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SPECIAL NEWS ISSUE: MEDICAL | TECHNICAL | PHARMACEUTICAL | INDUSTRIAL 11-14 NOVEMBER 2024 Patient positioning during cancer radiotherapy: Upright is alright ‘While upright radio- warned: therapy has a lot of potential, many challenges remain. The most cru- cial challenge is that we need more data and evidence to support the different decisions that have to be taken for upright radiotherapy.’ Reduced setup time, greater patient comfort Among the speakers was radiation therapist Sophie Boisbouvier of the Centre Léon Bérard (CLB) in Lyon, France. This academic institution dedicated to cancer care, research and education, has conducted re- search with Leo Cancer Care’s equipment an- nounced it will install one of the company’s patient positioning sys- tems to treat cancer patients. recently and r e c n a C o e L © Meanwhile, Dr Lennart Volz from the Department of Biophysics at the GSI Helmholtz Centre for Heavy Ion Research in Germany noted that several industry vendors are cost-efficient upright imaging systems. But he developing A CLB study has suggested that pa- tients prefer the upright posture while receiving radiation therapy, that organs move less during the treatment and that setup time is re- duced. Boisbouvier said: ‘Patients seem more comfortable and more satisfied in the upright position than the supine position.’ Leo Cancer Care CEO Stephen Towe said: ‘The centre has been in- The concept of delivering radi- ation therapy to cancer patients seated in an upright position is undergoing a major resurgence. with Evidence is already highlighting that patients feel more comfortable seated upright and enjoy better communication radio- therapists during their care. In ad- dition, there are indications of less internal organ movement, enabling more accurate treatment delivery. Manufacturers also point to upright systems taking up significantly less space by removing the need for a gantry in proton therapy) and being more cost-effective. (particularly evident strumental in gathering the re- search data that has really vali- dated the use of upright therapy clinically.’ The ESTRO session also heard Thomas Bortfeld from Mass- achusetts General Hospital discuss treatment concepts facilitated by upright radiotherapy, while Mark Pankuch from Northwestern Medi- cine Proton Center in Chicago told how his centre has treated almost 700 patients on an upright system. 510k clearance paves way for main- stream success Leo Cancer Care presented its upright technology, which has seen installations across several centres on both sides of the Atlantic. The underlying Marie concept – named after Nobel laureate and radiology pioneer Marie Curie – combines a CT scanner with an upright patient positioning system. Its positioning system recently gained 510k regu- latory approval in the United States for clinical use, with a similar pro- cess under way in Europe. UW Health in Madison-Wisconsin and McLaren Health in Michigan have begun installing the system while in Europe, CLB is being fol- lowed by the National Center for Oncological Hadrontherapy (CNAO) in Pavia, Italy, which will use the upright approach to deliver proton and carbon ion radiation therapy. Medical physicist Thomas ‘Rock’ Mackie is co-founder and Board Chair of Leo Cancer Care, and par- ticularly thrilled with the 510k ap- proval. ‘I think upright is going to become mainstream,’ he said. Implementation in the NHS In the UK, the charity Macmillan Cancer Support has announced a strategic investment of an undis- closed amount in the company and hopes that the funding will also pave the way for the upright care option available through the NHS. become to Experts acknowledge there are still challenges with upright radio- therapy solutions, there are ad- vantages and potential benefits, but there is optimism and enthusi- asm within the sector that such technology is destined to have a key role in cancer care in the not- too-distant future. ■ Upright technology brings a new dimension to cancer treatment by keeping the radiation beam fixed and slowly rotating the patient through it while seated in an upright position. Delegates to the recent ESTRO (European Society for Radio- therapy and Oncology) trade event in Glasgow heard the advances – and challenges – in the field, while a satellite consortium meeting or- ganised by upright systems manu- facturer Leo Cancer Care also at- tracted considerable interest with speakers and delegates from across the globe. While not a new technique, upright radiotherapy is enjoying a revival and becoming a hot topic. Dr Ye Zhang from PSI in Switzerland told the ESTRO session that the ‘poten- tial for upright treatment is sig- nificant’ in terms of reduced cost and clinical benefits. www.healthcare-in-europe.com Trusted to Capture Every Image: It Has to be Aquasonic® 100 For generations, Aquasonic 100 has been the preferred transmission gel for equipment manufacturers and medical professionals alike. From prenatal screening to advanced diagnostics, it stands alone as the choice for clear and consistent scanning. 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2 An overview DON‘T MISS: Trends and innovations at the HEALTH IT FORUM EH @ MEDICA confronted across How can innovations help to master the great challenges and demands with which healthcare is inter- national borders This central question will be given solid answers again at the MEDICA Health IT Forum, an established part of the programme at the trade fair. Sessions and talks will centre on issues like Artificial Intelligence (AI), Robotics and Virtual Care. The very first session deals with no less than two important topics on the programme stage of the forum, in Hall 13 on Monday, No- vember 11, starting at 11.00 a.m.: “Sustainable AI” not only con- siders technological, but also eco- logical, social and ethical aspects. AI systems should be powerful as well as responsible and friendly to the environment. There is still much work to do: Speaker Prof. Peter Boor, University Hospital RWTH Aachen, only recently em- phasised the issue in a publication about deep learning within pathol- ogy. The widespread use of deep learning in pathology could thus on the one hand cause a negative contribution to the warming cli- mate. Using digital pathology as an example, however, together with other authors he proves that with a few measures quality can be maintained while at the same time greatly reducing carbon emissions. In this context, generative AI has for some time now been the focus of public interest. On Tuesday, No- vember 12, starting at 1.00 p.m., this topic will be the discussed on stage. Dr. Julia Hoxha, head of the work group Health at the German AI Association, will moderate the discussion. She is also the co- founder and managing director of Zana. This start-up uses human speech as biomarker for example for COPD. This is how it works: AI models analyse and recognise voice pat- terns in order to predict a possible decline of health, especially for shortness of breath and the risk of exacerbation, by recognising an acute deterioration beyond daily fluctuations. This solution also supports clinical decisions and ob- jective assessment of the course of illness – and is a very innovative method. In this field, what is the view on the “AI Act” with which the EU member states have adopted the first law to regulate AI in the world “This law has far- reaching consequences for every- one involved, including hospitals and other users. If things go badly, the costs for these applications will increase.” This could however be mitigated by good planning and intelligent design, so Hoxha. For example, manufacturers should take care not to let their AI system fall into an unnecessarily high category of risk. Providers of AI solutions also expect that the “AI Act” will allow exceptions and mitigations for small companies and for science. Hoxha regards AI- based development of precision therapeutics by generating novel molecular structures and pre- dicting their properties as an im- portant area of application for AI within healthcare. Artificial Intelligence for new active agents The company Merantix Momen- tum is among those using AI to optimise active agents in the area of large molecules. In this context, it is helpful that AlphaFold by Google DeepMind makes it poss- ible three- dimensional structure of proteins. Dr. Bertram Weiss, Pharma Lead at Merantix Momentum, will also take part in the AI panel on stage during the MEDICA Health IT to predict the f r o d l e s s ü D e s s e M / n n a m l l i T e z n a t s n o C © Forum – just like Dr. Augusta Mod- estino, Head of Strategy at AICura medical. The company uses its proprietary platform to support biopharmaceutical companies in evaluating data and imaging using AI, in order to predict the reaction of patients to active agents, ident- ify ideal candidates for clinical studies, recognise at-risk patients and accelerate the development of medicines. Dr. Nilofar Badra-Azar will explain the use of data in this context from a political point of view. She is a consultant at the German Federal Ministry of Health in the Division Key Policy Issues Concerning Novel Technologies and Data Use. During the dis- cussion, Badra-Azar will be able to point to the Act governing the use of health related data and to the Act and strengthening of medical regis- tries. regulation on during Smart phones for therapy Digital solutions are already being used as therapy themselves. These companions recovery, “Health Companions 2.0” are the focus of Tech Talk on Monday, No- vember 11, starting at 2 p.m. For example, the company Frisk sup- ports other companies developing innovative strategies and sol- utions. On the programme stage, Dr. Cinthia Briseño, founder and managing director at Frisk, will meet Rouwen Hirth. He is the business development manager for the app solution “Constanze Care”. In this app, an integrated fe- male AI assistant and a team of fe- male experts work together to provide the best answers to ques- tions by pregnant users. The app provides information regarding which prenatal examinations are recommended during pregnancy, how women can prepare for the time post-partum and what helps babies with a tummy ache. The AI draws its knowledge from current scientific results, new medical guidelines and expert experience. Concerning medicines, Redcare Pharmacy’s “Shop Apotheke” is among the most well-known on- line pharmacies in Germany. The company sees itself as the leading livers them to the operation the- atre, opens the packaging and passes the sterile goods to the op- erating surgeon. In a current pub- lication, Bernhard reports that such systems have the potential to become invaluable tools for over- coming a lack of trained staff and to rationalise work processes with- in healthcare. However, the chal- lenges which result from the strict requirements inherent in a clinical environment, are large. changes