Moreover, would the livestream mean that parents don’t come to the hospital anymore because they are sitting in front of their screens at home? These were all valid concerns. To address them, team members of different professions spent time at the clinic of my colleague Dr Matthias Henschen who had been working with BabyWatch for two years.’ This cooperation indeed alleviated concerns and a majority of the team members were willing to try the webcam system. But staff concerns were not the only hurdle to overcome: considerable purchasing and follow-up costs were frowned upon as just anoth- er financial burden in the already cost-intensive paediatric depart- ment. In the end, purchasing and financing were secured through a fundraising drive initiated by the clinic and the support by the Friends of the Paediatric Clinic. Premature births during the coronavirus pandemic In the paediatric ICUs, specially trained nursing and medical staff care for the small patients 24/7 with immense dedication and expertise when a baby’s birth happens much too early or when complications arise. In paediatric departments, complying with Corona rules has severe effects on the neonates, par- ents and siblings. Because of the pandemic, in many hospitals around the world physical contact between parents and their babies was lim- ited in line with WHO recommen- dations. Michelle Wunderlich was thrown into this difficult situation: in November 2021, at the height of the fourth Covid-19 wave, the 37-year-old nurse gave birth to twins. After pre-eclampsia, Ella and Paul were born eight weeks early and were put into intensive care right away. “It was a horrible feel- ing,” the mother says and adds “I was worried sick about my children. In the first days after the Caesarean section I missed the babies in my belly – I felt incomplete.” Hundreds of questions overwhelmed Michelle and the babies’ father: how are our children in the incubator? Are they agitated? Are they sleeping or are they crying? Are they moving or calm? The camera made it possible for them to see their children and bond with them. The own fears, but also the grandparents’ fears slowly subsided and indeed the difficult situation had created a new kind of bond between the members of the family. After a few days – and in full compliance with the strict corona rules – Michelle Wunderlich and her husband were allowed to visit Ella and Paul. The first phys- ical contact was a moving moment for the young parents. The family live far away from the hospital, one of the grandmothers even lives in a different country. One of the babies’ status stabilized faster than the other’s and it could leave the hospital shortly before Christmas; the second one however had to stay for several more weeks. Caring for neonates has many high points and many low points. BabyWatch allows parents like Michelle Wunderlich and her hus- band to share the worries and the joy with siblings and relatives. The broadcast images enable physi- cal and psychological closeness. “Despite my daily visits in the paediatric clinic I was happy to see my baby on camera at home. It reduced the distance and I no longer had the feeling that I give one of the babies more of my love than to the other,” Michelle Wunderlich sums up her feelings. What does science say? A study conducted by Professor Proquitté of University Hospital Jena, Germany, during his time at Charité Berlin highlighted the psychological benefits of the BabyWatch system. Many parents, he said, feel guilty or even respon- sible for their baby’s premature birth. “Baby TV” helps parents feel closer to their children. Moreover, in the study hospital staff reported that – unexpectedly – with the webcams the parents visit their babies more frequently since early streaming creates a bond with their children in the hospital which increases the desire for personal and close contact. In addition, the frequent livestream via the web- cam alleviates the parents’ fear that their children are not well. ‘Some studies indicate that BabyWatch supports early bonding but there is no scientific evidence yet as to its effectiveness,’ explains Professor Holzinger. A highly anticipated new study conducted by private docent Dr Nadine Scholten from the University of Cologne might offer new insights. Her team at the department of medicine sociology, care research and rehabilitation science has been researching the topic in cooperation with four hospitals. Results are expected in  summer 2023. Report: Manuela Giesel Manuela Giesel Manuela Giesel is head of health communication and fundraising at Diakoneo KdöR. EUROPEAN HOSPITAL Vol 32 Issue 1/23

4 H E A LT H I T New generation of wearables Smart ring medical device for 24/7 blood pressure monitoring A smart-ring medical device is emerging as an effective and discreet wearable for round-the- clock blood pressure monitoring. Using photoplethysmography (PPG) signals to measure the bloodstream 24/7 through the wearer’s finger, a new feature of the “Cart-I plus” ring from man- ufacturer Sky Labs enables it to constantly monitor hypertension without user intervention. The company’s CEO Jack Lee dis- cussed the role of smart rings for continuous blood pressure (BP) monitoring during the Medica Trade Fair in Düsseldorf, Germany. His presentation, “Measuring blood pressure all day long with a ring- type medical device and AI plat- form”, highlighted how PPG sig- nal-based BP estimation is a prom- ising candidate for modern BP measurements. While conventional ambulatory blood pressure monitoring equip- ment can take measurements at regular intervals for 24 hours, it is limited by patient discom- fort in continuous use, such as waking up during sleep, or con- strained measurement posture. Lee said: ‘Hypertension may have no symptoms at all for months or years, but then can cause heart attack, stroke, and vision and kidney damage. So, it is important to get blood pressure checked regu- larly; non-invasive and cuffless blood pressure measurement is a key technology to manage hypertension continu- ously and conveniently.’ Detection of “white coat” and “masked” hypertension Using the Cart-I plus smart ring, he added, it is possible to measure active blood pres- sure for 24 hours, which helps reduce the risk of cardiovascular diseases through blood pressure variability and nocturnal hyper- tension monitoring. The device is also designed to detect both “white coat” hypertension (where office- based pressures are elevated and out-of-office pressures are nor- mal), and “masked” hypertension, where these effects are reversed. ‘In addition, 24-hour monitoring can help establish treatment strat- egies such as the type and dose of prescription drugs,’ Lee said. Sky Labs is currently running a clinical study on the use of the smart ring for continuous BP At-home diagnostics – including continuity and com- prehensiveness – make it suitable for managing chronic conditions in daily life.’ Alongside AF monitoring, the smart ring can collect data for oxygen saturation (SpO2), heart rate, and electrical activity (ECG). Autonomous cuffless blood pressure readings will be available in Korea early in 2023 and soon after in Europe and the US. Patient empowerment Data gathered by the ring’s PPG sensor is transmitted to a cloud platform where AI tech- nology can detect AF. It also uses ECG signals to provide additional information to the user’s doctor, often without user intervention. ‘The ring helps patients manage and track their health data contin- uously and automatically. It could be also valuable for people who live far from hospital or who are too busy to visit the hospital.’ With hypertension monitoring, Lee said there are further benefits for patients: ‘Home blood pressure monitoring is empowering and improves our ability to identify and Jack Lee Jack Lee is CEO and Founder of Sky Labs, a South Korean-based medical device start-up and preventive health- care company. Before he established Sky Labs in 2015, he was a research- er who developed 5G mobile tele- communications and advanced signal processing systems at Samsung elec- tronics DMC research centre. Having developed Cart-I for continuous Atrial Fibrillation monitoring, the product is now being evolved for monitoring blood pressure and other vital human indicators. treat hypertension, and to prevent strokes, heart attacks, heart failure and cardiovascular death. Thus, continuous monitoring regardless of time and place can help patients save time and money, and save their life by preventing diseases from occurring now and in the  future.’ Report: Mark Nicholls © Sky Labs monitoring, with results due to be published early next year. The Cart-I platform is already com- mercially available in Europe and the UK for monitoring heart rate and has proved effective in long-term monitoring for Atrial Fibrillation (AF), with accuracy of 96.9%. Lee explained: ‘A charac- teristic of chronic diseases is that they often require a long period of supervision, observation, or care. The features of the Cart platform Making remote patient monitoring simple oximeter for measuring physiolog- ical parameters. Respiratory rhythm Data is collected on changes in chest volume, patient movement and position. There is a pres- sure sensor for airflow through the nose/mouth, a temperature to monitor skin temperature, and a SpO2 sensor for pulse rate and oxygen saturation of the blood. An ECG signal is collected using a single-channel module through silicon electrodes placed on a chest strap. From recorded changes, res- piratory rhythm can be determined and help highlight how the patient is progressing. During the session, Czekaj detailed the device and the Aidmed mobile app for patient notification and interaction as well as discussed issues of patient adherence in the context of monitoring and motiva- tion. The device and app also allow for integration with other devices, such as blood pressure monitors, pulse oximeters, or spirometers. Ongoing challenges Czekaj said ongoing challenges for pulmonary rehabilitation include hospital wait times and shortag- es of qualified medical person- nel. But he suggests a program of home rehabilitation for COPD and post-Covid patients can deliver remote quantification, monitoring and motivation, and also be a pre- ventive measure. The patient mon- itoring via a simple-to-use wireless device with no cables, sees data transmitted to the cloud system and made immediately available for medical personnel. ‘This leads to a reduced risk of failed examinations due to online signal quality,’ he said: ‘The benefits for data collection are that it reduc- es digital exclusion, and with data transmission to cloud there is high availability, with no missing data or the need to go to the doctor with a disk, or for examination repetition.’ Benefits include increasing availability of rehabilita- tion services and with the biofeed- back facility, the processed data is immediately available. ‘That can lead to improved patient adher- ence, long-term patient follow-up, for patients and increases the availability of rehabilitation services,’ he added. Czekaj acknowledges that patients at times neglect rehabilitation rec- ommendations, but said that remote rehabilitation after diagnosis or a stay in a hospital helps improve the motivation to adhere to rehabilita- tion plans. ‘We increase availability and reduce the cost of diagnostics and provide a real alternative to interventional methods and station- ary rehabilitation,’ he said. ‘Our goal is to make an impact on pub- lic health through the introduction of effective pro-health rehabilita- tion on a large scale and achieve this through home/remote rehabil- itation, gamification and effective  patient motivation.’ Report: Mark Nicholls d e m d A i © EUROPEAN HOSPITAL Vol 32 Issue 1/23 d e m d A © i The portable medical device is worn on the chest. accessibility Increasing of remote and home monitoring for patients with pulmonary diseas- es can help improve treatment and rehabilitation adherence, and support health systems and hospitals in tackling waiting lists. The various advantages of remote monitoring systems were highlighted in a session focusing on “Preventing chronic diseases with diagnostics and analytics” at Medica trade fair. Among the speakers was Dr Łukasz Czekaj, CTO of medical device firm Aidmed, who examined the value of rehabilitation programs in the remote/telemedical paradigm for pulmonary rehabilitation of people with COPD (chronic obstructive pulmonary disease) and post-Covid patients. During the session “Simplifying patient monitoring and rehabilita- tion process for pulmonary chronic diseases, using IoT and machine learning”, he outlined how relative- ly straightforward devices such as the Aidmed One recorder can be used for assessment of a patient’s condition, breathing and aerobic exercises, and follow-up to assess progress. The portable medical device, worn on the chest, incorporates a pulse

6 E H @ E C R Interventional toolkit for use in space travel Radiologists shoot for the stars, aim for the earth French radiologists received prizes for the best interventional radiology toolkit for use in space travel at the JFR 2022, the annu- al meeting of the French Society of Radiology (SFR). The teams from Marseille and Créteil received the awards for their solutions to carry out inter- ventions in manned space flights, as part of the Mars IR Tool Box Challenge, an initiative led by the SFR and the National Centre for Space Studies (CNES, in French: Centre national d'études spatiales). ‘A lot of work has been done here,’ said Vincent Vidal, a pro- fessor of interventional radiology at Aix-Marseille University and a radiologist at Assistance Publique – Hôpitaux de Marseille (AP-HM), who coordinates the project. ‘One of the interns in the competition has even done his medical thesis on the embedded space kit.’ Though unique in their approach – one of the teams even simulated an alien attack –, participants all presented boxes featuring versa- tile, small and light material to per- form different kinds of drainage in space: needles, catheters and drains to drain a kidney with renal colic, urinary retention or a deep abscess. ‘Those would be the most typical interventions that could be carried out in space – biliary drain- age, vesicle puncture, etc,’ Vidal said. Performing interventions in a gravity free environment is a challenge that teams had to think of at the time of designing their toolkits. ‘Everything takes another very specific dimension,’ he said. ‘Objects float in space flights, so they have to be attached. Adding a suction system to collect the fluids when puncturing an abscess also makes sense.’ Teams will now continue to work together to create an optimal tool- box and test it in microgravity, Vidal explained. ‘We’ve never done an intervention such as drainage in space. We have two solutions to test it on simulators: Zero-G flights – parabolic flights – or underwater r e g u o R e d n a s i l é M © One of the toolboxes presented for the Mars IR toolbox Challenge. in a pool.’ The next step will be to distribute the box and find an industrial partner to embed the kit on a mission to the Moon or Mars. ‘Our toolkit may be taken on space flights, or it may just be a small link in the chain to one day take an interventional radiology kit into space,’ he said. Another use for the box may well be on Earth, for example in the Sahel or West Africa. ’This box will be able to serve in so-called spe- cific environments where there are only scarce resources,’ said Vidal, who is also active in Fair Embo, an association to help emerging coun- tries use interventional radiology. Tools with a terrestrial fallout Many of the innovations developed for health in space can be trans- lated back to Earth, according to Laure Boyer, a biomedical engineer at the Institute for Space Medicine and Physiology, who also took part in the project. ‘In space, the human body ages at an accelerated pace, so many things we develop for astro- nauts can also be used down here,’ she said. ‘Spaceflight is an interest- ing setting to create solutions for the aging bone. Astronauts develop osteoporosis just like women on Earth as they age, or people with a too sedentary lifestyle or who are bedridden because of an inju- ry.’ The efforts for the space pro- gramme might also produce solu- r e y o B e r u a L © Laure Boyer r e g u o R e d n a s i l é M © Vincent Vidal Laure Boyer is a biomedical engi- neer at MEDES, the Institute for Space Medicine and Physiology in Toulouse, France. She is responsible for the development of innovation projects for astronauts’ health and performance on future Lunar and Martian bases. Boyer graduated from the Superior Institute of Aeronautics and Space (ISAE – Toulouse) in 2012, and received her PhD in biomechan- ics from the Polytechnic School of Montreal in Canada in 2017. Vincent Vidal is the head of inter- ventional radiology in the Imaging Department at Timone University Hospital in Marseille, professor at the faculty of medicine and direc- tor of the Experimental Interventional Imaging Laboratory at the Aix- Marseille University in France. Vidal's research and clinical work are focused on embolisation and he is an active member of multiple interventional radiology societies (SIR, CIRSE, ESR, APSCVIR). tions for muscle problems, such as muscle atrophy, she added. ‘All the developments that are done for the International Space Station (ISS) or another space station have direct terrestrial fallout.’ For example, tele-ultrasound tech- nology was first developed in space. Space stations are tradition- ally equipped with an ultrasound probe, but astronauts may not have the necessary skills to operate it. Thus, experts have developed a tele-operated ultrasound device, in which the probe in space has a “twin” on earth – both devices are connected by satellite connectivity. When the sonographer on Earth watches what is happening in the ISS on video, he or she can manip- ulate the ISS probe remotely from the ground. ‘Tele-ultrasound was developed for the ISS, but the ter- restrial impact is direct. In places where we don’t have an ultrasound expert on-site, for example in sparsely populated areas, tele-ultra- sound can still make quality images at a distance,’ she concluded.  Report: Mélisande Rouger Sponsored · Optimization for CT An update for contrast agent injection The Accutron CT-D Vision is the next generation of the leading contrast agent injector for com- puted tomography from Medtron AG. Focusing on the needs of the user, the latest devel- opment stage of the Accutron CT-D improves the usability of the CT double-piston contrast agent injector and optimizes its integration into the radiological environment. With a RIS/PACS interface based on the DICOM standard, the IDS Software Option provides direct access to the worklist from the RIS (Radiology Information System), allowing users to assign the con- trast injection with the associated patient images and data and store them in the PACS (image archive). In addition, more data can now be tracked for optimal patient care with the Accutron CT-D Vision: By recording the puncture site on the patient, the size of the injection catheter, and the contrast agent type as part of the injection data, the Accutron CT-D Vision provides More than just MRI accessories www.allmri.com comprehensive traceability and documentation of contrast agent administration. Modern user interface The graphically redesigned user interface of the Accutron CT-D Vision supports easier use of the injector. It provides a comprehen- sive view of all parameters and visually highlights the most impor- tant ones. Selection from lists and a stored profile library simplify management. This makes upcom- ing examinations easier, clearer and more precise to program in a short time. With high-resolution touchscreens of 10" on the injection unit and 12" on the remote control, user comfort has been improved. In addition to better