In line with the UAE vision and Dubai Health Strategy 2016-2021 that seeks to make the population of the emirate healthier and happier by providing world-class healthcare services and fostering creativity and innovation, the Dubai Health Authority has established an Innovation Centre to support healthcare innovation. The launch coincides with the on-going UAE Innovation Month initiatives.

The new Innovation Centre is located next to the Rashid Medical Library in DHA. His Excellency Humaid Al Qutami, Director General of the Dubai Health Authority inaugurated the centre. He said, “At the DHA we are keen on harnessing new technologies and fostering innovation not just in the medical field but also across allied services such as healthcare management,  pharmaceuticals and medical devices so that all aspects of the health sector develop and thrive.

“In healthcare, innovation directly leads to better patient outcomes and this is the at the core of our strategy: providing high-quality patient-centric care. Through this centre, we aim to work consistently with the private health sector and universities to ideate and bring to life meaningful innovations in healthcare that will transform the health sector and directly benefit patients.”

Al Qutami highlighted that since DHA began the journey towards implementing new innovative technologies in healthcare, there have been significant achievements in the field of 3D printing. DHA has already conducted several successful surgeries using this technology. Moreover, the DHA dental department has implemented 3D printing in its practice.

Dr. Farida Al Khaja, Head of the Innovation Council at the DHA said, “This centre will be a catalyst and help us support innovation in healthcare, which transcends beyond the DHA and includes the medical community in the UAE and abroad. We are keen to work with stakeholders to develop innovations that will benefit patients and enhance the well-being of our community.”

Mai Al Dossari, Head of the Innovation Centre at DHA said, “The Innovation Centre will ensure round-the-year activation and participation. Harnessing creativity and innovation by generating and transforming ideas into reality to deliver value based and sustainable healthcare services by engaging all partners and stakeholders is our mission.”

She said in line with the DHA innovation strategy 2017-2020, the Authority will enhance the culture of innovation in the DHA, develop innovation management processes and implement innovation across DHA services.

Al Dossari added that the Authority will organise an annual hackathon and invite students to develop innovative ideas in healthcare.

Expanding patient-centric care in all areas of healthcare is not just an empty slogan. It’s a commitment we make as healthcare professionals to better the lives of the people we treat.

Whether patients select a hospital of their choice or are directed to one through their health maintenance organisation (HMO), they rightfully expect “the system” to provide excellent treatment. Patients cannot be expected to distinguish between the services provided by the clinical team and the staff supporting them.

If an error occurs, such as implanting expired stock, it does not matter to the patient whether the responsibility is with the supplier who did not update the stock on time, or the nurse who did not notice this, or the surgeon who did not bother to double check. The hospital, as a whole, is guilty and will be held accountable.

According to an article written by the American Society of Radiologic Technologists: “Most patients judge the quality of their healthcare much like they rate an airplane flight. Criteria for judging an airline are personal and include aspects like comfort, efficient service and on-time schedules. Similarly, patients judge the standard of their healthcare on non-technical aspects. Most are unable to evaluate the level of technical skill or quality of therapy, so the conditions they can assess — patient satisfaction and preserving health over time — become of the utmost importance.”

This article lays out six steps that can immediately be adopted in organisations to create a more patient-centric supply chain.

Step 1: Create full synchronisation between clinical and operational data
Delivery of modern healthcare is set up so that patients “travel” though several separate institutions on their “journey” to wellness. At each step, new files will be opened within a multitude of systems: the patient management system, the clinical data system, the queue management system, ERP systems. In best case scenarios, all these diverse systems will be connected through a common interface. More often, the desired level of interconnectivity is just not there.

Although the operational information surrounding the patient is no less important than the clinical data needed for optimal patient treatment, today in most medical institutions there is little or no correlation between these two data systems – it is impossible to know essential details about devices implanted in a patient by looking in the patient’s medical record.

Take for example hemodynamics monitoring systems, which are very good at data collection and interface effectively with most clinical systems. So why is this not the case on the operational side? Why is there no consolidation of essential data such as serial number, date of expiration and production series? A major road block to full integration of diverse data sources is the current standard of inventory management based on manufacturers’ bar code identification.

Often the medical team finds it difficult to record device details accurately because of outdated manufacturers’ catalogues, multiple methods of cataloguing the same products, and the introduction of unmarked items into the treatment room, which is particularly common during high stress periods. The result is a lack of integrity of the recorded information and a low level of reliability, which according to some reports is below 60 per cent.

A promising solution is to switch from bar code readers to optical character recognition (OCR) technology to capture data from operational inventory. OCR is already widely used in other areas of clinical medicine. For example, a tumour is optically captured (photographed) and the image is processed and analysed for size, shape, location and malignancy. OCR is now beginning to find its way into operational inventory management as well. On-site medical staff photographs the product as it is taken from the shelf. It is automatically input into the system, which recognises the product and assigns the appropriate SKU. No time-consuming data entry, scanning or searching through manufacturers’ catalogues.

Step 2: Instead of putting out fires, prevent them in the first place
Ask any organisational consultant how to streamline your facility and they’ll recommend that you switch from passive/reactive mode to an active/preventive approach. It is much easier to avoid mistakes before they happen than to fix them after the fact. In the healthcare industry mistakes can be a matter of life and death.

Take, for example, intraocular lens implants. In most hospitals, such inventory is managed at the item level, when in fact it should be managed at the next level down, which in this case would be the various sizes for each item. Protocol dictates that a nurse physically verifies that the correct lens size is available before surgery begins. Yet, sometimes patients are already on the operating table when it is discovered that the right size lens is not in stock and needs to be urgently rushed in.

The solution is to adopt a fully automated system that can track each item down to its most unique characteristic — even items that cannot be tagged. Such a system reduces delays, identifies vulnerabilities and resolves them autonomously. In this way, processes within the hospital departments and with third-party suppliers are improved. More importantly, the patient experience is enhanced.

Step 3: Improve connectivity throughout the supply chain
The supply chain includes several links: the clinical team, the logistics department, and third-party distributors/manufacturers. The formula for operational success is healthy communication and respectful cooperation between all stakeholders. Today, suppliers understand that they, too, must bear responsibility towards patients, even if they are not in direct contact with them.

In recent years, many medical institutions have switched to a consignment-based supply system, forcing the relationship between buyer and supplier to take on a new dynamic. Unfortunately, the day-to-day procedures of this newly evolved supply chain are often only partially implemented. On one hand, the hospital no longer manages inventory; this task has shifted to suppliers. On the other hand, it is difficult for third party distributors to successfully manage inventory long distance, without any real ability to monitor the inventory in real time. The result is lack of control and chronic confusion that often creates friction between hospitals and suppliers.

Today all sides understand that they must work together and that it is the hospital’s responsibility to create a common platform that provides full transparency so that suppliers can effectively manage inventory from afar. Any such platform must include intelligent, real-time tracking capabilities so that off-site suppliers can be more proactive at inventory stocking. This in turn, enables them to provide quick, effective responses so that patient care is never compromised due to lack of inventory.

