When people are asked where they would wish to be cared for, they usually say “at home.” How does the health-care system move from a building-intensive and uber-specialized model to a person- centered one at home?  There is almost no more sacred place or space than our homes. Homes represent who we are: the food, beverages, furnishings, traditions, neighborhoods, gardens, pets and plantings are all reflections of ourselves. Healthcare should be no different. Life-long health habits and behaviors are learned and honed across years in homes. Where better to initiate and continue health education and care than at home?

The model visualized makes the home the central place around which all other healthcare revolves; this is a very different construct from most healthcare today. Home is where people usually want to be, and where health decisions are made every day including diet, lifestyle, and other choices. The following eight areas address some of the factors making care at home more desirable and practical.

1. The aging of the world’s population. Much has been written about the gray tsunami. We know that the oldest old (those over age 85) are one of the fastest growing segments of the population. It is recognized that many aged people need assistance with activities of daily living and personal care. The question then becomes: How do we best care for this growing population? For example, what are the metrics that measure how well we are doing and what feedback should be sought from the care provided? Many older adults do not have one healthcare condition, but may have several comorbidities impacting their health.

Practical Application: Consider models and processes that bring healthcare to the person at home when possible. Consider the very frail oldest old, the homebound, the chronically ill and others where the logistics and experiences of getting out to go to the doctor’s office is an ordeal from a mobility and safety perspective. Now consider how we can get needed healthcare to these homes and who is best skill-matched to provide such care and support?

2. Much care can be safely provided at home with knowledgeable nurses and other clinicians. Care has been provided in homes for hundreds of years. Such care includes home visitors for mothers and infants, case management, infusion and medication therapies, specialized treatments, skilled nursing services, personal care, hospice and palliative care, and other models and care. In the United States, Medicare, Medicaid, and private insurance covers care in the home. This coverage is complex with a number of requirements. Generally, there must be physician orders for care and for any changes to that plan of care. There are a number of requirements and structures in place that can make obtaining care or obtaining enough hours of needed care a difficult process. The nurse who admits and cares for patients in homes must have a specialized knowledge base to provide care and have their organization receive appropriate reimbursement for medically necessary services. In addition, there are numerous standards related to documentation of the care provided and other requirements. There is a “For Further Reading” section at the end of this article for more information and resources. Home care is complex and this is the reason it is a nursing specialty. The complexity of the rules alone is sometimes akin to fitting a round peg into a square hole.

Practical Application:  The payers determine the rules and sometimes the person needing the care does not “fit” neatly into the model. Try to envision a healthcare space where the person is assessed and then services are based primarily on the assessed needs without the complex and sometimes byzantine frameworks that create episodic and uncoordinated care, particularly when the person must traverse across healthcare settings.

3. Emerging models of care that make the nurse central to the care of the patient and family constellation. In the home as a healthcare setting, the nurses function somewhat autonomously and provide of broad range of care and care management. Nursing is an important specialty of care in the home, with a focus on promoting health and healthy habits, education, and practical applications of care that support health and function. Home care nurses employ many skills and clinical reasoning or critical thinking strategies in care planning to help patients reach their unique, identified goals. In home care, nurses use skills such as observation and assessment, specialized teaching and training, management and evaluation of the patient’s plan of care, providing injections, caring for urinary catheters, and providing skin and wound care. For example, wound care could include assessment and management of the wound, teaching and training related to the wound, hands-on care of the wound, and infection control and prevention.

Practical Application: Nurses can play a pivotal and leading role in reframing healthcare and bringing healthcare back to homes and communities. Think of Lillian Wald and other nurse leaders who are the benchmark for what health and healthcare in communities could “look like”.

4. The team focus. There is an adage that, “no one is as smart as all of us.” In home care and hospice at home, the care is not “siloed,” the team communicates and coordinates and the patient is an active participant in care, care planning and in the identification of goals. There may be nurses, therapists, such as an occupational therapist, a physical therapist, speech-language pathologists or speech therapists, a social worker, a home health aide, chaplains and others. Each of these team members contribute their expertise to the plan of care so patients meet their identified goals and reach positive outcomes in a timely manner.

Practical Application: How does this model get replicated and enhanced in other care settings? What is the overlap and contribution of each team member to ensuring safety and quality? This interprofessional care and care planning is very important for patients and families as healthcare team members are role models for health, effective communications and advocacy.

5. The home environment as the setting for healthcare. Homes and housing are as unique as the people that live in them. Unlike the hospital, where patients are generally wearing the same clothes (a hospital gown), eating the same foods (the offerings from the kitchen), visitors must come at certain hours and may need to be a certain age and more. Now consider a home in any city or place in the world. It is the home care nurse or other team member who is invited in. Remember that usually we do not enter someone’s home unless we “know” them and have been invited in. Imagine a day full of “home visits” where in the morning neither the patient/family nor the nurse has ever met each other. And now the visiting nurse must establish a rapport and connect with the patient and family to “admit” them to the home care program and then provide care. (And there are usually productivity standards to do this effectively and efficiently). This is an entirely different headset from that seen in the hospital. The nurse or therapist is on the patient’s home turf. And think of what else we have in our homes; our own ways of cooking and eating, different ways of keeping a home or house “clean” (always open to personal interpretation) and maintained. There may be pets that might not qualify as house pets by some people. (As a visiting nurse for many years I have met patients with squirrels, crows, and snakes as pets and more!). And remember a dog or cat that is “close” to their owner may have very strong (read: negative feelings) toward a stranger (in this case the healthcare team member) who comes in and wants to “touch” their owner, such as when taking a blood pressure or helping them move in bed, or providing catheter or wound care. All these moving parts of complexity come together in a home visit and, when it works, great nurses make it look easy. It is not. Somedays the nurse makes 6-7 or more visits, depending on the care needed, the schedule and a myriad of other factors.

Practical Application: Nurses providing care in homes must have the well-honed interpersonal gift of “meeting people where they are” and acceptance of varying lifestyles, and "be able to converse and interface with new patients and their families on any number of topics. This comfort level with a diverse and changing “caseload” of patients does not happen overnight, and is forged though an effective orientation and with ongoing education, mentorship and role modeling.