readability, eye fatigue is also reduced. X-ray assistants and radiologists usually work at screens all day. With the Accutron CT-D Vision, they can choose between bright and dark light modes in the examination or control room to focus their con- centration on the imaging process. The new medical casters pro- vide more flexibility in a radiol- ogy environment with multiple exam rooms. The new "Valia" ceil- ing pendant from Ondal Medical Systems GmbH also makes the ceiling-mounted version more mobile, allowing for unrestricted 360° rotation. Approved for contrast-enhanced mammography Medtron AG has approved its con- trast injector for CT, the Accutron CT-D, as the first and so far only dual-piston injector for contrast-en- hanced mammography (CEM). The use of Medtron's Accutron CT-D injector as part of the CEM imag- ing procedures ensures a continu- ous and accurate flow of contrast agent. With machine contrast injec- tion, uniform contrast enhance- ment of tumor tissue is supported. The contrast bolus is accurately administered with the aid of the Accutron CT-D, which enhances the quality of the imaging. The ability to rinse with saline solution creates a compact contrast bolus. Post-flushing further spares the patient's veins by shortening the time that the contrast agent remains in the arm veins at high concentrations, which eventually n o r t d e M © lead to irritations of the vein wall. This improves patient safety. The Accutron CT-D supports radiog- raphers in an efficient workflow because the injection is automatic. As a result, radiographers have  more time for the patient. EUROPEAN HOSPITAL Vol 32 Issue 1/23

8 E H @ E C R Sponsored • Boehringer Ingelheim relies on Rein Medical for monitors and digital door signs Safety guaranteed, requirements fulfilled Pharmaceutical research compa- nies impose very high security standards on themselves for good reasons, as they are potential victims of cyberattacks and espi- onage attempts. This is no dif- ferent at Boehringer Ingelheim. Its systems must be particularly secure, which means they need to meet high standards. The com- pany checks this regularly. One way to ensure this is to separate the systems from the office net- work. Each monitor is assigned a separate port, which is checked via IT security. This has helped the biopharmaceutical company successfully stand their ground against any attacks so far. Mönchengladbach-based IT ser- vice provider Rein Medical has been supplying these monitors since 2019. The company and its solutions also underwent a secu- rity check prior to installation. Boehringer Ingelheim relies on eight Operion monitors with a 24” display size and two monitors with a 55” display size in its laboratories and work areas. Liver disease assessment The monitors are exclusively used to display information. With the 24" displays, the employees also have access to the Manufacturing Management Software (MMS), i.e., the holistic software for automatic production planning and control. They can use it to centrally enter data, and to operate and control workstations and systems. equally smooth. The displays run efficiently. Since the terminals are connected to the room information system via a terminal server, there is only one point that needs to be maintained. The electronic door signs also perform reliably. the selection In process, Boehringer Ingelheim's managers looked at a whole range of mon- itors from different manufacturers and assessed them based on pre- defined criteria. In the end, they chose Rein Medical because the company provides a broad product portfolio covering many different sizes. Their monitors also fulfil other essential requirements: They can be treated with commercial- ly available cleaning agents, have a retractable keyboard and meet all fire protection requirements as well as other specifications of the pharmaceutical company. After the choice of system, the introduction of the monitors went l a c i d e M n i e R © Knowing from the outside what’s going on inside This holds true for the 40 door signs that Boehringer Ingelheim has been using since April 2021. ‘Employees of the customer saw the digital door signs during a meeting at our headquarters in Mönchengladbach and were immediately interested,’ recalls Dirk Lambertz, the sales representative responsible for the project at Rein Medical. ‘They were particularly taken with the LED sta- tus display, which is quite unique in this form.’ Another feature that won them over was the possibility of adding individual content to the door signs. At that time, Boehringer Ingelheim needed a digital display to provide employees with key information about rooms and equipment on site. The display also had to meet the high requirements for periph- eral devices within the production rooms. After their cleanroom suita- bility had been successfully tested, the Doorsign displays were easily integrated into the IT infrastruc- ture. The high flexibility of the electronic door labels was helpful in this process. Thomas Jahn, automation engineer at Boehringer Ingelheim, regards the integrated LED frame as a par- ticular highlight of the door signs, as well as the possibility of control via both hardware contacts and software. ‘These control options are central to GxP alarms for criti- cal products,’ he explains. The data displayed comes directly from the company's internal build- ing and room information system and is shown on the Doorsign displays. This gives the employ- ees a better overview of what is happening in the laboratories and production rooms. The Doorsign solution was easily integrated into Boehringer Ingelheim's existing IT infrastructure and offers tremen- dous added value by making pro- cesses transparent. A very satisfied client Thomas Jahn regards the coopera- tion with Rein Medical as positive: ‘The introduction of all compo- nents went smoothly. When prob- lems did occur, we always received help quickly. We've also always been able to make an appointment quickly with the support team.’  www.reinmedical.com AI may give CT the edge over MRI To assess diffuse liver disease, MRI is currently the modality of choice. New developments in artificial intelligence (AI) could tip the scales in favour of CT imaging. At ECR 2022 in July, experts showed how AI technol- ogy enables CT to quantify liver fat as exquisitely as MRI. Global fatty liver disease prev- alence has reached an all-time high, with non-alcoholic fatty liver disease (NAFLD) affecting up to 25 to 30% of the population in the United States and Europe, according to recent studies. This calls for a necessary conversa- tion between physicians, according to Prof. Peter Galle, Director of the Internal Medicine Department at Johannes Gutenberg- Universität Mainz in Germany. ‘The sheer numbers force us to talk about fatty liver,’ he said as he opened the session. ‘Fatty liver increases the chance of developing the more serious diseases like fibrosis or hepatocellular cancer.' One of the main issues for medical teams is that supportive biomarkers to prove the presence of fatty liver currently do not exist. The diag- nostic process becomes a game of excluding every other underlying disease in every single case, which triggers the risk of overlooking patients, Galle explained. ‘Hepatitis C is commonly associated with fatty liver, and if you haven’t had to screen the disease in a patient with fatty liver before, you might overlook it,’ he said. Detecting hepatocellular cancer (HCC) early on is another problem for hepatologists. ‘We never really got into that in times where hep- atitis B and C were prevalent,’ he explained. ‘We were lucky then, because these were relatively small groups of patients with a very high risk of developing HCC. With fatty liver, it’s the very opposite; we Advertisement have a very large group and only moderate increase in HCC inci- dence. Screening and surveillance is even more of a problem.’ Assessing diffuse liver disease with AI-boosted CT MRI has traditionally brought great results in quantifying hepatic fat, iron, and fibrosis – which are all key measurements to assess dif- fuse liver disease. But with the recent introduction of AI tools in CT imaging, radiologists are now exploring whether this modality could provide similar results much faster. ‘It’s worth investigating because CT is done at such a high volume and we can also automate these measurements,’ said Perry Pickhardt, chief of gastrointesti- nal imaging at the University of Wisconsin in the US. 'This option can also feed into an MR surveil- lance scheme with initial detection by CT.’ Pickhardt and his team have looked at hepatic steatosis with both CT and MR, comparing the performance of both modalities. ‘We used unenhanced CT, which is more useful and effective at actual quantification of liver fat than enhanced scanning, and a phantom that was both MR and CT compatible and contained dif- ferent levels of fat covering the entire spectrum from 0 to 100%,’ he explained. The researchers found that there was a very nice linear correla- tion between Magnetic Resonance Imaging Proton Density Fat Fraction (MRI-PDFF) and unenhanced CT. ‘That means we can convert from one to the other – i.e. start with Images show automated and manual methods for measuring liver attenuation at non- enhanced CT in an asymptomatic 60-year-old man. Transverse (axial) CT image showing schematic depiction of automated (left) and manual (right) techniques. Automatically segmented liver is in green and manual region-of-interest (ROI) placement is in yellow. Automated Hounsfield units are based on volumetric segmentation of entire imaged liver, whereas manual Hounsfield units are based on areal mean within single ROI. Nonetheless, two values match well. Reprinted with permission from Graffy PM, Sandfort V, Summers RM, Pickhardt PJ. Automated liver fat quantification at unenhanced abdominal CT for population-based steatosis assessment. Radiology 2019; https://doi.org/10.1148/radiol.2019190512 CT and derive the equivalent MRI- PDFF value. Clinically, we can do things on the fly,’ he said, adding that the results also apply to fibro- sis assessment. Another study con- ducted in 400 healthy volunteers in Beijing showed a similar corre- lation between CT and MR. Radiologists can often tell if mild steatosis is present on ultrasound, but quantification remains diffi- cult. ‘There are emerging tech- niques in ultrasound, but they’re not at the level of what is done with CT or MR today,’ he said. Prevalence of hepatic steatosis is rising, and based on ultrasound, estimated to be between 20-30% depending on the population. ‘With CT measures and presum- ably MR in the same population, we find that about half the popu- lation qualify for at least mild ste- atosis,’ Pickhardt said. ‘But more importantly, we’d get about 10% qualifying for moderate or severe steatosis, which is becoming the main target.' Incidental steatosis can be non-in- vasively detected and quantified with either CT or MR. AI-boosted CT could be very useful in pre- dicting survival as well. Looking at a five-year curve, patients’ BMI provided no prognostic value, whereas liver fat qualification gave further insights in terms of pre- dicting death. ‘Liver and visceral fat does matter and non-contrast CT is quite good at showing these things. Since the number of CT scans is so great, we can actually do population-based opportunistic  screening,’ he said. Report: Mélisande Rouger EUROPEAN HOSPITAL Vol 32 Issue 1/23