Step 4: Choose the correct technology for the job
Whether using barcodes, RFID or other available technologies, it is crucial to choose a solution that can fully meet the needs of your own medical supply chain for many years to come. We are living in the digital age, the most intelligent period man has known, surrounded by Artificial Intelligence (AI) solutions and other advanced digital systems. Even organisations that do not have the budget to invest in the latest cutting-edge technology can utilise the technologies they do have access to, looking for new ways to integrate them into existing operating rooms and inventory management systems.

Take, for example, the cardiac pacemaker. These implants require periodic attention, such as battery or device replacement. The key here to life saving and cost-effective treatment is automated logistic tracking — the ability to manage the life span of the implants and provide timely response from within an integrated platform that can alert the appropriate people at the proper time and at the correct location. Humans cannot be expected to keep track of all this; it’s just too complicated!

However, the task of identifying supply chain weak points, articulating needs, vetting technologies and choosing the most suitable and comprehensive solutions should not be taken lightly. We are not talking about an off-the-shelf product, but a custom solution for each department and organisation. The main goal is to provide the medical staff with the ability to act quickly and effectively along with peace of mind so that they can focus on their patients.

A successful platform will enable the management team to process data and generate insights that will promote healthy relationships with all hospital partners. When comprehensive supply chain systems are running smoothly, the safety and quality of patient care increases.

Step 5: Let nurses be nurses
Hospital supply chains have become sophisticated networks that manage massive inventories of a wide range of items and products, sourced from suppliers of all sizes and managed by numerous employees. For example, a typical medical institution will purchase from over 22,300 different brands, 14,000 different drugs with about 30,000 staff members interacting with the system in some capacity.

As a result of the organisational changes already mentioned in this article, much of the responsibility for managing inventory has shifted to the nurses on the floor — the same nurses who administer hands-on patient care. On top of these responsibilities nurses now find themselves troubled by inventory levels, expiration dates and endless filling out of order forms. Procurement personnel, who are responsible for the operational aspects of the supply chain, often find themselves running after the medical staff for inventory related updates.

In a patient-centric supply chain the nursing staff is relieved of many of their current inventory duties so that they can once again centre attention on patient care. A top-level, executive decision that provides the tools to return responsibility for operational management to the logistics team and third-party suppliers is needed.

Step 6: Utilise the power of AI
Once a patient-centric supply chain management system has been implemented and optimised there is one more step that can be taken to increase a system’s efficiency. That is to recruit artificial intelligence (AI) for analysis and reporting. After accumulating a reliable body of data, it can be interpreted to derive insights that will enable continued tweaking of the system for even better results. If in the past much of data analysis was overseen by humans (even if computers were crunching the numbers), today AI can do it faster and more effectively.

Marvin Minsky described it as “a way of making a machine behave in ways that would be called intelligent if a human were so behaving.” One of the areas that AI has successfully contributed to is in the sphere of logistics and resource management.

For hospitals to continue to align their patient-centric goals with recent developments in technology and the demand to maximise efficiencies, they will increasingly rely on AI, which is actually the next stage of automation. AI-based tools and insights are already enabling medical and logistic teams to enhance their performance in a way that supports their professional capabilities, rather than replacing them. This trend will surely continue to strengthen in the future.

At the end of the day, both patients and healthcare management executives expect systems that are efficient, effective and emphasise the fact that healthcare is first and foremost about human well-being. Integrating existing technologies and software apps into patient-centric, supply chain platforms can make that happen.

Cancer immunotherapy—an approach that removes the barriers that protect cancer cells from a patient’s immune system—has revolutionised the treatment of many cancer types. About 40 per cent of melanoma patients, for example, respond to immunotherapy, enabling the immune system’s T cells to attack cancer cells and take control of the disease.

In a study published in the February 6, 2019, issue of Nature, a University of Chicago-based team working in collaboration with scientists at Tsinghua University and the Chinese Academy of Sciences, demonstrates, in mice, that they can boost the tumour control rate from around 40 per cent up to nearly 100 per cent by opening up a parallel pathway.

This study relies on manipulating these cells, which are a crucial component of the immune system. The primary function of dendritic cells is to process antigens and present them to T cells. They act as messengers, connecting the innate and the adaptive immune systems.

But a protein known as YTHDF1 influences antigen processing by dendritic cells. This protein was discovered and characterised in 2015 by Chuan He, PhD, the John T. Wilson Distinguished Service Professor in chemistry, biochemistry and molecular biology, and the Institute for Biophysical Dynamics at the University of Chicago. YTHDF1 controls the level of proteases that destroy potential tumour antigens. This limits their presentation to T cells.

These limits were a problem, he said. But when he and his colleagues eliminated YTHDF1, the dendritic cells increased their ability to engulf peptides, degrade them and present them to T cells. This opened up a new and potentially effective approach to treatment of cancer in patients who do not respond well to checkpoint inhibitors.

“Once we combined YTHDF1 knock-out with the checkpoint inhibitor anti PD-L1, we got almost complete tumour control in a mouse model,” he said. Instead of a 40 per cent response, nearly 100 per cent of treated mice with melanoma responded to anti-PD-L1.

The researchers confirmed that dendritic cells from mice that lacked YTHDF1 were more effective at antigen-presentation than dendritic cells from normal, wild-type mice. “Our data show that loss of YTHDF1 in dendritic cells attenuates antigen degradation and leads to improved cross-presentation and better cross-priming of CD8 + T cells,” according to co- corresponding author Dali Han, PhD, now at the Beijing Institute of Genomics.

Together with gastroenterologist Marc Bissonnette, MD, associate professor of medicine at the University of Chicago, his team performed an additional test using biopsies from human patients with colon cancer, a disease that is much less responsive to immunotherapy than melanoma. They found that tissue from patients with high levels of YTHDF1 had limited T cell infiltration, but patients with low levels of YTHDF1 had more T cell infiltrates. “This suggests that humans correlate nicely with our mouse data,” he added.

“An important question in cancer treatment is ‘how could we get better antigen presentation?’”, according to co-author Ralph Weichselbaum, MD, the Daniel K. Ludwig Distinguished Service Professor and chairman of radiation oncology at the University of Chicago. “This study opens a lot of doors,” he said. “It provides a whole new set of targets to the immune system, ranging from new sets of antigens to potential anti-cancer vaccines. This is the type of cross-divisional, interdisciplinary collaboration that could lead to unexpected discoveries.”

This supports the notion that reduced YTHDF1 often coincides with the T cell inflamed tumour micro-environment, which is crucial for successful immunotherapy, the authors note. YTHDF1 could be a therapeutic target for immunotherapy in combination with emerging checkpoint inhibitors or dendritic cell vaccines.