6. Technology and its use to improve safety, quality and costs. There has been much in the literature and news about the safety and quality equation in healthcare. Sadly, some have estimated medical errors may be the third leading cause of death in the U.S. behind heart disease and cancer. If true, this is an untenable position from a cost perspective—and not solely in dollars of course. The emergence of technology to identify potential problems, such as drug interactions, to avoid additional tests, such as in duplicative x-rays when the prior one is “lost” and e-based educational programs and innovations is a great thing for patients and clinicians alike. Telehealth, electronic health records and documentation software and systems can help with improving care and coordination which are needed from safety, quality and costs perspectives.

Practical Application: Embrace and learn new products as they become available and have the potential to help patients and families. Seek to become a “super user” should the opportunity emerge. Provide input to better enhance the products and their functionality.

7. Caring for people across the life span and where they are. Home care services can assist people regardless of age and healthcare problem. When caring for people of all ages and health challenges, it is important to be cognizant of their socioeconomic and psychosocial support circumstances. This is why care in the home is so different—it is holistic. For example, does the premature infant have the formula needed to grow and meet developmental and other goals? Does the frail elder, who lives alone and cannot leave their home unattended, have access to good foods and nutrition that support health needs? Is there a social worker who can help identify community resources and linkages to assist this patient and family? The types of people cared for in home care have a broad range of diagnoses. They can range from an older, obese adult with hypertension and chronic lower leg wounds to a young adult after a traumatic injury who is on a ventilator, with a tracheostomy and more. In some instances, these bedrooms look more like hospital rooms. The rooms and homes are often very uniquely individualized for that person, be it with their stuffed animals, video games, choice of movies and more.

Practical Application: Try to see people, families and their homes as a reflection of themselves. Skillfully and kindly frame questions to elicit information to be sure there is (enough) food, there is working heat or electricity and air conditioning, that they can afford their medications, and other resources to support health at home. These factors are important parts of health and care and can be determined during effective home visits.

8. Family, friend and other “lay” caregivers are starting to be recognized as an untapped resource. Who knows their family member or loved one the best? This is so fundamental. We must return to a common-sense structure for healthcare, and support these most important caregivers as part of the team! Some years ago I was in Thailand and Korea making presentations about home care. I remember touring a hospital and thinking “how neat is that; seeing family members in the hospital room with their family member? And bringing in food?” These family members, friends, partners and others should be more formally recognized and educated to improve care and outcomes. This is particularly true in some hospitals and health systems as this could assist in discharge planning and care once back at home.

Practical Application:  Embrace these caregivers for what they are: an engaged and interested care team member. Visit www.e-caregiving.com for resources related to educating and supporting caregivers.

Summary
This is the time to think about how to “reframe” healthcare. If home was the central place for health and healthcare, think of the costs that might be saved from a quality, safety, and costs perspective. For example, medication errors and related costs could decrease as there is only “one” patient usually in the home receiving care. The effectively educated and valued family caregiver could be an active part of the team and assist in care and advocacy. Talk about a person-centered model—it does not get any more individualized than that. It might also be time to have one glossary and language for healthcare. There should not be “medicalese” spoken by healthcare professionals and another easier language for patients and families. For safety and respect reasons, patients need to know the correct terms, such as atrial fibrillations and others terms whenever possible. This “same language” may assist in clarity of communications from a safety perspective.

Healthcare has been highly specialized and we have an aging population where this complexity might not be the best model. Perhaps it is time for a more thoughtful way to provide compassionate care?  Ask questions. Consider who might be the best direct care worker or nurse for a specific patient or patient population. In thinking about reframing or restructuring models to make the home the center of care, think of costs and the “true value” of person-centered, holistic care. This is especially true in hospice care, which I believe leads the models in truly person-centered care. Think of the healthcare world as you want it for yourself and your loved one. It may be a vision of the model where healthcare began – in the home.

For Further Reading
A Guide for Caregiving: What’s Next? Planning for Safety, Quality, and Compassionate care for Your Loved One and Yourself!  by Tina Marrelli

Handbook of Home Health Standards: Quality, Documentation and Reimbursement, by Tina Marrelli.

Home Care Nursing: Survival in an Ever-Changing Care Environment. By Tina Marrelli

Hospice and Palliative Care Handbook, by Tina Marrelli

No Place Like Home: A History of Nursing and Home Care in the United States, by Buhler-Wilkerson.

Nurse Manager’s Survival Guide, by Tina Marrelli.

People receive new hearts, lungs, livers, kidneys and corneas. Severed hands are reattached. But perhaps no transplant surgery heals severe physical and psychological injury at the same time like face transplantation.

Facial transplantation is the process of removing part or all of a donor’s face and attaching it onto a patient. It’s only performed for patients with severe facial deformities and significantly impaired function of facial structures. Skin, fat, muscles, nerves, tendons, cartilage and bone may be components of the transplant. Attaching nerves and blood vessels from the donor’s face to the recipient’s provides the potential (with extensive rehabilitation) for sensation, function and mobility similar to an uninjured face. In some situations, it may allow the recipient to regain the ability to speak, chew food, avoid ongoing use of feeding tubes, and regain his or her sense of smell. In other words, what it offers is a new lease on life.

Performing this type of life-changing surgery is one of the reasons Mayo Clinic’s Dr Samir Mardini got into medicine. In the summer of 2016, Dr Mardini was about to go on a well-deserved holiday with his wife and children when he got the call: A donor had been found.

The long-awaited surgery to give 32-year old Andrew Sandness a new face was about to become a reality. Dr Mardini abruptly cancelled the vacation and headed back to Mayo Clinic, where he would lead a large team of medical professionals who had spent three years meticulously planning and training for this procedure.

Sandness’s face was devastated by a gunshot wound more than 10 years earlier, and he had been receiving treatment at Mayo Clinic in Rochester, Minnesota. His new face would not look like his old one, but the donor’s facial skeleton (bony structure) was roughly the same size and shape as his, and the two men were close in age and skin colour, almost a perfect match.

“We had worked on creating a skull and facial bone structure that would be the ‘ideal’ for Andy based on his age, size and a CT scan he had a couple of years before his original injury,” said Dr Mardini, a plastic and reconstructive surgeon who specialises in reconstructing faces. “When we brought in the bones from the donor, we realised we could create the same height of the face, the same projection where the jaw is not too forward, not too back.”

Sandness’s care team was led by Dr Mardini and Dr Hatem Amer, the surgical director and medical director, respectively, for Mayo Clinic Essam and Dalal Obaid Center for Reconstructive Transplant Surgery.