1 0 E H @ E C R Stepping outside of healthcare to help the planet Radiologists as champions for health equity Climate change will impact health and complicate access to care for the most vulnerable, but radiologists can do more than just sticking to their jobs. They should step outside the confines of their specialty and promote health and wellbeing in their communities, an eminent American radiologist explained at the annual meeting of the Radiological Society of North America (RSNA). (VUMC) The responsibility of today’s radi- ology professionals is to create the best experience for patients, the community and beyond, Professor Reed A. Omary, Chair of the Department of Radiology at Vanderbilt University Medical Center in Nashville, Tennessee, told delegates. ‘I want to ask how we extend beyond the boundaries of being a traditional radiologist within the confines of our imaging centres and hospitals, and step out into the community and be advocates for civil action,’ he said. ‘And how radiologists can take the lead in promoting the health of the planet, because when we do […] that comes back to benefit the care of the patients we provide.’ Focusing on empathy focus on Radiologists should patient experience, which includes their emotions and perceptions, and understand the role of empa- thy. ‘It’s important to have the ability to step out of our shoes,’ the expert said. Everyone who has experienced the healthcare system knows how frustrating it can be to navigate, he went on. However, working with a human-centered design approach could help ease the process. ‘Instead of starting with data, we have to start with people,’ he said. ‘Once we can define what people need, we can ACCUTRON® CT-D VISION. SIMPLY MORE. SIMPLY MORE. Accutron® CT-D Vision. The diagnostics The diagnostics specialist that can do more. More comfort, more specialist that can do more. More comfort, more mobility, more operating safety. More integration mobility, more operating safety. More integration mobility, more operating safety. More integration through Injection Data Sharing with RIS/PACS connection. View now at medtron.com medtron.com Hauptstrasse 255 · 66128 Saarbruecken Hauptstrasse 255 · 66128 Saarbruecken www.medtron.com address the right problem to come up with ideas that we then can prototype. We can try to generate ideas, test them live, learn from that and make it better.’ the real places are where we can make the most difference and then we can generate big ideas that can solve the pain points in any system we’re trying to design.’ In January 2020, VUMC brought together residents, patients, radiol- ogists, administrators and nurses to address health equity. Participants were asked in rapid fire fashion to write down what they would see, feel or do when faced with a given situation. ‘We can define where the pain points are and vote on them,’ Omary said. ‘This will tell us where Scan now for a Virtual Experience! m o c . e b o d a . k c o t s – p l a m © equity issue.’ Many articles on sus- tainability and climate change have been published in 2022, showing the growing interest from radiolo- gists, and this number should rise in the next few years, Omary pre- dicted. He encouraged everyone to take action, including radiologists, to power down monitors and save energy, and educate about climate change in the curricula and at work. ‘We can partner with our entire supply range and ask what they do to limit their carbon foot- print, and establish green teams in our departments, hospitals and communities,’ he concluded.  Report: Mélisande Rouger Reed A. Omary Reed A. Omary, MD, MS, is the Carol D. and Henry P. Professor and Chair of the Department of Radiology at Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee. He has more than 20 years of experience as a practicing interventional radiolo- gist, NIH-funded scientist, and educa- tor. Omary is an avid public speaker who enjoys promoting sustainabili- ty and innovation in healthcare for national radiology organizations and for the public. Nationally, he serves as President of the Association of University Radiologists and President- elect of the Society of Chairs of Academic Radiology Departments. EUROPEAN HOSPITAL Vol 32 Issue 1/23 board of trustees for Stanford University. • Professor Jocelyn D. Chertoff is Chair of the Department of Radiology at Geisel School of Medicine, Dartmouth, and she serves on the board of a non-profit organisation that addresses climate change. • Dr Amy Patel, a breast radiol- ogist in Missouri, is a strong advocate for promoting women’s health and bringing more access to healthcare in her community. She was recently deemed by the Kansas City Chiefs American football team as Fan of the Year in recognition of her activist work. ‘These leaders have stepped out- side to make a difference,’ Omary said. ‘Be a leader in your commu- nity, and you’re going to help radi- ology, and beyond that, the planet.’ Establishing ‘green teams’ Climate change is the single big- gest health threat facing humanity, according to the WHO, and health- care is an important contributor to greenhouse gas emissions. ‘If healthcare as a sector were a nation, we would be the fifth larg- est emitter of greenhouse gases,’ he said. ‘That means we have a lot of work to do.’ Physicians and nurses are among the most trusted professions in the world and radiologists should build on that, he argued. ‘Our patients and community mem- bers expect us to be on top of things that will affect them. It’s our responsibility to address plan- etary health because the health of the planet is going to affect our community and unfortunately, like Covid, it will disproportion- ately affect those without access to resources. It becomes a health The group came up with three tangible outcomes and developed: • a curriculum for health equi- ty for all medical residents at Vanderbilt; • a set of micro grants where members of radiology department can partner with community members to promote health equity; the • a health equity lectureship, named after its founder, the late Matthew Walker III, a respected community activist. Radiology might also take cues from providers in other industries, for example Netflix or Amazon, who offer their customers sug- gestions based on their purchase history. ‘It’s about how we use technology to benefit our patients, their families and the referring physicians, and how we can go beyond the expectations, so that our patients and our referring phy- sicians start sharing stories about us,’ he said. Going beyond the system Radiologists must also expand out- side the healthcare system to pro- mote health and wellbeing, the expert went on. Some radiologists have stepped out of their tradition- al roles to support the community in ways that are unrelated to radi- ology, Omary said, providing his audience with three examples: • Dr Virginia Joy Simmons, a radi- ologist in southern California, has amassed one of the most important collections of African- American art in the country. She has served on the board of many arts organisations as well as the