thorough A special exhibition provides impul- ses for digital clinical networking Clinical hospitals are currently facing – brought about not least by the in- creasing concentration of medical treatments at specialised sites, the result of the hospital reform in Germany. In this context, digital networking and telemedicine will play an important part. How exactly this can happen is on view at the special exhibition “Hospital of the Future” in an activity area in Hall 13 (booth C04). Here, deci- sion makers from clinics will re- ceive input and consultations re- garding the following topics: • Digital infrastructure in a hospi- tal: finding trustworthy solutions for telecooperation, • Intelligent summaries of and processed patient data in stead of manual documentation: effi- cient use of medical resources, • Data driven telemedicine and ar- tificial intelligence in intensive care medicine: Care for patients in a personalised and predictive manner, • Far away yet with a close view of the patient: carrying out data- based teleconsultations. “Hospital of the Future” is orga- nised by the German telemedical society “Deutsche Gesellschaft für Telemedizin e.V.” in cooperation with Messe Düsseldorf. Expert support on planning and im- plementation is provided by the German centre for telematics and telemedicine Zentrum für Tele- matik und Telemedizin GmbH (ZTG) and the Clinic for Surgical Intensive Medicine and Intermedi- ate Care at the University Hospital RWTH Aachen. Visiting pro- fessionals at MEDICA 2024 and es- pecially the delegates of the 47th German Hospital Conference, which for the first time will be held right in the middle of the trade fair in the neighbouring Hall 12, will have the opportunity to participate in exclusive guided tours the special ex- hibition. They will be provided with an insightful option among many to gather information on the digitalisation of healthcare within this year’s MEDICA. ■ through f r o d l e s s ü D e s s e M / n n a m l l i T e z n a t s n o C © online pharmacy in Europe. Cur- rently, it is active in seven coun- tries: Germany, Austria, France, Belgium, Italy, the Netherlands and the “eHealth-CardLink” solution, Red- care Pharmacy offers an option to hand in electronic prescriptions. Switzerland. With With the help of their electronic health insurance card and a smart phone, customers can pass elec- tronic prescriptions to the Shop- Apotheke app. Alexander Braden, as Director Medication Manage- ment at Redcare Pharmacy, will be available for questions from an audience of professionals at the Tech Talk. Robots can help in many ways One feature of the digitalisation of healthcare is the use of robots. “Smart Robotics” is therefore the forum topic for the Tech Talk on Tuesday, November 12, starting at 12.00 noon. Dr. Manuel Ferla, TU Munich, School of Engineering and Design, is convinced that robot-assisted surgery provides doctors with valuable tools, which lessen the stress during surgery and which could lead to improved outcomes for patients. However, the volume of use regarding this new technology is still regarded as limited, due to the lack of inte- gration into existing clinical pro- cedures. Novel methods and tech- nologies aim to improve system integration in order to realise an improved perspective for ap- plications. Lukas Bernhard, Scientific Head at the TUM University Hospital Klini- kum rechts der Isar in Munich, has been part of the research group MITI and has worked on a robot that takes over various tasks dur- ing surgery in the unsterilised area. The robot fetches sterile ma- terials – for example sutures or surgical gloves – from storage, de- » Hall 13 / A33 EH @ MEDICA 2024
EH @ MEDICA Improving radiology workflows 3 AI weeds out unremarkable chest X-rays A commercial artificial intelli- gence (AI) tool used off-label was effective at excluding pa- thology and had equal or lower rates of critical misses on chest X-ray than radiologists, accord- ing to a new study. The findings were published in Radiology, a journal of the Radio- logical Society of North America (RSNA).* Recent developments in AI have sparked a growing interest in com- puter-assisted diagnosis, partly motivated by the increasing work- load faced by radiology depart- ments, the global shortage of radi- ologists and for burnout in the field. Radiology practices have a high volume of un- remarkable (no clinically significant findings) chest X-rays, and AI could possibly improve workflow by pro- viding an automatic report. the potential Researchers in Denmark set out to estimate the proportion of unre- markable chest X-rays where AI could correctly exclude pathology without increasing diagnostic er- rors. The study included radiology reports and data from 1,961 patients (median age, 72 years; 993 female), with one chest X-ray per patient, ob- tained from four Danish hospitals. “Our group and others have pre- viously shown that AI tools are ca- pable of excluding pathology in chest X-rays with high confidence and thereby provide an auton- omous normal report without a human in-the-loop,” said lead auth- or Louis Lind Plesner, MD, from the Department of Radiology at Herlev and Gentofte Hospital in Copen- hagen, Denmark. “Such AI al- gorithms miss very few abnormal chest radiographs. However, before our current study, we didn’t know what the appropriate threshold was for these models.” The research team wanted to know whether the quality of mistakes made by AI and radiologists was different and if AI mistakes, on average, are objectively worse than human mistakes. The AI tool was adapted to gener- ate a chest X-ray “remarkableness” probability, which was used to cal- culate specificity (a measure of a medical test’s ability to correctly Louis Lind Plesner Louis Lind Plesner, MD, is a Medi- cal Doctor, PhD Student at Herlev and Gentofte Hospital. His research interests include Radiology, Medical Imaging, Magnetic Resonance Im- aging, Ultrasound, and Computed To- mography. EH @ MEDICA 2024 Four examples of remarkable chest X-rays with missed critical findings. The artificial intelligence (AI) tool was postprocessed by the AI vendor by scaling each of the 85 remarkable individual predictions to a normalized value and using the case-level highest of the scaled scores as the overall probability score from 0 to 1 for “remark- ableness” (ie, the probability for abnormal or remarkable findings by the AI). (A) Chest X-ray in a 49-year-old female patient shows a slightly visible acute rib fracture (arrow) that was missed by the AI at all thresholds and also missed by the radiology report. (B) Chest X-ray in a 30-year-old female patient shows enlarged hilar lymph nodes (arrows) missed by the radiology report but not the AI at any threshold. (C) Chest X-ray in a 67-year-old female patient shows a tumor mimicking pleural plaque (arrow) that was reported in the radiology report (where the patient was referred for CT) and missed by the AI at the 98.0% threshold but not the 99.0% and 99.9% thresholds. (D) Chest X-ray in a 64-year-old male patient shows a central venous ca- theter possibly entering the azygos vein (arrows), which was classified as unremar- kable in the radiology report. The AI missed the critical finding at the 98.0% thres- hold but not the 99.0% and 99.9% thresholds. © RSNA; adapted from: Plesner LL et al., Radiology 2024 identify people who do not have a disease) at different AI sensitivities. Two chest radiologists, who were blinded to the AI output, labeled the chest X-rays as “remarkable” or “unremarkable” based on prede- fined unremarkable findings. Chest X-rays with missed findings by AI and/or the radiology report were graded by one chest radiologist– blinded to whether the mistake was made by AI or radiologist – as critical, clinically significant or clinically insignificant. The reference standard labeled 1,231 of 1,961 chest X-rays (62.8 %) as remarkable and 730 of 1,961 (37.2 %) as unremarkable. The AI tool correctly excluded pathology in 24.5 % to 52.7 % of unremark- able chest X-rays at greater than or equal to 98 % sensitivity, with lower rates of critical misses than found in the radiology reports as- sociated with the images. Dr. Plesner notes that the mistakes made by AI were, on average, more clinically severe for the patient than mistakes made by radi- ologists. “This is likely because radiologists findings based on the clinical scenario, which AI does not,” he said. “Therefore, when AI is intended to provide an automated normal re- port, it has to be more sensitive than the radiologist to avoid de- interpret creasing standard of care during implementation. This finding is also generally interesting in this era of AI capabilities covering multiple high-stakes environ- ments not only limited to health care.” AI could autonomously report more than half of all normal chest X-rays, according to Dr. Plesner. “In our hospital-based study popu- lation, this meant that more than 20 % of all chest X-rays could have been potentially autonomously re- ported using this methodology, while keeping a lower rate of clini- cally relevant errors than the cur- rent standard,” he said. implementation of Dr. Plesner noted that a pros- pective the model using one of the thresholds suggested in the study is needed before widespread deployment can be recommended. * Plesner LL et al.: Using AI to Ident- ify Unremarkable Chest Radio- graphs for Automatic Reporting; Radiology DOI: 10.1148/radiol.240272 ■ 2024; Source: Radiological Society of North America