The team numbered more than 150 people and included specialists from plastic and reconstructive surgery, transplant medicine, neurology, ophthalmology, dermatology, radiology, critical care, anesthesia, psychiatry, infectious diseases, immunology, pharmacy, regenerative medicine, nursing, social work, rehabilitation, rhinology, speech and language pathology and others.

The surgery itself was carried out by six plastic surgeons, one ophthalmologist and around 50 nurses and surgical technicians working for over 50 hours—one donor team and one recipient team.
The donor’s face had to be removed, and Sandness’s face had to be deconstructed before it would be reconstructed with a face transplant. Andy’s deformity would have to be enlarged to fit the donor’s face. There were three surgeons on the donor team and three surgeons on the recipient team, and Dr Mardini moved between the two. Everyone took breaks lasting one or two hours.

“Once we got the organs removed from the donor and placed on the recipient, then we had all six surgeons in one room and then the team could take real breaks,” says Dr Mardini.

Dr Mardini’s team developed the surgical plan for the cuts in the bone from CT scans of the donor and Sandness. The team used 3-D printing technology to produce 3-dimensional models as well as cutting guides. When they got to the bones in the surgery, they clipped those guides onto the bones of both donor and recipient, and the guides fit exactly where they needed to fit. Dr Mardini and his team were then able to pass the saw through little slots that made precise cuts in the right place and in the right angles on both the donor and the recipient so that the donor upper and lower jaws fit perfectly on Sandness.

“The virtual surgical planning and 3-D models allow us to make matching bone cuts on the donor and recipient so when the donor face is brought in and placed onto Andy’s defect it would fit perfectly,” explained Dr Mardini.

“You have to create a major defect to receive the transplant,” said Dr Mardini. “That's a very high-risk situation because after you've removed all the tissues that you plan to replace, the defect in the face is significant.”

3-D printing played another important role in the surgery. Once the team creates the defect on the recipient, they turn to a 3D-printed model of the donor's bones that had been removed—the upper and lower jaw, teeth and cheekbones. The team then fits that into the recipient’s defect. If it fits, they know the actual transplant will fit.

At the time of the surgery, there were six plastic and reconstructive surgeons and one opthalmologist who had trained so much that they were interchangeable. This was essential for a surgery lasting 50 hours.

Preparation was the key.

“There wasn't one person responsible for any one part of the surgery,” said Dr Mardini. “Everybody on the team was trained and ready to do any part of the operation.”

Consideration for the dignity of the donor and the feelings of the donor’s family are a critical part of the transplant experience , so the team wasn’t finished when Andy Sandness was wheeled out of surgery with his new face. The donor face was restored using complex facial prosthesis techniques so that at the end of the operation the donor was taken out of the operating room with a prosthetic face that looked almost identical to his own.

Before the surgery started, a team of anaplastologists (facial prosthetic specialists) took high-resolution pictures and made a mold of the donor’s face. They then worked for some 14 hours recreating freckles, wrinkles, hair, and different skin colors and contours of the donor’s face. They do this by putting 12 to 14 layers of paint, silicone and other material on the face until they get the result they are looking for.

“By the time we were done with our surgery, they came back with a silicone mold that looked almost identical to the donor, and then we sutured this prosthesis on to the donor, providing the family of the donor with a complete body and a face that was truly a match to the donor’s face” said Dr Mardini.

“ Our specialised teams of experts have a long history of providing complex care to patients who need hope and healing,” said Dr Mardini. “This is an extraordinary example of the teamwork, collaboration and compassion that we provide at Mayo Clinic, and I couldn’t be more proud of this team.”

While much of the investment in the past decade has been focused on building hospitals and primary care centers to address the growing healthcare needs of a rising population, there is a growing acceptance among healthcare regulators, investors and providers to look at models of care beyond curative services delivered in the hospital, and to focus particularly on preventative care, disease management and extended care which includes home-based health services. Much of the change in mindset is supported by evolving trends in delivery of health services in Europe, North America and South East Asia (more specifically Japan, Singapore and South Korea) which are seeing a rise in chronic disease prevalence, and a rapidly aging population, that has led to developing and implementing innovative models of care and changes in the care pathway which significantly reduces hospital admission, lengths of stay and thus the need for increase in hospitals. It has also helped many economies, particularly Germany and the Nordic countries in maintaining a less than 2% increase in health spending annually despite demographic changes and rising chronic disease prevalence.

The following three propositions could see rise investment within the next 4-5 years to help address the health services capacity gaps and improve access to highly efficient, coordinated care –

1. Urgent Care Clinics – Within the US and parts of Europe the urgent care clinics or walk-in clinics are a growing trend, and this model has remained popular in many developing countries in Asia and South America. They offer the advantage of being accessible, as the patient does not require a prior appointment, and are usually located in busy residential and shopping areas which is in close proximity to the patient population. The cost of treatment is inexpensive compared to a hospital setting or a specialized facility (between 40-70% cheaper based on various estimates), and these clinics are effective at treating injuries and illnesses that require an immediate attention (common colds, flu, minor respiratory ailments, minor cuts and wounds etc.), but do not warrant a visit to the emergency center. Growth in investment to set up walk-in clinics could help reduce the pressure on ER’s in acute hospitals and also help address the utilization of health services in more – expensive settings often leading to over – utilization of services and consultation with specialists which could be delayed and lead to higher costs. In the recent years, many large hospital systems and integrated health networks (IHN’s) in the US have set up urgent care clinics in communities they serve.
    
2. Ambulatory Care Centers – Ambulatory care is provided in an outpatient setting, with more advanced patient infrastructure compared to smaller urgent care clinics/ walk-in clinics, and is seeing growing attention and investment in Western economies particularly supported by innovation and advancements in health technology. The services at an ambulatory care center includes diagnosis, short stay observations, consultation, intervention (including day surgeries and minor procedures), and rehabilitation services. Ambulatory care centers are often equipped with advanced diagnostic infrastructure and laboratory services, and can perform procedures with the use of advanced medical technology. The NHS in the UK has moved a number of day surgeries and procedures out of the hospital, to be performed in an ambulatory care setting which improves access to patients, reduces waiting times and lowers costs. Cleveland Clinic and Mayo Clinic have set up ambulatory care centers, with some of these focusing on a specific condition or disease (e.g. respiratory or pulmonary conditions, obesity management, internal medicine etc) close to the catchment population they provide services to. They require lower capital investment, and can be adopted both in big cities served by large hospitals as well as smaller towns and remote areas, as the services in these facilities can be connected and supported by larger hospitals through telehealth solutions and applications. From the experiences in many countries, it has been seen that effective ambulatory care could help prevent the onset of chronic diseases (such as diabetes and CVD), control an acute episode, or can better manage a chronic disease or condition, and this could deliver a significant impact in the GCC region which is seeing a high prevalence and rising mortality from chronic diseases.
    
