2 W E D N E S D AY @ M E D I C A The brain sits at the PC – artificial intelligence in medical care Report: Cornelia Wels-Maug AI has made headlines for years, including in such scientific publi- cations as ‘Nature’, an indication of its high relevance, according to Dr Tobias Müller, Head of Digital Transformation at the Rhön-Klinikum AG. However, he also delivers a note of caution because studies are often aimed at demonstrating the equiva- lence of AI-based diagnoses with those made by doctors. ‘You have to read these studies very carefully,’ Müller advises. Some certified AI-algorithms for the medical sector can be bought already. According to Müller’s research, 34 of these algorithms are currently available, with many suppli- ers based in the USA and Israel. The majority, says Müller, are applications for the fields of radiology and neuro- radiology. screen.’ Rapid growth of medical knowledge Even now, AI is a great help for deci- sion support. The rapid growth of medical knowledge makes it impos- sible for individual physicians to keep completely up-to-date with the cur- rent state of research in their respec- tive medical disciplines as specialist medical knowledge doubles expo- nentially: Whilst in 1950 it would have taken 50 years for the volume of knowledge to double, it is esti- mated that, by the year 2020, this period will have shortened to just three months. AI: a ‘must’ in diagnosis of rare diseases Rare diseases diagnoses present doctors with additional challenges, especially as the short window of time spent with patients often makes it impossible to document all their symptoms. ‘AI is already a must- have for rare diseases today,’ reports Schäfer, who relies on tools based on AI-algorithms such as those supplied by Ada Health or Isabel Healthcare. ‘We need them in clinical routine Advanced LED optics technology Highly controllable medical lamps Based on the next generation LED technology, ACEM, of Bologna, Italy, reports that one of the firm’s newly launched lamps ensures cold light, long life and low energy consump- tion. ‘Starled3 NX grants a homoge- neous and shadow-less light thanks to its special LED optics, created by the company, that direct light beams according to needs,’ Acem reports. ‘The visual area is perfectly illumi- nated assuring both excellent visual comfort and working conditions. Its next generation LEDs produce an unparalleled quality of light with a colour temperature (CCT) of 4.500 °K and a colour rendering index (CRI) of 95. ‘The lamp offers a light intensity of 130.000 lux (160.000 optional) with a low energy consumption of 69W. ‘The life cycle of its LEDs is about 50.000 hours,’ the company adds. ‘Starled3 NX is composed by three reflectors that produce a well-blend- ed and intense cone of light focus- able through the automatic adjust- ment of the light spot diameter. ‘The slim, practical and compact design makes it perfect for several ACEM is at Medica Hall 10 / Stand B60 uses. The lamp is ergonomic, easy to move and to position and suitable for the laminar flows of the oper- ating room.’ lamp has Functions The easy-to- an clean shape and material, and the handle is removable for sterilisation. The functions listed here are con- trolled via an I-Sense control panel: Light intensity adjustment DoF - Depth of Field - for a deep light Endo - Light for endoscopy ideal for minimal-invasive surgery Size - Light spot diameter adjust- ment to focus the operating area Sync - Function (optional) useful to synchronise controls of the combined lamps: Starled3 NX double (twin dome configuration) and Starled3 NX together with Starled5 NX – which comes in the following mounted versions: ceiling, wall, trolley (ABPS battery on demand). A rechargeable battery aids mobility ABPS, a rechargeable battery-pow- ered system made by Acem, measures 550 x 340 x 240 mm and fits into the trolley base. The battery’s electronic control panel manages fundamental parameters, such as residual charge, type of power supply, recharge status and electrical power supply presence, and an automatic switch from elec- tric power supply to battery power so that the Starled3 NX can be used as a high-performance mobile unit, the manufacturer points out. because they deliver important diag- nostic assistance. They facilitate the recording of numerous symptoms without much effort,’ he says, and therefore help to improve the diag- nostic process significantly. But AI not only leads to improved diagnoses; it also creates new types of conflicts between ethical and legal considerations and the use of tech- nology, all of which need to be resolved. AI always requires users to think and to scrutinise the sugges- tions made by AI-based tools with their medical knowledge, as, says Schäfer: ‘The brain sits in front of the screen.’ AI and tumour detection Dr Felix Nensa, radiologist and sen- ior consultant at Essen University Hospital, heads a working group on artificial intelligence: ‘‘Big Data’ does not automatically mean ‘Big Value’,’ explains Nensa. ‘This only applies when we can analyse the data. We need AI to close this gap. Much data from radiological images is not yet being utilised,’ he points out. Nensa and his team are developing an AI application which, based on images of a primary tumour, can determine if it has already spread. This would not only do away with the need for a biopsy but would also shorten the time required for diagnosis, making it possible to start treatment faster. ‘This virtual technology works well in parts, although the results are based on just a small study. But the poten- tial is large,’ says Nensa. interventions respectively. The future of artificial intelligence Experts expect that the use of AI in medical practice will develop from the current rule-based to data-based and even feedback-based applica- tions. We will also see a change from only slightly automated to highly automated applications or proac- tive In the medium term, current AI appli- cations, such as prognostic scores, dose calculations or order sets will be complemented by data-based applications, such as context-based information, multifactorial disease risk prediction or automated triage. Autonomous diagnosis, however, is still in the distant future. It would require an algorithm to incorporate feedback, to continuously evolve and adapt and to design future scenarios. ‘We are still a long way off this,’ says Müller. On the way there, many questions must still be answered, such as ‘How can we obtain sufficient numbers of data training sets?’ ‘How can we assure sufficient data quality?’ ‘Who accepts responsibility for errors with algorithms?’ It is, however, undisputed that future AI applications will have to abide by the dogma that medicine must not do damage but must be safe and effective. respectively. Based on those images, the dermatology department created a dataset containing 2,656 facial images showing six common skin diseases (seborrheic keratosis, actinic keratosis, rosacea, lupus erythema- tosus, basal cell carcinoma and squa- mous cell carcinoma) and tested the ability of convolutional neural networks to diagnose those six skin diseases accurately. At a later stage, patients were asked to photograph their facial skin conditions with a mobile device. Subsequently, these were interpret- ed by an AI-based algorithm. ‘The results are comparable with those from dermatologists’, Huang says. In the case of psoriasis, he explains, the algorithm even performed slightly better than a group of 25 dermatolo- gists when interpreting a sample of 100 images. There is an insufficient number of dermatologists in the region so, backed by these findings, in November 2018 Xiangya Hospital resorted to launch the first derma- tology Internet hospital licensed to operate online in China. Furthermore, Xiangya is collaborating with over 100 other hospitals across 30 prov- inces and has established the first national skin cancer collaborative network to enable a faster access to diagnosis and subsequent treatment for patients. More AI-supported ser- vices Xiangya Hospital also deploys AI for other cases to make better use of Continued from page 1 limited resources via automation. This includes an interactive app that enables patients to upload their medical history, including pictures, ahead of an appointment, to free up time for the actual diagnosis when visiting a clinician. Another example is the so-called ‘smart cervical cancer screening’ programme, which assists in examining 60 million women annually by reducing the time it takes to evaluate the involved pap test slices. ‘We want to bring down the time for evaluation of the slides from currently 60 seconds to 50 and even 45 seconds’, Huang explains. ‘Currently, we review 200 slices per day; this programme will help us to increase this to 300 slices per day in the future.’ Health IoT – the future Huang is convinced that the future of healthcare will be data-based. Hence, he stresses the importance of IoT for generating a broader data base of medical information and out- lines his vision of health IoT. ‘H.IoT will be the new thing. We want to use health data more effectively to enable smarter care. For this, we need to establish a consistent management and quality control of health-related data from inside and outside the hospital. We even need to collect data that is small, dirty and incomplete’, Huang postulates. ‘Data is good. The future will be a smart home’, he confirms, urging his audi- ence: ‘Don’t be lazy’. EH @ MEDICA No 3 2019

4 W E D N E S D AY @ M E D I C A WHO: ‘Refugees do not bring diseases to western shores’ Detecting migrant health risks The migrant population is fast growing and heterogeneous. Experts at a session held during the European Congress of Radiology (ECR 2019) concluded that radiologists can play a key role in detecting and differentiating related diseases. Migration is a growing phenom- enon and has an impact on health, according to Jozef Bartovic from the World Health Organisation (WHO) in Copenhagen, Denmark. ‘We’ve seen a huge increase in migration over the last few decades, and about 10% of global population today are inter- national migrants. There is a huge heterogeneity of resources, back- grounds, exposure to risks, which are all important to consider in health- care. Refugees are just 7% of all migrants,’ he said. Key migration factors can lead to health problems before, during and after migration. War