4 An overview EH @ MEDICA DON‘T MISS: Hot issues, current trends and innovations at the LABMED FORUM Skills shortages and digitaliz- ation, trends in cardiology and oncology, future prospects in laboratory medicine, and healthy aging – these pressing topics are at the forefront of discussions at this year’s MEDICA Labmed Forum. What are the most exciting devel- opments in medicine at the mo- ment The specialist forums at MEDICA in Düsseldorf, the leading international trade fair for the healthcare and medical technology industry, will once again provide in-depth insights into this topic with their stage program during this year‘s trade fair (11 – 14 No- vember), for example on health IT, medical technology trends, health- care policy or laboratory medicine. The MEDICA LABMED FORUM has become one of the main attractions of the MEDICA supporting pro- gram in recent years with its in- formative short presentations and expert panel discussions. Under the buzzword “Laboratory 4.0”, a trend towards massive digi- talization and networking as well as big data applications and ar- tificial intelligence (AI) is currently emerging in laboratory diagnostics, says the Scientific Director of the MEDICA LABMED FORUM, Prof. Stefan Holdenrieder from the Ger- man Heart Center Munich, with a view to this year‘s focus. „So far, we have mainly looked at individ- ual laboratory values. In the future, we will analyze increasingly com- plex data patterns with machine learning and combine them into complex diagnostic scores. Labora- tory medicine is currently evolving from pure analytics towards data science. Interdisciplinary collabor- ation between laboratory experts and specialized data scientists, es- pecially computer scientists and biostatisticians, is becoming in- creasingly important.“ Day 1: Skills shortage and digitalization The MEDICA LABMED FORUM, chaired by Prof. Dr. med. Thomas Streichert, University Hospital Co- logne, will address the highly topi- f r o d l e s s ü D e s s e M / n n a m l l i T e z n a t s n o C © © cal issues of digitalization and AI on the opening day (11 November) of MEDICA 2024. The morning session will focus on the shortage of skilled workers, which, accord- ing to current surveys, is the most pressing problem in laboratory medicine. Dr. Ronald Biemann from Leipzig University Hospital, head of the Young Laboratory Sec- tion of the German Society for Clinical Chemistry and Laboratory Medicine (DGKL), will report on the sometimes dramatic shortage of young professionals in the medi- cal and medical-technical field. In the panel discussion, the speakers will look for ways out of the crisis with the help of automation and digitalization. In the afternoon, the focus will be on AI and big data tools that are al- ready available and those still in development. Image recognition using deep learning is already state of the art in the automated evalu- ation of differential blood images, while machine learning from large multivariate data sets, such as those generated every day in lab- oratory diagnostics, is still in the development stage. The exciting question of how large language models can help to make abstract laboratory findings more compre- hensible and whether AI really makes us smarter (or possibly dumber) will also be discussed. Day 2: Trends in cardiology and oncology Traditionally, on the second day of the fair, Prof. Stefan Holdenrieder will discuss current developments in laboratory medicine for the two disease complexes that determine mortality in the western world: Cardiovascular and cancer. In cardiology, the focus this diseases f r o d l e s s ü D e s s e M / n n a m l l i T e z n a t s n o C © year is on congenital heart defects. They can increasingly be corrected surgically in childhood and are also playing an ever greater role in adult medicine due to improved life expectancy. The speakers from the German Heart Center and the Technical University of Munich will shed light on the topic from a clini- cal perspective, and mathematician Prof. Frank Klawonn from the Helmholtz Zentrum Braunschweig will demonstrate the possibilities of modern data analysis using ma- chine learning as a guest scientist at the Heart Center. The afternoon program is dedi- cated to highly sensitive blood- based cancer diagnostics. With this examination technique, known as “liquid biopsy”, laboratory medi- cine is opening up completely new ways in oncology to monitor tumor progression more closely than is possible with conventional tissue biopsies. This makes it possible to recognize at an earlier stage when a treated cancer will flare up again, making a change therapy necessary. New methodological ap- in proaches such as the analysis of methylation profiles for the early detection of hereditary forms of cancer or single cell analysis using microfluidics are being discussed. Day 3: Future perspectives of labora- tory medicine On the “Young Scientists Day” of the MEDICA LABMED FORUM, young scientists will present their views on the future of laboratory medicine. As an introduction, the session leader, PD Dr. med. Verena Haselmann from the University Hospital Mannheim, will give an overview of the latest advances in the field and the obstacles that need to be overcome. New oppor- tunities include, e.g., wearables for the continuous recording of diag- nostic parameters, while obstacles include new quality requirements and the shortage of specialists. In the afternoon, the discussion will revolve around personalized ther- apies based on individual labora- tory value patterns, the interdisci- plinary interaction of laboratory and imaging in integrated diag- nostics and the use of AI. f r o d l e s s ü D e s s e M / n n a m l l i T e z n a t s n o C © © Day 4: Healthy ageing The final day of the forum is tradi- tionally dedicated to diagnostic re- search institutes and companies that want to open the door to new areas of application for laboratory medicine. The two sessions will be led by members of the Association of German Diagnostic Manu- facturers VDGH, Dr. Kai Prager and Dr. Peter Quick. They have chosen research into ageing from the per- spective of pathophysiology, diag- nostics and therapy as the topic for 2024. Discussions will include the latest findings on the genetic and epigenetic life clock, protein mis- folding and aggregation as the basis of neurodegenerative dis- eases such as Alzheimer‘s and Parkinson‘s and the role of the in- testinal microbiota in stroke. For the “finale” in the afternoon, in- teresting theories and practical ex- periences will be discussed on how the ageing process can be slowed down. Prof. Dr. Emrah Düzel, Uni- versity of Magedeburg, will present various anti-ageing drugs, Prof. Dr. Wolfram Ruf from the University of Mainz will explain the influence of anti-inflammatory agents, Prof. Dres. Monique Breteler from the German Center for Neurodegener- ative Diseases (DZNE) will talk about the influence of the environ- ment on the ageing of the central nervous system, and Prof. Dr. Claire Jacob, also from the Univer- sity of Mainz, will discuss ways of repairing lesions in the nervous system. ■ / G37» Hall 1 f r o d l e s s ü D e s s e M / n n a m l l i T e z n a t s n o C © EH @ MEDICA 2024
EH @ MEDICA 5 Point-of-care ultrasound in trauma Returning e-FAST ‘to its roots’ in Barcelona, Stagnation, under-use, unfulfil- led potential: At the EUSEM con- gress leading emergency physician Dr Joseph Osterwalder describes how e-FAST (Extended Focused As- sessment with Sonography for Trauma) – a key point-of-care ultrasound (POCUS) technique for trauma – has changed over the last two decades, and not necessarily for the better. Despite ultrasound having made great progress in terms of technol- ogy, price and indications, e-FAST – a standardized protocol-based POCUS that looks for bleeding in the chest and abdomen and pneu- mothorax – has seen a marked, the expert added. Originally intended for the primary survey in the ATLS (advanced trauma life support) system, it is now being used for wider applications and lesser con- ditions. At the European Emergency Medi- cines Congress (EUSEM), Oster- walder outlined how he believes that e-FAST should ‘return to its roots’ to redefine its place in im- aging. ‘The traditional use was in- tended for unstable or non-stabiliz- able patients large haemorrhages in the peritoneal, pleural and pericardial cavities as well as a large pneumothorax with- in a maximum of 1 to 2 minutes using ultrasound,’ said Osterwalder, who, until 2017, was Head of the Emergency Department at Kantons- spital St Gallen, Switzerland. to detect Use cases in the shock room In stable patients, he said e-FAST should be used to detect small bleedings in the peritoneal cavity by means of four additional sono- graphic views; include the examin- ation for retroperitoneal bleeding/ hematoma; injuries to the spleen, liver and kidney; and free intra- peritoneal air in the patient with repeat examination as necessary in the shock room. It was also in- tended long- established ultrasound indications during the emergency ‘ABCDE’ protocols in e-FAST patients: to look for airway obstruction, false intubation, pulmonary contusion, intracranial hypertension, retro- orbital hematoma, and fractures, and assist in monitoring and vol- ume management. apply to the Osterwalder continued: ‘Because musculoskeletal injuries are the most common injuries in moderate and severe trauma patients, MSK ultrasound should also be used as part of the secondary survey, es- pecially as its diagnostic accuracy is often equal to MRI.’ Exaggerated expectations Since the 1990s, e-FAST has been extended to stable patients and those with mild to moderate trau- ma, the expert said. However, he believes that this has led to exag- gerated expectations, with users not fully aware of the limitations of the technique, and even re- sulted in studies questioning the usefulness of e-FAST. EH @ MEDICA 2024 © Pocus © Pocus certainty Osterwalder points to the clear benefits for clinicians from e-FAST: more for decision- making on further procedures such as an indication for CT, oper- ating theatre, interventional radiol- ogy, and hospital admission for monitoring. ‘It also enables faster processes,’ he added. ‘There are no waiting times for CT examinations. It saves resources for teams that care for and monitor the patient, makes the attending physician more independent and also in- creases the degree of satisfaction.’ Benefits for patients include re- duced risks from CT examinations such as radiation exposure, al- lergic reactions, and renal insuffi- ciency from the contrast medium. The technique also avoids the need for emergency intubation in children and restless patients be- fore a CT scan can be performed. ‘There is no evidence to date that this reduces mortality and morbid- ity, nor that CT leads to better re- sults,’ explained Osterwalder, who remains convinced that redefining e-FAST has opportunities to ad- vance the field. ‘It can improve the diagnosis and treatment of moder- ate and minor injuries in places with limited resources, especially CT scanners, and lead to faster as- sessment and care of patients in highly specialized institutions.’ He also feels there is an opportunity for industry to work more closely with clinicians. Wide range of applications Osterwalder, who has significant experience operating as a field medic, further pointed out the po- tential of e-FAST in disaster, ex- pedition, and military medicine. The technique is already being used in all emergency situations, not only in EDs but also pre-hospi- tal, in the offices of general practi- tioners, hospital wards, ICUs, ships, expeditions, and theatres of war, he said. Application ranges from shock, women of childbearing age to ab- dominal pain during and after re- suscitation. trauma, unclear However, he said: ‘e-FAST has not developed any further for over 20 years, even though ultrasound has made huge progress in this time re- garding technical innovations such as Microflow, better and high-resol- ution probes, CEUS; falling prices, handheld devices and countless new, scientifically well-founded in- dications.’ He hopes that the profile of e-FAST can be raised and rede- fined to ensure it is used for opti- mal medical and clinical benefit. ■ Report: Mark Nicholls Joseph Osterwalder Emergency physician Dr Joseph Os- terwalder was Head of the Emerg- ency Department at Kantonsspital St Gallen in Switzerland (1988–2017) and Associate Professor for Emergen- cy Medicine at the University of Geneva. He is a Fellow of the Swiss Society of Rescue and Emergency Medicine, the European Society of Emergency Medicine, the Swiss and German Society of Ultrasound in Medicine and is a pioneer of emerg- ency medicine and emergency ultra- sound in Switzerland. When Sterility is Indicated... There’s Only One Choice: Sterile Aquasonic® 100 Ultrasound Transmission Gel. The World Standard for sterile ultrasound transmission. • Easy-to-open *Tyvek® overwrap Guarantees sterility of the inner foil pouch and the gel within • Consistent quality Aqueous, non-staining • Acoustically correct Visit booth #9D41 Medica 2023 • Non-injurious to transducers • Available in 20 gram overwrapped foil pouches, 48 sterile pouches per box *Trademark of Dupont® ISO 13485:2016 © 2018 Parker Laboratories, Inc. The sound choice in patient care is a trademark of Parker Laboratories, Inc. MKT-0101-2 REV 3
