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Dutch homecare goes global The more powerful management is the less creative it becomes everywhere.’ Financing can be done through government or insurer reimburse- ments and, for example, in partly through private contributions, as in China and India. In the Netherlands healthcare is covered by Social Security Systems and health insurers. In the early years, De Blok faced finance problems: the system was too unfamiliar. ‘Now there are good agreements with insurers. We signed three-year contracts based on results and not, as with other care- giving organisations, on fees, costs and volumes.’ Nurse and entrepreneur Although De Blok sees himself primar- ily as an entrepreneur, he maintains patient contact. ‘It inspires me, he explained. ‘For example, I received a Jos de Blok was awarded the prestigious Albert Medal from The Royal Society of Arts (RSA). ‘I received a letter from London about the nomination. I thought it was a joke, until they called me and explained they wanted to recognise the innovation and global impact of the concept. So, in 2014, I received this award, placing me on the same list as physicist Stephen Hawking. I feel really honoured.’ letter, after her death, from a 31-year- old breast cancer patient. She thanked us for the great last months of her life. ‘She had four new (caregiving) girl- friends who even took her on a stretcher to places she wanted to visit, one last time.’ The future ‘It’s crazy that management is the least creative when it has the most power,’ he observed. ‘Buurtzorg has 14,00 creative brains which invent and develop beautiful innovations with an enormous impact on self- reliance and well-being. ‘I predict that, in five to 10 years many organisations worldwide will have reversed their approach, defeat- ed by their own weapons: saving. And those savings will not be at the expense of healthcare providers and healthcare receivers.’ Buurtzorg is essentially a mod- ern form of old Dutch community nursing. Now it is the largest pro- vider of care. In addition, there is Buurtdiensten for community service, household and family assistance, like family care in the past. e m n o l s / k c o t S e b o d A © Home care in the Netherlands wors- ened. ‘The organisations grew big- ger, involving more and expensive management,’ observed nurse Jos de Blok. ‘Registration procedures became unnecessarily complicated. I enjoyed my job when I started in 1986, but that feeling changed. I knew there should be an easier way, without managers and at a lower cost. So, in 2006, I began the Buurtzorg concept.’ This is similar to the way district nurses in the Netherlands formerly worked: autonomously and using their own initiative. Buurtzorg has self-managing teams of ten to twelve people, who give one to one care for about fifty patients each. When mul- tiple care or other expertise is needed, several team members can handle it. Patients know their carers and care is tailored to their current needs. ‘This makes it measurable: care becomes cheaper, less care is needed, and patient self-reliance can be increased,’ de Blok explained. The teams hire their own col- leagues and organise the work, planning, training, assessment, etc. Everything revolves around questions: What’s happening? How are you solv- ing it? What’s the result? There are no policy plans to meet, and therefore no complaints from employees; eve- ryone focuses on their expertise and professionalism. ‘We started with four employees; now there are 14,000. I’m still impressed by all those who quit their jobs in the early days to work with us. Families also made Buurtzorg known around the country. It’s all viable now.’ The organisation is frequently acclaimed as the Netherlands’ most attractive employer. ‘We have just one office in Almelo to support the teams,’ de Blok explained. ‘All the support, including our software pack- Care at home is like invisible holding hands. ages, were created by employees. Sixty other Netherlands organisations now use Buurtzorg’s supporting soft- ware. Problems? No. But we face a shortage of new qualified staff.’ The concept’s first year was financed by De Blok’s consultancy firm, although his wish to introduce it to other organisations did not ini- tially materialise. ‘My ideas about less management and autonomous teams were too frightening. Some were will- ing to adjust, but all wanted to keep their management. I’m convinced that top down rules don’t work, so I started Buurtzorg as an autonomous company. The best ideas come from work in the field, not from manage- ment. People must have the oppor- tunity to come up with their own solutions.’ Example: In 2010 an employee initiated the ‘walker race’, after an 87-year old said there are no races for people using a walker. ‘She raised 10,000 euros to get the race started. It became the Rolympiade, an annual walker race covering 400 or 800 metres. Last year six over 90-year-olds – oldest 104 years – participated.’ This improves mobility, and reduces loneli- ness, he noted. There are around 100 more Buurtzorg projects. Beyond the Netherlands De Blok now sells Buurtzorg abroad. ‘The concept runs in Japan, China, Australia, Germany, England, France, Switzerland and Austria. Recently, I explained at a conference how to implement the system in a test envi- ronment and adapt it to local con- ditions. The universal components, such as teams, self-organising pro- cess, back office and IT support, work MEDICAL LIGHTING SYSTEM HALL 10 | STAND B60 WWW. H E A LT H C A R E - I N - E U R O P E . 