3. Beyond the Pill initiatives – Pharma companies and payers, driven by rising healthcare costs, disease burden and health technologies are embracing partnerships across the health ecosystem to deliver innovative solutions to patients which are aimed at better outcomes. The decades old business model which saw massive investment in drug development and sale of drugs by persuading physicians to prescribe their products, is beginning to see a considerable shift supported by a disruptive breed of innovators, who are developing applications and solutions that help improve coordination of care for chronic diseases and improve patient outcomes. Examples of this include, Livongo Health, who have developed a device which is the size of a mobile phone fitted with a cellular chip which monitors blood sugar levels for diabetes patients. Glooko is another application to support diabetes patients, and partners closely with Novo Nordisk, a leading pharmaceutical company, and IBM Watson, to gather data about patient compliance to medications and the impact of insulin medications. The health ecosystem continues to be reshaped by these health technology companies that use big data, sensors and AI for real – time remote monitoring of the patient’s conditions and trigger notifications and physician intervention where required to help manage risk factors. These could be particularly successful in the GCC region which has a high prevalence of diabetes and CVD patients, whose condition needs constant monitoring and coordination between specialists, nutritionists and fitness counselors, and this could help reduce the rising pressure on costs and health spending for health insurers and the governments.

While innovative and disruptive models need proactive investment facilitation support by regulators, it is imperative for the regulators to review policies and legislations that could enable the licensing of these facilities and applications, and encourage their roll out and set up to improve access to patient services for the community, also supported by health insurance coverage and inclusion in health insurers’ networks for facilities and applications providing these health services. 
 

Nearly one in five people in the Emirate have diabetes according to the International Diabetes Federation. Yet, according to healthcare specialists, the real worry is the burden of the numbers they do not know. Globally, 40 per cent of diabetes is undiagnosed and to understand its prevalence in Dubai, the DHA has collaborated with the Dubai Statistics Centre to carry out an emirate-wide household survey.

Dr Fatheya Al Awadi, Head of Endocrinology Department at Dubai Hospital, Chairperson of DHA Diabetes Committee, Vice President EDEC and General Secretary, Emirates Diabetes Society said, “Understanding the exact prevalence of undiagnosed cases is important for us to chalk out preventative and curative policies to combat the rise in the number of people developing diabetes. We are also been working on other extensive data that’s related to diabetes and this includes data on pregnancy and diabetes. By the end of this year, all DHA hospitals will have electronic patient files(Salama) and we will be able to know the exact number of diabetics across DHA health facilities as well as their co-morbidities and overall health profile.”

Besides focussing on data, the DHA also chalked out a series of initiatives in 2015. “We have a multi-faced strategy to deal with diabetes and we have carried out a series of initiatives over the last two years across the DHA to better the condition of those living with the disease and to educate the community about prevention and treatment methods,” said Dr Alawadi

Salama system across DHA hospitals

DHA has recently introduced the Salama Electronic Health Record, which will allow for uniform management diabetes across its health facilities so that every diabetic that visits a DHA entity receives the same level of diabetes care Dr M Hamed Farooqi, Director of the Dubai Diabetes Centre at the DHA said, “Unified multidisciplinary treatment for all patients is vital so that we control and manage effectively the sugar levels of our patients, ensuring that not only their diabetes is in control but also the complications that come along with the disease.  We have achieved on an average, one per cent reduction in the three-month average blood sugar levels of all patients- many of whom suffer from morbid obesity.”

Dr Farooqi said that, according to a UK prospective diabetes study, a one per cent reduction in the average three-month blood sugar levels means a 21 per cent decrease in the risk of developing any diabetes related complications and a 14 per cent reduction in the risk of having a heart attack. It also means a 12 per cent reduction in the risk of having a stroke and 37 per cent reduction in the risk of developing small blood vessel disease, including blood vessels in the eyes, kidney and feet.

Joint clinics: First-of-its-kind initiative in Dubai:
Dr Mohammed Hassanein, Senior Consultant Endocrinologist at Dubai Hospital and Member of DHA Diabetes Committee, said in 2015 that the DHA introduced joint clinics for diabetics with complications to ensure they receive highest level of multidisciplinary care in one location. He said the joint clinics provide an opportunity for diabetics to visit multiple healthcare experts at the same time rather than taking several appointments, which is time-consuming and inconvenient.

The joint clinic is the first-of-its kind initiative in Dubai. Dr Hassanein said, “For pregnant women who are diabetic, pre-diabetic or have gestational diabetes, we have a joint clinic so that they can visit their obstetrician and their endocrinologist at the same time.  This ensures excellent levels of multidisciplinary treatment and is time-saving.”

The clinic is available on a weekly basis at Dubai Hospital and on a monthly basis at Latifa Hospital. Similarly, the DHA also introduced two new joint clinics in Dubai Hospital. The first clinic is a joint clinic with nephrologists and endocrinologists for diabetics with kidney problems. This clinic will take place on a monthly basis. The second clinic is a bi-monthly clinic with thyroid surgeons and endocrinologists. Dr Hassanein said, “In the thyroid joint clinic, patients will undergo an ultrasound and biopsy on the same day and within two weeks they will receive a treatment plan which is based on inputs from multidisciplinary medical experts.”

Dr Hassanein said that feedback from patients has been very positive, it is extremely convenient for patients and importantly, it has reduced the number of admissions to hospitals due to diabetic complications.

Diabetic training for DHA doctors and nurses.
Recently 25 DHA nurses and doctors working in primary and secondary care completed their master’s degree with Cardiff University in the UK in diabetes management. The DHA has collaborated with the university to provide diabetes diplomas and master’s degrees to DHA medical staff members.