1 2 L A B O R AT O R Y / PAT H O L O G Y Sponsored • Promising combination: AFP, AFP-L3, DCP and GALAD score Enhanced early detection of liver cancer Worldwide, about one million people are suffering from hepa- tocellular carcinoma (HCC). In Germany alone, there are 9,000 new patients each year, most of them men between 50 and 60 years. When liver cancer is detected early, the prognosis is excellent, says Professor Dr. Ali Canbay, Director of the Medical Clinic at the University Hospital / K n a p p s c h a f t s k r a n ke n h a u s Bochum. While, unfortunately, current methods for early detec- tion are insufficient, Fujifilm Wako recently presented an approach Professor Canbay considers prom- ising: a combination of AFP, AFP- L3, DCP and GALAD score. HCC, the most frequently occur- ring malignant liver tumor, can be caused inter alia by cirrhosis and nonalcoholic fatty liver diseases. Since many patients are obese, sonography is often inadequate. “Thus, we need non-invasive mark- ers to be able to detect the tumor early,” Professor Canbay points out and adds that “Small tumors can quite easily be removed surgical- ly or be treated with other types n o i t a r o p r o C l a c i m e h C e r u P o k a W M L I F I J U F © The µTASWako i30 processes the tests for the early detection of HCC. Cervix, vulva and vagina ) 0 . 3 Y B C C ( t r A l a c i d e M r e i v r e S © Primary hepatocellular carcinoma in a cirrhotically remodelled liver. of interventions. Once the cancer has spread across the liver, how- ever, there are very few treatment options left.” Any decision regarding the appro- priate treatment, Canbay under- lines, should be made by physi- cians with comprehensive hepatol- ogy expertise: “We have to deter- mine exactly whether the liver can compensate for the removed tumor. While the liver is the organ with the highest regeneration capacity, liver failure can occur if not all complications are duly considered prior to the treatment.” innovative GALAD score, which takes the patient’s age and gen- der into consideration, can really exclude HCC. The combination of the test parameters is crucial.” In Bochum, the tests have been conducted for more than two years. Canbay himself was involved in the GALAD study. Patients from all over Germany present in his department to have this test done – which to date is available only in very few hospitals. “Despite the promising results, the health insurers don’t cover the costs for the test yet,” Canbay explains and adds that „We could detect HCC much more often in the early stage which improves the prognosis.” He considers the test a necessity since “25 percent of the population have metabolic syndrome. Moreover, the number of immigrants from coun- tries with a higher rate of viral hepatitis infections is increasing. Thus, we need to integrate the tests as soon as possible in the routine.” Tests without GALAD score are ineffective Many hospitals conduct only the lab tests AFP-L3 and DCP under their early detection protocol – an approach Canbay considers insuf- ficient: “When one test is negative, the other might well be positive. Only the combination with the He hopes that in two or three years’ time the health insurers will have changed their minds and pay for the test. It would make sense since a positive test result makes further time-consuming and expensive tests superfluous. “We can’t perform an MRI scan every six months – that’s far too expen- Professor Dr. Ali Canbay Professor Dr Ali Canbay is Director of the Medical Clinic of the University Hospital/Knappschaftskrankenhaus Bochum, Germany. He is a specialist physician for internal medicine and gastroenterology and holds additional qualifications in internal/critical care medicine, transplantation medicine and targeted tumor therapy. sive. But we can determine the GALAD score regularly to under- stand the development and detect an evolving HCC early.” Moreover, patients who undergo timely and successful treatment enjoy a high quality of life and even can resume working. Thus, the test is a win-  win option. Report: Sonja Buske More certainty with methylation tests for early detection of cancer A second-generation lab test for early detection of cervical cancer is the most recent addition to Oncgnostics’ portfolio. In par- ticular, the company’s solution will help women in countries with limited cancer screening. Moreover, new research on the early detection of vulval and vaginal cancer might soon ena- ble the development of tests for these cancers. In 2015, Oncgnostics, a then three- year-old University of Jena spin-off, launched GynTect, a test for the early detection of cervical cancer. It uses DNA methylation as a bio- marker that occurs specifically in cervical cancer or its precursors. At that time, GynTect was one of the first solutions worldwide to apply this technology to the early detection of cancer. Today, the test is marketed in several European countries and in August 2022, it was approved in China. Since GynTect detects six methyl- ated DNA regions, a maximum of ten samples can be processed at a time which makes GynTect more resource-intensive than conven- tional lab tests. Consequently, the test is less suitable for use in coun- tries with little or no screening and limited lab equipment. Thus, Oncgnostics developed a second generation of the test which was presented at last year’s Medica: ScreenYu Gyn. As it detects only one methylated DNA region it can be more easily automatized and up to 100 samples can be analysed in one batch. It was approved in May 2022 but is not being used yet. ‘Currently, we make the test availa- ble only to interested researchers,’ says Dr Alfred Hansel, co-founder and CEO of Oncgnostics, and adds ‘while we did our own study with 600 samples, we want to have the test verified by an independent third party.’ ScreenYu Gyn does not yet reach its predecessor’s accuracy; nevertheless, it is an alternative for developing coun- tries and rural and remote areas. Dr Hansel points out that ‘most new cancers occur in countries with little screening. There, our tests could be a useful tool.’ Self-pay service In Germany, the tests are currently a self-pay service, i.e., the costs of the tests are not covered by statutory health insurers but have e k s u B a j n o S © Dr Alfred Hansel with his lab tests for the early detection of gynaecologic cancers. to be paid by the women them- selves. Particularly women with a suspicious pap smear or a posi- tive HPV test are interested in the Oncgnostics test to get an unam- biguous result before the gynae- cologist repeats the test three to twelve months later. ‘A suspicious test result does not necessarily mean cancer,’ Dr Hansel explains and adds that ‘abnormal tissue and HPV infections usually heal by themselves; therefore physicians tend to wait and recheck after a certain period of time. For many women, this time of uncertainty means enormous mental stress, so they use our test to clarify the initial finding. GynTect not only reliably detects existing tumours; it can also provide information on the probability of cervical cancer.’ Early detection of vulval and vaginal cancer To date, there is no test for the early detection of vulval and vag- inal cancer. Due to the unspe- cific symptoms, it is usually an incidental finding. A methylation test using the same biomarkers as the cervical cancer test might be a solution, as Hansel and his team found in initial studies with a few hundred samples from two university hospitals. ‘Currently, our test recognizes 80 to 90 percent of all cancers, and we fully expect to reach 100 percent soon,’ the CEO says. In two years at most, he esti- mates, that goal will be reached since he and his team are focusing their full efforts on the project. If the health insurers start to pay for the test, the development might even be faster than with the pre- vious two tests since there are no  alternatives. Report: Sonja Buske EUROPEAN HOSPITAL Vol 32 Issue 1/23

1 4 L A B O R AT O R Y / PAT H O L O G Y Breast cancer diagnostics Precision pathology: an AI-led alternative to molecular diagnostics along with precision medicine and AI-based computational pathology research. Rantalainen underlined the impor- tance of a large retrospective pop- ulation representative studies with real-world data, and clinical infor- mation including outcomes from national registries. ‘Based on this collection of data, we then focus on developing various solutions from those studies,’ he said. ‘An in-house infrastructure and team drives studies from start to finish and has close collaborations with clinicians and industry.’ Deep learning to improve risk stratification The expert cited two studies that demonstrate how deep learning can be used to improve risk strati- fication for intermediate risk breast cancer patients. One looked at improving breast cancer histological grading using deep learning to provide relevant clinical decision making by train- ing a simple model to learn these representations and then apply that type of model to stratifying an NHG2 intermediate risk group of patients into high and low risk group. Another research paper that the group used concentrated on predicting molecular phenotypes from histopathology images. The KI group has now taken this academic research into the Stratipath clinical solution for risk stratification for breast cancer patients. A new phenotype modality In conclusion, Rantalainen said: ‘AI-based precision pathology can be an alternative to molecular diag- nostics with multiple advantages in the clinic.’ He indicated that histo- pathology images provide a com- pletely new phenotype modality for precision medicine applications that are information-rich, captures spatial variability, scalable and cost-effective in terms of lab-based assays. ‘The key is to be able to do this in large population representa- tion studies,’ he continued, adding that the approach offers numerous applications in routine pathology, precision medicine and for patient  stratification. Report: Mark Nicholls Mattias Rantalainen Mattias Rantalainen is Associate Professor and Research group Leader in the Department of Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. EUROPEAN HOSPITAL Vol 32 Issue 1/23 m o c . e b o d a . k c o t s – l e s k a r T _ x e l A © to look beyond what the human eye can see from images and extract information from large data sets for risk stratification, prognos- tic and treatment predictive mod- els. ‘This enables us to leverage digital pathology slides together with AI to extract specific informa- tion for research and for stratifi- cation of patients,’ he added. That facilitates AI-based phenotyping for subtyping and subgroup anal- ysis with standardized morpho- logical phenotypes and can also capture intra-tumour heterogeneity information. This, he added, is cost effective and scalable. Project overview The group’s activities range from early-stage research to clinical translation and implementation. It involves a KI umbrella project CHIME (Cancer Histopathology Image Epidemiology project); ABCAP (Advancing Breast Cancer histopathology towards AI-based Personalised medicine), with a focus on breast cancer precision pathology with partners in the Nordic Countries; and SWAIPP (Swedish AI Precision Pathology), with a focus on translation and implementation with 11 partners across healthcare, industry, aca- demia and patients. It has routes to