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2 W E D N E S D AY @ M E D I C A The ‘bionic’ radiologist Three steps towards healthcare improvements through new technology Professor Marc Dewey, Vice Chair of the Department of Radiology at Charité – Universitätsmedizin Berlin, made value-based radiology the main theme of the Wilhelm Conrad Röntgen Honorary Lecture during ECR 2018. Radiology practice needs change, he said, and radiologists should grasp at new technology to drive their future. His lecture was summarised in a recent comment in The Lancet. See Link: www.thelancet.com/ journals/lancet/article/PIIS0140- 6736%2818%2931193-0/fulltext Report: Sascha Keutel Dewey’s lecture presented a list of issues regarding current healthcare systems. Among foremost patients’ complaints on hospital admittance is being asked about their medical history multiple times from different staff members or departments. Also, patient care services that decide the clinical strategy and tests to be made have conflicts of interests and different aims. ‘We’re not using evidence-based approaches to make those decisions,’ Dewey said. the Additionally, idiosyncratic terminology in radiologists’ reports prevents major critical findings from being detected. According to Dewey, a recent study on determination and communication of critical findings in abdominal imaging found that one-third of it went undetected. (https://www.ncbi.nlm.nih.gov/pub- med/19581643). A vision of the future Dewey spoke of a Commonwealth Fund study that concluded that increasing healthcare spending per GDP does not equate to bet- ter patient outcomes, or the per- formance of the healthcare system measured by equity and accessibil- ity. Reality: the more money nations invest in their health care system, the worse the outcome in terms of per- formance is – a really dramatic result and reason to introduce value-based medicine in radiology, he said. The general goal of value-based radiol- ogy is to improve patient outcome with lower cost. ‘Sometimes that means doing less – especially less imaging.’ radiology, Value-based he believes, will gain a central role in addressing three issues: 1. Improving personalised decision- making about if, when, and which patients need diagnostic imaging 2. Increasing consistency in how Marc Dewey is Heisenberg Professor of Radiology, Vice-Chair of Radiology at Charité – Universitätsmedizin Berlin, Germany, and he presided over the Berlin Röntgen Society from 2011 to 2013. He received the Röntgen Award in 2009 and the Curie Ring in 2012 – the German Röntgen Society’s two highest scientific awards. Dewey was also secretary of the 2011 German Röntgen Congress. tured vs. non-structured reports (https://www.ncbi.nlm.nih.gov/pub- med/25286323). Dewey concludes that structured reporting improves the way radiologists’ discuss a case with referring physicians and plan treatment. Natural language processing may also help radiologists to avoid a pos- sible culture shock when classic dic- tation vanishes. While the structure is captured by natural language pro- cessing, standardised dictation could continue, he suggests. This would make transition easier because, in the end, ‘culture eats strategy for lunch’. Challenges and conclusion ‘Everyone wants to be an innovator, yet no one wants to change,’ he said, adding that addressing cultural issues is also important in changing radiologists’ practice. But, for Dewey, the ‘potentially greatest challenge is the half-life of clinical data’. A study on test order prediction tools found that the accuracy of data to predict inpa- tient orders has a half-life of only four months (https://www.ncbi.nlm. nih.gov/pubmed/28495350). As healthcare changes rapidly, research- ers won’t be able to use robust data older than five years. Thus, says Dewey, ‘we don’t need big data; we need good data!’ Success in the three listed areas will free the radiologist to participate more actively in patient care, where automated systems are not good (yet). 4D-CT perfusion images of the heart (Dr. Kakuya Kitagawa and Prof. Marc Dewey) Figure 3 Fractal analysis of myocardial MR perfusion imaging. Fractal analysis has been established as a method to differentiate obstructive coronary artery disease and microvascular dysfunction. In this patient, a perfusion defect due to coronary artery disease with a fractal dimension of 2.47 is depicted (arrows) (Dr. Florian Michallek and Prof. Marc Dewey) using a device to gain an automated analysis and then interpreting the results and strategies along with a patient. An existing example is 4D-CT of the heart, which produc- es three billion voxels for a single patient (Figure 1). Patients can’t hold their breath for long, so there’s heart and lungs motion. Can we manually adjust? Can we go through these three billion voxels? That’s very hard to achieve.’ Dewey then explained that radiologists need automated approaches that do registration and pre-processing before a doctor even begins. Figure 2 shows such a pre- processing example of automatic coronary tree segmentation based on 3D cardiac CT. The bionic radiologist makes use of automated pre-processed data, e.g. using fractal analysis (https://www.ncbi.nlm.nih.gov/pub- med/27436024) while still being the major interpreter and integrator of the data (see Figure 3). This com- bined approach to leverage both the consistency of automatic analy- sis and individual interpretation of human image analysis ‘is a paradigm shift,’ Dewey said. Linking findings to treat- ment recommendations Third: Structured reports that com- bine audio-visual information linked to patient data make them search- able and analysable and therefore improve reporting, Dewey believes. A study of pancreatic can- cer imaging showed that the evalu- ation greatly improved with struc- the LED lamp distributes shadow-less light Figure 1 images are acquired and inter- preted by the ‘bionic’ radiologist 3. Enhancing the link on findings and reports with treatment rec- ommendations and management decisions. Evidence-based decisions First: Decision support tools, based on evidence, could help to overcome too much imaging in the wrong patients. AI tools would allow bet- ter predictions and free up radiolo- gists’ time to talk to a patient. This needs a patient’s data integration with decision support tools, such as the European Society of Radiology’s iGUIDE and eGUIDE. The bionic radiologist Second: The integration of AI with human efforts – the ‘bionic radiolo- gist’ – has great potential to increase consistency in radiological image analysis and reduce errors. Dewey foresees a human doctor Figure 2 Automatic coronary artery tree segmentation (Dr. Christian Wald and Prof. Marc Dewey) STARLED5 NX, surgical lamp with LED technology boasts an excellent light quality, the specialist manu- facturer ACEM reports. ‘The special optics of its LEDs generates a shad- ow-less, clear and homogeneous ACEM is at Medica Hall 10 / Stand B60 MEDICA 12.–15. 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Acem’s development ACRIS ensures, via a microprocessor, the control of electrical curves typical of LEDs, to remain unaltered over time but maintaining a long life cycle, the company reports. ‘The colour render- ing index of √ is 95 and its colour tem- perature 4,500 K.’ The lamp can pro- duce a focused and ambient light, and the light field focusing system adjusts the light spot diameter accurately assuring an excellent sharpness of details in the operating area, Acem confirms. Starled5 NX is particularly suitable for minimal invasive surgery and is ideal for the preparation and treat- ment during the operation, monitor- ing of the patient and microscope operations. It has been designed for comfort and is light to move, due to its central handle, and the medical team can move it from the lateral handles assuring stability and constant illumination even during movement. The removable and sterilisable central handle also can house a video camera to video surgical operations accurately (alternatively, the video camera can be placed on a separate arm). ‘The lamp shape assures visual EH @ MEDICA No 3 2018
W E D N E S D AY @ M E D I C A 3 The revolution escalates New procedures in medical image analysis based on artificial intelligence offer numerous opportunities but still have their limitations, Michael Krassnitzer reports. ‘Is image computing an opportunity or a threat?’ asked Dr Paul Suetens, professor of Medical Imaging and Image Processing at University Hospital Leuven. During the recent European Radiology Congress 2018 held in Vienna he also provided his own answer: ‘It’s an opportunity if the radiologist takes advantage of this supporting technology. It’s a threat if it is discarded by the radiolo- gist – “I am too busy now” are words I often hear; then it’s other special- ists who are gratefully adopting this technology. ‘Image Computing, including image analysis, artificial intelligence, artificial neural networks und deep learning, is starting a revolution,’ Suetens is convinced. Artificial Intelligence (AI) is not new – research in this field was carried out as far back as the 1950s – but, whilst in the early days AI learnt from image descriptions, it now learns directly from the images, such as photomet- ric image characteristics. Suetens was involved in a project that used MRI images with BOLD contrast – with the image signal depending on the oxygen content in red blood cells – for a detailed inves- tigation into which areas of the brain are active during hearing and pro- cessing of language. Other types of image computing are based on geo- metric image characteristics, such as segmentation of thoracic images. Image computing also includes the exciting field of image genetics, in which Suetens is also involved. As a LED lamp distributes shadow-less light image data. Certain characteristics of human faces suggest a mutation of the SLC35D1 gene, which is asso- ciated with chondrodysplasia with snail-like pelvis, a very rare, lethal form of skeletal dysplasia. A further use of this link between facial images and genetic informa- tion is the reconstruction of faces from human DNA, making it pos- sible for instance to reconstruct the features of well-known persons of whom, long after they have died, only artistic representations have been available. Respective recon- structions based on saliva samples from living test subjects achieve astonishing resemblances. These applications are based on deep learning, which entails an arti- ficial system learning from exam- ples, then itself recognising inherent patterns and regularities. The basis of this is so-called artificial neural networks that are modelled on the workings of the human brain. ‘Deep learning is a new paradigm with a strong impact on medical image analysis. It is sufficiently accurate and fast to compete with the human expert for specific narrowly