Diabetes Transition Care Program for Young Adults:
Dr. Al Awadi said paediatric patients with diabetes are moved to the adult clinic when they are 13 years of age. To ease this transition, DHA will introduced soon a joint clinic with paediatric endocrinologists and adult endocrinologists so that young adults are comfortable in their new healthcare environment.

Diabetes app available: Hayati.
In addition to these initiatives, the DHA launched in the last quarter of 2015, a diabetes app to educate diabetics on better management of their condition.  Dr.Al Awadi said, “The DHA is keen to provide the highest level of care to diabetic patients and we will continue to roll out such initiatives which provide patients with convenience and ensure better patient compliance and outcomes.”

Every man has his own Waterloo; and healthcare leaders are no exception.

Leadership is perhaps the most written about topic in management. With so much available on the topic, we still see a dearth of true leaders across industries, including healthcare.

Effective leaders can direct healthcare organisations and groups to deliver on their promises to their patrons and patients. Complex as it is, the healthcare ecosystem needs leaders that can bring the diverse workforce together and infuse enthusiasm and a larger purpose. The challenge amplifies when you see a perpetual rift amongst the various internal stakeholders in the healthcare ecosystem. The doctors, management, nurses, technicians, support staff, outsourced staff, etc., all form a part of a complex jigsaw puzzle. Effective leadership is the only way to ensure that all participating entities deliver collaborative service at the ground level.

Working with numerous leaders over many years, we have seen a wide range of styles and personalities amongst people who lead healthcare organisations. Each is fascinating and intriguing in its own regard.

As a famous management guru once said, ‘To change the direction of an organisation, change its leader[s].’ It can also be concluded with considerable certainty that change initiatives and execution failures can be attributed mostly to the lack of effective leadership and unity at the top level.

What causes leaders to fail? Why does the CEO or the managing director, who are supposed to steady the ship, sometimes end up raking it beyond repair?

There are several traits that the boards and promoters need to watch out for among their leadership teams. After all, the most crucial investment that directly determines business results is the investment in leaders. Years of experience have led to a list of traits that create unsuccessful leaders:

Prisoners of the Ivory Cage: These are the leaders who walk into the office every day and seldom walk out of it before the day ends. They remain glued to their chairs and spend the entire day in the same room. Needless to say, they are poorly connected to reality and do not have a lot of hands-on knowledge of their organisation. They can’t leave their comfort zone and meet the waiting patients, nurses and doctors. Majority of these leaders are introverts and do not have deep relationships with their peers and subordinates. They hide behind the screen of the desktop and remain confined to the ivory and wood of the plush office.

Turf Warriors: This breed of leaders is persistently attempting to wrest power. They usually have a set of people loyal to them. The inner coterie they have includes informers and advisors on how to grow the influence and power for their ‘gang’ within the organisation. Most of the close advisors also have their own agendas and self-interests that they promote through the leader. Often, the organisation gets divided into clusters, each trying to claim victory over the others.

You witness abrupt changes in roles, and reporting of managers is common. This derails execution and strategy before any results are achieved. Eventually, the organisational goals are quickly replaced by individual agendas. Politics and manipulations rule the day, and the organisation suffers.

Walk Over the Conflicts: Organisations are wired for conflict. That is the very nature of any enterprise where people work together to achieve pre-set objectives. However, many leaders prefer to walk over the conflicts and do not deal with them head on. They think that the conflicting parties will resolve it themselves and that they are too busy to play the ‘agony aunt’ role. We recently met a hospital CEO who said he doesn’t want to bring the skeletons out of the cupboard and he expects the people to manage this aspect on their own. He said that, in his opinion, everyone on the team is a professional and they should handle these kinds of situations on their own. What he forgets is that the two department heads are also human beings with egos and fears. There is a lot at stake if the two factions do not unite. The performance of the leader and, hence, the hospital he leads depends upon how united the department heads are for the common cause.

On a Mission Without a Vision: These are workaholics but without any direction. They do a lot of work affecting the short term, but have failed to create a mid- and long-term direction for the organisation. They want to do everything under the sun, even if it is not remotely connected to organisational growth.

The day is packed with a lot of action. Back-to-back meetings and a lot of talk takes place daily. Everyone seems to be in a hurry to go somewhere. People stay back long after the office hours are over and make their teams stay back as well. You may get emails from them as early as 6 a.m. or as late as midnight. The fallacy that they will take the organisation far is soon broken when people realise that most actions are not connected to any long-term plan. There is no end goal, only directionless actions.

Megalomaniacs: These are the leaders concerned only with the glamour and fame that comes with leading a bunch of people. You can sit with them for hours and listen to the stories of their heroic exploits. They are on a never-ending journey of proving how great they are. ‘Me’ is the only topic that they seem to discuss. This behaviour springs from deep-rooted insecurity. The feeling of ‘I am not really good enough’ works overtime in the background as the person tries to prove how great he or she is.

These leaders try to make headlines in the trade publications. We know of some healthcare CEOs who unabashedly forward their press coverage and conference photos to a long list of contacts on Whatsapp. One look at their social media and you can easily conclude if the leader falls in this category. The organisations that these people lead do not usually have a strong second line of leaders. Moreover, you will often see organisational objectives being sacrificed for the benefit of this individual.

Bring Me the Yes Man: You can see these leaders surrounded by a group of sycophants all the time. They sing praises about the leader and agree to everything that he says, even if it means that they contradict themselves. The leader gives in to flattery and allows his judgement and decisions to be clouded. Any criticism is met with rejection and even scoff. People who ask questions are soon removed, under one pretext or another. People with low self-esteem usually give in to the flattery and want to be praised. They can never make good leaders.

Impatient: Some leaders do not seem to have time to wait for anything. Although there is little time to get things done in the corporate world, most management actions require deep thinking and prior analysis. They hire the wrong doctors, promote the wrong administrators, buy the wrong equipment at the wrong terms and open facilities in wrong places, just because they do not think anything through. Some of these decisions can cost the healthcare organisation heavily, and some of the losses can be irrecoverable. In short, someone who wants everything done yesterday jeopardises the tomorrow of the healthcare organisation. 

Denial Mode Leader: At the other end of the spectrum is the leader who sits on decisions in perpetuity. He never decides anything, thereby delaying all action. These leaders are very good at giving reasons and justifying things. They keep mulling upon numerous ‘what-if’ scenarios. They are also good at giving you the run around if you want something to happen. Soon the teams realise that nothing is going to move forward. They either keep pace with the leader or they go away.