clinical implementation of AI-based precision pathology, from research to clinical translation of regulatory approved solutions using breast cancer as an initial implementation case. Meanwhile, CHIME incorporates design of new studies, data gener- ation, and links with registry-based clinical data and other phenotypes, Precision pathology using Artificial Intelligence can provide an effective alternative to molecular diagnostics. Experts have highlighted how precision pathology using Artificial Intelligence can pro- vide an effective alternative to molecular diagnostics. This, say a team from the Karolinska Institutet (KI) in Stockholm, Sweden, can also offer multi- ple advantages within a clinical setting and support risk strati- fication. in Mattias Rantalainen, an Associate Professor and Research Group Leader the Department of Epidemiology and Biostatistics at the Karolinska Institutet, detailed how AI-based precision pathology is a cost-effective alternative to gene expression-based assays for breast cancer diagnostics. Speaking at the 9th Digital Pathology and Artificial Intelligence Congress in London, Rantalainen told dele- gates that routine histopathology assessment can lack precision in identifying patients with high risk for disease progression that could benefit from chemotherapy. During his presentation, he outlined how AI-based precision patholo- gy can discriminate high-risk from low-risk patients in a more cost-ef- fective way. He said the digital transition enables AI-based phe- notyping, stratification and offers decision support solutions. Less result variability, more safety and efficiency Rantalainen heads a research group focussing on digital med- icine, particularly in the area of tissue pathology and exploring how these models can be used by pathologists and oncologists. ‘Our main interest in AI precision pathology is that it improves rou- tine pathology in terms of decision support, reduction in inter-assessor and inter-lab variability, increased safety with an automated second reader and has efficiency gains,’ he said. 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1 6 L A B O R AT O R Y / PAT H O L O G Y Centralised image library and archive From regional to national: digital pathology network transformation Transforming a regional digital pathology network into a nation- al programme across the UK has the potential to save the NHS around £100m a year. Such a net- work – one that sees a centralised digital pathology image library and archive, as opposed to indi- vidual hospitals having their own infrastructure and teams to man- age it – can also offer a range of other benefits alongside signifi- cant cost savings. for NPIC The savings potential was raised by Basharat Hussain, Deployment Director (National Pathology Imaging Co-operative) at Leeds Teaching Hospitals NHS Trust, as he outlined the opportuni- ties and challenges of expanding a regional digital pathology network into a national programme across England. Speaking at the open- ing of the 9th Digital Pathology and Artificial Intelligence Congress in London in December, Hussain detailed how the NPIC grew out of the work of the renowned digital pathology department in Leeds. That growth initially expanded the network across West Yorkshire and then into other areas of north- ern England before taking in the national paediatric patholo- gy network, coordinated by Great Ormond Street Hospital in London, and the soft tissue network, includ- ing other hospitals in Birmingham, Manchester, Sheffield, Liverpool Technology transition m o c . e b o d a . k c o t s – y l f y t t i k © A digital pathology network can save money and offer a range of other benefits. the lessons to repositories, scanning magnifica- tion and image retention, the num- ber of users to access the system, performance level expectations, procurement decisions, integration, the decision to opt for a separate software and hardware vendor and to adopt a non-Cloud solution. Among learned, Hussain pointed out the produc- tion of the Leeds Guide to Digital Pathology, a how-to guide for others to learn the lessons of a massive digital pathology scale-up. Beyond that, he emphasises the need for scanners with DICOM image format, excellent connectiv- ity, a strong PACS platform, and a robust and scalable operation. and elsewhere in the country. It is now one of the largest digital pathology and AI programs in the world, he said. Increase in demand Hussain reminded delegates that Leeds has been at the forefront of digital pathology for 20 years, having built the first gigapix- el display for digital pathology (Powerwall), developed the Leeds Virtual Microscope and undertook academic research to drive clinical use of digital pathology in the NHS, as well as embracing AI. Highlighting how the project devel- oped, he said: ‘Funding has been a challenge and we are working in a period of an increase in demand – with less pathologists being trained, and more nearing retirement age – so the experience has made us more aware of ongoing sustainabil- ity issues around pathology.’ The initial phases saw £10m of funding, with £7m in indus- try co-funding, to deploy digital pathology at six regional hospitals for 750,000 slides a year and 1.2 petabytes (PBs) of data, along with establishing a training and educa- tion centre. That scope further expanded to cover 30 hospitals, 300 patholo- gists, up to 2.4m slides a year, and deploying over 40 scanners from the original 15, with 4PBs of storage, Hussain continued. He pointed out challenges along the way, including space constraint for scanners in busy laboratories, while other considerations included stor- age capacity and data transference Instant sharing for second opinions The system sees patient samples processed in the laboratory with a glass slide created and transformed into a digital image that is ingest- ed into the central infrastructure linked to the hospital, and is avail- able to pathologists to access. ‘The digital image enables the pathol- ogist to make their diagnosis and to present to clinicians at multi- disciplinary teams (MDTs) so the patient gets the right diagnosis and treatment,’ he continued. ‘The solu- tion also enables second opinions as images can be shared instant- ly with pathologists hundreds of miles apart.’ However, he empha- sised that the solution had to meet certain requirements: it must align with the terms of a green UK-based data centre, offer adequate storage capacity, a long-term archive tier, disaster recovery, back up and scal- ability to give rapid time to value for NPIC customers. ‘The scale up capabilities allow for growth of the platform as more trusts and organ- isations are onboarded,’ he added. Today, with dual data centres pro- viding real-time replication and 20 petabytes of storage, the NPIC net- work has the capability to store seven million whole slide images (WSIs). ‘The infrastructure is scalable to multi-exabyte levels and we have the potential to capture and store all WSIs across the UK and keep them for over 30 years,’ said Hussain. ‘There will be seamless site-to-site image sharing which is instantly available to hospitals in the NPIC network and we also have the potential to improve turnaround times for cancer diagnosis, faster deployment of AI capabilities, and continue with research capabilities – for example, the recent work with Genomics England to scan the 100,000 Genomes project – and support clinical trials. And, given the economies of scale, it could save the NHS £100m.’ With plans to onboard all current NHS partners by the end of 2023, the aim is to continue with IT investment, improve archiving, and reach out to further regions that have expressed an interest in joining the digital pathology network.  Report: Mark Nicholls Netherlands Cancer Institute switches to new digital pathology platform The Netherlands Cancer Institute (NKI), one of the top 10 compre- hensive cancer centers in Europe, will deploy a diagnostic platform from digital and computation- al pathology solutions provider Proscia, the company announced. The platform, Concentriq Dx is designed to expand digital pathol- ogy practice, laying the founda- tion for its pathologists to deliver personalized diagnoses that bet- ter inform treatment decisions. In doing so, the cancer center, which houses an internationally acclaimed research institute, will generate additional pathology data that can lead to clinical break- throughs, Proscia predicts. Digital pathology, which shifts the 150-year-old standard of care from microscope to whole slide image, is increasingly powering routine diagnosis as expectations for precision medicine intensify the impact of the pathologist short- age and rising cancer burden. An early adopter, NKI recognized that scaling its digital operations to further deliver on its commitment to excellent patient care would require moving away from its lega- cy software system. It selected the enterprise-grade Concentriq Dx to serve as the modern platform at the center of its growing oncology practice. Bringing more pathology data into its practice CE-marked under IVDR, Concentriq Dx is a singular, secure digital pathology platform that drives pri- mary diagnostic and other routine workflows across the connected laboratory.* NKI will draw on the platform’s interoperability to unify images from disparate scanners, bringing more pathology data into its practice. With live and asyn- chronous collaboration and remote image viewing, the solution helps pathologists to broaden access to specialists in an effort to provide higher quality diagnoses. The plat- form also offers interoperability with third-party image analysis applications, allowing NKI to iden- tify clinically impactful patterns, and is designed for realizing the promise of pathology’s computa- tional future. “Concentriq Dx will empower us to chart our path towards full digitization,” said José van den Berg, Head of the Department of Pathology at NKI. “The modern, enterprise-grade platform will ena- ble us to increasingly combine expertise and insight to drive pre- cision diagnosis. Our multidiscipli- nary teams work to provide per- sonalized treatment for all patients, and our pathology data plays an integral role in achieving this aim.” In addition to informing diagnoses, pathology data factors heavily into biomedical research that leads to new therapies and other break- throughs that advance precision medicine and improve patient care. NKI’s internationally acclaimed research institute works closely with its dedicated cancer center to create maximum impact for patients through foundational and I K N © The Netherlands Cancer Institute building in Amsterdam. translational clinical studies. By scaling its digital pathology prac- tice, NKI is paving the way to unlock even more value from its growing volume of data by increas- ingly incorporating it into research initiatives. “We are thrilled to help NKI take the next step on its digital pathology journey with Concentriq Dx,” said Arun Ananth, Proscia’s Chief Commercial Officer. “As we continue to expand our presence in Europe, we look forward to working with a world-class team that is committed to its patients through excellent clinical care and groundbreaking research.” *Concentriq Dx is CE-marked under IVDR and is available for primary diagnosis in the US during the Covid-  19 public health emergency. Source: Proscia EUROPEAN HOSPITAL Vol 32 Issue 1/23

