the european forum for those in the business of making healthcare work v o l 2 6 i s s u e 4 / 1 6 • a u g u s t / s e p t e m b e r 2 0 1 6 laboratory 4-6/19-20 • biobank develops research standards • testosterone and male heart problems • in reprocessing qualifications are vital surgery 21-23 • reconstruction or amputation? • gaining a suite for 3-d printing • procedures in your pocket contents news & management 1-3 lab & pathology 4-6/19-20 cardiology special 7-18 surgery 21-23 events 24 www.healthcare-in-europe.com exuding the aroma of hi-octane fuel, the glamour of multi- coloured racing leathers, flashy sponsored brands and the glitz of the circuits, motorcycle racing can be an irresistible fast-action sport. amid the roar of engines, the world’s leading motorcycle aces, such as marc marquez, valentino rossi or jonathan rea, hit around 300kmh on tracks across the globe. interview: daniela zimmermann high-speed duals thrill the crowds, but clearly the risk of accident and injury remain high, despite improve- ments over the last three decades in equipment, machines, safety fea- tures and medical facilities. at the core of these is the renowned clinica mobile, a fully equipped medical and physiother- apy centre ‘on wheels’ to treat riders and the wider motor- cycle racing entourage. since the 1970s, clinica mobile has grown from a group of car- ing and enthusiastic practitioners carrying medi- cal boxes to race circuits into a mobile diagnostic and treatment facility with 50 employees attending superbike world championship and motogp races. in 2015, for example, the facility performed 2,966 interventions for motogp alone, of which about 1,245 their own permanent medical facili- ties, but clinica mobile is still a critical resource for care and treat- ment. the unit constantly upgrades its equipment, the latest being an additional carestream drx-1 flat panel from medical imaging systems and it solution specialist carestream health. installed at the back of the truck this produces immediate radiographic images; the console captures images and a detector forwards exposures wire- lessly to the console for processing and display, and then onward to printing and archiving systems. the digital detector reduces expo- sure to x-rays compared to conven- tional systems and the light weight of the system makes this a versatile tool to conduct a range of tradi- tional tests, e.g. general and trauma radiography and orthopaedics. ‘carestream’s drx-1 is a high-tech w e r e for driv- ers and 1,721 for paddock staff. ‘very often it helps diagnose and treat minor injuries, but sometimes - 359 times in 2015 - an x-ray is required. all this must be carried out within our 65-metre square facility, which can treat up to eight patients simultane- ously,’ medical director dr michele zasa explains. circuits now have continued on page 2 ace motorcyclists gain instant radiographic imaging from a flat panel system clinica mobile’s drx-1 delivers high-speed care system, able to meet the diagnostic needs of the specialisms that we serve, allowing us to provide more timely and accurate support,’ zasa points out. ‘it’s a very important and extremely reliable tool, useful in case of falls and ascertained frac- tures. in diagnostics, you need to have good machines that produce excellent diagnostic images. i need to provide a good quality service to the top riders, so the quality of all our equipment is very impor- tant. in terms of diagnostics the carestream drx-1, is a very good system. for traumatology, we can diagnose more and more fractures and it’s important to see, if the rid- ers are in pain, whether there are minor fractures. dr michele zasa is the medical director of the clinica mobile, a fully equipped medical and physiotherapy centre ‘on wheels’, and sometimes riders’ refuge. checking for minor fractures is important – they will race anyway, but they can relax knowing what the pain is 7-18 esc special reports and more v o l 26 i s s u e 4 / 16 • a u g u s t / s e p t e m b e r 2016
2 european hospital vol 25 issue 4/16 news & management continued from page 1 clinica mobile delivers high-speed care ‘it doesn’t change much - they will race in any case, with the minor fractures, but for the psychology of riders it’s important that they know when they feel pain that there is a small fracture, thanks to the machine seeing this. if they under- stand, they feel more comfortable and self-confident.’ the images are of such high qual- ity that the riders are reassured and relaxed about their pain and raises confidence to return to the track. carestream has also benefitted. ‘being on board the travelling medi- cal centre during the races the drx systems are tested to the full, both by the conditions and physical param- eters,’ explained michele ferrarese, the firm’s southern europe cluster manager. ‘this enabled us to dem- onstrate efficiency, consistent per- formance and ease of use.’ while life-threatening crashes have diminished in recent years, clinica mobile – which is privately funded by the organisers of the world championship – has devel- oped and evolved due to the inher- ent dangers. founded by dr claudio costa in 1977, this mobile hospital is housed in a lorry, specifically equipped with physiotherapy beds, as well as x-ray and high intensity laser therapy and thermotherapy equipment used for inflammation and muscle relaxation. since 1977, clinica mobile staff have provided emergency treatments and saved many riders’ lives, with the unit keeping pace with medi- cal advances throughout the years. in 1988, this unit even received the blessing of pope john paul ii. however, its role has altered with the building of permanent medical centres at each circuit to deal with life-threatening emergencies. nowadays, riders who crash on track are treated by local medical personnel in the circuit medical cen- tre although, in less serious cases, they may still be transferred to clinica mobile for further treatment. most of the mobile unit’s work is to provide generic medical treatments, pain therapy, orthopaedic advice and imaging evaluation. attending each race are two doc- tors – an anaesthetist and ortho- paedic specialist – as well as four physiotherapists and a radiology technologist. the facility also treats many oth- ers who work at the track, for example managers, mechanics and journalists, any of whom might suf- fer a range of ailments. ‘it’s a mix of diagnostics, general medicine, traumatology consultation, and pain therapy to get riders back on the track as soon as possible,’ explains zasa who, having worked for clinica mobile since 2011, became the unit’s medical director in 2014. ‘you’ll see plenty of riders on our beds, especially on friday and saturday afternoon, having physiotherapy treatments.’ the unit has also developed a family doctor approach for riders by offering gp-style services with blood checks and other tests. ‘clinica mobile has seen a lot of drama, but it’s also a second home for the riders. they come here for relaxing massages, or simply to chat and find a good environment. we cook outside and they come for a snack, or lunch, without having any pressure from their team, or journal- ists. this is very nice. they come not as top riders, but as normal boys having fun and enjoying life.’ details: www.clinicamobile.com www.carestream.com/drx uk hospitals face funding black hole nhs takes radical steps t head off financial crisis report: mark nicholls radical steps have been taken to address a growing financial cri- sis facing hospitals across england. under new rulings, nhs england will allow the worst affected hos- pitals to relax critical performance indicators, such as waiting time targets, as the nhs financial crisis deepens. the move is part of a package of measures taken by nhs bosses after hospitals exceeded their budgets by a record £2.45bn last year, triple the previous year’s level. under the strengthening financial performance and accountability in 2016/17 report from nhs improvement and nhs england, fines for missing targets for acci- dent and emergency units, cancer and routine operations have been scrapped. they will be replaced by a regime of “trust-specific incentives” being set up to help the worst-performing trusts tackle financial problems, with specialist senior managers drafted in to help some get out of trouble. for the past few years, uk hospi- tals have been fined if they missed key targets – such as the four-hour a&e wait, the 62-day cancer treat- ment deadline and 18 week waits for routine operations. with successive government plac- ing great emphasis on targets to raise performance, the relaxing of them is seen as a radical step. hospitals will instead simply have to improve on current performance to access any extra money being invested in the nhs this year. with nine out of ten hospitals in it must review its priorities for the nhs and be honest with the public about what it can deliver with the money it has been allocated,” he added. chris hopson, chief executive of nhs providers, which represents trusts, said: “we have to rapidly regain control of nhs finances, oth- erwise we risk lengthening waiting times for patients, limiting their access to wider services and other reductions in the quality of patient care.” in response to the strengthening financial performance and accountability in 2016/17 report, stephen dalton, chief executive of the nhs confederation - which represents 85% of nhs providers and commissioners - said: “this is a serious moment for the nhs. cuts to social care and public health as well as added pension costs are just some of the factors making it extraordinarily difficult for the nhs to bring down costs and demand this year. “we recognise the importance of financial rigour, however it should be recognised that the service has when two spanish oncologists launched the first independent spanish oncology forum this may in madrid, european hospital’s cor- respondent spoke with dr javier cortés, co-organiser of the event, to find out more about its expected impact in their field financial difficulties, the new meas- ures are designed to cut the £2.45bn overspend to £250m. nhs england chief executive simon stevens said this was a make- or-break period with the pressures across the nhs “real and growing.” “we need to use this year both to stabilise finances and kick-start the wider changes everyone can see are needed,” he added. meanwhile, it has also emerged the financial problems in hospitals almost meant the department of health failed to balance its budget overall. richard murray, director of policy at the king’s fund - an independent charity working to improve health and care in england – described the overspend as “further evidence of the serious financial crisis engulfing the nhs.” he added: “the prospects for the current financial year are grim, with national leaders already admitting that the nhs will be in deficit again despite even more stringent controls on spending. “the extension of the special measures regime, and other meas- ures announced, could be an oppor- tunity to provide support for the most financially challenged nhs organisations. but it still leaves large numbers of other nhs trusts strug- gling to balance the books and meet key performance targets.” the king’s fund has also stated that staffing levels within the nhs will have to be cut if the govern- ment wants to bring nhs finances under control. “if the government is serious about restoring financial balance, richard murray having previously worked at the depart ment of health as an economic adviser and in a number of senior roles, richard murray moved to nhs england as chief analyst in 2013 before joining the king’s fund in january2014 as director of policy. longer weanin these patients nee a study on weaning patients in inten- sive care units (icus) has compared those who underwent prolonged weaning off mechanical ventila- tion (mv) with patients classified as undergoing ‘simple’ or ‘difficult’ weaning. dr xiu-ming xi from the department of critical care medicine, fuxing hospital, capital medical university, beijing, lead researcher of the team in china, explained that the findings indi- cate that patients who experience prolonged weaning should receive closer attention. clinicians treating such patients should, he suggested, place greater emphasis on actively controlling the diseases initiated by mv, to improve cardiopulmonary function and nerve and mental state, and begin functional rehabilitation exer- cises as early as possible to reduce the mechanical ventilation time. ‘in addition,’ he said, ‘tracheos- tomy should be considered earlier for patients who suffered from pro- longed weaning because tracheosto- my improved patients’ comfort and communication, reduced sedative use, and may have contributed to earlier weaning.’ prolonged weaning occurs in patients who fail at least three weaning attempts or require seven days of weaning after the first spontaneous breathing trial (sbt) and those falling into this area were at greater risk of dying. researchers found that patients in the prolonged weaning group had a longer mv duration, with 18% of patients in the prolonged wean- ing group needing prolonged mv. in addition, incidences of re-intu- bation, ventilator-related pneumo- nia, and mortality were significantly increased. the study also showed that the patients with a low glasgow coma scale score – a neurological scale giving a reliable and objective way research: patients who experienced ‘prolonged’ weaning from mechanical ventilation show significantly higher mortality rates, mark nicholls reports onboard are four physiotherapists, a radiologist, an anaesthetist and an orthopaedic specialist