impacts on mental health before and after migration. Violence during migra- tion, for instance smuggling, burns or drowning, has consequences on a migrant’s health. Discrimination and low levels of integration in the host country can also trigger health problems. The WHO refugees and migrants’ health in Europe report states: Migrants do not bring diseases with them to their country of destination. ‘Refugees and migrants are generally in good health, but can be at risk of falling ill during the transit period and in the receiving countries, due to poor living conditions and adjust- ment to their new lifestyle,’ Bartovic pointed out. Considering the incubation period of most bacterial and viral infections, most migrants will be either cured or dead by the time they arrive in the destination country. Living in a refugee camp, for instance, can pro- voke a number of diseases that can be fatal and take up considerable healthcare funds if untreated. Very early detection and correct treatment of diseases is key. ‘The links between migration and radiology are worth exploring, espe- cially regarding access to services, legal barriers, health service capacity and continuity of care,’ he said. TB or not TB The most common migration dis- eases relevant to radiology are pul- monary and extrapulmonary tuber- culosis (TB), according to Tim Weber, senior physician at the Institute of Diagnostic and Interventional Radiology in Heidelberg. ‘TB is the most common infectious disease in the migrant population. There’s a dif- ference between TB in the migrant population, which affects mainly young people, and TB in the host population, where it’s typically a dis- ease of the elderly.’ The main challenge for radiolo- gists in pulmonary TB is to differenti- ate between active and inactive TB. Active TB typically presents as con- solidations with cavitations and for- mation of centrilobular nodules due to bronchiolitis after bronchogenic spread of microbacteria. Necrotising adenopathy and pleural effusion are further signs that should alert the radiologist. Inactive TB is character- ised by fibronodular scarring, volume loss and calcifications. An important feature in ambiguous cases is stabil- ity of imaging findings over time, so follow-up is recommended. Pulmonary TB is atypical in HIV+ patients; especially in patients with CD4 lympho count <20/nm typi- cal features of TB. ‘Typical features of TB like cavitation or adenopathy are lacking, and other unspecific consolidations are primary imaging findings,’ Weber said. radiologists know Rapid diagnosis in this fragile pop- ulation is important. also of note: TB risk is 20 times higher in HIV+ patients. Most that extrapulmonary TB can affect any organ, because haematogenous spread of microbacteria is almost always present during primary TB. Extrapulmonary TB can be abscess forming, but can also present with soft tissue infiltration. ‘This is also a reason why extrapul- monary TB is known as the great imitator, mimicking a variety of infec- tions and neoplastic diseases,’ Weber explained. Sometimes no imaging findings can help distinguish between intes- tinal TB – TB ileum – and Crohn’s disease. One can detect fistula and chronic inflammation, e.g. prolifera- tion of mesentery fat, possibly pre- sent in both diseases. In pulmonary TB, the main task is to differentiate between active vs. inactive TB, and consider TB in any pulmonary infil- trate. ‘Extrapulmonary tuberculosis should be considered in any sug- gested inflammatory or neoplastic disorder,’ he advised. Worm-caused diseases Cystic echinococcosis (CE) and schistosomiasis are two other com- mon conditions that mainly affect migrants. CE is caused by dog tapeworm and has a global distribution. Almost eradicated in most western industrial Technical officer Jozef Bartovic at WHO/ Euro, contributes to the PHAME project, the Knowledge Hub and the Migration and Health Knowledge Management Project. Previously, working for the Regional Commission for Western Asia of the UN Secretariat in Beirut, Lebanon, he covered migration and displacement issues in the Arab region. Originally from Slovakia, after com- pleting political studies he worked in the UK for the Ministry of Health, Public Health England (Health Protection Agency) and the NHS on screening programs, sexual and reproductive health and primary care access. Hyperfine aims to make magnetic resonance imaging accessible and available anywhere, anytime, to any patient who needs it through the world’s first low-cost, point-of-care MRI system. Hyperfine POC MRI device is currently 510(k) pending and is not available for sale in the U.S. ties who have limited or no access to medical imaging. “We completely reexamined MRI from the ground up,” said John Martin, MD, Hyperfine’s Chief Medical Officer. “Our system will open avenues to reach patients in clinical settings never before imag- ined for MRI.” Hyperfine’s POC MRI creates standard clinical contrast images as well as informative 3D renders. Hyperfine is developing software that improves with each use via deep learning algorithms to reconstruct images and aid in the diagnosis of pathologies. “Hyperfine is changing how medi- cine is practiced with point-of-care MRI,” said Jonathan M. Rothberg, PhD, Founder and Chairman of Hyperfine Research. “More than just a revolutionary imaging system, it is a platform for new applications. Our cloud-based software develop- ment kit will enable third parties to create AI applications for our device. Ultimately, Hyperfine aims to facili- tate stroke triage, continuous moni- toring of unstable patients, and MRI guidance of surgical interventions.