“It will be really interesting to test how the human system works with potential dendritic cell vaccines or small molecule inhibitors that can suppress the activity of YTHDF1 in human cancer patients,” according to corresponding author Meng Michelle Xu, PhD, a former member of the He and Weichselbaum laboratories. “We have not yet seen any measurable toxicity, as far as we can tell, related to knocking down YTHDF1 in mice,” he added. “At this point, this appears to be a very benign system. We hope to begin early testing in patients within one year.”

For more information visit uchicagomedicine.org.

Healthcare is one of the fastest growing sectors in the Middle East and the UAE is no exception, with healthcare expenditure estimated to reach US$21.3 billion by 2021. The intense potential within health was apparent at Arab Health 2019, where industry professionals across the sector verticals turned out in force for the largest sector expo in the region.

To provide greater insight into the current business landscape in the region, strategic communications consultancy group, Hanover, conducted a survey of businesses at the conference to gauge confidence in the region in 2019.

“We wanted to find the key drivers and the barriers to growth, as well as the areas where industry insiders are expecting to see the greatest growth,” explains Simone Elviss, Director – Healthcare, Hanover Middle East.

Business confidence

According to the barometer (Fig 1), when businesses were asked how confident they were that they would grow in the region this year, 87.9 per cent of businesses felt positive or very positive that their revenues would grow this year compared to 90 per cent last year. In contrast, 11.5 per cent felt that their growth prospects were neutral (2018: not asked) and no one described prospects as negative (2018: 2 per cent).

Fig 1

Barriers to growth

Respondents were asked to name the major barriers to growth faced by their business in the region. The chart (Fig 2) shows the numbers of times a response was chosen as companies responding to the survey could choose more than one barrier.

“Two barriers stood out clearly, the first being the highly competitive marketplace that exists within the region, with an increasing number of companies competing for customers, resources and suppliers,” Elviss says. “Competitiveness has moved up from second place last year, shifting regional geo-politics from the biggest barrier to the fourth spot.”  

Fig 2

The second biggest barrier to growth was government policies, which was also a key issue last year and again noteworthy because government policies to expand access to healthcare are also mentioned later as one of the greatest drivers of growth.

According to Elviss, “It may be that individual companies face challenges with specific policies related to their sectors, despite the overall direction being positive. Respondents described the regulatory environment and product registration key areas of policy that presented challenges.”

The price of oil, as well as payer focus on value and price, were other barriers that were mentioned by respondents with a lower priority.

Biggest drivers of growth

The overall increase in healthcare spend from private and public sources again tops the list as the biggest driver of growth in the region, followed closely by rapid market and infrastructural growth (Fig 3).

“Alongside positive government policies striving to enhance all aspects of the system, this trifecta is representative of development of healthcare in the region in terms of the offering and access within the region to quality and affordable healthcare options, providing opportunities for businesses in all areas of the system from delivery to technology and medicine,” Elviss explains. “This perfect storm underpins industry confidence in the region but nods also to the highly competitive environment and a need to differentiate and demonstrate value to clients, customers and patients.”

Fig 3

The future

Respondents were asked to name which areas of healthcare they expected to see the biggest growth. Medical devices topped the list with consumer health and pharmaceuticals following closely. These were seen to have greater opportunity than the development of infrastructure or IT systems and solutions for health systems – perhaps an indication these areas are seen to be over-competitive, or difficult to differentiate the offer.

“As systems drive efficiencies and cost savings, devices which differentiate hospital offerings, improve outcomes for patients or support with e.g. remote monitoring could be a real boon in this market,” Elviss says.

While globally, the frontier of innovation is shifting towards service and software offerings, the survey respondents expected to see a similar level of innovation in products and physical tech within the region as they do in software and digitisation. This reflects the overall confidence in devices, over-the-counter (OTC) and prescription medicines and is a clear nod toward the desire within the market for hospitals and clinics to be equipped with state-of-the-art tech to serve their patients.

Year of Tolerance

Tolerance is a key virtue of Islamic culture and 200 different nationalities peacefully coexist in the UAE, and to this end, the country has declared 2019 the ‘Year of Tolerance’ as it strives to demonstrate its inclusivity and mutual respect across religions and cultures. But tolerance is a somewhat abstract concept when it comes to healthcare and Hanover questioned the industry on what its place in this sector truly is.

“The result was overwhelmingly positive, with respondents believing that tolerance is an essential part of healthcare – throughout the patient journey,” says Elviss. “The idea of inclusivity 
came through strongly, as respondents talked about ensuring all patients – no matter their nationality or role in society – have equal access to quality healthcare and that provision is sensitive to different cultures.”

In addition, in a culture where fear and stigma can often influence healthcare decisions, the idea of tolerance ensuring openness and patience were mentioned.

Artificial Intelligence

Finally, industry specialists were asked how they thought Artificial Intelligence (AI) would alter healthcare in the next 10 years.

In the context of previous answers limiting the importance of technology, the reaction to AI was broadly positive and touched a variety of areas of the patient journey. A major theme was data capture and analytics, information sharing and using big data to make predictions and support clinical decision-making.

Hand in hand with this was the potential improvements in personalising care and treatment options based on large data sets. Another theme was the augmentation of human capability – being able to do things better or more efficiently.

In addition to this was the potential to reduce reliance on unskilled or lower skilled labour – and the concurrent potential to build a highly knowledgeable and skilled workforce to harness these technologies.

“Closely aligned to the UAE’s goals was the potential for AI to support patients in pre-disease stages, triggering awareness of potential health concerns and allowing them to seek preventative care at an early stage,” Elviss concludes.

Radiographer and Radiological technologists are key decision makers in the delivery of radiology diagnostic services to patients. Within clinical, they operate services in general radiography, fluoroscopy, portable, mammography, dental, computed tomography, ultrasound, magnetic resonance image and nuclear medicine. Traditionally, radiographers are responsible for producing high-quality diagnostic images that answer the clinical problem at the lowest radiation level. These images are essential in the modern diagnostic setting. They collaborate with and support consultant doctors in the delivery of crucial services in these areas. While the final diagnosis has traditionally been the role of the radiologist, changes driven by research, education, technology and service have increased the demand for clinical and diagnostic input by radiographers.

Although several researches have been conducted internationally, very little is known about how the health sector is affected by limiting the role of the radiographer to a technical domain in the Middle East. The current undergraduate preparation for radiography practice meets best practice, however, what is not known is how the reality of clinical practice affects recruitment and retention of radiographers.

Radiographers showed a strong desire to research, learn and innovate, and the dynamic and efficient technology development has helped to change their work and made them ready to adopt new changes. The shortage of radiologists and the spread of medical diagnostic imaging has created a situation in which highly trained, highly skilled radiographers have been called upon to fill the gap in diagnosis and image interpretation services. 

An example of where radiographers are working at image interpretation, and diagnosis already exists in the UK’s NHS healthcare system, where radiographers deliver services, are recognised as advanced practitioners, and incorporate the provision of final clinical reports by appropriately trained radiographers. Several countries including Canada, Australia, Norway and Denmark changed their healthcare system by developing models of advanced radiographer practice, which includes definitive clinical reporting. The competency and performance of trained radiographers to provide definitive clinical reports was investigated in many articles worldwide, and it is stated that radiographers’ reports have high confidence and accuracy. 