6 EH @ MEDICA Between good practice and financial pitfalls Delivering molecular pathology at lower costs m o c . e b o d a . k c o t s - s n o i t a e r C t r A t i m m u S © moving to next generation se- quencing (NGS)-based testing as the new standard of molecular pro- filing testing, he made suggestions for lowering costs when using NGS assays. For those countries that require comprehensive molecular testing, his tips included: • use one large NGS panel for all indications; • ensure a daily large volume of cases to efficiently fill each run; • ensure yearly large volumes of cases to efficiently use the same equipment, personnel, and infra- structure; • ensure yearly large volumes of testing that will lower the price of equipment and assays sig- nificantly; and • use competition among com- panies as hope for a future de- crease in overall sequencing costs. With the field of predictive prog- nostics and diagnostics rapidly growing for many indications in the coming years, his take home message was to move to cen- tralisation of pathology. He sug- gested that this would lead to only very few labs which not only have efficient knowledge and concen- tration of knowledge, but are also able to stay cost effective. The Tunisian perspective Professor Karima Mrad, Head of the pathology department at Salah Azaïz Institute in Tunis, Tunisia, outlined the position with molecu- lar pathology in her country. In her presentation, she looked at the funding opportunities and issues for middle income countries, and shared the experiences from neigh- bouring African countries. She said: ‘Molecular pathology in middle income countries is a big challenge; it is a challenge to get not only the devices but also the reagents, and to get assurance quality tests.’ With limited access for new cancer therapies, she said there were issues around availabil- ity of reagents, lack of space for machines and concerns among doctors about access to molecular pathology tests. However, she said there were good quality staff, though some were taking up posts in Europe. Mrad, who is President of the Tuni- sian Society of Pathology and Cy- tology, compared the molecular pa- thology service in Tunisia with neighbouring countries. While Tunisia has access to six real-time PCR units, an NGS plat- form coming soon, two FISH (Flu- orescence in situ hybridization) stations and good quality IHC, Al- geria has one NGS platform, five PCR platforms and FISH; Morocco has two NGS platforms, five PCR and three FISH stations. Fur- thermore, other countries in West Africa see even greater lack of availability for molecular pathol- ogy and immunohistochemistry (IHC). She said: ‘Developments of mol- ecular pathology programmes should take into account the local incidence and mortality of dis- eases. To improve molecular pa- thology, sustainable collaboration in activities and funding is highly needed. We hope by this we can improve molecular pathology in Tunisia so we may be part of larger international collaborations and re- search efforts.’ ■ Report: Mark Nicholls Karima Mrad Karima Mrad is Head of the pathol- ogy department at Salah Azaïz Insti- tute in Tunis, Tunisia, and President of the Tunisian Society of Pathology and Cytology. She is associate editor on the board of French journal “Annales de pathologie”. Her research inter- ests include gynaecopathology, par- ticularly ovarian and uterine tumours. Ed Schuuring Ed Schuuring is senior clinical scien- tist in molecular pathology and Pro- fessor in Molecular Oncological Pathology at the University Medical Center Groningen, Groningen, the Netherlands. His research includes identification of prognostic/predictive epigenetic and molecular markers for clinical outcome, response to im- mune-chemo-radiotherapy, and gene-targeted therapy and treat- ment-resistance in cancers. He is a senior member of the Dutch Society of Pathology and has co-authored various international guidelines on Molecular Pathology. DON‘T MISS! MEDICA INNOVATION FORUM - Highlights MONDAY 11:10 Wearables and Health Tech – Predicting, developing devices, and exploring new technologies 12:45 Driving cybersecurity in the Internet of Medical Things 13:30 Bridging healthcare and technology – Taiwan‘s vision for the future of smart health TUESDAY WEDNESDAY 11:05 3D-Bioprinting technology enabling biofabrication of biomimetic and biosynthetic tissue precursors 11:45 Optimizing custom medical device production with 3D printing & online solutions 12:45 Cancer treatment using ultrasound technology THURSDAY 11:35 Rescaling NMR drug discovery – A holistic approach to the lab of the future 11:05 Transforming healthcare – The disruptive power of ambience intelligence and AI agent networks 12:10 Worldwide access to high quality bio-sampling and diagnostics for all people 12:25 Healthcare in the era of Generative AI 15:00 13th MEDICA Startup Competition: Welcome and introduction 12:40 Net zero health impact – Towards sustainable hospitals » Hall 13 / E63 EH @ MEDICA 2024 Molecular pathology should be- come centralised in fewer labs to improve efficiencies and affor- dability, according to leading European experts. Ed Schuuring, Senior Clinical Scientist in Molecular Pathology and Professor of Molecular Oncol- ogy in the Department of Pathol- ogy at the University Medical Center, Groningen, suggested this would deliver a concentration of knowledge and lead to a more cost-effective solution in the way molecular pathology labs operate. In a session at the 35th European Congress of Pathology in Dublin, which also looked at pathology in favour of developing countries, delegates also heard the experi- ences and challenges of molecular pathology in African countries. In his presentation, Schuuring out- lined how molecular pathological methods are classified into five cat- egories, based on size-tested ge- nome and the associated costs of each. Explaining that costs are cal- culated on factors such as the on- going costs of the assay, purchas- ing personnel, validation and lab and IT infra- structure, he noted that there are significant variations in drugs and tests across Europe. equipment, The expert also compared the availability of biomarker test types for cancer patients in eastern and western European and Asian coun- tries, and then globally. He further discussed the cost-effectiveness of parallel versus sequential testing of genetic aberrations for Stage IV non-small cell lung cancer (NSCLC) in the Netherlands; and cost-effec- tiveness analysis of cell-free DNA- based molecular tumour profiling platforms for the detection of EGFR mutations in NSCLC. In con- clusion he said: ‘The availability of targeted drugs varies enormously between countries worldwide, and consequently there is a large vari- ation in predictive testing method- ologies.’ How to lower the costs of NGS tes- ting Observing that predictive testing is
EH @ MEDICA Challenges and opportunities Molecular pathology in Europe: in search of standardization 7 Marius Ilié is Professor of Pathology at the Nice Medical School, Univer- sity Côte d’Azur and Surgical Pathol- ogist at the Clinical and Experimental Pathology Laboratory/ Biobank Côte d’Azur, Nice University Hospital. He is Co-Chair of the ESP Working Group on Molecular Pathol- ogy, with special interests in thoracic pathology, melanoma, molecular pa- thology and biobanking. Giorgio Stanta is Professor of Pa- thology at the University of Trieste and the first to develop reproducible technologies for RNA extraction from clinical tissues. He is chairman of the OECI Biobanking and Molecular Pa- thobiology Working Group and vice- chairman of the ESP Molecular Pathology Working Group. Kurt Zatloukal is Professor of Pa- thology and head of the Diagnostics and Research Center for Molecular Biomedicine at the Medical Univer- sity Graz in Austria. His research fo- cuses on the molecular pathology of metabolic liver diseases and cancer as well as molecular diagnostics and machine learning approaches for digital pathology. Frédérique Pe- nault-Llorca Frédérique Penault-Llorca is pro- fessor of Pathology at the University of Clermont-Ferrand and CEO of the Comprehensive Regional Cancer In- stitute Centre Jean PERRIN, Cler- mont-Ferrand. A member of the European Society for Medical Oncol- ogy (ESMO) and the French Society of Pathology, her main area of inter- est is female cancers, quality assur- ance and molecular pathology. IHC biomarkers and LDT – still alive and kicking and Frédérique Penault-Llorca, pro- fessor of pathology at the Univer- sity of Clermont-Ferrand, focused on standardization of the thera- nostic immunohistochemistry (IHC) through the preanalytical, analytical, postanalytical phase. She stressed that IHC biom- arkers will be around for a while, despite suggestions of their declin- ing the quality of the tissue and the re- sults, she underlined the need for education and training as well as providing guidelines for scoring, reporting, and monitoring internal quality. importance. Regarding She also examined implementation of new biomarkers safely into clini- cal practice, emphasizing the need for a sufficient number of cases; testing, training, and monitoring; and standardized reports that are clear for clinicians in line with cur- rent guidelines. ‘Heterogeneity still exists, despite major progress in the last 20 years,’ she said, adding that standardization of the pre-ana- lytical phase is the cornerstone of the subsequent analysis. The use of lab-developed tests (LDTs) will re- main important in Europe because of economic issues and equipment constraints, despite IVDR regu- lation. She also pointed to the value of education and the Molecu- lar Pathology Masters course, out- lined in detail by Marius Ilié as the final presentation of the session. During his lecture on standard- ization through training, Ilié, Pro- fessor of Pathology at the Nice Medical School and co-chair of the congress session, outlined the benefits of the course: • delivering objective evaluation of knowledge and competences of the new