Day Dreamers: Occasionally, we have come across leaders who live in a fantasy world of their own. They are not bothered by anything that might have a bearing on the future of their organisation. These people are usually very intelligent and have a good creative instinct, but all of that is pointed in the wrong direction. They are mostly busy with unrelated thoughts about the future. The dreams may range from buying the next-generation equipment (which is irrelevant anyway) to changing the organisational structure (which was just changed a few months ago).

 About-to-be-stabbed Syndrome: In other words—paranoia. This was known as the disease of the kings. Many rulers would spend a lot of energy tracking down real or imaginary assassins and plotters. Some leaders in healthcare and other industries are victims of the same syndrome. They are always on vigil, often at the cost of the organisations’ growth and efficiency. Most of the productive time is spent seeking out often non-existent conspirators.

The next generation of leadership is either non-existent or becomes stagnant under these leaders. They do not encourage career growth of their juniors, and are poor trainers and guides. As a result, people do not look up to them for direction. Most of them, in the end, fall prey to what they had always feared—conspiracy. Eventually, the board has them removed for lack of performance.

I Know it All: We call it the IKIA syndrome. This is very common, especially in healthcare. Some victims of this syndrome are highly qualified doctors who land in management leadership roles. The main damage is done not only by limited knowledge, but by the resistance to learn anything new. They are dismissive of anything that will add value by saying that they already know it. Poor listening costs dearly, not only in terms of organisational growth, but also in terms of relationships at work.

If you are leading a hospital or a healthcare group, please consider whether you fall under any of these categories. Most people will find some faction of the above-listed elements in their leadership styles. If you find yourself saying, ‘I don’t fall under any such category and I am doing perfectly fine,’ you may be heading for a pitfall.

The path to victory begins with awareness and we invite you to look into your patterns of managing people, irrespective of your job title. There will be enlightened leadership at the end of the tunnel for all of us.

What are Probiotics?

Probiotics are living microorganisms, including bacteria that affect human health in a beneficial way. The World Health Organization defines probiotics as “live microorganisms which when administered in adequate amounts, confer a health benefit on the host.” They are found in the human body, most often in the gut, where trillions of them exist in unique populations. Probiotics vary in terms of the different types, amounts and exact location within the human body. The probiotic bacteria act in several ways to enhance health. These include, but are not limited to, effects on food absorption, immunity and levels of inflammation. Probiotics can also be found naturally in certain foods such as yoghurt but are also sold in more concentrated formulation as dietary supplements to be eaten or applied on the skin or mucosa of the body.

What are the differences between Prebiotics and Probiotics and Synbiotics?

Prebiotic is basically a non-digestible plant fibre which acts a carbohydrate food source for probiotics. Prebiotics are the food source for probiotics. The most common type of prebiotic is inulin, a product found in naturally occurring foods like oats, soybeans, banana, leeks and asparagus as well as onions, garlic and chicory. On the other hand, a probiotic is a live microorganism that can improve human health. The final term, synbiotic is used to describe a product that is a combination of a prebiotic and a probiotic. Theoretically it has been suggested that synbiotics may offer more benefit than just taking a prebiotics or probiotic but the evidence is quite scanty.

Can a Normal Diet Supply Probiotics?

Today, just as in the past, people can nurture and partially modify their gut bacteria by using certain foods. Even though yogurt is the most common probiotic-carrying food, other food sources can have probiotics. These include natural sources, often derived from fermentation practices, such as yogurt, kefir, kombucha, kimchi and raw unfiltered apple cider vinegar, cheeses, miso, and buttermilk. Interestingly, the benefits of fermented food have been known about for over 5000 years in human society. In addition to natural sources, many foods such as cereal, juices, smoothies, nutrition bars are supplemented with probiotics because of their potential benefits.

What Bacteria live within our Gut?

Before explaining how probiotics work it is important to understand the complexity of the bacterial population in the gut. The bacteria (microbiota) that live within the gut are known as the “intestinal microbiome” and we have been living (usually in peaceful coexistence) with these bacteria for thousands of years. We already know that the human microbiome is an incredibly complex ecosystem with significant diversity. In fact, it is fair to say that there are over 500 different bacterial species that make up 100 trillion microorganisms weighing up to 2kg in each human being. So specific is this mixture in each human being that it is akin to a unique genetic fingerprint. And not unsurprisingly, the person to whom you owe most in giving you a unique set of gut bacteria is your mother as the bacteria are transferred from mother to baby during normal vaginal delivery.

How do Probiotics work?
Probiotics works by replacing, restoring and or altering the complex populations of living organisms that already live within the gut.
We also know that certain diseases have, as one of their causes, dysregulation or imbalance in the billions of multiple bacterial organisms that live within the human gut. This dysregulation/imbalance may contribute to diseases in multiple ways, either directly by actions on the lining of the gut, or indirectly by the signals and interactions they have with the body via the gut wall.
Probiotics can help by modifying the bacterial population so that they more resemble the pattern seen in the gut of a healthy person. Transplanting different bacterial populations into the body alters the balance of the existing bacteria and this change can lead to an improvement or resolution of disease.

What are the Different Strains of Probiotics?

The many different strains of probiotics are usually identified by their Latin names. The most common probiotic you may have heard of is called Lactobacillus. Other common names include strains like Bifidobacterium, Enterococcus but many others exist as well. Interestingly, each of these strains may have one or more different subtypes. For example, in the Lactobacillus family, Lactobacillus exists in over 150 different species including Lactobacillus acidophilus, Lactobacillus bulgaricus, Lactobacillus casei ss. casei, Lactobacillus fermentum, Lactobacillus helveticus and Lactobacillus plantarum. Studies have demonstrated that different probiotic strain subtypes have different effects in combating disease and promoting human health.

What Diseases can be affected by Probiotics?

Many diseases can be affected by probiotics ranging from antibiotic related diarrhoea, vaginal yeast infections and urinary tract infections to Irritable bowel syndrome and the prevention or reduction in the severity of colds and flu. But there are many more conditions where probiotics may be useful including the management of eczema, obesity and even Alzheimer’s disease!

Can Probiotics help in Managing Obesity?