Radiographers are able to make first line interpretation of images in support of patient management and, following approved postgraduate training. Nevertheless, irrespective of the level of preparatory education it is not necessarily the case that the role of a professional in one country will translate to another healthcare setting in another country. 

The radiographer reporting practice will continue growing in the future and will become crucial to the delivery of efficient and timely imaging services in the UK. The acceptance of the need to move services towards better 24- hour provision can only emphasise the value of radiographers’ contributions. 

Preliminary clinical evaluations and clinical reporting are core parts of the radiography profession’s scope of practice, and the benefits are well evidenced and far-reaching. By developing their scope of practice in this way, radiographers are helping the clinical imaging service meet the needs of patients and referrers for rapid access to the right imaging examinations and the ensuing outcomes and reports. 

Healthcare systems in any country who would like to move towards implementation of radiographer’s role in image interpretations should work extensively with the academic institutes and professional bodies to develop proper education and training programmes. Typically, this will involve a formal postgraduate degree together with extensive clinical training and supervision. The accuracy of radiographer and confidence in image interpretation and reporting will improve with appropriate education and training. 

Professional societies and organisation at the national and international level should work hand-in-hand to develop and highlight the importance of the new role of the radiographer through developing professional journals, professional excellence and to define a set of standards, which can be followed by local bodies. 

How Do We Get There?

It is a long way to go, much work to do but we have got the energy, enthusiasm and at the end, we will do it. A strong collaboration between different parties related to radiographer practice to discuss the advancement of the radiographer practitioner role in several pathways is required, such as:

• Development and innovation of the role acceptance by health organisations and the clinical team
• Establishment of a multi-disciplinary research
• Motivation of the radiographer to accept advance practice role

In addition to the above pathway, a strategic plan for five to 10 years should be developed, including academic degree programmes for radiographers, and membership at national and/or international societies for the radiographers who wish to improve their career pathway. Moreover, it is very important to believe that the introduction of an advanced radiographer practice role in the medical imaging services will revolutionise it.

The Magnitude of Stroke in the UAE

Stroke is a devastating disease for the patient and family and is estimated to cost the UAE around AED 3 billion per year, with additional cost to the economy of a further AED 4 billion in lost productivity, disability and informal care. About 20 per cent of patients die within the first year (and most of these patients die within the first three months) and over 50 per cent of survivors are left with long-term disability.

A disproportionately high share of the disability burden arises within the 30-50 per cent of patients with proximal large artery occlusive stroke. Many of these patients will have a mixture of cognitive, mood and physical function problems.

Stroke Types and Treatment Options

Almost 85 per cent of strokes are ischaemic, resulting from a blood vessel becoming blocked. Brain tissue is then damaged from a lack of oxygen and nutrients. Up to 10-20 per cent of people with ischaemic strokes from large vessels occlusion are suitable for and respond to intravenous thrombolysis. However, many of those treated will not benefit because the blood clot is too large and does not completely dissolve.

In addition, some patients cannot receive the treatment due to contraindications such as recent surgery, late presentation or being on anticoagulant (blood-thinning) drugs. For some of these patients, the evidence suggests that mechanical thrombectomy performed within six-twenty-four hours of the onset of symptoms is an effective treatment that can reduce brain damage and prevent or limit long term disability. Evidence suggests that the quicker this intervention is delivered the greater the benefits. Other than established intravenous thrombolysis, there are no other acute interventions that have been shown to reduce the area of infarcted brain despite efforts to develop new and more effective thrombolytic agents or neuroprotective drugs. 

Large Artery Occlusion (LAO) Stroke

The group of patients that are likely to benefit from mechanical thrombectomy are those with proximal occlusion of the internal carotid or middle cerebral arteries who present early after the stroke before there is irreversible ischaemic damage to the brain. These patients, often with extensive thrombus, are much less likely to respond to the conventional intravenous thrombolysis and more likely to experience severe disability. Around 40 per cent of ischaemic strokes are caused by a large artery occlusion (LAO). 

For patients who do not respond to intravenous thrombolysis there has previously been no active intervention available to prevent brain damage. Treatment in these patients is limited to rehabilitation and high-quality nursing care. 

The Intervention A specially-designed clot removal device is inserted through a catheter into the blocked artery to remove the clot. The catheter is usually inserted into the femoral artery in the groin and advanced up to the location of the blockage. The clot removal device is then inserted through the catheter to remove the clot (thrombus) blocking the artery. The device could be just an aspiration catheter or stent retriever or the two combined.

In addition to introducing this procedure, the intervention will require a new model of care, which builds on existing acute stroke networks to improve outcomes for adults and improve access to the procedure as soon as possible after the onset of stroke symptoms.

There are approximately 7,000 stroke admissions in the UAE per year. Currently, around 12 per cent of all stroke patients receive intravenous thrombolysis and the majority of patients suitable for thrombectomy will come from this group, with the remainder made up of those for whom intravenous thrombolysis is contraindicated.

Latest Literature Review

An extensive search of the international research literature was undertaken to establish the effectiveness of mechanical thrombectomy. Sixteen relevant research studies; seven trials, and a further nine systematic literature reviews and meta-analyses (two of which use secondary analyses of pooled trial data) were identified as relevant and were examined in detail. All seven trials examined the effects of mechanical thrombectomy on patients who were functioning independently prior to their stroke. All reported strongly positive findings, with the proportion of people who could function independently at 90 days following stroke increasing by between 19-35 per cent. All trials also examined the safety of the mechanical thrombectomy, usually by monitoring total mortality and the probability of an intracranial haemorrhage. None of the trials showed a significant excess of either of these outcomes compared with best medical treatment.

The facilities, personnel and equipment required to undertake thrombectomy take time to coordinate. These studies provide valuable insights into the time this takes, measured by time from arrival in a healthcare facility to arterial puncture. For most patients admitted direct to the thrombectomy hospital site, arterial puncture was achieved within an hour and a half of admission (median 81 minutes) and in just under two hours (median 116 minutes) for those requiring transfer to the thrombectomy centre (Goyal et al., 2016). The trials differed in aspects of their design, including the interventions allowed as best medical therapy. However, many examined the effects of adding mechanical thrombectomy to a best medical therapy protocol that included intravenous thrombolysis (which has to be administered within 4.5 hours of stroke onset), with prompt initiation of further therapy (aiming for clot retrieval within six hours). 