professionals in the field; • facilitating movement of young molecular pathologists within the EU; • improved harmonization and standardization of clinical and molecular pathology; and • providing support for the con- tinuously increasing use of diag- nostic, prognostic and predictive biomarkers directly related to treatment choices. Ilié said of 87 applications, 23 stu- dents from 18 countries were ad- mitted on the two-year course. With an array of modules, candi- dates will be certified molecular pathologists on the course, which will reinforce a standardized ap- proach to molecular pathology. ■ Author: Mark Nicholls Versatile & Open Platform Machine Vision Technology AI & Robotics Visit Brain Navi at Hall 16 D12 info@brainnavi.com +886-3-6579438 MK-AD-24-1113 m o c . e b o d a . k c o t s - m o c . l e x i p w a R © Ensuring reproducible results through standardization and A central issue is irreproducibility of clinical research, Stanta pointed out. At the root of this, he also pointed out, lie problems of ex- perimental design inter- pretation, the complexity of bio- logical and medical information, the pre-analytical condition, highly sophisticated methodologies, intra- tumour heterogeneity, and in- stitutions using similar, but dif- ferent biomarkers. and specification Solutions, however, include design and analysis support, medical tu- mour boards, CEN (European Com- mittee for Standardization) tech- nical ISO standards, internal and external control, and new sampling tech- niques such as liquid biopsy. Stanta underlined the need for an expert steering committee, suggesting that those driving the European Masters on Molecular Pathology would be best placed for this task. ‘We have huge difficulties in stan- dardization because of continuous development of diagnostic molecu- lar pathology, so the standard- ization must be plastic with con- tinuous corrections,‘ the expert summarized. IVDR: No time to waste Kurt Zatloukal from the Institute of Pathology at the Medical University of Graz discussed reference materi- als for standardization, guiding delegates through the IVDR (in vitro diagnostic medical devices regulation) and its associated chal- lenges, particularly with calibration of devices and control materials. Even though the window for im- plementation has been extended until May 2026 due to the chal- lenges of the Covid-19 pandemic, he warned that time was of the es- sence as the process could take several years: ‘The new regulation gives very specific requirements for a diagnostic assay, not only if it is manufactured by a company and CE marked but also when we do it in our own laboratory.’ Tackling standardization of mol- ecular pathology at a European level remains a major challenge, according to speakers at the 35th European Congress of Pa- thology in Dublin. One leading expert warned it would be ‘very difficult’ to achieve, though the session also heard about poten- tial solutions such as educational steps to consistently train future pathologists at a high and con- sistent level. Session co-chair Olli Carpén, Pro- fessor of Pathology at the Univer- sity of Helsinki, said that as new assays emerged for prognostication and prediction of drug distribution to appropriate patient groups, stan- dardization of pathology was of paramount importance. In his presentation, Giorgio Stanta, Professor of Pathology at the Uni- versity of Trieste, said: ‘Everything is changing continuously and we have to follow these changes, but standardization of molecular pa- thology is not an easy task. We have an urgent need for standard- ization of the molecular analysis, reproducibility, exchange- ability in- among stitutions to obtain safety and effi- cacy of treatment for the patient. European and ‘The necessity of molecular pathol- ogy standardization in Europe is related to a more precise diagnosis, prognosis, and prediction of the most suitable therapy and basis of choices of treatment.’ Stanta, an expert in molecular pa- thology and diagnosis for oncol- ogy, outlined the work conducted so far, and challenges still to be overcome. He highlighted how the European Society of Pathology (ESP) Molecular Pathology Work- ing Group is working with the Or- ganisation of European Cancer In- stitutes towards standardization in heterogeneity, pre-analytical conditions, and clini- cal evaluation of NGS (next gener- ation sequencing) in breast and co- lorectal cancer. ‘All these projects are very important for clarity,’ said Stanta. (EEIC) EH @ MEDICA 2024
8 EH @ MEDICA Pros and cons of diagnostic techniques Liquid biopsy vs. tissue biopsy: Getting the best of both worlds which is much too high.’ He under- lined the importance of following ESMO (European Society for Medi- cal Oncology) recommendations and guidelines but also noted that with some differences in US guide- lines, there was a pressing need for global harmonization. Emerging biomarkers call for complimentary approach The benefits of using both liquid and tissue biopsy become evident in the context of emerging biom- arkers, Hofman pointed out. Some of these markers are not detectable on liquid biopsy and may only be detected on tissue biopsy. ‘This is particularly true for an increased number of proteins, including some targets of antibody drug con- jugates, which can be detectable and quantified only on tissue biopsy.’ With future and current biomarkers for non-small cell lung cancers (NSCLC), he advocated seeing tis- sue and liquid biopsies as com- plementary. ‘For our patients, we need to be sure about the right sample, so this is why now we need to think about the integration of liquid biopsy. Because some- times it is a complementary ap- proach but not an alternative ap- proach if tissue biopsy is not available.’ While he pointed out that in the US, liquid biopsy was a first line approach, he suggested Europe was not yet at that stage. Mix and match to suit clinical needs When dealing with lung cancer and the use of small tissue speci- mens, he felt blood specimens should be integrated into the pro- cess. ‘By tissue biopsy, we can see some mechanisms of resistance that we cannot see in liquid biopsy. For example, we know that ex- pressions of some proteins are only on the tissue. ‘In tissue biopsy, gene am- plification and detection of large gene deletion is probably higher than in liquid biopsy, but there are advantages of doing liquid biopsy, such as we do not need hospitali- sation.’ He further pointed to technical, lo- gistical, and biological issues and limitations that come with both ap- proaches. Liquid biopsy is non- invasive, repeatable, can be done as an outpatient, and is cost effec- tive but with no histological evalu- ation and cancer diagnosis. Turna- round time for tissue biopsy is always longer, creates the need for hospitalisation and is invasive, but offers histological evaluation, stan- dardisation of workflow and sensi- tivity fusions/amplification. ‘The best strategy is to match tissue and liquid biopsy at the same time,’ said Hofman. for Use cases and challenges in lung cancer For advanced lung cancer, doing tissue and liquid biopsy provides an opportunity to increase detec- tion of actual genomic alterations and create global molecular por- traits of the tumours. This can in- crease the number of target possi- bilities, though he pointed out concordance was around 70%. ‘If we have negative results on tissue, then we have to look at the liquid biopsy results and vice versa,’ he added. for Additional challenges inte- gration of liquid biopsy in thoracic oncology include screening and the detection of minimal residual disease and when post-surgery to take the blood sample, but there is Paul Hofman Paul Hofman is a Professor of Pa- thology and Head of the Laboratory of Clinical and Experimental Pathol- ogy at Pasteur Hospital, and Director of the IHU RespiraERA, Nice, France. His research focuses on lung cancer, including molecular pathology, biom- arkers, and diagnostics. He is also in- vestigating next-generation sequencing approaches to link per- sonalised medicine and molecular bi- ology. still a gap in introducing that into daily practice, the expert reported. Tissue exhaustion becomes a growing challenge To avoid tissue exhaustion, he said NGS should be performed in-house as sending samples outside the lab will not be sustainable in the near future. Against a backdrop of current and emerging biomarkers, Hofman concluded: ‘We need to work hand in hand for tissue biopsy and liquid biopsy because we have more and more biomarkers to look for with less and less tissue, so we need to avoid tissue exhaustion. If there is tissue exhaustion, we can switch rapidly to liquid biopsy.’ However, he warned that as the next gener- ation of pathology emerges, there is a need to be aware of false negative results in liquid biopsy. ■ Author: Mark Nicholls Tissue biopsy and liquid biopsy can increasingly be used as com- plementary or alternative ap- proaches, with advantages and limitations to each. While speak- ers at the recent 35th European Congress of Pathology in Dublin were quick to highlight that liquid biopsy was not about to replace tissue biopsy, the focus looked at the benefits and chal- lenges of each through the lens of four expert speakers. For his presentation, Professor Paul Hofman focused on the ad- vantages and limitations of liquid biopsy versus tissue biopsy in tho- racic oncology. In looking at how both biopsy techniques can be complementary, the Professor of Pathology and Head of the Labora- tory of Clinical and Experimental © Pathology at the Pasteur Hospital and Director of the IHU RespirE- RA, Nice, examined the landscape in thoracic oncology therapeutic decision making. Hofman further explored emerging biomarkers and molecular testing in thoracic oncol- ogy, provided insights on when and how to use tissue biopsy and liquid biopsy, and outlined recent developments of cf-DNA testing. in alterations With more and more targeted ge- nome thoracic cancer, looking for disease is a growing challenge, Hofman said. He emphasised the need to use NGS (next-generation sequencing) to address this. ‘We also need to consider what is not targeted; there is at least 40% of patients in West- ern countries without any genomic alteration with an associated drug, Assistive mobility system to reduce strain on care staff An easier way to transport hospital beds The most important resource of a company – including hospitals – is its staff. This is reason enough to think about optimis- ing working conditions. The two companies Linak and Tente have done just that and are pres- enting an innovative solution for patient transport at the hospital bedside at the Medica tradefair in Düsseldorf. The joint project, called WeAssist, is designed to take the ergonomics of transport with a hospital bed to a new level. This assistive mobility system “understands” what the user wants to do. In this way, help- ing the user with every ma- noeuvre, for example, when ne- gotiating