In 2014, Chinese researchers discovered that in a preliminary trial involving different diets in 93 obese volunteers, those volunteers fed supplements that included prebiotics (a precursor to probiotics) lost around 5 kg on average over a 9-week period. In another study, 125 obese subjects were split into 2 groups. Half of the subjects were given the probiotic Lactobacillus rhamnosus as part of the weight loss diet over 12 weeks and half were not given the probiotic. This 12-week period was followed by another 12-week period aimed at maintaining body weights. The study results found there was a greater average weight loss in women who received the probiotic compared to the women who did not receive the probiotic. Moreover, the change in body weight persisted in the second 12 weeks when the diet was no longer followed!

Other kinds of information lend their support to a relationship between gut bacteria and obesity. For example we know that in people who are overweight or obese there is less bacterial diversity seen in the gut than in the normal weight subject, and we also know that antibiotic usage and dietary modification can alter the characteristics of the gut bacteria. Put together, the current research helps support a relationship between the intestinal microbiome and obesity.

How Can I choose the Best Probiotic?

Choosing the best probiotic is often challenging because of the wealth of incomplete information and because of the preponderance of unsubstantiated claims made by some manufacturers. Not everything that is published on the web is true!  Nevertheless a few general principles should guide choice. The first port of call should be checking high quality patient information portals like NHS Choices from the UK and NIH MedlinePlus in the USA and more scientific websites such as NICE (National Institute for Clinical Health) or the Cochrane Database. These websites can help sort the wheat from the chaff when deciding if a probiotic works or not in a medical condition.

Once you have decided to use a probiotic, other criteria can help inform your choice. These include product quality, a term that encompasses the source of the probiotic as well as manufacturing and storage issues. Generally speaking it is best to pick a probiotic with a high count of colony forming units (CFU Count) such as 15 to 100 billion as well as a probiotic that contains a cocktail of strains (between 10 and 30). Another thing to consider with probiotics is their survivability with some higher quality probiotics requiring cooler storage temperatures to optimise their survival. Last, but not least, the amount of validated research and evidence should be considered when picking a probiotic.

The Bottom Line

It is eminently clear that probiotics have a part to play in the promotion of human health given their long use over human history. In addition, the scientific advances made in human DNA sequencing and understanding human genome as well as the advances in understanding the intense “crosstalk” between the human body and the gut bacteria has led to a much better understanding of how to modify human health and disease by targeting the gut bacteria. Although we know that gut bacteria are important and that probiotics can alter their composition and function, there is still a lot of detail that needs to be discovered to allow us to use probiotics in a targeted precise way that will optimise their potential. The race is on to find the best combinations of probiotics for specific diseases in the realm of personalised targeted medicine – a race that is worth billions of dollars.

Dr Nigel Umar Beejay is the Chair of the Gastroenterology Conference track at the 2018 Arab Health Exhibition and Congress.

“We are what we repeatedly do. Excellence then, is not an act but a habit.”

- William Durant

Surgery is a demanding career with great rewards and equally great challenges. In order to sustain our careers as well as the careers of our colleagues, it is important to understand and address the physical, psychological and spiritual challenges of surgery. With rare exception, the majority of surgeons who prematurely leave surgery do so because they find the work to be physically, emotionally or spiritually incompatible with the vision they have for their life. Understanding these issues and providing solutions to improve surgeon wellness can help prevent societal loss of these highly trained professionals and suffering for surgeons and their families.

“In the classic training program, we have taught how to perform surgery, but we have not taught how to live as a surgeon.”

- D Campbell

Although many surgeons truly love their work, 60% of surgeons would retire if they could. The average age for leaving the practice of surgery is less than the expected age of 65 and has been reported to be as low as 57.  This exodus of practicing surgeons is a loss to society, particularly given the significant shortage of surgeons worldwide. It also reflects tremendous personal loss since the most common cited reason for early retirement is burnout. Four dimensions play an important role in understanding the challenges surgeons face and developing strategies for a rewarding career in surgery.

1. Physical well-being

Some illnesses that limit a surgical career are unexpected and not preventable, but others are easily detected and effectively treated with appropriate use of healthcare services. More than 25% of surgeons over 50 fail to schedule a screening colonoscopy, cardiac exam, and, for the men, a prostate examination.

“Sadly, a surgeon can much more easily obtain a detailed ergonomic assessment and direction for improvement of his or her golf swing than of his or her surgical “stance” or movement.”

- A. Park

Performing surgery is physical work and therefore has associated specific work-related injuries. In general, the factors that increase the risk of musculoskeletal injury are awkward body posture, frequent repetitive movement of the upper extremities, and prolonged static position. The focus required during surgery results in particularly long periods of time in a static position, greater than that is seen in most other professions.  

There are also numerous design issues that contribute to the ergonomic stresses of surgery. Primary among them is that the operating room design has not significantly changed in the last 50 years. Most operating room tables were designed for open procedures. They are adjustable between 72.5 and 121.5 cm, and therefore do not go low enough for an ergonomically appropriate position for minimally invasive procedures, particularly if the patient is obese.

The instruments and monitors used for minimally invasive surgery can also be problematic as they were initially modified from instruments used by otolaryngology. For example, the traditional “tower” configuration of monitors used in otolaryngology is a significant ergonomic issue for minimally invasive surgeons since the screen should always be in front of the surgeon and not to the side. Not being able to move the monitors to this position increases the risk of neck injury.

The handles for instruments used in minimally invasive surgery come in only one size, compared with eight sizes of surgical gloves, a fact that creates issues for surgeons with smaller hands (glove size ≤ 6.5). In addition to being an awkward size for many surgeons, instrument handles often require non-ergonomic motion, particularly for surgeons with smaller hands.

Finally, because of length and other design requirements for laparoscopic instruments, 4 to 6 times more force is required to use these instruments when compared to instruments used in open surgery. The lack of smaller instruments and this need for increased force places women at particular risk for instrument-related ergonomic injury. Solving these ergonomic design issues requires collaboration between manufacturing companies, engineers and surgeons, a process that is now underway.

Exercise plays a particularly important role in the prevention and treatment of musculoskeletal pain from ergonomic injury. Of all forms of exercise, strength training is shown to have the most improvement in musculoskeletal pain in the first two months of exercise, which continues to improve with continued exercise, and persists over time. Yoga, Tai Chi and Pilates may be particularly good exercises for surgeons since they require core strength through rotational movement. The role of exercise in maintenance of health cannot be over emphasised.