defined tasks,’ says Suetens. However, deep learning still has its limitations. ‘Deep learning is still in its infancy,’ admits Suetens. If only a limited amount of data is available, or where the issue is around complex forms and deformations, neural net- works do not function very well. ‘A neural network is nothing other than a large number of individual data Professor Paul Suetens heads the Division Image and Speech Processing in the Department of Electrical Engineering at Katholieke Universiteit (KU) Leuven, Belgium. He is also chairman of the Medical Imaging Research Centre at University Hospital Leuven. His research focuses on medical imaging and medical image computing, which methodologically lies in the domains of computational science and machine learning. He has authored more than 500 peer-reviewed papers in international journals and conference proceedings and is author of the book ‘Fundamentals of Medical Imaging’ (3 editions, 2002, 2009, 2017). processors which are linked with one another – comparable to neurons in the human brain,’ explains Suetens. However, the human brain has around 86 billion nerve cells, whilst an artificial neural network only has 20 million nodes. ‘When we increase the number of nodes the results become worse – and we don’t yet know why this is,’ Suetens admits. Result of a study of a selected set of SNP genotypes in a normal population. Faces A and B show the effect of two extreme SNP variants in gene SLC35D1. Mutations in this gene cause Schneckenbecken dysplasia. The colour images show the differences between faces A and B of some local features (from left to right: strain, curvature change and distance). Significant local differences, such as at the orbits, may define characteristic biomarkers for this particular genetic disorder. (Courtesy of Dr Peter Claes, KU Leuven. Reprinted from Paul Suetens, Fundamentals of Medical Imaging 3rd edition, Cambridge University Press, 2017.) Face reconstruction from solely contextual properties (a set of gene variants responsible for facial development, supplemented with age, BMI and gender). Top: reconstructed face. Bottom: real face, unknown at the time of the reconstruction. The model was built using a database of 3-D pictures, DNA, age, BMI, and gender of an admixed population. (Courtesy of Professor M. Shriver, Pennsylvania State University, and Dr Peter Claes, KU Leuven. Reprinted from Paul Suetens, Fundamentals of Medical Imaging 3rd edition, Cambridge University Press, 2017.) member of an international research team, he linked a database contain- ing 3-D facial images with genetic information. One of the results was that biomarkers, which point towards genetic mutations, were found in the d n a , n e v u e L U K , n e b b o R d i v a D r D f o y s e t r u o C s r o t a g i t s e v n I N A E L C R M Gain fascinating insights Latest Ultra HD resolution gives superb picture quality comfort and is particularly suitable for laminar flows in the operating room,’ the Italian firm adds. ‘All the functions of Starled5 NX are managed by the handy, digital and easy-to-read I – SENSE control panel positioned on the cardanic structure and adjusting.’ EH @ MEDICA No 3 2018 www.ikegami.de . medical@ikegami.de 12 – 15 Nov 2018 Please visit us in Hall 10/B12
4 W E D N E S D AY @ M E D I C A Coronary angiography will lose diagnostic value The changing face of imaging in cardiology While the question is still debated as to whether MRI is the better CT, along comes a potential game changer – a new data based 3-D reconstruction method of heart anatomy and function that aims to replace diagnostic coronary angiography. In the near future not only adult patients with coronary heart disease could benefit from this new technique but also children with complex congenital heart defects. Meanwhile imaging is conquering the cardiac operating room (OR). Report: Emilie Hofstetter Long before coronary heart disease (CHD) manifests its presence on an ECG, CT and MRI can detect it due to low perfusion caused by a stenosis of the coronary vessels. Dr Bettina Baessler, radiologist and researcher at the University Hospital Cologne, Germany, looks into multiparamet- ric imaging strategies. She considers both techniques complement one another although MRI definitely pro- duces images that are ‘more beauti- ful, almost works of art’. Professor Ulf Teichgräber, Head of Radiology at University Hospital Jena, Germany, agrees and thus predicts the demise of cardiac angiography. His opinion is corroborated by the recently completed SYNTAX III study, whose results will be presented at the Transcatheter Cardiovascular Therapeutics Symposium 2018 in San namically relevant blockage is pre- sent, i.e. whether the patient needs a stent or a bypass. In 2015, Professor Pamela S Douglas, cardiologist and Head of Multimodal Imaging at the Duke Clinical Research Institute in Durham, North Carolina, USA, showed the potential benefit of this method using 584 patient cases from 11 hospitals. Ten patients with sus- pected CHD underwent diagnostic cardiac catheterisation, but the sus- picion was confirmed only in three patients – seven underwent unnec- essary catheterization. Six out of ten patients with suspected CHD, whose FFRCT was determined first, did not need angiography. In three out of the four patients who did receive angio, the suspicion was confirmed – i.e. only one patient underwent an unnecessary angiography. ‘This feasible and safe method shows a significantly lower rate