The Benefit of Mechanical Thrombectomy

Five systematic literature reviews synthesised the results of the same/similar pool of studies and reached similar conclusions. The absolute chance of patients being able to function independently at 90 days after stroke were improved by around 20 per cent (19-22 per cent) among those undergoing mechanical thrombectomy compared with controls (Bush et al., 2016, Marmagkiolis et al., 2015, Lambrinos et al., 2016, Touma et al., 2016, Anonymous, 2016). This suggests that for every four to six patients undergoing thrombectomy following stroke, one more will be able to function independently at 90 days, compared to those that receive thrombolysis alone. The studies that pooled individual level data gave similar findings. The larger of these calculated median disability scores at 90 days, and concluded that the median score on the Modified Rankin (mR) scale for those who received best medical therapy was four, i.e. that patients were moderately severely disabled. In contrast, the median score at this time for patients who had also undergone mechanical thrombectomy was two i.e. they were able to function independently. Further, using a “differences in differences” approach mechanical thrombectomy increases the odds of being in a less disabled category at 90 days (one point different on the mR scale) by more than two-fold (Odds ratio 2.26 p<0.0001) (Goyal et al., 2016). 

Time Is Brain, Do Not Delay

Pooled analysis allowed other factors to be explored, particularly the significance of time from symptom onset to key events in the treatment pathway, such as decision to treat (randomisation), start of procedure, and restoration of cerebral blood flow. 

The HERMES study (Saver et al. 2016) identified that the absolute chance of being functionally independent 90 days after thrombectomy diminish by 3.4 per cent with each hour’s delay to starting the procedure (arterial puncture), and the probability of a beneficial reduction in decline in disability (one point on the mR scale at 90 days) fell by 5.3 per cent for each hour’s delay. Whilst treatment benefits fell, the outcomes for those undergoing thrombectomy were better than those receiving best medical therapy for up to seven hours from stroke onset (i.e. where arterial puncture could be achieved within this time). In summary, for every four to six people with an acute ischaemic stroke who present with an identifiable occlusion in the anterior cerebral circulation who undergo mechanical thrombectomy, one more person will be functioning independently at three months compared with if they had received intravenous thrombolysis alone.

Window of Treatment

Rapid treatment is important, as the benefit from mechanical thrombectomy falls by 5.3 per cent for every hour of delay. However, the percentage that can be expected to be independent declines from 50 per cent for thrombectomy within three hours to 45 per cent at 4.5 hours, to 40 per cent at six hours and to 33 per cent by eight hours, even with a favourable advanced brain imaging profile in the patients treated beyond six hours. Some patients where advanced brain imaging indicates the continuing presence of salvageable brain tissue may still have better outcomes from thrombectomy than best medical treatment alone, even if thrombectomy occurs up to 24 hours after onset. There is no evidence to support later treatment in the absence of a favourable advanced brain imaging profile. 

Complications of Stroke Mechanical Thrombectomy

Symptomatic intracranial haemorrhage is no more common among people who had thrombectomy (4.4 per cent) than best medical therapy (4.3 per cent). Death rates at three months appear lower for those undergoing thrombectomy (15.3 per cent) than for those receiving best medical therapy (18.9 per cent), though these differences were not statistically significant. 

Brain Haemorrhage

Specifically, to ensure that those with the most to gain achieve important benefits, a decision should be made on both thrombolysis and on referral for thrombectomy within 4.5 hours of stroke onset, ideally achieving arterial puncture within six hours. 

Criteria for Mechanical Thrombectomy Treatment 

Inclusion Criteria: 

Mechanical thrombectomy will be routinely performed for patients, of all ages with proximal occlusion of the internal carotid or middle cerebral arteries who present early after the stroke before there is irreversible ischaemic damage to the brain. 

The criteria that would need to be met for treatment are: 

1) Thrombectomy (clot retrieval) can be achieved within six hours of the onset of symptoms, unless advanced brain imaging (perfusion or multiphase computed tomography angiography (CTA)) indicates substantial salvageable brain tissue is still present up to 24 hours after the onset of symptoms. And either: Where there has been an inadequate response to intravenous thrombolysis by the time of groin puncture, OR b) for patients who are unable to receive intravenous thrombolysis because they are on anticoagulants or have had recent surgery, and 

2) Where a proximal occlusion (intracranial carotid; and/or, M1 or proximal M2 segments of middle cerebral artery) in the anterior cerebral circulation is demonstrated on vascular imaging.

3) Where there are no major new ischaemic changes on plain computed tomography (CT) or MRI brain scan

4) With significant new disability with a score of >5 on the National Institute of Health Stroke Score (NIHSS) 

5) Previously independent in activities of daily living (Modified Rankin score less than three). 

The National Institutes of Health Stroke scale (NIHSS) 

The NIHSS is used to measure the severity of a stroke. It scores areas such as level of consciousness, vision, sensation, movement, speech and language with a maximum of 42 points representing the most severe symptoms. 

The levels of stroke severity on the NIHSS are categorised as: 0: no stroke/5–15: moderate stroke/16–20: moderate/severe stroke/21–42: severe stroke.

Modified Rankin Scale (mRS)

This is a functional assessment scale that measures the degree of disability or dependence of people who have suffered a stroke. The scale runs from perfect health without symptoms to death: 

0: No symptoms. 

1: No significant disability. Able to carry out all usual activities, despite some symptoms. 

2: Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities. 

3: Moderate disability. Requires some help, but able to walk unassisted. 

4: Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted. 

5: Severe disability. Requires constant nursing care and attention, bedridden, incontinent. 

6: Death.

Exclusion Criteria:

1) No proximal intracranial large artery occlusion

2) No appropriate vascular access or contraindications to arterial puncture 

Patient Pathway

The model of care includes; the admission of patients to an emergency department in the nearest hospital with a hyperacute stroke unit (HASU); undertake the initial investigations including CT or magnetic resonance (MR) angiography; start treatment with intravenous thrombolysis as appropriate; and then transfer urgently those who might benefit from thrombectomy and fulfil the inclusion criteria, to the nearest thrombectomy centre that fulfils the criteria and is equipped to provide thrombectomy services. 

Auditing Points and Outcome Measures 

• Treatment related mortality
• 30-day mortality post treatment
• Disability at six months
• Disease/procedure-related complications such as symptomatic intracranial haemorrhage
• Disease-associated complications (e.g. lower respiratory tract infections, urinary infections, from SSNAP)
• Time from onset to thrombectomy
• Time from onset to arrival at thrombectomy centre
• Time from arrival to arterial puncture
• Time from arterial puncture to thrombectomy. 

Conclusion

Acute ischemic stroke is a major cause of death or disability in industrialised countries. Significant modifiable factors influencing the clinical outcome are the time span between symptom onset and revascularisation, recanalisation rate and the occurrence of symptomatic intracranial haemorrhage (sICH). Recanalisation has been shown to be the most important modifiable prognostic factor for favourable outcome in ischemic stroke treatment. Successful recanalisation overall increases the chance of favourable outcome 4-fold compared to patients without recanalisation, and decreases the mortality rate 4-fold. The importance of recanalisation is even more pronounced in basilar artery occlusion, where the chance of an independent life is only 2 per cent in patients without recanalisation. 

Recanalisation success depends on the site of vessel occlusion: proximal large vessel occlusion such as the Basilar, ICA or M1 segment have a limited recanalisation rate after IAT and especially after IV rtPA. Therefore, the key aims of mechanical treatment approaches for acute ischaemic stroke treatment are achieving rapid and efficient reperfusion with short procedure times and high recanalisation rates while extending the treatment window.