4 european hospital vol 25 issue 4/16 laboratory & pathology with 800 professional par- ticipants and 400 industry part- ners, the german congress of laboratory medicine (dklm) (mannheim. 28-30 september) is the largest in-vitro diagnostics professional event in german- speaking countries. for the second time since 2014, the event is jointly organised with the umbrella association for german medical technologists and analysts (dvta). the congress theme ‘labor- medizin verbindet’ (lab medi- cine connects) reflects the fact that laboratory medicine is an interdisciplinary subject like no other and connects those who are involved in medicine across disciplines. it works almost imperceptibly in the background, hardly noticed by patients. european hospital spoke with this year’s congress president, professor berend isermann, from university hospital magdeburg, about the key topics at the congress and challenges the discipline faces. during our talk, professor isermann outlined key topics chosen for the 13th dklm. ‘in addition to inter- disciplinary poct management the scientific presentations will focus on new inflammation mechanisms our knowledge of causes and mecha- nisms of current and future diseases is on ice – not the perpetual ice of the polar caps but artificial ice. it is stored in biobanks at -80 to -160 °c. one of europe’s leading biobanks is the interdisciplinary bank of biomaterials and data würzburg (ibdw), germany. since 2013, bioma- terials culled at würzburg university hospital are stored centrally for research purposes in a state-of-the- art facility. any discipline can make use of the quality-assured bank content. ibdw is one of the first biobanks to implement the concept of ‘broad consent’ and to almost fully automate its processes. availability of biomaterials will allow research on issues and diseases that are not even known today. broad consent since 2010, the german federal ministry of education and research (bmbf) has supported the estab- lishment of centralised structures at five selected german locations to systematically collect liquid and solid human biomaterials. the university hospitals in aachen, kiel, heidelberg, berlin und würzburg were the first to implement cen- tralised biobanks and the umbrel- la organisation ‘german biobank nodes’, founded in late 2013, will continue to develop the concept. the purpose of a biobank is stor- age of patient tissue, blood and dna samples donated for research. prior to participating in a study, a patient signs a detailed consent form describing the research and the future use of the donated samples. ‘this broad consent is unique,’ says professor r jahns md, cardiologist and director of the interdisciplinary bank of biomaterials. ‘drawing on our experience, a working group of the german ethics commission drafted a text template for non-spec- ified storage and use of donor mate- rial for medical research purposes, since we don’t know today what research might be necessary 20 years down the road. the consent survives the death of the donor.’ ethically and legally this is a balancing act that requires numer- ous accompanying measures. for example, the donor can withdraw consent at any time, research results must be presented to the donor and the public in a transparent and comprehensible way and, prior to the release of material that is not tied to a specific purpose, an ethics committee must approve the research project for which the mate- rial was requested. automation makes repro- ducibility a further unique feature of the würzburg biobank is the high degree of automation. it facilitates quality assurance and makes processes and results reproducible and compa- rable across locations. the oecd standard that defines handling of human biomaterials requires end- to-end documentation of the sample path, from sample taking to storage. ‘we document each and every step with a timestamp,’ jahns explains. ‘on average we have ten to twelve timestamps per sample – completely automated. we are pioneering this process in germany.’ the lack of reproducibility of research results prompted the federal ministry to intensify funding of centralised biobanks. healthcare facilities have long been collecting blood and tissue samples in refriger- ators. any graduate student can take a frozen sample, thaw it, remove whatever he or she needs and refreeze it. in a modern biobank, a blood sample is separated into smaller 300 ml units prior to stor- age. these subsamples are usually sufficient to perform a triple assay that conforms to academic stand- ards. ‘such a smaller sample will usually allow serial triplets. thus one blood sample will generate 10 subsamples. when a researcher requests a sample, only one sub- sample will be removed, the others remain at -80°c. it is a basic princi- ple of a biobank to turn one large sample into several smaller ones.’ keen protection currently, close to 200,000 liquid samples and 3,500 tissue samples are stored in würzburg, allowing 1.2 million aliquots and 16,000 tis- sue sub-samples. each sample tube is identified by an engraved unique barcode. 96 tubes fit on a rack, which is scanned prior to storage. the data are transmitted to the lab information system, which records the location of each tube. every piece of information is dou- ble-coded which means only the system itself knows where a certain sample is. ‘we can request a sample by entering a code. a virtual server and a double firewall make unau- thorised access from outside pretty much impossible. the biobank is close to 100 percent safe.’ biomarkers and molecular signature and biomarkers, the improvement of basic care by means of inno- vative diagnostic technologies, the diagnostic challenge posed by meta- bolic pandemics, new diagnostic approaches of cellular reprogram- ming, and liquid profiling,’ he said. ‘participants, however, will not only learn about the most recent research findings, they will also be offered numerous professional development and training events in the form of workshops and seminars.’ liquid biopsy or liquid profiling: will pathologists invade lab turf? ‘indeed, liquid biopsy and liquid profiling are different terms for the same procedure, which origi- nates in oncology. cell-free dna or rna, meaning cell-free nucleic acid, in blood allows the evaluation of tumour development. tumour growth and tumour decrease can be shown quantitatively and new muta- tions can be detected. ‘laboratory medicine can use this procedure to detect many more changes, mostly epigenetic ones, such as damages to the beta cells at the onset of type 1 diabetes, or cell failure with type 2 diabetes. the potential is much wider and not at all limited to oncology. this is why we clearly prefer the term “liquid profiling”. the term “liquid biopsy” misleadingly suggests that the tech- nique is similar to tissue biopsy and thus an element of pathology. what it really is, is liquid profiling – a procedure lab medicine has known and been doing for decades with the only difference being the fact that before we used blood proteins to establish a profile of a disease or a tumour. cell-free nucleic acid is just another parameter. ‘we are convinced that surveil- lance analysis is our job. there is a long-standing division of labour, which makes sense. this does not cut into the tasks of pathologists, quite the contrary: the two will complement each other very well. histology will always be the first step: evaluating the lesion in situ and establishing the grade. this cannot be done using cell-free rna/ dna – it will remain the patholo- gist’s domain. ‘furthermore, the search for muta- tions in tissue will continue to be necessary as they are important tumour markers. however, gener- ally speaking, a technology such as molecular diagnostic testing ought not be limited to a single group. we are not doing that and we expect others not to do that either.’ poct developments ‘point-of-care testing is becoming ever smaller and more compact. the current trend is called microfluidics, which means less volume and fewer reagents are required bedside to achieve accurate results. however, it is important to carefully evalu- ate where poct is necessary, as it is still an expensive procedure and less reliable than lab procedures in terms of specificity and sensitivity. obviously, there are situations and locations where poct is indi- cated, be that emergency medicine or a remote doctor’s office in the countryside. for the industry, poct is a major growth segment. in view of these considerations, we expect poct to be a controversial issue at the congress.’ assuring poct quality ‘no doubt, poct is real technologi- cal progress and will become better and better. at the same time, correct pre-analytics has to be guaranteed – which is problematic because basically everybody works with the devices. moreover, the quality of the results may well turn out to be a problem, since the people using the devices are not necessarily those who maintain them and ensure compliance with the law. ‘another issue is data manage- ment. it does not suffice to print the findings in a report and file it in the patient record. the data and results must be entered in the information system. at my institution, university hospital magdeburg, we have a poct system and a working group that takes care of all issues and aspects involved in this technology. to support e-health, data that were generated at any location have to be input in the information system to make them available for everyone who needs them. ‘in my opinion it’s clearly the task of the labs to ensure quality along the entire chain from pre-analytics through analytics down to post-ana- lytics. in healthcare we have long been pioneers in terms of quality assurance und quality management – and we want to keep it that way.’ lab medicine challenges and major future changes ‘that’s a very complex question. one of our main concerns is – as in many other disciplines – to attract talent. we started a number of initiatives to promote junior professionals from graduate level programs to funding a chair. we offer train-the-trainer courses and established a junior academy together with the german research foundation. we put a lot of effort in these programmes and they do bear fruit: we could gener- ate interest and the programmes are well accepted. ‘going forward rather than simply generating data, we have to focus on analysing and managing complex data sets to be able to cull more relevant information from these data. systems diagnostics is a major change on the horizon and it’s an issue in our junior academy. there will be more bio-informaticians in the labs – a development we wel- come because the natural scientists in our discipline have always been very innovative.’ temperatures rise over labour division, cost increases and higher appreciation german biobank develops standards for european research association conflict at the 13th dklm frozen samples are scientists’ gold with a medical degree from the university of würzburg, professor roland jahns became a cea fellow in sophia antipolis (france) and dfg fellow at the institute of pharmacology and toxicology in würzburg. he specialised in cardiology in 2002 and received the gobio award of the german federal ministry of education and research (bmbf) in 2006. in that year he also became chair of the working group at rudolf virchow centre for experimental biomedicine. he became a professor in 2008 and, since 2011, has been in charge of implementing the university hospital würzburg central biobank, becoming its director in 2013.