of unneces- sary invasive angiographies,’ Douglas confirmed. Investors seem to buy in: HeartFlow, which today is already cooperating with the Big Three – GE, Siemens, Philips – recently raised USD 240 million to further develop the technology, launch new studies and drive commercialisation of its product. To establish 3-D imaging in con- genital heart disease treatment, paediatric cardiologists Animesh Tandoon and Tarique Hussein found- ed VARYFII Imaging, LLC, in Dallas, USA. They construct complex ana- tomical models of the individual patient’s pathologies using MRI or CT data. Cardiologists as well as surgeons can enter the virtual and augmented realities of the anatomi- cal models with the help of data headsets to lift certain structures, analyse and t h e m and thus devise the best strategy to correct reposition 3-D reconstruction of a coronary system, detached from the heart muscle. Fractional flow reserve in the individual vessel sections is colour-coded. Courtesy: HeartFlow, Inc. Y-conduit of right and left internal thoracic artery in epicardial ultrasound. A: 2-D Long axis view, B: 2-D short axis view, C: Colour Flow Mapping long axis, D: Colour flow short axis. Courtesy of Di Giammarco the heart defect prior to surgical intervention. ‘Our heart beats in 3-D, so why not examine it in 3-D?’ asks Dr Sandy Engelhardt, researcher at the Computer-Assisted Surgery Group at the Department of Simulation and Graphics in Otto von Guericke University, Germany. In addition to treatment planning and education she envisages a further application of this new technology: informing the parents of the young patients. The flow must continue Imaging has arrived in cardiac sur- gery – during the intervention itself and combined with flow meas- urements. Professor Gabriele Di Giammarco, cardiac surgeon at Gabriele D’Annunzio University Hospital in Chieti, Italy, considers the combination of high-frequency epi- cardial ultrasound (ECUS) and transit time flow measurement (TTFM) in a single device ‘decision making’ and explains: ‘Hard calcifications in the aorta, I can feel. I do not feel the dangerous soft plaques. With MiraQ, I see them in intraoperative ultrasound, can adapt my strategy and perform surgery in no-touch technique and off-pump.’ Dr Daniel Wendt, Managing Senior Physician at the Cardiac Surgery Department of University Hospital Essen, Germany, uses intraoperative flow measurement of newly created bypasses not only for quality assur- ance purposes – he records a follow- up intervention rate of slightly below three percent – but also for training purposes: ‘It’s a tool to improve your skills, helps flattening the learning curve.’ The combination of risk minimisation and qual- assurance ity has proved s u c c e s s f u l . In 2017, the Oslo-based manufactur- er Medistim sold prod- ucts and p r o c e d u r e s worth NOK 229.8 million, up 14.6 percent over the previ- ous year – another chapter in the suc- cess story of surgical intervention in CHD patients. EH @ MEDICA No 3 2018 The physician, using smart glasses, in the virtual space has just removed the aorta at its root from the heart to examine it separately. Observers can follow on conventional screens. Courtesy of S. Engelhardt Diego in September. A team com- prised of a radiologist, cardiologist and surgeon (Heart Team A) evalu- ated the angiogram of a patient, calculated the SYNTAX II score and decided on the type of therapy, either invasive or non-invasive. The team members then saw the multislice CT (MSCT) scan with 3-D reconstructed coronary vessels and the relevant fractional flow reserve (FFRCT) and could either confirm or revise their decision. A second team (Heart Team B) of those profession- als received CT and FFRCT of the same patient first. The team mem- bers calculated the Syntax III score, decided on the type of therapy and then saw the angiogram in order to either confirm or revise their deci- sion. ‘The Syntax score was designed to inform the decision “invasive or non-invasive”, based exclusively on anatomical features,’ Teichgräber explained. ‘Syntax II took comorbidi- ties into account and now Syntax III includes a functional component – FFRCT. Thus coronary angiography will lose importance in diagnostics and therapy planning.’ Non-invasive first To date, only the California-based HeartFlow Inc. can calculate FFRCT. Based on data obtained in a conven- tional CT, the company’s software, using flow mechanics, can recon- struct heart, aorta and coronary ves- sels in terms of geometrics as well as pathophysiology and function in 3-D. Moreover it visualises the flow and can thus show whether a haemody-
in Andrea Fiore graduated in Electrical Engineering and Physics from the University of Rome ‘La Sapienza’. Between 1994-97 he wrote his PhD thesis on nonlinear frequency conversion semiconductor waveguides at Thomson CSF Central Research Laboratory (Orsay, France). He held postdoctoral appointments at University of California in Santa Barbara, at the Ecole Polytechnique Fédérale de Lausanne in France and a research position at the Italian National Research Council. Between 2002-07, as assistant professor he led Quantum Devices activities at the Ecole Polytechnique Fédérale de Lausanne. Since October 2007, he has been Chair of Nanophotonics at Eindhoven University of Technology, the Netherlands. meter, or about one million times smaller than the typical atom size). Sketch of the proposed microspectrometer Applications of the spec- trometer