Among adverse events to contrast media (CM), immediate hypersensitivity (IH) reactions raise the highest level of concern for radiologists and patients, since they may lead to severe anaphylactic shock within minutes after injection, sometimes leading to death. The frequency of reactions to iodinated CM (ICM) was reduced with the use of non-ionics in the 90s, but not the frequency of death. Numerous pre-treatment protocols have been implemented, but their overall efficacy remains unclear.

Gadolinium chelates used as contrast agents for Magnetic Resonance Imaging were initially thought to be safe and to induce less adverse reactions than iodinated agents. This is probably true for mild reactions, since the osmotic load of a regular gadolinium chelate injection is four times lower than an iodinated contrast one.

However, severe reactions and cardiovascular arrests have still been described with all the gadolinium chelates available on the market, leading to similar pre-treatment strategies despite the lack of evidence supporting them.

For decades, a true allergic mechanism was discounted by the community, who have advocated non-specific, so-called “anaphylactoïd” or “pseudo-allergic” reactions and identified risk factors such as “previous reaction”, “asthma”, and “allergy to drugs”. Several pre-treatment protocols have been tested, mainly based on antihistaminic drugs and corticosteroids. However, these do not prevent severe reactions and anaphylactic shocks.

Over the last 20 years, cumulative evidence has been published in literature about the involvement of a true allergic mechanism in some IH reactions to contrast material for iodinated agent and a few cases have been reported for GBCM.

It is important to differentiate allergic from non-allergic reactions, because allergy implies immune memory of the epitope, and recurrence (even at very low doses) with the culprit CM and potentially with other CM containing the same epitope (cross-reactivity). 

Drug allergy is associated with increased tryptase and histamine concentrations in plasma during the first hours of the reaction and is diagnosed by positive intradermal skin testing with diluted drug solutions.

Most of the published studies included retrospective cases tested years after the reaction, or lacked precise clinical history, name of culprit agent, or were mixed immediate and delayed reactions.

In France, we conducted the first prospective study of IH reactions to iodinated or gadolinium-based agents (CIRTACI study). It needed to be multicentre, since the incidence of severe reactions is so low, in order to include a few hundred reactions over the term of the study. Based on an incidence of 0.1 per cent moderate and severe reactions, we included 31 centres from across France that were able to provide allergy testing shortly after the reaction. We assumed that each centre could perform at least 7,000 injected examinations per year, meaning that 600,000 examinations could be obtained over a three-year period, so that we could include 600 reactions. 

However, after two years, the inclusion rate was lower than expected, and we decided to continue the study for a total of 4.5 years. Between 2005 and 2009, 319 patients presenting with IH reactions to iodinated or gadolinium-based contrast media were included. After appropriate medical treatment, blood sampling for histamine and tryptase measurements was performed, and six weeks later an appointment with an allergist for skin testing was organised. All 10 iodinated and five gadolinium agents on the French market were tested.

We classified the reactions as allergic when intradermal skin tests were positive to the culprit contrast solution diluted to the tenth (as recommended by the European Network for Drug Allergy), potentially allergic when skin tests were positive only with the pure solution, and non-allergic otherwise. 

Among 245 skin-tested patients, we identified 41 allergic reactions to iodinated agents, and 10 to gadolinium-based ones. The frequency of allergy increased with the severity of the reaction. Similarly, histamine and tryptase concentrations increased with the severity of the reaction, confirming the findings. Cardiovascular symptoms were highly linked to allergy.

The group called “Potentially Allergic” presented clinical symptoms and concentrations of histamine and tryptase intermediate between those of the allergic and non-allergic groups, suggesting that some allergic patients are missed when using the recommended skin testing criteria. 

Implications for Clinical Routine

This prospective study shows that allergy is responsible for 21 per cent (and possibly more) IH reactions to contrast agents. Allergic patients are at high risk of recurrence if skin-test positive contrast media (culprit or non-culprit) are administered. Patients who have experienced life-threatening reactions and cardiovascular symptoms in particular should be managed with the highest care, as they are most probably allergic to one or more other contrast media.

A systematic follow-up of the patients experiencing IH reactions would vastly improve the safety of patients, by blood sampling rapidly after the onset of the reaction to measure histamine and tryptase, and then by sending the patient to an allergist with competence in drug allergy, in order to perform skin tests. The culprit agent should be contra-indicated for life, together with the other agents inducing skin cross reactivity. 

These results strongly support reorganisation of radiology departments, with better identification of previous reactors, elimination of systematic premedication, availability of sampling kits with needles and vials on resuscitation trolleys, and identification of drug allergists to send reacting patients within one to six months following the reaction.

An increasing volume of medical imaging procedures combined with a demand for more rapid access to diagnostic services, is putting high pressure on medical imaging departments. Because of that a communication strategy should be adopted, to explain the procedure in an understandable manner, adapted to patient social and economic characteristics, giving the adequate information for him/her to be able to make a proper decision. 

We need to incorporate into our daily practice the understanding of the concept that the 21st century patients have higher expectations and are becoming more demanding, as they are progressively being part of the process and therefore have access to information, allowing them to make better informed choices. 

It’s important to be aware that a patient’s listening is motivated by universal needs: The need for compassion; the need to be heard; the need to be recognised. From a tone of voice or acknowledgment, the patient can readily hear if the white coat standing in front of him/her is someone who can care enough to listen. 

Medical imaging departments present an excellent test environment to study interventions to enhance patient satisfaction as: a) the imaging environment is highly complex, and workflow and time schedule constraints are extensive; b) there is a wide spectrum of patients referred from multiple clinical specialties whose conditions vary in acuity, ranging from outpatients undergoing routine examinations to critically ill patients undergoing emergency imaging studies. 

Research indicates that training Radiologists and Radiographers to make simple modifications in their language and behaviour during patient care, can significantly impact patient satisfaction, which can impact quality-of-care. Authors have also described that radiographers have reported that as the use of technology has increased, traditional radiographer communication has decreased, mainly due to the fact that the implementation of picture archiving and communication systems (PACS), electronic health records (EHR) and digital imaging shorten turnaround times and increase medical imaging department volume without a subsequent staffing increase. 

Radiographers usually are the only ones that are in contact with patients and might notice duplicate or inappropriate examinations before they occur and the ones to be asked about the risk. Therefore, its crucial to develop guidelines with clearly defined roles and responsibilities on how to communicate risks in a harmonised way, to avoid patient misinterpretation in their imaging clinical pathway. 

Teamwork is needed wherever multiple individuals with multiple skills are required to work interdependently to achieve a favourable outcome. This means that teamwork is absolutely critical in the management of patients, since healthcare is a complex activity, which needs many different types of professionals, with different knowledge, skills and competences and with specific roles. 