1 8 S U R G E R Y Hospital program: Returning Seniors to Orthopedic Excellence (RESTORE) Facilitate recovery from hip fracture surgery by geriatric patients a Caregivers at the University of Texas Southwestern Medical Center in Dallas, Texas, have developed programme designed to facilitate recovery by geriatric patients follow- ing hip fracture surgery. The Returning Seniors to Orthopedic Excellence (RESTORE) pro- gramme is designed to provide stellar comprehensive collabo- rative co-managed care for older adults with orthopaedic inju- ries. The Global Burden of Diseases, Injuries, and Risk Factors Study estimates that globally, 178 million new fractures occurred in 2019. Of these, 14,2 million were hip fractures – a 107.4 % increase in women and a 76.0 % increase in men since 2009. Hip fractures are a major cause of disability and m o c . e b o d a . k c o t s – a c i r f A w e N © The RESTORE programme involves starting mobility measures on the same day as the operation. Patients should try to walk at least three times a day. RFA, MWA, CRYO and IRE under scrutiny dependency in the elderly. Twenty- five percent of elderly patients die within a year after fracturing a hip, and 33 % require transition to a more restricted living environment, according to research conducted by the Italian National Research Council’s Neuroscience Institute. Megan Sorich, DO, an orthopae- dic surgeon and the director of RESTORE, became interested in developing a programme that might help reduce these sobering statistics. She was awarded a ger- iatric trauma fellowship after her surgical residency and joined UT Southwestern Medical Center in 2019 with the goal of establishing an outstanding Fracture Liaison Programme. launched A multi-specialty team with a collective goal RESTORE was in February 2021. To obtain pro- gramme approval, Sorich discussed its benefits with hospital adminis- trators, to show that this would be cost saving, and that its implemen- tation could potentially reduce the time from emergency department (ED) processing to surgery, and length of stay. She sought support from key stakeholders in geriat- RESTORE and NICHE treatment recommendations • After diagnosis, offer a regional anaesthesia block (fascia ilicus) to manage pain prior to surgery and to potentially help decrease the need for narcotic pain medication. Avoid excessive medication throughout a patient’s stay to help prevent delirium. • Perform surgery as soon as the patient is medically able to undergo the procedure, preferably within 24 hours of hospital admission. • Start mobility procedures on the same day surgery is performed, with early ambulation at least three times daily as soon as the patient can be weight-bearing. • Maintain judicious pain control and ice/cold packs on incision 24/7. • Toilet use as soon as possible. Establish a sleep-conducive environment at bedtime hours for patients to have a regular sleep schedule. Discourage daytime sleeping with activities and daylight environment. ric medicine, hospital medicine, orthopaedics, anaesthesia, physical therapy, and emergency medicine. The RESTORE team is very diverse, and includes physician specialists in emergency medicine, internal medicine, geriatrics, anaesthesiol- ogy, and pain management, as well as nutritionists, physical and occupational therapists, discharge planning coordinators, geriat- ric resource nurses, and geriatric patient care associates. Sorich says that the team works cohesively to help establish standardized patient care, to expedite patients to surgery, and to better manage post-surgical care. Their collective goal is to reduce length of stay, reduce in-hospital mortality rates, and reduce postoperative compli- cations of patients who have frac- tured their hips. Sorich and colleagues describe the procedures adopted by UT Southwestern in detail in Geriatric Nursing, starting with emergency department “fast-tracking” a patient suspected of having fractured a hip to the radiology department, to Thoracic interventions: emerging techniques Experts presented state-of-the- art and emerging techniques to treat chest tumours and dis- cussed common issues in the management of pneumothorax at RSNA 2022. Current ablation methods in the thorax include radiofrequency ablation (RFA), microwave ablation (MWA), cry- oablation (CRYO), irreversible electroporation (IRE) and pulsed electric field. thermal Transbronchial abla- tion is an investigational meth- od that could be interesting for the treatment of lung tumours, said Professor Michael Lanuti, MD, Director of Thoracic Oncology for the Division of Thoracic Surgery and the Thoracic Surgery liai- son to the Massachusetts General Hospital Cancer Center in Boston. ‘Image-guided thermal ablation is already adopted as a tool in the armamentarium for oligometastatic disease, lung cancers or in case of failure of stereotactic radiotherapy,’ he told the audience. Thanks to new technology pro- viding higher resolution, surgical teams can now navigate to the lesion site using electromagnetic navigation bronchoscopy or newer navigation platforms such as ION and Monarch. For real time con- firmation of position, they can use cone beam CT or CT fluoroscopy, or ultrasound bronchoscopy when it is available. ‘The main benefit for bronchoscopic ablation is that it can reach nodules in the middle lung m o c . e b o d a . k c o t s – 7 7 9 1 g n a j o t o t © There are many new promising treatment options for tumours in the chest area, especially the lungs. zone that cannot be reached with the percutaneous technique,’ Lanuti said. ‘If the bronchoscopic ablation is implemented with robotic naviga- tion, the no-hand approach makes it possible to perform cone beam imaging without provider exposure to radiation.’ The technique choice will depend on the lesion location – the concept of lung zone depend- ence, he explained. Heat management in different tissues ‘In the periphery, many of the approaches are applicable, but in the central zone, most are danger- ous. This might be where image guided RFA or non-thermal pulsed electric field can play a role,’ he sug- gested, adding that there are other factors to consider before deciding on therapy. ‘CRYO is associated with less pain for a lesion that is located along the pleura or for peripheral location close to the chest wall.’ Heat management is a factor for the percutaneous approach as well as transbronchial thermal ablation. ‘There’s the suspicion that micro- wave could mitigate this phenome- non,’ Lanuti said. ‘But CRYO is usu- ally preferred for lesions abutting airways.’ Transbronchial thermal ablation should be performed in tumour locations that allow for it. ‘The propagation of heat or cold is unreliable in a tissue where you had previous radiation,’ he said. Interstitial lung disease is under evaluation and thermal ablation coming down the airway might reduce the risk of pneumothorax. Transbronchial thermal ablation could be used as part of a one- stop-shop approach, where teams can diagnose and directly treat the lesions. ‘We’re still in the clinical trials. To be successful at this, you need to have a champion in your institution, and that can be either a pulmonologist or a thoracic sur- geon. A lot of pulmonologists are moving in that space, as well as theragnostics interventionists, who can biopsy the lesion and treat it,’ said Lanuti, who recommend- ed using transbronchial thermal ablation for tumours smaller than 2 cm. ‘The benefit is that it’s repeatable, and with bronchoscope techniques, perhaps there’s less pneumothorax. We need prospec- tive studies to standardize the tech- nique,’ he concluded. Chest tube management In the following talk, Maria Lucia Madariaga, MD, Assistant Professor of Surgery at the University of Chicago, focused on the finishing touches of chest tube placement after pneumothorax (PX), an action that is required in 2 to 15% of all PX cases. ‘When a patient has a lot of soft tissue or they’re obese and you put a pig tail in, the pig tail could migrate out of the pleural phase even though it may look like it’s still attached to the skin,’ she said. The two most important things to remember in this scenario are how to tape the tube to the patient and how to secure the chest tube con- nections, she explained. ‘A loose chest tube stitch could also have fatal consequences. It’s very impor- tant in your daily examinations of the patient to make sure that attach- ments are attached to the patient. Bad stitching of the chest tube can lead to chest tube falling out. Once you saw the tube in, whether you do a single stitch at skin level or Roman sandal technique, make sure the tube is not able to move in and out.’ A Heimlich valve sometimes comes as part of the chest tube in sur- geon kit as a way to evacuate air. However, some surgeons may be confused as to what to do with it, Madariaga said. ‘One common misconception is that the valve is placed in series with the whole chest tube contraction. You don’t need to use this valve unless you’re taking the patient home.’ A bad tape job is when the connection is obscured. ‘The tubing connecting to the pleurevac and the tubing connecting to the patient could be completely disconnected within this tape monster and you would never know,’ she said. A good way to secure connection is to make it visible, 180 degrees from the tubing and to use one single line of tape. ‘Using tie bands at the connection sites can also show you that the connection is secure and visible,’ she suggested. EUROPEAN HOSPITAL Vol 32 Issue 1/23