Measuring light gives a spectrometer a wide range of applications - two most interesting being the medical and food industries, says Fiore. Used, for example, to measure CO2, check the pill you take is correct, measure blood sugar level via thin skin on the earlobes. Another application is for the OR, to get skin and tissue infor- mation . Also, during cancer surgery, the spectrometer may determine whether exposed tissue is cancerous and help decide how much tissue is removed, he suggests. The frequency range is too small to use in on a big scale, Fiore points out. ‘The sensor covers only a few percent of visible and near-infrared, the most used part of the spectrum. We need to expand this range for Top: Optical-microscope image of the fabricated microspectrometer Bottom: Electron-microscope image of the active area, with a zoom-in on the photonic crystal cavity more general use. We also will need to integrate a light source so that the smartphone sensor can func- tion independent of external sources. So, it will take years before the new spectrometer will be integrated within a smartphone and at least ten years before it’s on the market.’ The future Many companies and scientists are developing microspectometers, with different approaches. The Eindhoven team is also working to enlarge the measured spectrum width. ‘The tech- nology will get there,’ Fiore assures. ‘The question is only whether a mar- ket for these microspectrometers exists and, if so, which company will produce them. But if I am correct, the future will show that having a spectrometer in your smartphone is as normal as having a camera. The only thing is the future will have to wait a couple of years.’ W E D N E S D AY @ M E D I C A 5 Phone measures light spectrum generates a tiny electrical current that is measured. It is very precise, retaining just a very tiny frequen- cy interval and therefore measur- ing only light at that frequency.’ Two of the membranes were placed closely, one above the other, allow- ing them to influence one another: a slight change in distance means the light frequency that is measured also changes. To ensure a varying dis- tance between the membranes the researchers incorporated a MEMS (micro-electromechanical system). A similar type of MEMS is already present in smartphones and other devices to sense free fall and put the sensitive parts in a secure mode before ground impact. Fiore: ‘Using our present system, the sensor covers a wavelength range of around thirty nanometres, within which the spectrometer can discern some hundred thousand frequencies. This is exceptionally precise because we can control distance between the membranes to just a few tens of femtometers’ (one femtometer is one millionth of a billionth of a Report: Madeleine van de Wouw Checking a lump for malignancy, find out if the air is clean or food is fresh just with your smartphone? It’s possible, according to research- ers at the Eindhoven University of Technology, the Netherlands. Their recently presented spectrom- eter is small enough for insertion into a smartphone. But the device is not yet ready for use on a big scale, Professor Andrea Fiore, supervisor of the Eindhoven research team points out. Spectrometry is the analysis of visible and invisible light. Every mate- rial and tissue has its own spectrum of light absorption and reflection. Some information on the spectrum of visible light is already gathered by our eyes – it gives the colour of the material. The invisible part of the spectrum also carries a lot of useful information, and can be ‘seen’ by a spectrometer. However, current devices are large due to the work: splitting light into frequencies (different colours). Each frequency must be measured sepa- rately, which can only be made some tens of centimetres after the splitting. Small versus big device The new microscale device was cre- ated by Zarko Zobenica, a PhD candi- date at Eindhoven under the supervi- sion of Professor Fiore and colleague Dr Rob van der Heijden. It is a small version of the normal tabletop spec- trometers currently used in scientific labs. The difference is the way the small spectrometer works. The researchers developed a sen- sor that uses a photonic crystal cavity, a ‘trap’ of just a few micrometers into which the incoming light falls if it has the right frequency. Fiore: ‘This trap is contained in a mem- brane, into which the captured light D O N ’ T M I S S MEDICA’S LABMED FORUM 2018 Thursday, 15 Nov 11.00 – 11.15 a.m. Liquid biopsy Prof. Dr. Georg Hoffmann Deutsches Herzzentrum München, Scientific Organisation Dr. rer. nat. Dr. med. Christof Winter Institut für Klinische Chemie und Pathobiochemie der TU München EH @ MEDICA No 3 2018 50 μm1 μm1 μm500nm