a ramp. The intuitive and t s i s s A e W © self-explanatory design approach makes it possible to operate the system without any training, the companies state. The new solution also aims to re- duce the immense cost pressure on hospitals. The option of retro- fitting existing beds reduces ac- quisition costs. While this is even easier if a Tente and Linak system is already installed in the beds, the companies point out that the up- grade can be retrofitted inexpen- sively in just a few minutes. New bed projects do not require large resources either, as the use of WeAssist can be realised with little effort and at a favourable price. The assistive system is designed to offer the support that a second person would also provide when pushing the bed. This means that the bed transport can be carried out by just one person. This per- son is noticeably relieved, while the second person has time to take care of other important tasks. The system also significantly improves the ergonomics of bed transport, the companies report, as the strain on the spine, muscles and joints is reduced. Moving the bed is intu- itive and requires less effort, with the effect being comparable to using an e-bike instead of a regu- lar bicicle. The companies point out that thanks to its health-promoting ef- fects, the WeAssist system counter- acts the increase in absenteeism in healthcare professionals, as the back no longer has to be bent ex- cessively when transporting beds. This leads to reduced strain on joints, muscles and the spine, so medical care staff feel the relief immediately and benefit from sig- nificantly improved working con- ditions and less effort. Visitors to Medica will have the opportunity the WeAssist system live on a bed and drive it themselves. to experience Hall 12 / B53» EH @ MEDICA 2024
EH @ MEDICA Improving quality and efficiency Preparing for AI in clinical laboratories 9 What clinical lab managers need to think about ‚Don’t get enamoured with AI for your lab,‘ McClintock cautioned. ‚Always remember a clinical lab’s primary objective: to deliver the right information to the right per- son at the right place and right time in the right way. No system today can integrate all potential outputs of AI tools,‘ he em- phasized. ‚LIS, EHR, and middle- ware solutions take considerable effort to integrate with any AI tool without encumbering the pathol- ogist, laboratorian, or clinician. For starters, you need to think about data governance, data pipelines, regulatory guidelines, ethical re- view, custom programming and coding, computational computing power, either locally or in the cloud, cybersecurity, and risk man- agement. ‘Don’t forget the cost and availabil- ity of AI maintenance, support and quality control, which all require new IT support skills. There are also AI specific tools, such as al- gorithm drift. And then, in the end, will the AI tool save you enough money or at some point be re- imbursable so that it can pay for itself ’ to Experts recommend that lab man- agers need to focus on generating clinical evidence for AI benefits and understand the barriers and challenges implementation when they select a tool. New train- ing on AI is essential. In general, experts recommend implementing the new tool while still keeping the existing system functioning, to give practitioners time to learn and get comfortable with AI while main- taining the status quo as back-up. McClintock also described a new framework for clinical AI life cycle implementation, from idea gener- ation to final validation, go-live, and system maintenance. By adopt- ing a similar AI lifecycle, he en- couraged attendees to embrace the potential of AI in their labs. Co-presenter Christopher Lee Wil- liams, MD, Assistant Professor of Pathology at the University of Ok- lahoma Health Sciences Center, concurs. ‚Will AI be replacing staff in labs ‘ he asked rhetorically. ‚Probably not. The practice of lab- Advertisement oratory medicine has been con- stantly evolving, often due to in- creasing automation. I think that AI will be another tool in our tool bag, to aid in efficiency and quality control. With a steady increase in an aging population in the United States, we are going to need all the help we can get.‘ ■ Report: Cynthia E. Keen Christopher Lee Williams Christopher Lee Williams, MD, is the Director of Informatics in the De- partment of Pathology at the Univer- sity of Oklahoma Health Sciences Center in Oklahoma City, where he also serves as an Assistant Professor. Dr Williams’ current research inter- ests include how to operationalise AI tools for analysis and reporting in the laboratory setting, and in opti- mizing UI/UX design for laboratory workflows. David McClintock David McClintock, MD, is the Chair of the Division of Computational Pa- thology and Artificial Intelligence within the Department of Laboratory Medicine and Pathology at Mayo Clinic in Rochester, Minnesota, USA. His primary clinical interests include clinical informatics, laboratory work- flow optimisation, digital pathology implementation, analytics, and clini- cal ML/AI model deployment. His re- search interests include understanding the role and effects of digital pathology within the clinical laboratories and the use of AI and ML for improved diagnostics, more efficient workflows, and better pa- tient outcomes. c i n i l C o y a M , k c o t n i l C c M d i v a D Mayo Clinic Clinical Kidney Stone Workflow with Machine Learning Some year in this decade, AI tools will become ubiquitous within clinical laboratories. AI has the potential to increase the accuracy of laboratory testing and improve the quality and effi- ciency of operations and service of testing labs. Clinical laboratorians must prepare to help lead this initiative, for their knowledge will be the key to suc- cessful implementation. They need to learn how AI algorithms are de- veloped and validated, how to jus- tify and analyze impact from the perspective of clinical laboratory medicine, and how to implement them to best benefit the patient and the hospital. Several scientific sessions at the Association for Diagnostics and Laboratory Medi- cine (formerly the AACC) Annual Scientific Meeting focused on this topic. AI is in its naissance in medical lab development, and this was very ap- parent in the technical exhibition of the ADLM/AACC meeting. David McClintock, MD, Chair of the Divi- sion of Computational Pathology and AI in the Department of Lab- oratory Medicine and Pathology of Mayo Clinic, pointed out that only 30 out of the 941 exhibitors at the meeting included the terms ‚ar- tificial intelligence‘ (AI) and/or „machine learning“ (ML) in their product/company descriptions on the AACC exhibitor website. Ten companies included „analytics“ in their description, but only four were separate analytics-based com- panies selling clinical lab AI/ML software. ‚This is an emerging space, just as radiology PACS was 30 years ago,‘ McClintock said. ‚Now is the time to learn about it or perhaps even start to developing models that can benefit your lab.’ Uses of AI/ML in the lab There are numerous ways that both simple and complex AI tools can aid a clinical laboratory. These include: • Automated spectroscopic data analysis and disease detection; multivariate analysis of disease EH @ MEDICA 2024 conditions; test interpretation; image analysis • Digital for microbiology, haematopathol- ogy, immunology, and forensics; • Data entry automation for spe- cific tasks and processes; • Creating standardised reports for lab test results and automated entry In- formation System (LIS); Laboratory into • Minimising laboratory testing for inappropriate test orders, pre- dicting test results from other available data on patient chart, and reducing redundancy and duplication of lab tests, based on prior type and date of tests al- ready performed; • Data analytics for laboratory op- erations planning, such as pre- dicting volume workflow, em- ployee requirements, etc.; staffing • Identifying and alerting for ab- normal test results; • Auto-verification of test results for quality control. Automating spectral analysis for kid- ney stones and fecal analysis Mayo Clinic spent six years devel- oping an AI model to automate the spectral analysis of stones passed by patients. It is based on the clas- sification of 708 unique kidney stone types. In the first 90 days of implementation, commencing April 2023, 20,000 stones have been re- viewed, 40% of which were newly able to be bulk auto-released to pa- tients’ medical records. the model was Before im- plemented, the conventional work- flow began with cleaning and dry- ing the stone, after which it was ground into a fine powder and manually analyzed with FTIR spec- troscopy. A technician manually entered the results into a LIS, fol- lowed by a second technician re- viewing the interpretation. Only then are results uploaded to a pa- tient’s electronic medical record (EHR). AI tool to automate multiple proces- ses After evaluating how AI could im- prove workflow, reduce costs, and . r D © increase efficiency, the Kidney Stone lab at Mayo Clinic Rochester, in conjunction with an innovative AI team from Mayo Clinic Florida, created an AI tool to automate multiple processes following FTIR spectra analysis. The AI model was trained on 70,000 kidney stone spectra and validated with 16,491 kidney stone spectra. Quality as- surance required 81,517 kidney stone spectra. the then it and ‚This is a lot of data, which took a lot of work, and a lot of computing time,‘ commented McClintock. ‚But now the process is automated and is achieving our expectations. If a stone is not complex, the AI system classifies in- formation is automatically entered into the LIS and subsequently re- leased to the patient’s EHR. When it identifies a stone as complex, the results produced are manually flagged for review by a technician. The lab is now saving a lot of time, which equates to tangible cost sav- ings and opportunities for labora- tory staff work reduction/redi- rection.’ Other applications of AI in the clinical labs also exist, such as commercially developed AI tools in clinical microbiology to detect fecal ova and parasites (O&P). For most labs, up to 95% of O&P cases can be negative, and thus the pro- cess of reading slides can be mon- otonous. The investigational AI- assisted screening tool (Techcyte, Orem, UT) uses a convolutional neural network to identify and count parasite cysts and tropho- zoites, yeast, and red and white blood cells and groups them by class. Techcyte claims the tool is five times more sensitive than man- ual examination, with a sensitivity of 98.9%. It produces findings within 30 seconds instead of the average five minutes, automatically uploading negative findings to a LIS. Positive samples are flagged for technologist review and assess- ment. At Mayo Clinic, this test has just been implemented, with initial impressions positive by laboratory staff who can now comfortably re- motely review slides.