“ Tim Weber MD is a senior physician at the Institute of Diagnostic and Interventional Radiology, in Heidelberg University Hospital, Germany. countries, there is only scarce data on prevalence in migrants – however, CE will be diagnosed in a large number of refugees or migrants. CE causes cystic expansive mass, which can grow in any part of the body, mostly the liver or the lung. Serology test can be negative in a number of patients and imaging is essential for diagnosis. CE shows with specific pathogno- monic signs on imaging, such as the water-lily sign (CE 1), the rosette sign (CE 2), the Swiss cheese sign (CE 3b) and the ball of wood (CE 4). ‘The major CE feature is that there is complete absence of vascularity, thus contrast imaging studies should be performed to exclude neoplasm,’ Weber said. Schistosomiasis, a set of diseas- es caused by trematode worms, or blood flukes, is very common in trop- ical and subtropical regions; more than 150 million people are affected in sub-Saharan Africa alone. The worms produce eggs that are embolised via the portal vein to the liver, inducing chronic liver inflam- mation, which can lead to periportal hepatic fibrosis or Symmer’s pipe stem fibrosis. Here also, imaging can help, nota- bly to differentiate between liver cir- rhosis and schistosomiasis. (MR) Smart insole detects signs of foot ulcer Stevens Institute of Technology has signed an exclusive licensing agr sensing system that detects early signs of foot ulcers befor n o t u o b n o B © EH @ MEDICA No 3 2019 Low-Cost Point-of- Care MRI System Hyperfine Research Inc. is introduc- ing the world’s first low-cost, point- of-care (POC) magnetic resonance imaging (MRI) system at the American College of Emergency Physicians (ACEP) Scientific Assembly 2019. In inventing POC MRI, Hyperfine aims to make MRI available anytime, any- where, to any patient who needs it. aging the ten million-fold improve- ment in computing power since the first MRI systems were designed, the revolution in green electronics, and advances in large-scale integration. Hyperfine’s portable MRI is 20 times less costly, 35 times lower power, and 10 times lighter than the most popular current MRI machines. Hyperfine makes MRI inexpensive, accessible, and easy to use by lever- The compact, open-design scan- ner wheels directly to the bedside, plugs into a wall outlet, and allows for direct contact with the patient. It operates via a simple user interface on a tablet and does not require trained technicians, shielded elec- tronics, or separate hospital facili- ties. Hyperfine potentially makes MRI available to patients who cannot safely be transported through a hos- pital, as well as the 4.7 billion people in rural and low-resource communi-

6 W E D N E S D AY @ M E D I C A UK tests high-speed remote medical diagnosis Ultrasound scanning via a 5G network Report: Mark Nicholls To demonstrate advances in 5G connectivity for healthcare, a UK team has linked a paramedic in a simulated ambulance to a hospital- based clinician. The paramedic wore a robotic or ‘haptic’ glove, which received signals over the live 5G network. Using a joystick, the clinician remotely direct- ed the paramedic to move the ultra- sound sensor to where on the patient the clinician wanted to scan. Really high quality and in real-time From this examination, high-quality ultrasound images were transmitted to the clinician in real-time, over the high-bandwidth 5G connection. In From left: Gerry McQuade, CEO of BT Enterprise, with Fotis Karonis, BT 5G Executive Advisor, and Cameron McVittie, Operations Manager at West Midlands Ambulance Service, with the haptic glove and ultrasound used in the ambulance simulation Dr Omkar Chana is programme director for citizen wellbeing at WM5G, covering health and social care and the emergency services. With a PhD in physics, his career has covered hi-tech data and analytics and business strategy specific to the NHS and healthcare, as well as mergers and acquisition. addition, a camera in the ambulance transmitted images of the paramedic and the patient to a second screen at the clinician’s workstation to offer an overall view. WM5G – which aims to acceler- ate deployment of the infrastruc- ture needed for 5G, and is building health, industry and mobility testbeds in the West Midlands region – point- ed out the benefit of enabling ultra- sound scans to be performed in the field, and reviewed remotely, facili- tates quicker diagnosis and onward treatment. The demonstration was hosted by the Medical Devices Testing and the Evaluation Centre (MD-TEC), in the University Hospital Birmingham (UHB) simulation lab, at the Institute of Translational Medicine, along with British Telecom (BT), the West Midlands Ambulance Service, and WM5G. ‘5G will help us to roll out this next generation of health- care technologies,’ said Tim Jones, UHB Chief Innovation Officer. ‘In the future, our clinicians will be able to deliver holistic specialist advice in real time, potentially forming virtual multi-disciplinary teams to provide the best patient care using intelligent IT links.’ Doing what you cannot do with 3G or 4G Dr Omkar Chana, WM5G pro- gramme director, added: ‘The ultra- sound demonstration was a flavour of what we can really do with 5G. You cannot do that with 3G or 4G. And, although it was 5G ultrasound, Andy Street, Mayor of the West Midlands, tries out the haptic glove alongside Omkar Chana, from WM5G, and Fotis Karonis and Jeremy Spencer from BT, watched by Paramedic Cameron McVittie, Operations Manager at West Midlands Ambulance Service Smart, Portable Carbohydrate Monitoring System Innovative device to estimate carbohydrate metabolism Kyocera Corporation (President: Hideo Tanimoto) announced that its smart, portable carbohydrate moni- toring system was named the Grand Prix Runner-Up in the Smart X cat- egory at the 2019 CEATEC Awards. The first of its kind, Kyocera’s car- bohydrate monitoring system is designed to enhance wellness by estimating carbohydrate metabolism based on measurements of pulse- wave patterns from the user’s heart- beat. It was unveiled for the first time at CEATEC 2019 in Japan, one of Asia’s largest tradeshows for IT and electronics, with commercial avail- ability planned for 2020 and applica- tions including dietary support and managing pre-diabetic conditions. Development Background Kyocera developed the world’s first portable wellness device for esti- mating carbohydrate metabolism by analyzing pulse-wave patterns with a gyro sensor. Once the user touches the device to their wrist, the moni- tor measures pulse waves to esti- mate carbohydrate metabolism in the blood in around 8 seconds, and the result is then visualized via a smartphone. Since it uses a gyro sensor which is commonly used in everyday electronic devices such as smartphones, the company believes it will be able to offer the product at an affordable price once commercial- ized. “We are honored to be recog- nized with such a prestigious award at CEATEC 2019,” said Hiromi Ajima, an engineer at Kyocera’s Medical R&D Center, who developed the device. “Using just this simple device with Kyocera’s carbohydrate monitoring system connects with a smartphone app e r i W s s e n i s u B : o t o h P your smartphone can provide you with better information about your health and help you achieve a higher level of wellness,” he explained. About the 2019 CEATEC Awards Selected from applications submitted before the CEATEC 2019 tradeshow, CEATEC Award candidates were judged not only from the perspective of academic, technological, market- ing, and future potential, but also on the basis of pure innovation. The Smart X category in which Kyocera was named Grand Prix Runner-Up this year includes solu- tions, business models, technologies, products, services, software, and applications that are judged to con- tribute to ground-breaking innova- tion in specific industries and markets – such as mobility, logistics, smart factories, smart energy, smart life- styles, healthcare, and entertainment – contributing to the advancement of CPS/IoT and the realization of Society 5.0 (Ultra-Smart Society). Tim Jones is Executive Chief Innovation Officer at University Hospital Birmingham. He joined UHB in 1995, became Head of Service Improvement in 2002 and led the New Hospital Clinical Redesign Programme, before being appointed to the role of Chief Operating Officer in June 2006. In September 2008, he was appointed Executive Director of Delivery, which incorporates board level responsibility for Research & Innovation, Education and Workforce. what we are demonstrating can lend itself to any aspect of clinical imaging and real time communication. Also, it does not have to be in an ambulance, it can be in a care home, or GP sur- gery, and the image quality is just as good as it would be in a hospital.’ The NHS long-term plan Technological solutions – driven by 5G – are at the forefront of the lat- est NHS Long Term Plan as the NHS endeavours to meet the challenges of increased demand and an age- ing population. ‘With low latency and the ability to communicate in real time, coupled with faster speed, massive amounts of data can be put through. With ultrasound, the clini- cian can see everything in real time. If he says “move left”, the paramedic in the ambulance moves the probe left – immediately,’ Chana observed. ‘It means the clinician can decide that the patient may not actually need to go to hospital, or may need to be taken to hospital quickly and go straight into surgery because of what they see on scan.’ A futur Report: Mark Nicholls Whilst researchers acknowledge ultrasound, when used as a tool to assess intracranial pressure in an emergency, is not a replacement for current gold standard invasive approaches, they believe it has enor- mous potential as a non-invasive and fast, cost-effective, and patient- friendly way to assess possible brain injury at a patient’s bedside. Consultant anaesthetist Dr Chiara Robba, a specialist in the field, sug- gests the use of ultrasound for intrac- ranial pressure (ICP) assessment can become standard practice in the not too distant future. In recent years, Robba, from the San Martino Hospital in Genoa, has worked with colleagues at the University of Cambridge, United Kingdom, to explore the suitability of ultrasound to conduct brain scans in an emergency setting. One recent study compared the relationship between ultrasound- based non-invasive ICP (nICP) and invasive ICP measurement in neu- rocritical care patients and found that it was a ‘promising and easily available technique for identifying critically ill patients with intracranial hypertension’. She outlined latest developments EH @ MEDICA No 3 2019