6 W E D N E S D AY @ M E D I C A A solution to improve stroke prevention AI system screens early Phase AFib Here at Medica, the Taiwanese start-up Maisense is demonstrating Freescan, its artificial intelligence (AI) based solution to screen for stroke through the early detection of atrial fibrillation (AFib). Speaking of the system’s aims, Maisense summed up this huge health problem. ‘Every four minutes, someone dies of stroke. Thirteen per- cent of these are classified as haem- orrhagic stroke. When the arteries of the brain weaken or break, allowing blood to spread in the brain tissues, haemorrhagic strokes occur. They are most often caused by chronic hypertension. Up to 87% of strokes are classified as ischaemic. An ischae- mic stroke occurs when a clot, or mass, blocks a blood vessel, cutting off blood flow to part of the brain. There are two main risk factors for ischaemic strokes: arterial stiffness and atrial fibrillation (AFib). The research ‘Changes in arterial stiffness independently predict stroke in patients with essential hyperten- sion’, published in 2018 European Society of Cardiology (ESC), shows a demonstrated association and prediction between arterial stiffness and stroke for essential hyperten- sion patients, Maisense points out. ‘The Framingham Heart Study (FHS) identified common factors and char- acteristics contributed to cardiovas- cular disease. Low-density lipoprotein (LDL), also called “bad cholesterol”, is a notable enemy of arterial elas- ticity and fosters arterial stiffness. High LDL level raises the chances of a heart attack because it deposits in the walls of blood vessels that nar- rows the arteries or even clog. Other risk factors such as age, hyperten- sion, smoking and diabetes are high- ly related to cardiovascular diseases.’ screening seriously as a key measure- ment for stroke prevention.’ AFib is usually diagnosed on an ECG, but if a patient’s symptoms don’t occur while he sees the doctor, or if they are back to normal at the time, the doctor would could not give proper advice. The Maisense Freescan device and my Freescan App deliver an all-in-1 solution, utilising artificial intelligence Maisense is at Medica Hall 11 / Stand B26 (AI) for early AFib detection, arrhyth- mia (bradycardia and tachycardia) detection, pulse wave velocity, and blood pressure monitoring in a single AFib patients have a five-fold increase in stroke risk compared to those without. 4.5 million people in the EU are affected. It, and accounts for approximately one-third of hospi- talisations for cardiac rhythm distur- bances. The European Heart Rhythm Association (EHRA), which published those quoted numbers, released a classification system of AFib-related symptoms in 2014. The EHRA also stressed the fatal consequence even if AFib symptoms are not notice- able to the patient or they may not feel uncomfortable. ‘Since an AFib episode can come and go, many patients may be undetected and therefore didn’t receive timely treat- ment,’ said Benjamin Chiu, CEO of Maisense. ‘That’s why we take AFib Founded in 2012, Maisense produced Freescan, the world first cuff-less blood pressure monitor, measuring directly from the wrist pulse. The firm gained the ‘Best Investment Potential’ award from Taiwan’s Ministry of Economic Affairs, and the 2015 National Innovation Award in Taiwan, and was ranked second among the Top 10 Innovative Health Products at the Arab Health 2016 fair in Dubai. In 2017, Maisense received the ‘Taiwan top 10 coolest innovative start-ups award’ from the Ministry of Science and Tech in Taiwan. Freescan has received EU CE medical certification and is now among only ten of the significant finalists in the Medica App Competition, which will all be presented from 3pm on 14th November at the Connected Healthcare Forum (Hall 15. Stand C24.) device. Users adopting Maisense’s solution can assess their risk level of stroke anytime, the company adds. ‘From the patient’s perspective, the solu- tion makes it very easy to measure and record all these biomedical signals at any time. Patients can monitor their own health con- ditions and take early action. Through the web-based Patient Care System, doctor also can be informed immediate- ly when abnormal inci- dents occur – if a patient activated this function under doctor-patient privilege. It also provides sufficient data for doctors to make a quick assessment, thus avoiding unneces- sary healthcare spending, saving time and improving efficiency. Since Apple announced its Watch Series 4, which can record ECG and has received FDA approval, it is believed that considerably more peo- ple know the importance of irregular heart rhythm detection. The all-in- one Maisense system screens the top three causes of stroke: arterial stiffness, hypertension, and AFib in just one device. Even a special kind of foot control ‘Sensational’ innovations for radio surgery Back in 1987 Meyer-Haake GmbH introduced the first high-frequency surgical device with an output power in the megahertz range. Due to the high-frequency it was possible to conduct surgery with minimal heat development, resulting in less ther- mal damage and tissue shrinkage. Thus, the firm’s devices were quickly bought. firm, explains. ‘By pressing the fin- ger switch on the handpieces, or squeezing the tips of the bipolar for- ceps together, it can be switched to the respective output mod, without touching the device itself. ‘An absolute sensation is the development of the new foot pedal. With this, the modes can be changed, the output power increased, or IAE – C20 Meyer-Haake GmbH is at Medica Hall 5 / Stand P21 again. Additionally, in all five output modes five personal settings for sur- gical procedures can be saved. All surgical parameters can be read out, printed, or saved on the computer via a USB stick. ‘Never before were so many novel- ties offered in a radio surgical device that’s Made in Germany,’ the manu- facturer adds proudly. Meyer-Haake also produces the special tissue adhe- sive EPIGLU. decreased, and the device activated or deactivated. ‘The device offers parameters for more than 40 surgical procedures from eight medical fields, which can of course be changed and saved For its latest models – radioSURG 2200 ‘PT’ and ‘PTA’ – innovations