10 EH @ MEDICA Latest developments in contrast media utilisation Striking the balance between diagnostic efficacy and patient safety remains critical when uti- lising iodinated contrast media to deliver the best imaging out- comes. Currently, 300 million CT exams are conducted across the world every year, with 40% contrast-enhanced exam. While playing a crucial role in diag- nosis and treatment of disease, CT expert Efthimios Agadakos believes the medical profession has a duty to do its utmost to minimize patient from contrast media. risk A session at ECR 2024 in Vienna heard about latest developments, trends and breakthroughs in contrast media utilisation in CT, MRI and ultrasound imaging, and explored the question of how do- sage may be further lowered using modern protocols. Focussing on CT imaging, Agadakos offered in- sights into approaches he feels can contribute to enhanced patient safety and better-informed clinical decisions. As Chief Radiographer at Laiko General Hospital in Athens, he highlighted the role of imaging in modern clinical practice, offering invaluable diagnostic information across a wide spectrum of medical specialities. ‘It can improve visual- isation of anatomy and pathology, enhance lesion detection and vas- culature, identify ischemic con- ditions, enhance surgical planning and guidance as well as monitoring treatment response,’ he said. ‘But it is imperative to acknowledge the associated risk of iodine in contrast media.’ Why a lower dose matters Risks from radiation levels and ad- verse reactions mean that optimal iodine delivery is pivotal in yield- ing precise and reliable diagnosis, while maintaining patient safety and healthcare efficiency. Agada- kos said that lower iodine dose can reduce risk of allergic reactions and contrast-induced nephropathy, decrease vascular complications, enhance patient comfort and ex- perience, minimise radiation ex- posure, and optimise resource utili- sation. Protocols can also be adapted for children, the elderly and for patients that need repeat CT scans. protocols and smart injection sys- tems. ‘Iterative reconstruction al- gorithms enable the use of lower tube currents or voltages, driving lower iodine doses without diag- nosing compromising diagnostic accuracy,’ he told delegates. One study using a low KV and low iodine dose with abdominopelvic CT achieved a 40% iodine dose re- duction and 50% radiation dose re- duction. ‘Meanwhile, dual-energy CT allows for better iodine contrast enhancement at lower doses, thus reducing the total iodine load on the patients,’ added Agadakos. Perfect timing Artificial Intelligence applications assist in reducing need for IVCM (intravenous contrast media) by analysing patient data such as weight, age, renal function and medical history to tailor person- alized contrast doses for optimal imaging, the contrast-induced risks. and minimise The expert went into detail on a range of options that can be ap- plied to help reduce iodine dose when using CT. These include tube voltage selection (automated or manual), iterative reconstruction algorithms, cinematic rendering, Dual Energy CT, AI applications, Photon-counting CT, personalized Machine learning algorithms can predict the required iodine dose and flow weight, select low KV or dual-energy CT scanning based on individual patient characteristics. When using personalized proto- cols, he said bolus triggering is a “must” with contrast-enhanced CT as it facilitates ‘perfect timing for contrast enhancement, produces accurate imaging and reduces the need for higher iodine concen- trations.’ Meanwhile, photon count- ing CTA facilitates lower iodine dose by enhancing the detection of contrast media, particularly in small vessels, he added. Finally, advanced contrast injectors equipped with intelligent tech- nologies offer precise management of contrast administration. Agada- kos said the aim is to strike a bal- ance between diagnostic efficacy, image quality and patient safety and comfort. ‘By embracing the la- test advancements in CT tech- nology and adopting tailored strat- egies for iodine dose reduction, we can push the boundaries of diag- nostic excellence while prioritizing patient safety,’ he continued. ‘But we must continue to col- laborate, innovate, and elevate the standard of patient-centred care in medical imaging, ensuring that every patient receives the highest quality of care and a positive and reassuring experience in the CT de- partment.’ The session also heard from Peter Murphy, Unit Manager, MRI, PET CT & DXA, Alliance Diagnostic Medical Imaging Ireland and Cork University Hospital about current issues with Gadolinium-Based agents with MRI, and Barbara Kraus from Wolkersdorf, Austria, speaking on indications and proto- cols for ultrasound contrast agent administration. ■ Efthimios Agadakos Efthimios Agadakos chief radiogra- pher of the Medical Imaging Depart- ment at Laiko General Hospital, Athens, Regional Director Europe ISRRT (International Society of Radi- ographers and Radiological Technol- ogists) and President of the Panhellenic Society of Radiological Technologists Greece. His areas of in- terest are in CT, radiation protection and patient safety. Awarded a MSc in Health Services Management from the National School of Public Health in Athens, he is currently completing his PhD thesis in Medicine at the University of Athens on low radiation dose protocols in CT. New PET technique reveals pancreas tumors A new PET scan reliably detects benign tumors in the pancreas, according to research led by Radboud university medical center. The study in adults was published in the Journal of Nuclear Medicine. Earlier results from pediatric pa- tients were also published in this journal. Current scans often fail to detect these insulinomas, even though they cause symptoms due to low blood sugar levels. Once the tumor is found, surgery is possible. The pancreas contains cells that produce insulin, beta cells. Insulin helps the body absorb sugar from the blood and store it in places like muscle cells. This regulates blood sugar levels. In rare cases, the beta cells malfunction, resulting in a be- nign tumor called an insulinoma. This almost never spreads, but it still causes problems due to excess- ive insulin production, leading to low blood sugar. ‘People with this condition have little energy due to low blood sugar and often faint’, explains Marti Boss, first author of the study. ‘It‘s a very challenging disease. It often takes a long time before patients get a diagnosis. We can perform blood tests, but they can‘t confirm if a tumor is the cause or where it‘s located. Various scans like CT, MRI, and PET are available, but don’t always show the insulinomas.’ Removing the tumor surgically re- solves the problem, but first, the tumor‘s location must be known. Martin Gotthardt, professor of Nu- clear Medicine at Radboudumc, ex- plains: ‘In the past, surgeons would start cutting away portions of the pancreas until they found the tumor. If it was at the end, the en- tire pancreas would be gone. You can live without a pancreas, but you‘d struggle with severe diabetes and would constantly have to man- age your blood sugar. So, a better scan was urgently needed.’ Gotthardt and his team developed a completely new scan, the so- called Exendin-PET scan, which allows for the precise localization of insulinomas. They previously published results from a study in children, where the insulinoma is congenital. Now, they present find- ings from a study in adults, where the insulinoma developed grad- ually. In the study, 69 adult patients with suspected insulinoma participated. The Exendin-PET scan detected tu- mors in 95% of the patients, com- pared to 65% with the current PET scan. When combined with CT and MRI, the current PET scan usually detected the tumor, but in 13% of cases, the insulinoma was only vis- ible on the new scan. Boss adds: ‘We believe the new scan can re- place all other scans. All the insuli- nomas we found with the new scan were removed, and all those pa- tients were completely cured after surgery, even though some had been sick for decades.’ The new scan is based on a sub- stance found in the saliva of the Gila monster, a type of lizard native to desert areas in the United States. Gotthardt explains: ‘We knew this substance specifically binds to a molecule on these tumors, the GLP1 receptor. The substance from the saliva wasn’t very stable in the human body, so we created a more chemically stable version, called Exendin. We then attached a radio- active substance to it, so it could be visible on a PET scan. Now, this mildly radioactive Exendin appears to perfectly detect insulinomas.’ The next step is to introduce the Exendin-PET scan into clinics as the standard scan for people sus- pected of having an insulinoma. Researchers will now assess how the scan improves patients‘ quality of life and how much money can be saved if other scans, like CT and MRI, are no longer needed. In ad- dition, Gotthardt‘s team is investi- gating the potential use of Exendin for the treatment of insulinomas in a new research project called Light- Cure. ■ Source: Radboudumc Publisher mgo fachverlage GmbH & Co. KG E.-C.-Baumann-Str. 5 95326 Kulmbach/Germany Phone +49 (0) 9221 949-311 Fax +49 (0) 9221 949-377 Managing Directors: Eva-Maria Bauch, Stephan Behrens Editor and Production Manager: Tim Hofmann (TH) Phone: +49 (0) 9221 949-176 E-Mail: redaktion@european-hospital.com Editor: Wolfgang Behrends (WB) Founded by Heinz-Jürgen Witzke ISSN 0942-9085 Correspondents Austria: Michael Krassnitzer (MK) Germany: Cornelia Wels-Maug (CWM) Dr Christina Czeschik (CC) Great Britain: Mark Nicholls (MN) Spain: Mélisande Rouger (MR) USA: Cynthia E. Keen (CEK) Subscriptions Lena Krauß kundenservice@mgo-fachverlage.de Subscription rate 4 issues: 32 Euro, Single copy: 8 Euro. Printed by: mgo360 GmbH & Co. KG, Bamberg, Germany Publication frequency: quarterly Representatives Germany, Austria, Switzerland: Toni Lauterbach Phone: +49 9221 949-374 E-Mail: t.lauterbach@mgo-fachverlage.de France, Italy, Spain: Eric Jund Phone: +33 493 58 77 43 E-Mail: jund@european-hospital.com GB, Scandinavia, BeNeLux: Simon Kramer Phone: +31 180 6200 20 E-Mail: kramer@european-hospital.com Taiwan: Charles Yang Phone: +886 4 232 236 33 E-Mail: medianet@ms13.hinet.net USA & Canada: Hanna Politis, Media International Phone: +1 301 869 66 10 E-Mail: hanna@media-intl.com All company, brand and product names in this publication are the property of their respective holders. Users must obtain per- mission from those holders before copying or using the owner’s trademarks, product and company names or logos. EH @ MEDICA 2024