One individual working alone cannot achieve the target of taking care of a patient and from the concept defined in 1926 by Francis Peabody that “the secret of the care of a patient is caring for the patient” we moved nowadays to: “the real secret of the care of a patient is teamwork”. 

According to the WHO, communicating radiation risk in paediatric imaging, the major challenge in communicating the benefits and risks of medical imaging procedures that use ionizing radiation is the existence of insufficient awareness and understanding of radiation protection issues by health professionals. Research has shown that there is widespread underestimation of doses and risks. There is a need to ensure that all referring medical practitioners have sufficient background, education and resources to communicate clearly and effectively about the benefits and risks of imaging procedures. 

Effective communication with patients and caregivers is increasingly recognised as critical to patient-centred care, and an important component of effective healthcare delivery. This is also true in the paediatric population related to communicating radiation benefits and risks from medical imaging. However, the quantity and quality of communications training that most healthcare professionals receive, and the lack of resources available to them, present a hurdle to effective communication in these settings. 

Communication with patients and caregivers is one of the requirements of the new International Basic Safety Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources. Communication of benefits and risk of medical interventions forms the basis of good medical practice. There are several stakeholders who have an interest in providing high-quality care to the patient undergoing imaging procedures. It is essential for them to participate in the risk–benefit dialogue. 

In conclusion, despite the pressure on medical imaging departments to produce more, we must dedicate time in communicating effectively with our patients. 

Because each patient has his/her own needs and perceptions, we need to be able to identify those needs and perceptions and adapt our messages accordingly, keeping them simple, objective and understandable. 

We need to engage with our patients, comfort them, talk with them and show that we particularly care about them.

The way we image cancer could change dramatically in the next decade. This will probably be determined not only by the improvement of existing hardware or the advent of new cutting-edge imaging tools but rather because of two important disruptive technologies that apparently have little to do with medical imaging. The first innovation is related to the technical improvements of molecular diagnostics, in particular the advent of next generation sequencing; the second is related to the advent of deep convolutional networks for Artificial Intelligence (AI).

In order to evaluate the impact of new technologies one must keep in mind that, with some approximation, there are two types of cancer patients: those with metastases or locally advanced disease, that undergo medical therapy or radiotherapy and still have a dismal diagnosis, and those that have cancer diagnosed early enough to be treated with surgery. The latter have a higher probability of being cured.

Imaging can contribute significantly in detecting cancer at an early stage, even before symptoms arise. Examples of imaging test for early diagnosis are mammography, low dose lung CT, Virtual Colonoscopy and prostate MRI. Mammography is adopted within European boundaries for large scale, usually government sponsored, screening programmes; in other countries, mainly those outside Europe, breast screening is on a voluntary basis. The use of mammography has brought about a reduction of breast cancer mortality of approximately 20 per cent. Lung CT is being used in high risk patients (i.e. mainly smokers) in the U.S. and Russia with similar results in terms of impact on survival. Looking to the future we soon expect European guidelines to introduce prostate MRI as the first line examination in patients with high prostate specific antigen (PSA). Finally, three randomised trials have shown that Virtual Colonoscopy can compete with other screening tests, i.e. FIT, sigmoidoscopy and colonoscopy, in a screening setting.

So how can AI and molecular biology be game changers in the context of early diagnosis? Recent literature supports the statement that AI will probably be adopted by radiologists to detect and characterise cancer and might even take over simple tasks, such as detecting lung nodules, thus increasing the efficiency of screening programmes. Today, AI algorithms can identify lung nodules and breast cancer at least as well as expert human readers; they can also distinguish benign from the malignant lung nodules with a higher accuracy than humans; furthermore, computer-aided diagnosis has also allowed radiologists to detect more prostate cancers at MRI and more cancerous polyps at virtual colonoscopy.

Recently, a blood test has been developed at John Hopkins University that can detect eight common cancer types through assessment of the levels of circulating proteins and mutations in cell-free DNA. On average, for eight cancer types the sensitivity of the test was 70 per cent but was near 100 per cent for ovary and liver cancer. If findings will be confirmed, we will be on the verge of a paradigmatic shift. Indeed, in the future it might not be necessary to screen all individuals but only those with suspicious findings at a routinely performed blood test. Only individuals with a positive test will undergo imaging, probably supported by AI detection and characterisation algorithms, to confirm diagnosis and localise cancer. Hopefully, investments will be available in the future to validate the new tests and to implement them in screening programmes. Unfortunately, as of today, only 5 per cent of funds for cancer research go into early diagnosis.

Following radical surgery, some cancer patients eventually develop local recurrence or distant metastases. High risk patients are monitored by CT or MR so that treatment can be started as soon as possible in case of recurrence. Some patients actually have minimal residual disease after surgery that is not detectable by imaging. In stage II colorectal cancer patients, presence of circulating DNA in blood has been shown to be almost 100 per cent specific. In future, patients with cancer could be monitored with liquid biopsy and imaging be performed only in patients with suspicion of disease recurrence at the blood test.

When patients develop metastases, they can be treated with drugs that inhibit growth of cancer cells and determine their death. CT and occasionally MRI are used to measure objective response to treatment by summing up the diameter of most significant lesions. Change in sum of diameter is evaluated at successive timepoints and compared to baseline. Usually tumours treated with chemotherapy initially shrink, but in a large percentage of cases eventually grow back. When this happens, we say that cancer has become resistant to therapy. Actually, cancer is a genetic disease and now drugs are available that target patients with specific somatic mutations; but drugs become ineffective as new mutations develop downhill. However, if molecular drivers of resistant metastases are found then the patient can be treated again with a different drug. We call this adaptive therapy. After more lines of therapy, metastasis start behaving differently, some may shrink, others may grow, sometimes at different rates. This behaviour is defined mixed response. 

So, in the future of cancer imaging, as the number of drugs and lines of treatment increase, we will not be able to assess response properly if we look at the patient as a whole. It will be necessary to evaluate the dynamics of each single metastasis. This will allow us to detect early on lesions that escape control as the new resistant clones proliferate. These lesions are a major concern and should be investigated by re-evaluating their mutational status and maybe could be treated aggressively, for example by surgery or if accessible by percutaneous ablation. Attempts are ongoing to identify lesions that will start growing back before they actually do, by radiomic analysis. Images are like the dark matter of the universe, they have hidden information derived, for example, from the spatial distribution of pixels, that may be decoded and processed to obtain scores of probabilities. Combining radiomic and genomic data could yield more robust and accurate information and might allow early identification of patients or of individual lesion that will become resistant to treatment.

Of course, we also expect significant improvements in imaging technology. In the future Magnetic Resonance Imaging could substitute CT for most oncologic examinations, providing superior tissue contrast and additional functional information. With new generation phase array coils and high field magnets it will also be possible to perform whole body examinations in a few minutes, increasing patient throughput and without exposure to ionizing radiations. Linking diagnosis to treatment will allow implementation of new strategies for treatment of advanced cancer. In particular, the new medical discipline of theranostics will allow targeted therapy of specific cancers by radioisotopes on targets preliminarily assessed by a diagnostic nuclear medicine test.

