EH 2_2015

EUROPEAN HOSPITAL Vol 24 Issue 2/15 6 NEWS & MANAGEMENT Consider your future care when young enough Personalised medicine in ophthalmology Ambient assisted living systems Computerised tailor-made retinopathy therapy If we believe the prognoses on demo- graphic change, deciding how we want to be treated if ill, or in need of care, will not remain easy, unless society agrees on a decisive migra- tion policy to help ensure medical care in Germany can be safeguarded for the future. Along with the option of imple- menting selective, work-related migration, the technological advanc- es, which have developed rapid- ly over recent decades, offer the potential to take the strain of nurses and carers, or even to replace them. Strongly affected by demographic change, countries such as Japan and Germany are making large invest- ments in the development of these technologies. AAL = ambient assisted lives The talk is of Ambient Assisted Living Systems. These aim to create an “intelligent” environment that can adapt independently, proac- tively and situation-specifically to the needs of the elderly and those needing care in their own homes for as long and as independently as possible. The range of AAL systems already available along with those currently in development is huge – from hobs that turn off automati- cally after a period of time, to shoe soles equipped with GPS to help track dementia patients, to patients’ lifting systems, and even to robot nurses. Four of these AAL Systems, pri- marily designed for use in geri- Report: Michael Krassnitzer Nowadays the concept of personalised medicine is usually applied to oncol- ogy. However, there are other clinical disciplines in which therapies tailored to the individual patient are within reach, viz. ophthalmology. In the researchers’ limelight is intravitreal drug delivery since the outcomes of injections into the vitreous differ from patient to patient. Ophthalmologists in Vienna, Austria, are working on software to identify suitable therapy for each individual patient. Intravitreal injections (IVI) are indi- cated for retinopathies such as age- related macular degeneration (AMD), diabetic macular oedema (DME) or retinal vascular occlusions. Antibodies are injected directly into the vitreous, which serves as a drug reservoir, and released to the retina over the course of a few weeks. Thus, for the first time retinal diseases can be treated directly – and successfully. Thanks to intravitreal injections AMD is no longer the prime cause of blindness. However, there is a catch: In order to be on the safe side, the treatment must be repeated every few weeks – for life. ‘This is de facto impossible,’ says Dr Sebastian Waldstein, ophthalmologist at the Department of Ophthalmology and Optometry at the Medical University of Vienna, who is also in charge of the research focus Macular Degeneration at Vienna Reading Centre (VRC). ‘First, most patients simply cannot afford the monthly treatment finan- cially,’ he points out, adding that it is also too stressful for the patient.’ Indeed, only a minority of patients need monthly treatment, he says. ‘For about two thirds of patients much longer intervals are entirely sufficient – in fact, some patients need only a few injections.’ Even better, ‘The course of retinal dis- ease and the best treatment strategy can be predicted with a probability of ninety-nine percent probability’ using optical coherence tomography (OCT), a diagnostic procedure largely developed in Vienna, that has revolu- tionised ophthalmology within a few years. In OCT, hundreds of scans are combined to produce a 3-D image of the retina, which in turn allows reconstruction of the macula within seconds. However, the computing power behind this contactless pro- cedure also poses a problem: the data volume generated in OCT is so huge that the ophthalmologist can no longer interpret it. To eliminate this quandary, Dr Waldstein is developing innovative computer-based methods to analyse large clinical image data sets. To provide his research with an institutional framework, he initiated the Christian Doppler Laboratory for Ophthalmological Image Analysis, which he currently coordinates under the supervision of Professor Ursula Schmidt-Erfurth. The first results are already available: ‘The algorithms we developed need three exams to reli- ably predict the retinal status at the next scheduled exam and to predict whether the patient will suffer a relapse in the course of treatment,’ Dr Waldstein explains. These prelimi- narily tested methods must now be applied to large patient cohorts. ‘We delivered the proof of principle and expect prototypes for the large-scale evaluation to be available in one to two years.’ It may well be that the physician will not be able to comprehend the calculated results based on the algo- rithms. ‘The parameters that lead to the predictions might be highly com- plex,’ Waldstein says. ‘The analysis of big data is often a black box method. In short: the prediction is correct, but we don’t understand why.’ Dr Waldstein aims to provide software integrated into the OCT system, to offer a score or probability for the outcome that allows a physician to select the best possible treatment. atric care, were introduced at an Evangelical Academy congress in Berlin. Two are already in use, SAMDY and Care-O-bot 4, the oth- ers still in development. Networked Living – SAMDY SAMDY stands for Sensor-based Adaptive Monitoring System for behavioural analysis of the elderly and, following a development and pilot phase in 2013, is now used on a regular basis by the Social Network St. Georg, a regional care provider. To help enable old people to live at home for as long as possible, their flats and houses are fitted with a range of sensors that register their daily movements and actions. These motion and contact sensors are fixed to external doors as well as to fridge and oven doors along with tracking systems and bed sensors. The latter can register movements during sleep and different depths of sleep, as well as monitoring the heart rate. As soon as the sensors register a breach of the norm, specified as deviations from pre-defined, normal behaviour(s), a wireless warning system alerts members of the (nurs- ing) care service to take immediate, appropriate measures. Care-O-bot 4 – the Service and Care robot Development of the 4th generation Care-O-bot, a robot developed by a Working Group at the Fraunhofer Institute for Manufacturing Engineering and Automation in Stuttgart, was completed at the beginning of 2015. The system will be introduced his April, during The 8th AAL Congress. As a mobile service and care robot its purpose is to assist the user in the household and, just like SAMDY, enable the user to live at home as independently as possible. Care-O-bot safely moves around people, recognises typical household objects, can grip them and take them to certain locations, can set the table or open doors and drawers. With respective program- ming, it also reacts when someone has fallen and is lying on the floor, immediately establishing contact with an emergency service provider. How do we want to live? As yet, advanced AAL technologies such as robots are not yet fully uti- lised worldwide, their development and testing is sufficiently advanced to expect them to be widely used. However, before this happens, we should ask ourselves: Do we want this? Do we want to live at home alone and surrounded by technol- ogy when ill or old? Do we want our every movement registered and passed on to third parties, as is required for the concept of the SAMDY system? Do we want a robot to bring us water? This is an individual issue as well as one for society as a whole, and all of us should think about answers here to ensure that we don’t feel we have become overtaken by these devel- opments. This is the firm opinion of Professor Arne Menzeschke, one of the congress organisers, Head of the Department for Ethics and Anthropology at the Institute for Technology, Theology and Natural Sciences at the Ludwig-Maximilian University, Munich. MEERSTAR – the ethical evaluation instrument He developed a tool to evaluate AAL applications in the context of a study initiated by the Federal Ministry of Education and Research (Ethical Questions around Ambient Assisted Living Systems) that col- lects and evaluates the advantages and disadvantages of new techno- logical approaches and develop- ments and all their aspects (legal, economic, social and moral). Since 2012, there has been a recom- mendation that all AAL projects promoted by the Federal Ministry of Education and Research should carry out a Model for the Ethical Evaluation of Socio-Technological Arrangements (MEESTAR) in the form of two-day workshops. Conclusion Today, the fit among us should answer the question of how we would like to be cared in the future, and should establish procedures that will enable us to live a truly self-determined life to the end. New technologies in health and geriatric care promise great benefits – and risks – all of which were aired this February during Evangelical Academy congress in Berlin. Interestingly, an instrument to check the ethical dimensions of new developments was also introduced, Bettina Döbereiner reports Completed in 2008, this interactive Service Robot Care-O-bot 3 can collect and deliver objects, opening and closing drawers for this purpose. Its interactive touchscreen provides a multitude of entertainment and communication functions. Video telephony, for instance, facilitates communication with relatives and friends. The robot can also remind the user about appointments or, for example, taking a medication. If a user falls, the Care-O-bot can move towards them, simultaneously establishing a video link with an emergency control centre Fraunhofer/Photo:JensKilian (c)MUW Based in the Department of Ophthal mology and Optometry at the Medical University of Vienna, ophthalmologist Sebastian M Waldstein also leads research on macular degeneration at the Vienna Reading Centre (VRC). Additionally, supervised by Professor Ursula Schmidt- Erfurth, he coordinates the Christian Doppler Laboratory for Ophthalmological Image Analysis, a publicly funded, inter disciplinary research group set up to develop innovative computer-based methods to analyse large clinical image data sets. A native of Salzburg, Dr Waldstein studied medicine in Innsbruck and Vienna. Subsequently he has received prizes and awards from international professional associations such as ARVO, Max Kade Fellowship and ESASO. An intravitreal injection (IVI) Date for the diary 29-30 April 2015 The 8th AAL Congress Messe Frankfurt Frankfurt am Main, Germany

EH 2_2015

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