EH @ MEDICA 11 Healing wounds faster with the power of AI Swift Medical, a pioneer in digi- tal wound care, has unveiled the new Skin & Wound 2 platform. As the gold standard for the digital wound care segment which it helped to create, Swift’s award- winning platform has been used for over 50 million patient assess- ments in home health, ambulatory, acute, and skilled nursing settings. With over 22 peer-reviewed pub- lications, the company has stayed true to its commitment to clinically validate its groundbreaking inno- vations and has proven outcomes in accuracy, equitable AI and im- proved healing rates. “Skin & Wound 2 demonstrates our continued commitment to em- powering clinicians with the most advanced tools available, enabling the delivery of superior wound care outcomes,” said the company‘s CEO, Dwayne Sansone. “For nearly a decade, Swift Medical has been committed to delivering an in- . c n I l a c i d e M t f i w S © clusive, unbiased approach to digi- tal wound care. We see it as our moral responsibility to harness the power of generative AI to revol- utionize patient diagnostics, ensur- ing highly accurate results for every skin tone. Our mission is to heal our world faster by leveraging AI to ensure that every patient, re- gardless of their background, re- ceives the most precise and equi- table care possible.” Skin & Wound 2 is built with the advancements of the healthcare landscape in mind and to take further advantage of Swift’s pat- ented AI technologies. The new platform incorporates the latest FHIR standard, along with the best- in-class docu- mentation in the market, which is integrated with premier tightly EMR platforms like Homecare Homebase. It features a seamless modern user interface allowing for expedited evaluations and sub- millimeter accuracy. imaging and “Homecare Homebase has been the leader in integrating the most advanced and reliable patient- focused technologies. Our deeply collaborative partnership with Swift provides our customers with the best digital wound care sol- ution in the market to help patients heal faster,” said Scott Pattillo, Chief Strategy Officer. In 2024, Swift surpassed 600,000 wound care evaluations in a month by over 21,000 clinicians of all types. Swift’s dedication to enter- prise scalability without compro- mising quality has been the driving force for the advent of Skin & Wound 2. The new platform will enable rapid deployment of new features, including several ad- ditional ground-breaking capabil- ities planned in the next year. ■ Source: Swift Medica, Inc. Soldering wounds with light and nano thermometers Not every wound can be closed with needle and thread. Empa researchers have developed a soldering process with nanopar- ticles that gently fuses tissue. and The soldering technique is ex- pected to prevent wound healing disorders life-threatening complications from leaking su- tures. The team recently published the promising method in the jour- nal Small Methods and applied for a patent. The idea of suturing a wound with a needle and thread dates back more than 5,000 years. Since then, this surgical principle has not changed much: Depending on the skill level of the person perform- ing the operation and the equip- ment, cuts or tears in the tissue can be joined together more or less perfectly. Once both sides of a wound are neatly fixed to each other, the body can begin to close the tissue gap permanently in a natural way. However, the suture does not always achieve what it is supposed to: In very soft tissues, the thread can cut through the tis- sue and cause additional injury. And if the wound closure does not seal on internal organs, permeable sutures can pose a life-threatening problem. Researchers at Empa and ETH Zurich have now found a way to solder wounds using lasers. cine. The team led by Oscar Cipo- lato and Inge Herrmann from the Particles Biology Interactions lab- oratory at Empa in St. Gallen and the Nanoparticle Systems Engin- eering Laboratory at ETH Zurich therefore tinkered with a smart wound closure system in which laser soldering can be controlled gently and efficiently. For this pur- pose, they developed a bonding agent with metallic and ceramic nanoparticles and used nanother- mometry to control the tempera- ture. The elegance of the new soldering process is also based on the inter- action of the two types of nano- particles in the bonding protein- gelatin paste. While the paste is irradiated by laser, titanium nitride nanoparticles convert the light into heat. The specially syn- thesized bismuth vanadate par- ticles in the paste, on the other hand, act as tiny fluorescent nano thermometers: They emit light of a specific wavelength in a tempera- ture-dependent manner, allowing extremely precise temperature regulation in real time. This makes the method particularly suitable for use in minimally invasive sur- gery, as it does not require stirring and determines temperature dif- ferences with extremely fine spa- tial resolution in superficial and deep wounds. Soldering usually involves joining materials together by means of heat via a melting bonding agent. This thermal reaction must remain within narrow limits for biological materials, at the same time, the temperature is difficult to measure in a non-invasive way. This has been a problem for the application of soldering processes in medi- Once the team had optimized the conditions for „iSoldering“ (intelli- gent soldering) via mathematical modeling in silico, the researchers were able to investigate the per- formance of the composite materi- al. Together with surgeons from the University Hospital Zurich, the Cleveland Clinic (USA) and the Czech Charles University, the team EH @ MEDICA 2024 achieved fast, stable and biocom- patible bonding of wounds on or- gans such as the pancreas or liver in laboratory tests with various tis- sue samples. Equally successful and gentle was the sealing of par- ticularly challenging pieces of tis- sue, such as the urethra, fallopian tube or intestine, using iSoldering. A patent application has now been filed for the nanoparticle compos- ite material. But the researchers didn‘t stop there: They succeeded in replacing the laser light source with gentler infrared (IR) light. This brings the soldering technology another step closer to be used in hospitals: „If medically approved IR lamps were applied, the innovative soldering a p m E © Soldering wounds with a nanoparticle paste and light: Oscar Cipolato and Inge Herrmann in Empa‘s Particles-Biology Interactions laboratory in St. Gallen. technology could be used in con- ventional operating rooms without additional protection laser measures,“ says Inge Herrmann. ■ Source: Empa – from KOB Pedilay® adjustable, ready-to-use secondary dressings made of soft non-woven fabric which adapts to the patient‘s anatomy: Quick & easy to apply – readjustable with hook and loop fasteners. Secure protection & wearing comfort – e. g. ideal for patients with ulcus cruris. www.pedilay.com E18» Hall 5 /
12 EH @ MEDICA Technology applications in diagnostic imaging How digital twins will support the radiologist of the future twin Digital technology can transform clinical practice by aiding patient-specific prediction and supporting personalized treatment models. Expert speak- ers at an ECR2024 session in Vienna focussed on how radiol- ogy will play a leading role in the advance through data ac- quisition via a range of imaging modalities. The session was chaired by radi- ologist Professor Valeria Panebian- co from the Sapienza University of Rome, who also outlined her de- partment’s work with digital twin technology. To set the stage, she provided a rough definition of what a digital twin can be: • an evolving digital profile that helps optimise digital perform- ance; • a dynamic digital representation; or • a virtual representation of a physical object or system across its lifecycle. The key concepts are that the two systems – physical and digital – should exist side by side on a real time basis. Panebianco said; ‘As simulation models, digital twins will transform clinical practice as they will pro- vide patient-specific prediction for the prevention, screening and dis- ease diagnosis as well as person- alization and assessment of re- sponse to therapy.’ Bridging the human-digital divide The expert delivered insights on the future development of digital twins in radiology through clinical, computational, digital and virtual pathways, noting that it is ‘where the real clinical world meets digi- tal’. However, the complexity and prognostic heterogeneity of dis- eases make it necessary to apply computational tools and precision medicine. ‘However, ‘The data for digital twins’ develop- ment can be derived from many different medical specialities,’ she continued. radiology stands out for multiple factors as radiologists make diagnoses and assess therapy response, which are the main predictive clinical ques- tions to which digital twins have to reply.’ Radiology produces large amounts of data from different modalities such as CT, MRI and ultrasound, providing a rich foundation for quantitative and in- formation. To achieve the goal of making viable predictions, the data fed to the digital twins must be ac- curate as well, Panebianco said. functional She pointed to current examples of digital twin applications, such as in cardiology to inform on clinical decisions, in orthopaedics to main- tain musculoskeletal health of sol- diers, and in multiple sclerosis for simulation models for treatment outcomes. Outlining the work to develop digi- tal twin technology at the Univer- sity of Sapienza, she said her focus is on validating wearables, liquid biopsy and imaging biomarkers in prospective studies to construct the digital twin. She concluded: ‘Radiology is able to provide a bridge between the human being and the digital twin by shortening the gap and enhanc- ing the development of this inno- vative digital solution.’ Efficiency, personalization, research Meanwhile, Huan Xuan Nguyen, Professor of digital communication in engineering at Middlesex Uni- versity in London and Director of the London Digital Twin Research Centre, went into more detail on what he called the “three pillars” of digital twins in healthcare: • models developed for healthcare facilities and organizations, de- signed to improve efficiency of hospital or departments; • digital twins of the human body for personalized diagnosis, treat- ment planning, treatments and interventions; and • models geared towards disease research, medicine and device development. However, he cautioned that im- plementation of digital twins in healthcare come with high deploy- ment and maintenance costs, with significant investment needed in technology platforms to achieve vi- able results. Nguyen also outlined technical challenges, with notable issues around data collection and inte- gration, computational resources, model accuracy and validation, as well as privacy and security con- cerns. The effort needed to over- come these challenges might still be worth it, he added: ‘The benefit in healthcare and radiology is that you can have greater predictive ac- curacy with a digital twin, treat- NEWS ∙ REPORTS ∙ INTERVIEWS ∙ VIDEOS ∙ SOCIAL MEDIA S a y i n f rm e d ment plan optimisation and can test scenarios without interfering with real patients. ‘It can also be used for research and training and to familiarise pa- tients with equipment. Finally, per- sonal care and treatment is one of the most important potential bene- fits of the digital twin.’ Need for a regulatory framework Dr Ilena Rapisarda, a private law researcher from the Department of Law at the University of Catania in Sicily, explored ethical and legal is- sues of digital twin technology. the While technology’s devel- opment might still be in its infancy, the field is rapidly evolving, she said: ‘Clinicians will be able to simulate aspects of treatments on patient digital twins and determine which option is likely to be the most effective. courses for engineers, computer scientists and developers, with par- ticular reference to ethics in the de- sign of technologies. ■ Author: Mark Nicholls Huan Xuan Nguyen Huan Xuan Nguyen Professor of digital communication in engineering at Middlesex University in London and Director of London Digital Twin Research Centre, with research inter- ests include that include digital twin modelling, digital transformation and machine learning. to twin technology offers ‘Digital great opportunities revol- utionize healthcare systems, and ethical issues should not prevent development of such technologies but should integrate with it.’ However, the expert warned that conflicts of interest must be regu- lated by adopting an ethical ap- proach, with the new technologies governed by the law. She said it was necessary to adopt an ap- propriate regulatory framework, especially regarding the allocation of responsibilities between the dif- ferent actors involved in the pro- duction and use of digital twins. The framework should also intro- duce ethical principles of auton- omy, responsibility and transparen- cy in codes of conduct and training Valeria Panebianco Valeria Panebianco Full Professor of Radiology at the Sapienza Univer- sity of Rome with a specialist interest in diagnostic imaging focused on GU, screening programmes and precision medicine. She is scientific co-ordi- nator of a range of projects on digi- tal medicine applications in healthcare. EH @ MEDICA 2024