8 W E D N E S D AY @ M E D I C A Biopsies with MRI-compatible ultrasound system Biopsies are standard procedures in interventional radiology, not least for patients with a suspected tumor. In this instance, MRI is increasingly the method of choice for guiding minimally invasive tissue sampling. In an ongoing R&D project, Fraunhofer researchers have now developed a system that allows acquisition of ultrasound images simultaneously to an MRI scan. These multimodal data are then combined and mapped onto one another, meaning that the high-contrast MRI images can still be utilized, in combina- tion with the live ultrasound images, once the patient is no longer inside the MRI scanner. In other words, only one MRI scan is required at the beginning of the biopsy procedure. Afterwards, the biopsy can be safely performed under the guidance of a combination of real-time ultrasound images improved with MRI contrast. Scientists from the Fraunhofer Institute for Biomedical Engineering IBMT have teamed up with fellow scientists from the Fraunhofer Institute for Digital Medicine Mevis and from Saarland University Medical Center to create the system, named Kombus. This combination of high-contrast MRI images and live ultrasound images enables to plan the needle path without the need for repeated MRI scans. “Each time the patient breathes in or out, the positions of the internal organs shift,” explains Dr. Marc Fournelle, scientist at Fraunhofer IBMT. “The physician must therefore plan and perform the biopsy in one and the same breathing phase.” Tests on a phantom model have demonstrated the proper functioning of the hardware-software combination. Clinical studies are expected to get under way over the coming months. In addition, the research team will be presenting their system at the joint Fraunhofer booth (Hall 10, Stand G05) at Medica. DiPhAS KOMBUS: an MRI-compatible, 256-channel ultrasound system. Continued from page 7 Cambridge University. While there remains a lack of aware- ness of the potential of this relative- ly new technique, she believes it can become a care standard for patients in emergency units, intensive care or the operating theatre where patients are at risk of neurological complication, as well as at the bedside and to be used in the same way ultrasound is deployed to monitor the rest of the body. For a clinician, she explained, per- forming a brain ultrasound at the bed- side can identify issues of concern and prompt further tests – or offer reassur- ance that all is well. ‘From a patient’s perspective, it is safe monitoring, does not cause any harm but adds informa- tion. When it becomes routine clinical practice, it’s going to reduce the num- ber of CT scans, the number of radia- tion exposures and transfers.’ 20 international experts Over the last two years, exponents of the technique – including Robba – have been presenting US potential at conferences, and she is currently working with 20 experts from around the world on a consensus paper as well as looking at training require- ments, standards and competences for practitioners to be able to use ultra- sound as a technique to assess the brain, including the estimation of ICP in an emergency. Yet, amid the enthusiasm for the new development, Robba also urges cau- tion because the scientific evidence still T M B I r e f o h n u a r F : e c r u o S is a consultant Chiara Robba in anaesthesia and intensive care at the San Martino Hospital in Genoa and an consultant at Cambridge honorary University Hospital the UK. Her research interests cover ultrasound for intracranial pressure, traumatic brain injury, intracranial haemorrhage, and areas of general intensive care, including mechanical ventilation and sepsis. in needs to be assembled and she stressed the technique should not replace the gold standard invasive methods to measure brain trauma pressure because there are limitations to the ultrasound approach with just the four “windows” for assessment. However, Chiara Robba concluded: ‘The benefits are potentially huge. In the future I think this should become a standard of care in the same way as echocardiography is for the heart.’ Editor-in-Chief: Brenda Marsh Printed by: WVD, Möhrfelden, Germany Editorial team: Wolfgang Behrends, Sonja Buske Senior Writer: John Brosky Executive Director: Daniela Zimmermann 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 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. 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