www.kugel-medical.de c o lo r u p yo u r l a b equipment for histo-pathology labs visit us in cologne hall 11.3 · booth no. 52 azg_km_european-hospital_103x133.indd 1 29.07.16 12:49 6 european hospital vol 25 issue 4/16 laboratory & pathology professor peter guggenbichler is only too aware of infection prevention and control issues in hospitals. prior to his retirement in 2013, from the children’s hospital at erlangen university hospital, in germany, he led the infectiology and preventive medicine department, for 25 years. ‘after countless nights on the inten- sive care ward i realised that the staff does not adhere to infection prevention and control guidelines because, realistically, these can- not be adhered to,’ guggenbichler explains. according to the guidelines, nurs- es and doctors are supposed to disinfect their hands between 50 to 80 times during just one shift. after each fifth to sixth application of a disinfection agent they should also wash their hands because oth- erwise the hand disinfection agent merely spreads the dirt. according to the infection specialist this is not achievable: ‘staff would spend more than an hour per shift on hand disinfection, and in case of emer- gencies there is no time for this, anyway. this prompted me to think about alternatives and to precisely analyse the workflows in the hospi- tal and on the intensive care ward.’ every year around 5% of in- patients in europe develop hospi- tal acquired infections (hais). of the 1.75 million patients affected, at least 10%, i.e. around 175,000 people, do not survive this (source: www.escmid 2015). the risk of nosocomial infections is there- fore higher than the risk of being involved in a road traffic accident. the staff’s hands are contami- nated but so are hospital surfaces, and pathogens and multi-resistant organisms are transmitted with every touch. be it hospital fur- niture, touchpads, control knobs, cables, floors, computer keyboards or telephone receivers – as soon as something is touched it is no longer germ free, even if previously disin- fected. surfaces that can kill patho- gens would therefore be ideal – and this is exactly what guggenbichler has worked on for years, initially with antibiotics and disinfection agents and, since the 1990s, also silver. ‘in 1999 we developed an out- standing silver technology, which is still effective for external ventricle drainages for intracranial pressure, and is therefore still successful on the market. however, the most silver technologies do not work for the impregnation of surfaces because the pathogen-killing silver ions are used up after 3-5 weeks. as with disinfection agents and antibiotics, silver ions are incorporated into the metabolism of microorganisms, so they must be dissolved out of a hydrophilic surface and are then lost. this means that a number of silver technologies on sale is basi- cally ineffective, and this is not being questioned enough.’ guggenbichler and his team have now developed a technology which, with the help of various transition metal acids (mostly zinc molybdate in situ, i.e. the polymer itself), can generate h30o+ ions, reactive oxy- gen species and photocatalytic activ- ity from tiny amounts of water, and this has a strong antibacterial effect detected very early in blood – via a liquid biopsy – which can act as biomarker. ‘biomarkers are also interesting for cardiologists. we take different samples over time from a patient with poor cardiac pump function and compare them looking for biomarkers that tell us how the heart will recover after a myocardial infarction. ‘the interesting point is that we collect prospectively but do the research retrospectively and still obtain valid results. thus the sam- ples are the scientists’ gold,’ jahns explains. going forward, the number of biobanks to be funded in the context of the german biobank alliance will be doubled. the aim is for germany to improve inte- gration on the european level in the biobanking and biomolecular resources research infrastructure (bbmri) to be able to contribute significantly to research on rare and widespread diseases such as diabe- tes, hypertension or cancer. on the surface. ‘the basic assump- tion about the effective mode of action is that hydrating oxonium ions (h3o+)(oh2)n (n=1.3) in con- tact with micro-organisms initially remove the hydration water and finally also the remaining water molecule. the now naked protons can attack the cell walls of bacteria in an unspecific way by perma- nently denaturising their protein shells and fimbriae. additionally, the protons can block the effect of essential enzyme systems inside the cell. the entire process is known as proteolysis (coagulation necrosis),’ the scientist explains. the result is a slightly acidic surface, similar to the acid man- tle of the skin, which, with a ph value of 4.2 – 4.5, quickly kills germs. additionally, there is the positive zeta potential, i.e. a posi- tively charged surface that attracts negatively charged microorganisms, so that overall there is a synergistic effect. zinc molybdate is neither water nor alcohol soluble, so cannot be removed by disinfectants. it is thermally stable and non-toxic. both elements, molybdate and zinc, are essential trace elements in the body, which even if they should become dissolved, remain below the permit- ted threshold level for 24 hours by factor 250. ‘obviously nurses will have to continue washing and disinfecting their hands, but if they forget to do so once in a while the conse- quences will be less dramatic. the new technology is a kind of safety valve: instead of disinfecting hands 60 times a day it can be done every 20-30 minutes instead, because the surfaces will remain self-disinfecting for many years.’ to achieve this, there is no need to refurbish the entire hospital because the zinc molybdate can be applied retro- spectively as a transparent film to telephone receivers, furniture and fittings etc. like any normal lacquer. guggenbichler already discovered this mode of action around ten years ago. but his discoveries really gath- ered pace since his retirement from the hospital and the foundation of the start-up company amistec, and patients will soon benefit from this. paints and lacquers for large med- ical devices are now ready for use. however, the possibilities go way beyond this; airline seats, car air conditioning systems, shower trays and even underwater power cables will soon be self-disinfecting. we can only hope that hospitals will not miss the boat. with the rapid increase of multi-resistant patho- gens and talk of the post-antibiotic era, there is an urgent need for action in the prevention of infection. details: http://www.krankenhaushygiene. de/informationen/hygiene-tipp/ hygienetipp2015/557 surfaces impregnated with zinc molybdate self-disinfect for years the sustainable pathogen killer josef-peter guggenbichler studied medicine at the university of innsbruck and qualified as a paediatrician at the mayo clinic, rochester, minnesota, usa. after his return to austria he became a professor at the university of innsbruck (1980-’90) and then he worked as an extraordinary professor at the department for infectiology and preventative medicine at the children’s hospital, university hospital erlangen, germany (1990- 2009). guggenbichler holds more than 30 patents for the antimicrobial impregnation of surfaces and is cofounder and managing director of the start-up company amistec (www.amistec.at) founded in 2011. figure 1: results of effectiveness testing of staphylococcus aureus (sa), escherichia coli (ec) and pseudomonas aeruginosa on hospital furniture with different additives and concentrations. the method used in the study was droplet application: application of 108 cfu/ml in 100 µl. 238: zinc molybdate one percent, 239: molybdenum trioxide one percent, 240: zinc molybdate 0.5 %, 241: molybdenum trioxide 0.5 %. all micro- organisms were destroyed within three hours. figure 2: results of effectiveness testing of lacquer sample with zinc molybdate 0.25 % using different technologies (ma13 – ma 15), contact plate method. application of 107 cfu/ml in 10 µl. determination of bioburden with rodac plates after 0, 3, 6, 9 hours. all microorganisms were destroyed within three hours. continued from page 5 frozen samples are scientist’ gold the robotic cryostore at ibdw (holding 600,000 biosamples) azg_km_european-hospital_103x133.indd 129.07.1612:49
r o m e • i ta ly 2 7 a u g - 3 1 a u g 2 0 1 6 n e w s a n d t e c h n o l o g y u p d a t e s f o r c a r d i a c c a r e cardiology 2016 www.healthcare-in-europe.com www.healthcare-in-europe.com research by a team at john hopkins university (jhu) in baltimore, usa highlights the patients who are most likely to face lethal arrhythmias. when patients suffer arrhythmia, cardiologists often respond by fit- ting a small defibrillator implant to sense the onset of arrhythmia and jolt the heart back to a nor- mal rhythm. however, the ques- tion remains over how they decide which patients need the implant and the invasive surgery needed to fit it. aiming to address this, a team from the department of biomedical engineering and institute for computational medicine at jhu has developed a non-invasive 3-d virtu- al heart assessment tool to help doc- tors determine which patients face the highest risk of a life-threatening arrhythmia and would benefit most from a defibrillator implant. early evidence suggests the new digital approach yielded more accu- rate predictions than the current blood pumping measurement used by most physicians. ‘our virtual heart test significant- ly outperformed several existing clinical metrics in predicting future arrhythmic events,’ professor natalia trayanova, the university’s inaugu- ral murray b. sachs professor of biomedical engineering, said. ‘this non-invasive and personalised virtu- al heart-risk assessment could help prevent sudden cardiac deaths and allow patients who are not at risk to avoid unnecessary defibrillator implantations.’ a pioneer in developing personal- ised imaging-based computer mod- els of the heart, she has worked on the project with cardiologist katherine c wu, associate profes- sor in the johns hopkins school of medicine, whose research has focused on mr resonance imaging approaches to improving cardiovas- cular risk prediction. for the study, trayanova’s team formed its predictions by using the distinctive magnetic resonance imaging (mri) records of patients who had survived a heart attack but were left with damaged cardiac tissue that predisposes the heart to deadly arrhythmias. the study involved data from 41 patients who had survived a heart attack and had an ejection fraction – a measure of how much blood is being pumped out of the heart – of less than thirty- five percent. patients in this range are usu- ally recommended implantable defi- brillators, however, with the jhu team concerned about this measur- ing score system, they invented an alternative to these scores by using pre-implant mri scans of the recipi- ents’ hearts to build patient-specific digital replicas of the organs. using computer-modelling tech- niques developed in trayanova’s lab, the geometrical replica of each patient’s heart was brought to life by incorporating representations of the electrical processes in the cardiac cells and the communication among cells. in some cases, the virtual heart developed an arrhythmia, and in others it did not. the new non-invasive way to gauge the risk of sudden cardiac death due to arrhythmia has been named the varp (virtual-heart arrhythmia risk predictor). subsequent tests showed that patients who tested positive for arrhythmia risk by varp were four times more likely to develop arrhythmia than those who tested negative. varp predicted arrhyth- mia occurrence in patients four- to-five times better than the ejec- tion fraction and other, invasive and non-invasive, existing clinical risk predictors. ‘we demonstrated that varp is better than any other arrhythmia prediction method out there,’ trayanova confirmed. ‘by accurately predicting which patients are at risk of sudden cardiac death, the varp approach will provide the doctors with a tool to iden- tify those patients who truly need the costly implantable device, and those for whom the device would not provide any life-saving benefits.’ wu said that the early results indi- cate the more nuanced varp tech- nique could be a useful alternative to the one-size-fits-all ejection frac- tion score. trayanova is hopeful the new risk prediction methodology could also be applied to patients who had prior heart damage, but whose ejection fraction score did not tar- get them for therapy under current clinical recommendations. the next step is to conduct fur- ther tests involving larger groups of heart patients. the virtual-heart arrhythmia risk predictor natalia trayanova phd is the john hopkins university’s inaugural murray b. sachs professor of biomedical engineering in the department of biomedical engineering and institute for computational medicine. she received her doctorate at the bulgarian academy of sciences in sofia (1986) and post-doctoral training in biomedical engineering at duke university. her research focuses on understanding the normal and pathological electrophysiological and electromechanical behaviour of the heart. the virtual heart arrhythmia risk predictor. patient-specific heart models are constructed from clinical imaging data. a virtual-heart model is then used to predict the patient risk of lethal arrhythmias. identifying patients with cardiac injury at risk for lethal arrhythmias using a combination of cardiac imaging and computational simulations. from the patient’s scan (blue), a virtual heart is constructed and the presence of arrhythmia, indicated by the non- uniform electrical activation (red-yellow), is revealed. researchers have developed a personalised 3-d virtual heart that can help predict the risk of sudden cardiac death. mark nicholls reports r o m e • i ta ly 27 a u g - 31 a u g 2016
d7947_esc-365-european-hospital.indd 1 21/07/2016 09:32 cardiology 12 european hospital vol 25 issue 4/16 within the theme ‘prediction and prevention’, the 2016 british cardio- vascular society annual conference held in manchester this june, fea- tured innovative and interactive presentations, sessions, workshops, panel discussions, debate and a fas- cinating scientific programme. the keynote speech, ‘big data: a big deal for cardiology?’ deliv- ered by professor viktor mayer- schoenberger, professor of internet governance and regulation at oxford university’s internet institute, focused on the role of information in a networked economy. the bcs lecture ‘elucidating the genetic basis of coronary artery disease; implications for prediction, prevention and treatment’ was deliv- ered by professor sir nilesh samani, british heart foundation (bhf) chair of cardiology at leicester university, who was knighted in 2015 for his services to medicine and medical research. professor cliff garratt, chair of the programme committee and bcs vice-president (education & research): ‘over the last few years, professor samani’s group has led large-scale studies that have identi- fied multiple genetic loci that affect risk of coronary artery disease. this presentation will present the cur- rent state of the discovery pro- cess, discuss what we have learned and illustrate the clinical translation potential of the findings.’ prediction and prevention in acute coronary syndromes, the title of the bhf bench-to-bedside session - consisting of presentations (basic, translational or clinical) focused on a particular clinical condition – focused on the work of the bhf centre for cardiovascular science at the university of edinburgh. ‘over the last 30 years, this edinburgh unit has led the way in describing new underlying causes of coronary heart disease, improving the identification of those at great- est risk, and ultimately demonstrat- ing several innovative ways to treat coronary heart disease,’ explained professor garratt. the sir thomas lewis lecture saw professor michael ackerman from the mayo clinic focus on prediction and prevention of sudden cardiac death in the young, while clinical anatomist, author and broadcaster professor alice roberts discussed what embryology of the heart and other organs has taught us about our evolutionary origins. in recent years, the bcs confer- ence has gained recognition for offering ‘something completely dif- ferent’ and, following on from the year’s well-received presentation on music and the cardiovascular system, the focus for the popu- lar tuesday afternoon auditorium session was photography and the heart. the conference also provided coverage of all the new develop- ments in cardiology and cardiovas- cular science in training, a dedi- cated imaging track, arrhythmias with sessions on af ablation and on first–line management of cardiac arrhythmias; intervention with ses- sions on acute coronary syndromes, myocardial infarction and percu- taneous management of structural heart disease; heart failure; and adult congenital heart disease. sessions also included clinical science and translational research, basic science and hot topics, the young investigator’s prize, resus- citation, education for revalidation (e4r) and international sessions in association with the european society of cardiology and the american college of cardiology. an area for interactive education included 100+ hot topic sessions, poster sessions, simulator training, and an imaging village with interac- tive, supervised ct, mri, echo and nuclear imaging work-stations. garratt said the conference, again held with the british heart foundation, has attracted progres- sively increasing numbers of del- egates over recent years. ‘there is little doubt that there’s an increasing - rather than decreasing - need for today’s cardiologists to have a broad understanding of all the major subspecialist areas. the british cardiovascular society annual conference is uniquely positioned to facilitate this in one meeting.’ the 2016 british cardiovascular society conference prediction and prevention big data, the genetic basis of coronary artery disease and sudden car- diac death in the young were among key subjects for british cardiolo- gists at their 2016 annual conference, mark nicholls reports remote monitoring through smaller, more effective, insertable cardiac monitors is playing a significant role in delivering care improvements for heart patients. greater sensitivity and versatility of devices, as well as more patient- friendly implantation options, were issues outlined at the cardiostim 2016 ehra europace world con- gress on cardiac electrophysiology, held in nice, france. the ‘improving patient outcomes in arrhythmia management’ scien- tific session focused on biotronik home monitoring systems, dur- ing which experts from australia, switzerland and the usa discussed the latest research on how remote monitoring systems and insert- able cardiac monitors (icms) can improve patient outcomes. in highlighting the rising impor- tance of using remote monitoring via icms to enable earlier diagnosis and prevention in patients who have arrhythmias (but are not yet indicated for a pacemaker or icd), the senior cardiologists also outlined how home monitoring is reducing mortality, hospitalisation and health- care costs. during the congress, berlin-based cardio and endovascular medical technology specialist biotronik also unveiled findings of the first-in- human trials of its new biomonitor 2 icm device to delegates with experts. covering 30 patients, this pilot study revealed high r-wave amplitudes and a 93.8 percent suc- cess rate for daily home monitoring transmissions from a device that can be inserted in as little as two minutes. ‘for icms to have a significant impact on early arrhythmia diagno- sis, reliable detection including sens- ing, data quality and transmission is critical,’ lead investigator dr sze- yuan ooi, from sydney, explained. ‘this study shows promising results for biomonitor 2 in all of these fields. the high transmission suc- cess rate is key because we need robust, high-integrity data for our patients to derive the maximum benefit.’ biomonitor 2 has an extended sensing vector with the combination of the rigid (55mm long) and flex- ible (33mm) part allowing adjust- ment to the shape of the body. sensitive to changes in heart rhythm with the automated detec- tion of atrial fibrillation, bradycar- dia, sudden rate drop or high ven- tricular rate, this device can make up to six ecg transmissions a day. ooi described the biomonitor 2 as a ‘big step forward’ in terms of technology, design and implantation technique, compared to the first generation biotronik biomonitor device. ‘the pilot study showed that the r-wave amplitude is greater than the original biomonitor device, the implantation pro- cess was easy, straightforward and quick and the other impor- tant finding out of all this was the device sensitivity and versatility increase smaller and more effective insertable cardiac monitors cliff garratt is professor of cardiology at the institute of cardiovascular sciences, professor of cardiology at manchester university and hon. consultant cardiologist at central manchester university foundation trust. a clinical academic with an interest in arrhythmias and clinical cardiac electrophysiology, his research and clinical interests focus on the mechanisms and management of atrial fibrillation and familial sudden cardiac death syndromes. d7947_esc-365-european-hospital.indd 121/07/201609:32
headquarters: schiller ag, altgasse 68, ch-6341 baar phone +41 41 766 42 42, fax +41 41 761 08 80 email@example.com, www.schiller.ch designed for users who value state-of-the-art technology, schiller’s cardiovit ft-1 offers: easy 1-2-3 steps outstanding signal quality for adult and paediatric ecg bidirectional wi-fi communication improved interpretation algorithm with etm sport for athletes maximum performance in a compact electrocardiograph explore the new ecg world: schiller’s cardiovit ft-1 visit us at the esc in rome 27.8.-31.8.2016 e4-0200 eh_2016-08_ft-1_210x297_en.indd 1 11.08.2016 10:41:59 cardiology 15 www.healthcare-in-europe.com rom page 12 d versatility increase hospital zurich, who discussed how earlier management of atrial and ventricular arrhythmias is enabled by detection with icms, and dr niraj varma, from the cleveland clinic, who spoke about improving out- come of icd and crt-d patients by continuous remote monitoring. ‘efficient workflow and robust transmissions are critical to leverag- ing the benefits of remote monitor- ing,’ varma said. biotronik home monitoring facilitates this with daily automatic transmissions that pre- serve the highest order of data integrity, and are yet easy to handle. ‘this is a key reason why this system has been associated with improved clinical outcomes in sev- eral trials and why the current remote monitoring guidelines are based largely on home monitoring data,’ varma explained.’ professor josep brugada is medical director of the cardiovascular institute, at hospital clínic, university of barcelona, spain, and a past president of the european heart rhythm society. with his brothers, pedro and ramon, he identified brugada syndrome, a genetic disease characterised by abnormal electrocardiogram (ecg) findings and an increased risk of sudden cardiac death. the group of patients treated with sonr was 75%, compared to 70.4% in the echo group. it also emerged that optimisation with sonr resulted in a significant improvement in clini- cal response for patients with atrial fibrillation and renal dysfunction. professor brugada from the cardiovascular institute, hospital clinic, university of barcelona, said: ‘in order to deliver the very best crt treatment to our heart failure patients, there has been a real need for an optimisation solution that is both automatic and efficient. ‘the results of the respond-crt trial have shown that sonr perfectly meets this need. the high rates of responders together with the ben- eficial improvements in clinical out- comes indicate a significant advance- ment in crt therapy, one that will allow us to better treat a larger num- ber of heart failure patients. ‘automatic optimisation with sonr was as effective as echo-guided opti- misation - 75% v 70.4% – so the primary efficacy end point was met, that a clinical response was in favour of sonr but especially patients with history of af and renal dysfunction, and optimisation, using the sonr contractility sensor, showed signifi- cant reduction of 35% in rates of heart failure hospitalisation during long-term follow up.’ implanted cardiac resynchronisa- tion devices resynchronise the con- tractions of the ventricles of the heart by sending tiny electrical impulses to the heart muscle, helping the heart to pump blood more efficient- ly throughout the body. the sonr sensor uses measurements of car- diac contractility to optimise cardiac resynchronisation therapy. singh, from massachusetts general hospital, boston, explained that although echo-guided optimisation was considered the gold standard in terms of reducing the number of non-responders to crt, it was not widely used because of the com- mitment of time and resources it requires, as well as patients needing to attend the clinic. he added that the sonr can optimise av and vv intervals on a daily basis and on weekly basis for both rest as well as for exercise so patient do not have to come into the clinic or have echo guided optimisation. ‘the device using the sensors can automatically optimise the heart, overcoming the inadequacies of existing optimisation strategies and logistical issues with echo-guided optimisation strategies.’ respond-crt was a prospective, multicentre, randomised, double- blind study designed to evaluate the safety and efficacy of the sonr system. 1,039 patients were enrolled at 125 sites in europe, the usa and australia, who were implanted with a crt-d (cardiac resynchronisation therapy and defibrillation) device, which combines the function of an implantable cardiac defibrillator (icd) with cardiac resynchronisation therapy (crt). patients were randomised 2:1 to receive either av or vv optimisation with sonr or echocardiography, with the study meeting all of its primary safety and efficacy end points. continuous cardiac resynchronisation reduces hospitalisation ng af and renal ion care nce of all imaging modalities – including ate prosthetic heart valves in a new series phone +41417664242, fax +41417610880 eh_2016-08_ft-1_210x297_en.indd 111.08.201610:41:59
cardiology 16 european hospital vol 25 issue 4/16 to sharply focus on the specialised requirements in echocardiography, toshiba engineers built from scratch the aplio i900cv with a total rede- sign of hardware and software. the new aplio i-series is a premi- um addition to the award-winning aplio 500 platform, which today is used in more than 31,000 clini- cal settings worldwide. ‘the system works very fast with a reduced requirement for user interaction, which translates into a significant time saving for the echocardiography lab,’ accord- ing to the head of cardiovascular imaging at the hospital clinico san carlos in madrid, spain, professor leopoldo perez d’isla md. the impressive speed of the new architecture and the resulting time savings, ‘means that we are improving the cost-effectiveness of the echo-lab, avoiding patient discomfort caused by unnecessary waiting times and increasing opportunities for patient examinations’. the aplio i-series jumps ahead to a next generation with an archi- tecture that gives it on-board capa- bilities for ultra-fast processing of advance applications, and with a new range of high frequency and ultra-wideband transducers. to maximise the potential of the new architecture, the aplio i-series matrix transduc- ers utilise a new lens material that effectively introduces a new tech- nology. thinner, lighter and with more flexible cables, a wide range of aplio’s i-series transducers fea- ture the intelligent dynamic micro slicing (idms) capability. new with the aplio i900cv is a 3-d transoesophageal echocardi- ography (tee) transducer that ‘is exactly the tool we need,’ according to professor hans-joachim nesser md. the head of the cardiology, angiology, medical intensive care for the 2nd internal department at the elisabethinen hospital in linz, austria, stated, ‘we have long wanted this, and here it is bringing the possibility to view aortic leaflets, or to measure mitral valve para meters where we can not only see the opening, but can even see the stitches where the valve has been repaired.’ yet, thanks to the new ultra wide- band transducers, a tee exam is not always required. nesser found that, with the wider coverage and what he called extremely good penetra- tion up to 28 centimetres, ‘we can evaluate the aortic valve area with a transthoracic approach. we are able to see distinctly four-chamber views, and have found really fantastic reso- lution in subcostal views.’ continuous wave doppler on the i900cv has a quality not seen before that enables a fast, excellent quality of signal definition that allows an easy diagnosis to determine myocar- dial performance. after working with cardiovascular imaging fusion on the i900cv, nesser concluded, ‘this is the future. in one display using a hybrid format we see calcified segments of coro- nary arteries derived from ct along with a quantification of the stenosis thanks to 3-d strain imaging, and at the same time a superimposi- tion to the myocardium derived by ct. using a very nice tool called activation imaging, we can add measurements to determine torsion, an important parameter for a variety of diseases, or see areas where there is delayed contraction. we can see rest and stress, related to a specific coronary artery as a superimposi- tion on a ct image, enabling us to make a decision as to intervention.’ aplio i-series processors are so fast that the system boots up in 15 seconds. aplio i-series platforms are 30% lighter with a panel streamlined by a reduction of 50% for buttons and controls. the panel arm supports a 23-inch high-definition display and is so flexible it can fold flat for easier, more convenient handling. and the aplio i-series platforms come with an optional second console, a detachable wireless tablet that displays real-time images and can control all operations. the aplio i-series rolls out in three versions where the aplio i700 is designed as a multi-service plat- form across diverse medical special- ties, and the aplio i800 responds to the more exacting requirements of radiology and women’s health departments. yet it is the advanced features and functionalities of the aplio i900cv that are specifically designed to target specialised examinations and interventions in cardiology. at the heart of an enhanced image quality that was described as ‘stun- ning’ by clinicians is the ibeam technology. electrical dynamic focus with individual matrix element con- trol and multiplexing with ultra-fast processing narrows and sharpens the signal for real-time 3-d beam forming. the advanced architecture in the aplio i-series takes pioneering toshiba ultrasound functions to a new level. • advanced superb micro- vascular imaging (smi) combined with the new transducers becomes more brilliant with reduced motion artefacts, for never-seen perfusion examination capabilities across all regions of human anatomy. • quad fusion capability creates impactful viewing for interventional procedures or advanced diagnostics, with a simultaneous combination of ct/mri images with real-time ultra- sound and 3-d ultrasound rendering of a live procedure. • super precise 3-d imaging is boosted by aplio i-series ibeam and thin slice acquisition to render near- photo quality images of anatomical structures. professor adrian lim md, from imperial college london said that, beyond the obvious improvements in ergonomics and speed with the aplio i-series platform, for users of previous models of toshiba ultra- sound systems, ‘there is a very famil- iar workflow such that everything becomes intuitive the moment you step to the console.’ ‘this is the future’. medical scientists endorse a new platform toshiba beams in on cardiology ultrasound next-generation aplio i-series premium platform delivers high- frequency probes, advanced applications and ultra-fast processing at a simple touch of a button, aplio demonstrates the mitral valve as seen by the surgeon to facilitate visual assessment of the leaflets for better surgical planning aplio’s advanced wall motion tracking technology provides immediate visual and quantitative access to global and regional myocardial wall motion dynamics in 2-d and 3-d the automated mva tool provides concise anatomic and functional assessment of the mitral valve. the function’s quad display offers a clear overview of different scan planes live 4-d imaging: the new ultra wideband transducers have a wide coverage and an extremely good penetration up to 28 centimetres. an area of just one square centimetre can be seen and clearly defined
cardiology 17 www.healthcare-in-europe.com editor-in-chief: brenda marsh art director: olaf skrober managing editor: sylvia schulz editorial team: sascha keutel, marcel rasch senior writer: john brosky executive director: daniela zimmermann founded by heinz-jürgen witzke correspondents austria: walter depner, michael kraßnitzer, christian pruszinsky. china: nat whitney france: annick chapoy, jane macdougall.germany: anja behringer, annette bus, bettina döbereiner, matthias simon, axel viola, cornelia wels-maug, holger zorn. great britain: brenda marsh, mark nicholls. malta: moira mizzi. poland: pjotr szoblik. russia: olga ostrovskaya, alla astachova. spain: mélisande rouger, eduardo de la sota. switzerland: dr. andré weissen. usa: cynthia e. keen, i.t. communications, nat whitney. subscriptions janka hoppe, european hospital, theodor-althoff-str. 45, 45133 essen, germany subscription rate 6 issues: 42 euro, single copy: 7 euro. send order and cheque to: european hospital subscription 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new siemens equipment 55% of heart recipients now survive for 10 years 3-d transducers prove their mettle in cardiology transplants – a much neglected topic the 3-d tee transducer is fast and offers high volume a small report in the press prompt- ed examination of a much neglected topic. the report read ‘heart centre at university hospital no longer carries out transplants’, and referred to the university hospital frankfurt, one of the 22 heart centres that perform these transplantations. so what happened? only four trans- plants were carried out there between 2010 and 2013, and in 2014 and 2015 only two to three were performed per year. why? the same report also men- tioned that around thirty patients per year wait for donor hearts at this hos- pital. donor hearts continue to be in short supply, and organ donation is the problem. there have bee n no improvements in that situation, not only in frankfurt, or all of germany, but also across europe and globally. the ratio between those who received donor hearts and those waiting for donor hearts is increasingly unfavourable. figures from switzerland show an ‘average’ european example: when 33 people received donor hearts in 2005 not even double that number. i.e. 63, were waiting for donor hearts at the time. ten years later, in 2015, the number of transplants‘only’ increased to 40, whilst the number of patients on the waitlist increased to 134. in germany, says professor f w mohr, president of the german society for thoracic and cardiovascular surgery, more than 1,000 patients are currently one of the first facilities to pur- chase a complete set of the 3-d tee transducer, including the equipment, was the department of cardiology and angiology at university hospital magdeburg, as thomas groscheck, specialist physician for internal medicine at the echocardiography lab explains. since july 2015 he has worked with the new siemens transducer – and is enthusiastic. ‘in our department we treat all types of cardio-vascular disease, from cardiac insufficiency to hyperten- sion, valve repair and aortic valve replacement,’ thomas groscheck explains. ‘we perform all neces- sary studies prior to an intervention and do the follow-up for all car- diac patients, particularly those who underwent valve surgery or received a valve replacement.’ this is where the 3-d tee transducer comes in very handy. ‘what’s so special about this 3-d probe is that it is fast and offers high volume’, the specialist explains. this allows live images with a high frame rate, particularly in 3-d, which is very interesting during valve interventions. ‘i found the hardware and the software in the equipment to be very fast. thus you get high temporal and spatial waiting for donor hearts. however, only 320 hearts were actually transplant- ed. ‘the average patient has very little chance of receiving a donor heart. the organs donated are only allocated to particularly urgent cases,’ mohr explains. at the beginning of the 1990s still more than 420 heart transplants a year were carried out. the allocation of donor hearts in eight european countries (germany, belgium, netherlands, luxembourg, austria, slovenia, hungary and croatia) is coordinated by eurotransplant based in leiden, netherlands. the allocation is based on medical criteria, with no consideration given to national or any other criteria. eurotransplant works with a catchment area of 135 million people across europe. there are simi- lar organisations in scandinavia, cover- ing about 25 million people, or for eastern europe, along with the inter- nationally active society for heart and lung transplantation based in addison (texas, usa). a look at international figures and developments helps to better under- stand the situation. as is known, the first ever heart transplantation was carried out by professor christiaan barnard and a 31-strong team in south africa in 1967. the number of operations increased to 100 transplants (worldwide) in 1980 and to 4003 in 1990, with reported figures of 4203 in 1992, 4364 in 1993, 4429 in 1994 and 4396 in 1995. according resolution with regard to valve visu- alisation in 3-d. this translates into much better quality than our previ- ous transducers delivered.’ length of examination in terms of time spent on exami- nations the new tool also offers benefits. ‘the prep examination for a valve intervention takes ten min- utes on average,’ according to mr groscheck. ‘image acquisition and patient handling pre- and post-exam take about twenty minutes. after to the society for heart and lung transplantation, a total of 80,106 heart transplantations were carried out in 300 officially designated centres between 1967 and 2007. from the mid-1990s the numbers decreased continuously to around 3,000 per year. significantly better and more effective prophylaxis and major advanc- es in treatment, along with the lack of donor organs, are considered the rea- sons for this decline. in january 2016 more than 10,000 patients were waiting for donor hearts across the eight european countries coordinated by eurotransplant. if it had not been for advances in treatment the number of those waiting for donor hearts would be much higher still, say the specialist medical societies. however, documenting advantages and disadvantages with statistics does not do justice to the topic of heart trans- plantations. the history of heart transplants is also one of particular success. as is known, the first person to receive a donor heart, transplanted by prof. christiaan barnard in 1967,‘only’ survived the operation for 18 days. in those days the prospects of a ‘longer’ life after the operation were also generally not particularly rosy. however, over the course of the years and decades not only the surgical pro- cedures and the expertise and routines improved but also the direct care and aftercare for patients. that time all images are available, including the valve models.’ data acquisition is fast and the analysis can be speeded up when all tools for automatic valve assessment are used. the raw data that are gener- ated and which, theoretically, can be read by any machine, are turned into dicom images, which in turn can be viewed with any dicom viewer.’ handling transducer handling has been one of the main problems was, and remains, rejection of the donor organ. not least through the discovery and development of the immune suppres- sor cyclosporine has it been possible to achieve major success in this field. this ring-shaped, small protein which con- sists of 11 amino acids was discovered by the swiss biologist hans peter frey in 1969 and was publicised in the 1970s. it then led to the development of other, very effective drugs. it is assumed that the current, five- year survival rate is around seventy-five percent and the ten-year survival rate is still at around fifty-five percent to conclude, there are three things we can hope for: firstly, that the num- ber of those requiring donor hearts will continue to fall due to improved medical knowledge and prophylaxis, along with healthier lifestyles in large parts of the population. secondly, that the number of organ donors increases rather than decreases, and lastly that the survival rate con- tinues to increase closer towards the 100% mark through more experience, knowledge, routine and capabilities of the surgeons, along with advances in technology and aftercare. improved. with its plastic grip it is lighter than metal models. ‘this makes the transducer easy to handle,’ the physician reports. ‘nevertheless it takes some to get used to the new probe. the head is a bit more angular, not quite as round as we were used to. the loca- tion of the function buttons and the two knobs to control transducer head movement could be improved ergonomically. the control elements are no longer centred, which means the probe has to be held in a certain way in order to use it in an optimum way.’ however, these are the only handling issues thomas groscheck encountered with the new trans- ducers. temperature advantages there is one feature groscheck is particularly enthusiastic about: ‘with this transducer, temperature issues are a thing of the past. finally! although the device does have a cooling mode with reduced trans- mission performance, i have never been compelled to us it. despite the fact that in 3-d mode the trans- ducer heats up to about 40 °c, i always could easily complete longer sequences.’ thus interruptions due to overheating – a common prob- lem in longer examinations with high sound intensity, particularly in 3-d – are no longer required. ‘in 3-d mode, the 3-d tee transducer works for minutes without any tem- perature problems. that makes life much easier for patient and physi- cian alike. obviously, patient safety has been considerably improved with this device,’ groscheck points out. hand in glove the overall interaction of all ele- ments and components of the new transducer convinced the expert. ‘with a bit of training using the transducer is no problem. transducer, software, and process- ing programmes for the valve mod- els – they are all well aligned and integrate easily in any daily work- flows. even though the device with all its functions and settings might seem a bit technologically intimi- dating at first, actually using it is a real pleasure particularly because it works without a hitch and the individual components work hand in glove,’ groscheck sums up. thomas groscheck is an internal medicine specialist in the echo cardiography lab in the cardiology and angiology department, university hospital magdeburg. following his initial training as a nurse he attended medical school at charité – university hospital berlin. he is currently completing his doctorate. walter depner, writer and consultant specialising in the laboratory field phone: +86-0755-81324036 phone: +496735912993, e-mail: email@example.com phone: +33493587743, e-mail: firstname.lastname@example.org phone/fax: 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cardiology 18 european hospital vol 25 issue 4/16 two new techniques have emerged for cardiovascular diagnostics that are enabling software to help sur- geons and cardiologists measure, and thereby better manage car- diac disease. both rely on powerful computer processing to expose the secrets of the heart. bon-kwon koo md, from the seoul national university hospital in south korea, has successfully shown how building on technique recommended in cardiology guide- lines, called fractional flow reserve (ffr), a retrospective computational analysis of ct exams can pinpoint the plaque rupture that, up to two years later, would cause a confirmed medical emergency for a patient. the creator of the frr tech- nique, nico pijls md, from the catharina hospital in eindhoven, the netherlands, has since devel- oped a technique for the quantita- tive assessment of microcirculatory blood flow and resistance, the vital irrigation of heart muscle. without ffr, a cardiologist has to subjectively interpret fuzzy angio- graphic images to decide if the blockage is so severe it needs a stent the medtronic corevalve evolut r system received its ce mark of approval this august to treat aortic stenosis in patients with an interme- diate risk for undergoing convention- al surgery for a valve replacement. this is a controversial indication for transcatheter aortic valve implanta- tions (tavi) – one that has been eagerly sought by some clinicians but resisted by others. to re-open the vessel. introduced by pijls 20 years ago, ffr is an inva- sive technique in which a catheter is pulled across a suspected coro- nary lesion to objectively measure differences in blood pressure on either side of a blockage and gives the cardiologist evidence to decide whether to place a stent or not. koo builds upon this critical measurement, but uses a non-inva- sive technique. instead of pushing a catheter into the patient, a super- computer analysis of the patient’s ct angiography exam can deter- mine blood pressure measures on either side of suspected lesions. this technique has been validated in studies sponsored by heartflow, based in redwood city, california, and the company now offers this service to cardiologists. going one step further, physi- cians at 11 heart centres in europe and asia initiated a study, led by koo, to test a hypothesis that going backwards, they could look at cta exams and identify not only which patients were at risk for a plaque rupture, but specifically identify the plaque that was going to rupture. director of the structural heart pro- gramme at the university hospital in bonn, germany, stated: ‘the highly- anticipated intermediate risk indica- tion marks an important milestone for the industry as we look to safely expand tavi access to younger and less sick patient populations.’ a medtronic spokesperson told european hospital that ‘a majority of the patients treated with tavi in for the emerald study, spon- sored by heartflow, koo added computational fluids dynamics and fluid-structural interaction simula- tion to the ffr-ct calculations for 226 coronary plaques among the 71 patients enrolled. emerald investigators first identi- fied patient cases where the culprit plaque rupture had been document- ed using angiography, or intravas- cular imaging such as oct or ivus. then the investigators searched the patient file to find a ct exam that had been performed ahead of the medical emergency. the average among enrolled patients was an exam performed one year earlier. these ct images were then run through the emerald algorithms to assess plaque composition, lesion geometry and the haemodynamic forces. results from the retrospec- tive emerald study were presented in may this year in paris, at the interventional cardiology confer- ence, europcr. ‘non-invasive haemodynamic data from ct was a better discrimina- tor of lesions causal of acs than stenosis severity or adverse plaque characteristics,’ koo concluded. moving to a prognostic potential, koo suggested the combination of all plaque characteristics might fur- etration with the indication for a vastly larger population of patients at intermediate risk for savr is not known, though widely expected to be significant. evidence from head-to-head clini- cal trials has indicated that savr and tavi are fairly evenly matched for efficacy, though with dif- ferent complication pro- files. traditional surgery poses a greater risk for ther improve the pre- diction of plaque-related clinical events to optimise treatment strategies for high- risk patients. emerald is an exploratory study, said heartflow ceo john stevens, ‘and it shows we are very good at i d e n t i f y i n g the plaque at high risk for rupture eight times in 10, which is not just good but extraordinary. for the moment we still have several hundred more patients cases for validation’. dr pijls also presented his novel approach for measuring microcir- culatory in myocardial irrigation at europcr 2016, and when he had finished the panellists applauded in admiration and one of the audi- ence step forward to say: ‘it blows my mind.’ the calculations for this novel car- diac quantification are so complex it took the software engineering of st. jude medical to capture them. the procedure, which required a con- trolled injection of saline solution yet little is known about the dura- bility of tavi valves that were first introduced in 2002 and did not reach a significant patient population until 2007. unlike surgical valves, the delicate valve leaflets for tavi devices are squeezed, or crimped, to fit into the cath- eter that snakes through the femoral artery. once in place, the valve stent holding the leaflets is expanded. placing a prosthesis that is expected to last eight years in an 80-year old patient at high risk for surgery has been seen as a benefit for extending the patient’s life from an expected one year out to eight years, which is widely accepted as being the expected limit of tavi valve durability. the question of placing the shorter-term tavi device in a 70-year-old patient who could undergo surgery and receive a time-tested savr valve is at the heart of the current controversy. the extension of tavi to lower risk patients was the focus for the great debate in may 2016 at europcr, which pitted three leading clinicians on either side of the question. into coronary arter- ies, is so complex that paris-based hexacath stepped in to invent a new catheter so that pijls could realise his experiments. pijls then streamlined the proce- dure to conform to a standard cath lab workflow and removed depend- ence on operator interpretation. as a result, using the hexacath rayflow monorail infusion catheter combined with one of st. jude’s pressure wires for ffr, and then standing back to watch the results on the st. jude monitor, an inter- ventional cardiologist can measure volumetric blood flow directly in selective coronary arteries during cardiac catheterisation and simulta- neously, with the same guide wire, calculate the absolute myocardial blood flow, collateral flow, and myo- cardial resistance. ‘we don’t know yet what it all means, but at least we have a method to measure it,’ nico pijls concluded. the debate at europcr quickly centred on valve durability because earlier the same day, at the same congress, results from the first effort to study valves beyond the three- to five-year follow-up in manufacturers’ studies was released. danny dvir md from st. paul’s hospital in vancouver, canada, effectively punctured the balloon of tavi enthusiasm with a report titled ‘a first look at long- term durability of transcatheter heart valves: assessment of function up to 10 years after implantation’. among the 378 patients enrolled, dvir reported that the median time to degeneration of the implanted valve was five years, and at eight years, some form of valve degenera- tion affected half of all patients with early tavi devices. ‘everyone should know there is the phenomenon of valve degenera- tion, so that when we target younger patients, the lower risk patients who may survive longer, their valve may fail,’ he advised. break-through techniques tap software to reveal disease causes despite unknown valve leaflet durability… exposing the secrets of the heart tavi is approved for lower risk patients coronary interventions often rely more on art than science as the decision to treat a patient tends to be based on what clinicians can see, a subjective interpretation of cardiac imaging. younger patients will receive artificial valves shown to degenerate at five years for half of all patients, john brosky reports medtronic announced its next- generation evolut valve was granted regulatory clearance in europe for cases where a decision to go ahead with the procedure is made by an interdisciplinary heart team. meanwhile edwards lifesciences, the dominant provider of tavi devic- es in europe, reported to investors that it filed for a ce mark to expand into this same indication with its sapien 3 tavi valve in the second quarter of 2016, and that it expects approval in late 2016 or early 2017. in the medtronic announcement professor eberhard grube md, europe will continue to be of the extreme and high-risk patient popu- lations, but expanding the indication for the corevalve evolut r system will help heart teams provide excel- lent clinical outcomes for broader indicated patient populations.’ tavi procedures currently hold a 37% share of the market in europe, against traditional surgical aortic valve repair (savr) according to esti- mates from wells fargo securities. medtronic devices are used in 31% of those procedures against a 52% share for edwards lifesciences. the opportunity to expand tavi pen- bleeding, kidney dam- age and the onset of atrial fibrillation requiring a pacemaker implantation. tavi has strug- gled against persistent paravalvu- lar aortic regurgitation and a high pacemaker implantation rate. yet, for patients at lower risk for traditional surgery, who tend to be younger, the key concern among cli- nicians is the durability of the valve leaflets on tavi devices. savr valves have a long history regarding dura- bility that stretches to 25 or 30 years.
the rapid evolution of clinical laboratory diagnostics and enabling technologies means that “next generation” devices are coming online every five years instead of every 12-20 years. aacc’s emerging clinical & laboratory diagnostics conference (formerly the oak ridge conference) gives clinical laboratorians and other health professionals a chance to review these advances at the earliest opportunity, while providing bioengineers with an arena to display and discuss their research. scientific sessions > diagnostics and big data: leading the way in precision medicine > the expanding role of companion diagnostics > new possibilities in liquid biopsy: understanding molecular changes in real time > advances in next generation sequencing for clinical diagnostics > poster session – emerging clinical & laboratory diagnostics for more information go to www.aacc.org/emergingdx2016. emerging clinical & laboratory diagnostics in the healthcare ecosystem n o v e m b e r 1 0 - 1 1 , 2 0 1 6 | s a n d i e g o , c a u s a the emerging clinical & laboratory diagnostics conference is the event industry leaders attend to stay informed on today’s hottest topics and future trends. where else can you find tomorrow’s technology today? keynote speaker amy e. herr, phd lester john & lynne dewar lloyd distinguished professor of bioengineering at the university of california, berkeley. keynote presentation the interface of engineering, materials sciences, and biological systems c m y cm my cy cmy k aacc_ad_registration_full-page_a4 .pdf 1 7/26/16 8:54 am 20 european hospital vol 25 issue 4/16 laboratory & pathology achieving a faster workflow a modular approach to urinalysis jane macdougall the reasons why doctors request uri- nary analysis are varied – perhaps to detect a possible or suspected infec- tion, or to screen for kidney diseas- es. in all cases a reliable and rapid result is the major aim. urinary microscopy and culture have been the mainstays of urinary analysis for many, many years both of which require time and specialist handling. when microscopy is performed, in addition to the numbers and types of bacteria present the number of squamous epithelial cells and leu- cocytes also need to be assessed, to serve as indicators of contamination and infection respectively. the fully automated un-series from sysmex offers a modular approach to urinalysis including analysers, digital imaging, samplers and software. now available in europe, these where introduced at jib this week. the different systems all aim to provide quality results for clear diag- nosis while significantly increasing workflow and reducing human error for an overall result of improved clinical laboratory efficiency in the work-up for kidney and urological diseases and urinary tract infections. the detection system is based around fluorescence flow cytometry. the highly sensitive detection level allows the machines to identify, with high precision, different par- ticles within the urine sample. the incorporation of a new blue laser enhances bacterial screening capa- bilities, allowing rapid classification, while a new depolarised side light scatter easily discriminates between red blood cells and crystals. coupling to a fully-automated imaging system enables turnaround times to be significantly reduced. built into the analysis software are smart algorithms and different diag- nostic parameters, enabling casts and epithelial cell differentiation, which will help lead to the efficient and accurate diagnosis of kidney disorders. the new system has expanded on the older series’ original five parameters; red blood cells, white blood cells, bacteria, casts and epi- thelial cells to include nine oth- ers; squamous cells, non-squamous cells, hyaline casts, non-hyaline casts, fungi, spermatozoa, crystals, mucus and white blood cell clumps. this has been made possible due to the inclusion of new reagents to stain nucleic acids and surface membranes; both result in better differentiation of bacteria, fungi, white blood cells, epithelial and other cells. the company claims the enhanced detection system means fewer false positives and negatives and therefore a reduced re-testing rate. ‘in turn, this workflow is opti- mised thanks to dedicated work area management software that helps with smart rules and quality control reagent management.’ the company reports. ‘the easy-to-use system also can be used to analyse other body flu- ids, such as cerebrospinal, pleural, ascitic, joint, etc.. sysmex adds that it hopes, with this completely scalable offering, that the company has tackled one of the key challenges faced by laboratories: balancing diagnostic/ analytical needs with the available hardware and software. further information is available at www. sysmex-europe.com/urinalysis and at the micro-website www.art-of-particles.com n o v e m b e r 10 - 11 , 2016 | s a n d i e g o , c a u s a aacc_ad_registration_full-page_a4 .pdf 17/26/168:54 am