have been developed that are ‘sen- sational’, Meyer Haake (which also produces the tissue adhesive Epiglu) reports. ‘A well-known designer in the medical field created the case, which offers a clearly arranged, self-explan- atory touchscreen and five outputs – Cut, Cut Coag, Mono Coag, Bipo Coag and Bipo Auto (‘PTA’). ‘In addition to the permanent coagula- tion, the coagula- tion degree can be set in nine strengths and the coagula- tion time in 10 steps up to one second,’ the • A new compact lightweight housing, specifically designed for mobile equipment. • A low weight, less than 8.5 kg, combined with compact dimensions, 116 mm diameter and 342 mm length, allows significant reductions in the equipment supporting structures. • A range of tube inserts up to 54 kW peak radiographic power at high rotation speed is available for this unit. Visit IAE at MEDICA – Hall 10, Booth B 73 • www.iae.it EH @ MEDICA No 3 2018
W E D N E S D AY @ M E D I C A 7 Seeing and navigating through a patient’s body Augmented reality to aid surgeons Virtual reality (VR) has been widely used by video game developers and film and animation producers. The next technological advance – aug- mented reality (AR) – which many associate with Pokemon, has found a very different use. During Medica 2017, the firm Taiwan Main Orthopaedics Biotechnology (www.surglasses.com) introduced the first ever smart sur- gical glasses featuring augmented reality and a navigation system. The demonstrated prototype focused on effects, such as burnt of soft tissue and skin, or in a worst case sce- nario it can cause cancer,’ it explains adding that, according to studies, surgeons are the biggest victims, because they perform similar opera- tions at least once a week. ‘But,’ the firm continues ‘the world’s first smart surgical glasses can make big changes. It dramatically reduces the necessity of taking X-rays during operations. Traditionally, in each ses- sion approximately 150 X-ray photos are taken, but this new technol- level of risk, such as in spine, brain or in other soft tissues. The smart surgical glasses Foresee-X also enables the surgeon to focus on the operational field instead of on computer screens and monitors, the manufacturer notes, adding that it enhances accuracy by monitoring every movement of the surgical tools, such as puncture nee- dle, trocar etc. Also highlighted is the ability to zoom in and out. Screening surgical procedures through smart tablets and collecting a trauma case. This year a completely new model for spinal surgery is on show. The company reports accuracy is less than 2 mm. As one of the fastest growing start-ups in Taiwan, it won a most innovative product of the year award for this device, which is equipped with 3-D X-ray vision assisted by AR. This helps to reduce the radia- tion exposure of the whole surgical session and yet the surgeon can see through patient’s body, the firm points out. Surgeons usually perform ortho- paedic surgery using a C-arm or another form of X-ray technology, which makes radiation exposure inevitable. ‘Due to high level of toxic radiation both patient, surgeon and medical team can suffer from side ogy lowers this number from 150 to about 20 X-rays. By reducing the number of X-rays taken it can pre- vent later side effects. ‘But, it’s not just radiation expo- sure; it also enhances accuracy, saves time and improves overall perfor- mance. The most important feature of this new technology is augmented reality technology. Which means, for example, when surgeons put on the glasses and look at their patient they will be able to see through the patient’s body and understand the skeleton structure where they are planning to operate.’ Smart surgical glasses, Foresee-X was FDA-approved at the end of 2017 and, the Thai company pre- dicts, ‘in a near future it will be used in very delicate surgeries with a high data for academic purposes is also listed as an asset. Caduceus Taiwan Main Orthopaedics Biotechnology has now produced Caduceus, the 2nd generation smart surgical glasses. During an earlier interview, Professor Wang Min-Liang said, ‘We have submitted all the doc- uments to FDA, CE and are waiting for approval. In the meantime, our R&D team is working to improve the hardware system, because every part and each factor has to be perfect.’ His firm’s technology is to be adapted for spine, ENT and brain surgeries, with expected FDA and CE approval of the 2nd generation smart glasses by 2019 Marsh, Mark Nicholls. Malta: Moira Mizzi. Spain: Mélisande Rouger, Eduardo de la Sota. The Netherlands: Madeleine van de Wouw. USA: Cynthia E. Keen, i.t. Communications, Lisa Chamoff. Subscriptions Dorothea Fleischer, Theodor-Althoff-Str. 45, 45133 Essen, Germany Subscription rate 6 issues: 42 Euro, Single copy: 7 Euro. Send order and cheque to: European Hospital Subscription Dept Editor-in-Chief: Brenda Marsh Art Director: Olaf Skrober Editorial team: Wolfgang Behrends, Beate Schenk, Sascha Keutel Senior Writer: John Brosky Printed by: WVD, Möhrfelden, Germany Executive Director: Daniela Zimmermann Publication frequency: bi-monthly Founded by Heinz-Jürgen Witzke ISSN 0942-9085 Correspondents Austria: Michael Kraßnitzer, Christian Pruszinsky. China: Nat Whitney France: Jane MacDougall. Germany: Anja Behringer, Annette Bus, Walter Depner, Cornelia Wels- Maug, Holger Zorn. Great Britain: Brenda Representatives China & Hongkong: Gavin Hua, Sun China Media Co, Ltd. 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