2 0 S U R G E R Y Sponsored • No complications Hip arthroplasty for femoral neck fractures Arthroplasty for femoral neck fractures has seen enormous progress in recent years, but complications due to infections are still a major problem. With good preparation and the right technique, however, orthopaedic surgeons can take away much of the horror of this scenario. At the Heraeus Symposium as part of the German Congress of Orthopaedics and Trauma Surgery (DKOU), three experts discussed the most important risk factors and how they deal with them. ‘Hip surgery – it has to be said – is high-risk surgery,’ Prof Ulrich Liener introduced his audience to the topic. Studies place the com- plication rate for femoral neck fracture treatments at 75%, with more than every tenth patient requiring repeated surgery. In this context, the Head of the Clinic for Orthopaedics, Trauma Surgery and Sports Traumatology at the Marienhospital in Stuttgart empha- sised the role of infectious compli- cations in particular: ‘It's a disaster for the patients,’ he put it suc- cinctly. Higher mortality, reduced mobility, severe pain – all in all, a significant reduction in the qual- ity of life, which also negatively the actual surgical technique,’ the expert emphasised. In addition, antibiotic-loaded bone cement has been shown to be an effective tool for infection con- trol, Liener explained. Studies have shown how patients bene- fit from cemented arthroplasty in femoral neck fractures; compared to cementless stem anchorage, it significantly lowers periprosthet- ic fracture rates, prolonging the implant’s life by a factor of 3 to 4. Also, mortality over the entire period of hospitalisation decreases, the expert pointed out. ‘Cement is not only an effective means of fixing the prosthesis in place, it is also a good vector to deliver anti- biotics to where they are needed in a highly concentrated way.’ In particular, high-dose, double-load- ed bone cement (gentamicin and clindamycin; G+C) shows longer and broader effects. ‘I have been using this cement for a long time in all my high-risk and elderly patients because it greatly reduces the infection rate.’ Strong representation of patients over 75 Following up, Prof Dieter Christian Wirtz also picked up on the impor- tance of patient age: ‘In patients According to studies, the complication rate in the treatment of femoral neck fractures is 75%, and more than every tenth patient requires a second operation. m o c . k c o t s i © hip arthroplasties, the expert clar- ified, referring to current figures: ‘This is mainly due to periprosthet- ic fractures, which has an increased sition between the cemented endo- prosthesis and the cortical bone is visible on the X-ray. To achieve this, the bone is first sealed distal- ly with an intramedullary stopper. ‘Not only does this prevent the appearance of unsightly “cement sausages”, but the stopper also enables thorough irrigation and retrograde filling of the medul- lary canal.’ The subsequent pres- sure irrigation clears the spon- gious bone of fat and blood parti- cles. ‘This prevents fat embolisms and allows interdigitation of the cement into the bone.’ Finally, the shaft is filled in a ret- rograde fashion with bone cement – applied distally to the stopper and then filled proximally. This technique prevents air bubbles from getting into the bone cement, which could later lead to cracks. Optimal interlocking with the bone is then ensured by proximal med- ullary sealing, which allows the bone cement to be further solidi- fied with the necessary pressure. ‘This is seen later on the X-ray as a whiteout.’ After this, the stage is set for the insertion of the endo- prosthesis – Hailer urges his col- leagues to be patient during this step, because air bubbles can also form in the cement coat if the stem is inserted too quickly. The curing time of the bone cement of about twelve minutes must be observed for the repositioning, otherwise the torsion of the stem changes and can lead to instability. is lower Perioperative complications Despite the occurrence of Bone Cement Implantation Syndrome (BCIS), mortality in cemented patients, as previously shown by Liener. Nevertheless, it is important to differentiate the patient group in advance: Elderly, male and multimorbid patients rep- resent a particularly fragile group, calling for an adapted approach to the cementing technique, Hailer cautioned. BCIS-related complica- tion can be prevented even in vulnerable patient groups through thorough pressure irrigation of the bone even before insertion of the medullary plug, renewed irrigation with plenty of fluid as well as dis- pensing with proximal medullary sealing and maximum pressure build-up. Last but not least, Hailer highlighted the advantages of the lateral approach for hemi (HEP) and total endoprostheses (TEP), which reduces the risk of dislo- cation by three to five times com- pared to the dorsal approach.  Report: Wolfgang Behrends EUROPEAN HOSPITAL Vol 32 Issue 1/23 results therefore argue in favour of implants with a matte surface (Ra <2.5 µm), which create a firm bond with the bone cement and thus reduce the risk of fractures. The export also recommended the use of dual-mobility cups – especially for older patients. This type of implant also benefits from cemented fixation, and Wirtz once more emphasised the advantages of antibiotic-loaded bone cement in this context: ‘It may of course be a matter of cost, but the evidence clearly speaks in favour of it.’ He also addressed concerns regard- ing antibiosis leading to increased formation of resistant pathogens. These have not been confirmed, the expert pointed out. The third speaker of the sympo- sium, Univ Prof Dr Nils Hailer emphasised the special role of Germany in cemented arthroplas- ty. For example, PMMA – also known as Plexiglas –, which is today widely used as bone cement, was invented here, the head of the Department of Orthopaedics, Trauma and Hand Surgery at Uppsala University Hospital listed. In addition, Hamburg University Medical Center was among the first to add antibiotics to the bone cement. Given this pioneering role, the expert found it curious that the technique is hardly used in operations in Germany: ‘We should cement a lot more,’ was his assess- ment. How to achieve a successful “whiteout” In addition to the differentiation of the patient groups – regarding to age, gender and comorbidities – the correct cementing technique is crucial for treatment success. To illustrate, Hailer showcased the “whiteout” as a distinct quality feature: If done correctly, no tran- s u e a r e H © From left: Prof Nils Hailer, Prof Dieter Christian Wirtz, Prof Ulrich Liener affects the clinic and the surgeon. Good preparation makes all the difference However, careful pre-planning of any procedure can go a long way to improve the chances of success, Liener noted. For example, dia- betes – a high-risk factor for the development of infections – can often be modified by adjusting the HbA1c value to >7.5% in the last 24 hours before surgery. Other fac- tors include antibiotic prophylax- is, treatment of pre-existing infec- tions, limiting surgery duration, regular changing of gloves during surgery and well-adjusted patient blood management (PBM). ‘These are all rather simple measures that can be implemented without great effort but reduce the risk of infection enormously – probably even more so than by changing over 75 years, osteoarthritis is – after high blood pressure – the second most common condition requiring treatment, even more so than dia- betes or coronary heart disease,’ said the expert from the Clinic and Polyclinic for Orthopaedics and Trauma Surgery at Bonn University Hospital. Accordingly, this age group accounts for a large propor- tion of hip replacements – about 41.6% of the more than 147,000 annual procedures are performed on patients over 75. This poses an additional challenge for arthroplas- ty: older patients frequently suffer from deficits in primary stability due to osteoporosis, cognitive and motor impairments, a higher risk of dislocation and falls, and are also more frequently affected by complications during surgery. Cementing can noticeably reduce the revision rate for elective total occurrence rate in cementless tech- nique procedures for patients aged 75 upwards’. Especially women with osteoporosis within this age group benefit significantly from the use of cement, Wirtz said. This also applies to patients with femo- ral neck fractures. Here, too, regis- ters show a significant advantage of cemented treatment. Implant surface: polished or matte? The choice of implant surface can also prevent complications, the expert continued: so-called Exeter implants with a highly polished surface (Ra <0.1µm) do not bond with the surrounding bone cement, but jam in the surrounding mantle. This axial migration can lead to longitudinal cracks in the cement mantle. ‘Especially in older patients, this significantly increases the risk of periprosthetic fractures.’ Study