Oncologic imaging tools provide high diagnostic accuracy in the detection of cancer, are reliable in the assessment of tumour response and deliver useful information for planning of targeted therapies. In the future, AI will increasingly support the radiologist by further improving lesion detection and characterisation, by contributing to the development and validation of new predictive imaging and by improving patient workflow. Integration of genomic and radiomic information will be sought, so that each individual patient may benefit from the best possible treatment and change in therapeutic strategy put in place when a tumour progresses.

Breast cancer is the most common form of cancer among women impacting 2.1 million women worldwide. According to the World Health Organisation, in 2018, it is estimated that 627,000 women died from breast cancer — that is approximately 15 per cent of all cancer deaths among women. X-ray mammography has always been the ‘gold standard’ for routine screenings for breast cancer with the main aim being to help in the reduction of mortalities from breast cancer by bringing about an early detection of the disease, before the women feel the symptoms, and to detect cancer at a stage when it is most treatable.

Indeed, with this goal in mind, mammography has played a leading role. The Breast Cancer Surveillance Consortium in North America carried out a study over six years, which included 401,548 examinations on 265,360 women. The study concluded that cancer detection, due to mammography, rose to 34.7 per 100 examinations.

As a stark increase from a previous such study conducted in 2005, which showed the cancer detection rate to be 25.3 per 100 examinations, these performance measures can serve as national benchmarks that may help to transform the marked variation in radiologists’ diagnostic performance into targeted quality improvement efforts.

However, according to Dr. Lavina Verma, who is a specialist radiologist at Aster Clinic Bur Dubai, UAE, there are some shortcomings faced when mammography is used as the only radiological tool in order to assess a patient’s risk for breast cancer. “One of the primary reasons for the shortcomings is the presence of dense breast tissues (parenchymal tissue) in the breasts of some patients, which has resulted in false negative results (15 to 20 per cent) of mammograms for those patients that have dense breasts,” she explains.

As a result, healthcare professionals around the world agree that mammography can longer be used as a ‘one-size-fits-all’ approach and that there are ongoing efforts to develop and clinically translate alternative modalities that could provide for new contrast mechanisms and may potentially improve lesion detection and diagnosis. “The challenge is to use new technologies to increase cancer detection rates without also increasing recalls and false-positives,” notes Dr. Verma.

Some of the new and emerging technologies include:

• Digital Breast Tomosynthesis (DBT)
• Dedicated Breast Computed Tomograph
• Elastography
• Molecular Breast Imaging (MBI)
• Positron Emission Mammography (PEM)“A newer breast imaging modality Digital Breast Tomosynthesis (DBT) and more recently, Dedicated Breast Computed Tomography have been developed to alleviate the tissue superposition problem,” says Dr. Verma. “Increasingly, DBT is being used as an adjunct screening tool for the detection of breast cancer.”

DBT or 3D-mammography, is a mammography technique in which multiple mammographic images are acquired of compressed breast from multiple angles by using low dose x-rays and are then reconstructed into overlapping thin slices that can be displayed either individually or in a cine loop. The radiation dose received when DBT is combined with conventional 2D mammography is nearly double that of digital mammography alone, but within the established and acceptable safe dose. 

Dr. Verma highlights a multi-centre clinical trial conducted by Hologic that has found that DBT takes only seconds longer than conventional 2D digital mammography, and can assist in increased cancer detection (by 27 per cent), increased invasive cancer detection (by 4 per cent) and decreased call-back rates (20-40 per cent), localising structures in the breast and improved lesion and margin visibility. Also, clinical data shows that 3D mammography was helpful for all breast densities.

“Multiple studies have demonstrated that with DBT, breast cancer detection rates are improved by 33–53 per cent (sensitivity) and that false-positive recall rates are simultaneously reduced by 30–40 per cent (specificity). However, all of these modalities rely upon x-ray attenuation contrast to provide anatomical images, and there are ongoing efforts to develop and clinically translate alternative modalities,” she explains.

“Ultrasound and Magnetic Resonance Imaging (MRI) are two supplementary breast imaging modalities that retain their sensitivity in women with dense breasts, and when used in addition to mammography, can demonstrate an increased cancer detection rate compared to mammography alone,” adds Dr. Verma. “Elastography is another test that can be done as part of an ultrasound exam and is useful in revealing if the area is more likely to be cancerous or a benign (non-cancerous) tumour.”

According to Dr. Verma, the new emerging modalities like Molecular Breast Imaging (MBI) and Positron Emission Mammography (PEM) could provide for new contrast mechanisms and may potentially improve lesion detection and diagnosis. 

MBI utilises a tracer and a custom camera in order to detect breast cancer. Unlike, mammograms, that take an x-ray image of the breast, MBI creates an image that shows a difference in the activity of the tissues. Those tissues that contain cancer cells can be identified because they appear to be brighter than their less active counterparts. PEM, on the other hand, works very similar to mammography, with the only difference being the injection of a positron and the use of a dedicated camera. 

“The advantage of PEM over regular mammography is that it provides a far more specific image,” Dr. Verma says. “However, the drawback is that it cannot be used for regular breast cancer screenings, since the patient is exposed to slightly higher radiation doses as compared to other screening modalities.

”When asked about the basic rules for screening standards in the UAE, Dr. Varma outlines how breast cancer screening must be provided in accordance with the breast screening and diagnosis care pathway as provided by the The National Cancer Screening Committee. She also describes how, in addition, the following activities should be included:

• History and risk assessment
• Clinical breast exam (physical exam)¢ Screening mammogram — Screening mammography must involve two x-ray images for each breast; craniocaudal (CC) and mediolateral oblique (MLO).
• All women must be informed about the results of screening within three weeks (15 working days) of the date of screening mammogram.
• Women with abnormal mammogram, who require further assessment and diagnosis, must be recalled/referred to Diagnostic Breast Assessment unit within five working days of screening mammogram date.
• Assessment and diagnostic work up of screen-detected abnormality is best achieved using the triple assessment: 1. Imaging; usually diagnostic mammography and ultrasound; 2. Clinical examination; and 3. Image-guided needle biopsy for histological examination, if indicated. 
• Cytology alone must not be used to obtain a non-operative diagnosis of breast cancer. 
• Clinical examination is mandatory for every woman with a confirmed mammographic or ultrasound abnormality that needs needle biopsy and for all women recalled because of clinical signs or symptoms

According to the Abu Dhabi Department of Health (HAAD) screening guidelines, women should typically start having regular mammograms from the age of 40 onwards. And the screenings should be scheduled twice a year. However, for those women who have a family history or genetic predisposition to breast cancer, the screening age can be even earlier, at 30. Screening MRI and Ultrasound of the breast is recommended as adjunct to screening mammogram for women with dense breast/s or increased risk.

“In future, as assessment of risk and breast tissue density becomes a reality, more personalised screening will likely be added to that screening mammography regiment,” Dr. Varma concludes.