23 www.healthcare-in-europe.com surgery why the scepticism? ‘we are caught between the tech- nological viability of these inno- vations – their use and potential benefits – and their economic via- bility,’ explains surgeon andreas kirschniak, at tübingen university hospital. ‘in countries with case- based reimbursement schemes, par- ticularly in germany, the fact that using these systems frequently does not make economic sense is the major obstacle,’ he points out. if the use of a robot-assisted surgery system costs more than the insur- ers will reimburse, hospitals quickly question the legitimacy of such technologies. the current robotic versus laparoscopic resection for rectal cancer (rolarr) study (https:// c l i n i c a l t r i a l s . g ov / c t 2 / s h ow / nct01736072study) was expected to offer renewed hope that the robotic industry can deliver systems which indeed will improve onco- logical outcomes. ‘unfortunately the study did not yield the expected results. there are indications of a trend towards improved outcomes, but statistical significance could not be reported,’ kirschniak says. the bottom line for physicians is sim- ple: does it makes sense to acquire such expensive equipment – with the total cost of ownership going beyond the acquisition price and including substantial amounts for training and operating costs. ‘we are smack in this tension between economics and viable healthcare innovation,’ he regrets, although still convinced that robot-assisted surgery will prevail: ‘particularly with interventions that require closures in minute spac- es through minute accesses, such as d’hoore rectopexy, a robot is unbeatable.’ enter haptic feedback ‘when your fingers touch the tissue you feel how strong it is, you feel its elasticity, the pressure you are exert- ing,’ kirschniak explains, ‘and, even with forceps and a needle holder, you do get haptic feedback to a cer- tain degree.’ but on the next level, in laparoscopic interventions when long instruments are used, haptic feedback is close to non-existent. ‘this is where the robot enters the stage. it can exert far more force than a human surgeon. when the surgeon at a workstation asks the robot to pull the tissue, it executes the command, no matter what,’ says kirschniak. today, robotic systems do not provide feedback on the force they apply in vivo. ‘but, two systems are scheduled for launch in the course of the next two years that offer precisely this type of haptic feedback.’ for kirschniak this is a major benefit since any intervention, be it with or without robotic assistance, has to be as gentle as possible on the patient. ‘in a joint project with darmstadt technical university (financed by the german research fund), we developed such a robot. and it works very well,’ kirschniak is pleased to report. the force applied in the new robot is not measured at the tip of the instrument in the sterile area but in the adjacent non- sterile area and the values are fed back to the surgeon. we will see… ‘imagine your tests have shown precisely how much force you can apply on a certain tissue with- out causing micro-trauma!’ that, kirschniak believes, would be major progress because, in almost all sur- gical interventions, tiny and often invisible ruptures occur, mostly because every patient is d i f f e r e n t , every tissue is different. ‘i’m truly convinced that this new technology will be used in numer- ous indications particularly due to the robot’s ability to move ‘around the corner’ and in minute spaces,’ kirschniak emphasises. ‘true, robot- ic surgery still has to prove its met- tle, but once the first robots with haptic feedback are commercially available i am sure the market will react and new applications will be developed.’ robotic surgery still has to prove its mettle haptic feedback is a possibility robot-assisted surgery still meets with considerable scepticism even though intuitive surgical’s da vinci system has been around for more than a decade. however, few surgeons and researchers are seeking ways to expand the surgical toolbox. not so the members of the working group ‘surgical technology and training’ at the general, visceral and transplantation surgery department, university hospital tübingen: they are particularly interested in haptic feedback for robot-assisted systems. ‘several systems are about to be launched. these are exciting times,’ says andreas kirschniak, head of the tübingen working group and surgeon by training. made in italy, the starled7 nx design is naturally handsome, practi- cal, compatibility with laminar flows and provides excellent light qual- ity. ‘the special optics of its leds generates a shadow-less, clear and homogeneous light assuring visual comfort and best working condi- tions,’ acem spa confirms. the 57 next generation leds are circularly placed and split into seven,’ and, the manufacturer adds, the device gener- ates an ir-free light, excellent colour temperature and a practically endless life cycle at low consumptions. with high illumination level of 160.000 lux, a colour rendering index of 95 and colour temperature of 4.500 °k the exact chromatic scale of human body colours can be achieved, acem points out. ‘the lamp is provided with acris, an innovative system realised by acem that ensures, by the use of a microprocessor, the control of electrical curves typical of leds to remain unaltered over the time but maintaining a long life cycle (about 50.000 hours),’ the firm adds. other assets include light field dimension adjustment through opti- cal-electronic management, i-sense control panel, adaptable and adjust- able illumination levels for different tasks, and more. ‘this light allows visualisation of the operating field as well as the sur- rounding environment clearly and is particularly suitable for minimal invasive surgery and for preparation and treatment during an operation, monitoring of the patient and micro- scope operations,’ acem adds. on demand, the removable and sterilisable central handle can house a video camera to record surgical operations accurately and the video camera can also be placed on a separate arm. details: www.acem.it shadow-less clear homogenous lighting andreas kirschniak md heads the ‘surgical technology and training’ working group at the general, visceral and transplantation surgery department at tübingen university hospital. his clinical focus is colorectal and pelvic floor surgery, robot-assisted surgery and the surgical treatment of chronic inflammatory bowel disease.
24 european hospital vol 25 issue 4/16 events • checking for cleanliness and soundness • care and maintenance • functional testing • labelling • packaging and sterilisation • documented release of medical devices for use/storage there are also spatial and organi- sational aspects to the process, along with the provision of procedural, working and legal instructions. the documentation states: ‘it is assumed that somebody is suitably qualified if these contents were cov- ered in the course of their recog- nised training in a respective medi- cal profession and if this training was successfully completed. if the contents were only partially covered during this training, or were not cov- ered based on the most up-to-date guidelines they will have to be cov- ered or brought up to date through the attendance of suitable, further on-the-job training. without proof of training in a respective medical pro- fession specific training is necessary.’ quality assurance includes water hygiene there is no recognised apprentice- ship/profession in the reprocessing field. one manufacturer therefore offers an academy for training and advanced training in this subject. some manufacturers of flexible endoscopes also carry out hygiene and microbiological examinations as stipulated by the robert-koch- institute and the bfarm during man- ual and automated reprocessing. quality assurance not only includes the inspection of medical devices as to potential contamination but also the hygienic innocuousness of water supplies and water used for rinsing. the reprocessing industry claims the savings potential to be up to fifty percent of the original costs of medi- cal devices. report: brigitte dinkloh a largely aged population is already a reality in some countries, and this will become a worldwide prob- lem by 2047, when the number of the earth’s old people is likely to surpass the number of young people. far-reaching social, health and economic consequences are predictable, not least an increase in neurological diseases such as stroke, dementia and parkinson’s disease. the world federation of neurology (wfn) has dedicated this year’s world brain day, to be held on 22 july, under the heading brain health and the ageing population. ‘politicians and health authorities are concerned about the ageing population and the challenges this presents, but mental health is often still not on national and internation- al health agendas,’ laments professor raad shakir, president of the wfn. currently, 800 million people, or 12% of the world population respec- tively, are over 60 years old. by the 2050 this number is expected to increase to 2 billion people, rep- resenting 21% of the population. whilst the majority (70%) currently live in the highly developed coun- tries, by the middle of the century the predominant number of those aged over 60 (80%) will be found in less developed countries. with an ageing population the proportion of healthcare expenditure they take up –currently around 50% in developed nations, will increase to more than 65% by 2030 and, around 2050, this process will also happen in the less developed countries. with ageing the frequency of stroke, dementia and parkinson’s disease increases. neurological dis- eases already have more of an impact than cardiovascular diseases and cancer. stroke is the most com- mon neurological disease and the number one cause of disabilities. ‘yet, stroke is a treatable and avoid- able disease. with effective interven- tion the outcome for patients can be improved and the severity of the dis- ease lowered. the best precaution against stroke is controlling high blood pressure and to stop smok- ing,’ explains professor mohammad wasay, from karachi, current chair- man of the wfn public awareness committee. he also describes dementia as avoidable and treatable, although genetic predisposition also plays an important part. around every ninth person worldwide currently suffers dementia. it is a challenge for society as a whole, because those affected require increasing amounts of care and care facilities. with around an estimated 818 mil- lion dollars spent on the 46 million people affected worldwide, demen- tia is already the most expensive brain disease. it is predicted that, by 2050, dementia will affect 131 mil- lion people. professor wolfgang grisold, wfn general secretary, is calling for more investments in neurological treat- ments and care. ‘limiting healthcare expenditure is not a suitable option, in view of the increasing number of those affected. society must bear the cost of adequate and humane care of older people and neurolo- gists should be advocates for these patients,’ he believes. extending rehabilitation capaci- ties and capacity for long term care should be among the highest priori- ties of an ageing society. palliative medicine is also likely to play an increasingly important role, because only palliative medicine with a neu- rological orientation will be able to limit the effects of an incurable disease and improve quality of life. ‘although we have already taken some big steps towards diagnosis and treatment of neurological dis- eases, there’s an ongoing disparity regarding access to treatment. this becomes particularly clear with the distribution of hospital beds avail- able in neurology worldwide. in africa there are only 0.3 beds avail- able per 100,000 inhabitants; in southeast asia it is 0.8 beds. the lower the household income of a region the lower the number of hospital beds for neurology, neuro- surgery and paediatric neurology,’ grisold points out. ‘the situation is particularly bad in cambodia, myanmar and parts of africa, which is absolutely unacceptable.’ the declared objective of the world federation is to ensure access to neurological diagnosis and treat- ment for patients worldwide. ‘i hope that world brain day can support us with this objective,’ he adds. * the world federation of neurology (wfn) was founded on 22 july 1957 with the objective of promoting the quality of neurology and brain health worldwide. this ngo is a union of 119 national neurological societies, which cooperates closely with other healthcare organisations, such as the who and the alzheimer’s society. world brain day has been held since 2014 with an annually changing key topic. neurological diseases are often underestimated, underfunded and not diagnosed no health without brain health continued from page 22 staff qualifications are vital