Sleep deprivation and chronic sleep restriction are major contributors to poor health and loss of well-being. For surgeons who take a call and experience sleep deprivation, the issue is not only loss of sleep, but an inability to “catch up” on lost sleep. Adults require 8 hours of sleep a night, with only a small percentage who do well with 7 hours of sleep. However, 60% of surgeons reported an average of less than 6 hours of sleep per night, resulting in chronic sleep restriction. Being on call and working the next day was the norm for previous generations, but based on these data this schedule may not lead to optimal patient care. The use of caffeine to counteract sleep deprivation may also be problematic, since increasing amounts of caffeine can negatively affect surgical performance.

“Surgeons share an unwritten but understood code of rules, norms, and expectations. This code includes coming in early and staying late, working nights and weekends, performing a high volume of procedures, meeting multiple simultaneous deadlines, never complaining, and keeping emotions or personal problems from interfering with work. These are hallmarks of dedicated professionals that should be celebrated and rewarded. However, there is a fine line separating dedication from overwork; if unchecked, overwork could lead to counterproductive, unhealthy, or even self-destructive behavior that may affect patient care.”

- CM Balch

2. Emotional well-being

Practicing surgery is not easy, and most who choose to be surgeons know and embrace this fact. The act of operating on another human being is stressful, and requires psychological fortitude as well as skill. As a result, the surgeon-patient relationship is unique, and results in deep and special bonds with patients. The surgeon-patient bond is accompanied by a strong, culturally reinforced sense of responsibility. The unspoken implication is that surgeons are responsible for all that happens after a procedure and therefore should be available at all times. Unfortunately, as a result, those who seek time to rest or are suffering for any reason (physical, psychological or spiritual) often feel that they are somehow “less”.
Additional stressors for practicing surgeons include medical errors, adverse outcomes and malpractice lawsuits, all of which are associated with an increased risk of burnout and depression. In these situations, the surgeon inevitably becomes a “second victim” as a result of emotional trauma.

This trauma adversely affects the ability to work, particularly in the areas of memory, recall of knowledge, and attention. Becoming a “second victim” is not an uncommon situation. All physicians experience errors and adverse outcomes. 42% of all physicians will be sued during their career, a number that increases to 90% for surgeons. Focus therefore on emotional integrity by protecting and nurturing important relationships; use debriefing strategies with trusted friends and family after stressful events; and seek professional help for symptoms of depression or anxiety.

3. Burnout

“Burnout” is characterised by a combination of losing enthusiasm for work (emotional exhaustion), viewing and/or treating patients and colleagues as objects (depersonalisation) and nurturing the feeling that others could do your job better than you (low personal achievement). Burnout occurs in all specialities, but is particularly prevalent in the surgical specialities with up to 42% of surgeons meeting the criteria for burnout. The incidence of burnout for all physicians has increased over time, which can be attributed in part to changes in the delivery of medical care which have increased job stress without increasing job satisfaction.

All physicians will experience some or all of the components of burnout during their career. The key is to recognise these symptoms when they occur and intervene quickly and effectively. The first step, which may fly in the face of surgical culture for many surgeons, is to acknowledge this is real, and not a sign of personal failure. Individuals can then experiment with different interventions and strategies for physical, emotional and spiritual self-care.

It is important to not be isolated; “Human beings heal by telling stories.” Having a safe space to “debrief” by sharing the events of the day cannot be overemphasised as a tool in preventing and treating burnout. Therefore, protecting and nurturing close relationships at and outside of work is an essential component of physician self-care. Mindfulness, other meditation practices and/or religious practices are also effective tools in preventing and treating burnout. Physicians who practice mindfulness and learn mindful communication show improved overall burnout scores as well as improvement in each of the three domains of burnout (emotional exhaustion, depersonalisation and achievement).

“Burnout is not a problem of people but of the social environment in which they work.”

Our goal as a profession should to be identify personal or career limiting issues in our colleagues and ourselves early enough to prevent suffering and, if not recognised, true tragedies. We should also work together to change our environment and our culture to promote and encourage self-care and health.  

4. Spiritual well-being

Human beings have a need for meaning in their life and their work. Spirituality provides the context for that meaning, and is an essential part of human wellness. Burnout, often described in emotional terms is also a spiritual malady, “a deterioration of values, dignity, spirit, and will.” The importance of spirituality is recognised by surgeons. Along with protected time for relationships, surgeons rank meaning in work and “focusing on what is most important in life” as the most essential strategies to promote wellness. The perspective gained and tools learned through a spiritual practice allow physicians to gain control by changing their perspective, which may be the single most powerful antidote to physician stress and burnout. Developing a spiritual strategy to deal with the pressure and stress of work can lead to seeing work as not a place where energy is expended, but a place where renewal can occur though the meaning and challenges encountered every day.

The importance of true rest, not just for physical recovery but as a spiritual practice, cannot be overstated. Taking a full day, or even a half-day, to just play, rest, and relax is amazingly restorative. Taking a “digital time out” can be an important part of recovery from work. The constant stimulation of the digital world we live in can compound the stress we feel at work. Finally, taking the vacation days that you are given should be considered important ways to improve spiritual well-being.

The practice of surgery offers the potential for tremendous personal and professional satisfaction. Few careers provide the opportunity to have such a profound effect on the lives of others and to derive meaning from work. Seen through the lens of spiritual self-care, times of stress can be viewed as a moment to step back, an opportunity to evaluate priorities or even a time of professional growth. In this context, a bad day (or longer time period) is not necessarily a sign of burnout, but may be a sign to focus on renewal.

Conclusion

The art of surgery requires surgeons to be physically, emotionally and spiritually sound. Surgeon well-being should therefore be both an individual and institutional priority. Individually, surgeons should consciously develop plans for well-being that incorporate aspects of physical, emotional and spiritual self-care. Surgical groups should develop curricula and ensure that the principles and practice of self-care are taught and understood. These principles include attention to routine health care, exercise, healthy food, ergonomics, sleep and adequate rest as well as the presence of trustworthy friends to share struggles and joys.

Institutions should develop proactive plans to support personal wellness such as insuring comfortable places to rest, eat and talk and providing healthy food in the workplace. All surgeons and administrators should work to develop policies and a culture that recognises the importance of appropriately limiting time in the hospital, supporting individual efforts at self-care, and providing the time for genuine renewal.

These are the eternal duties of a Physician: First … to heal his mind and to give assistance to himself before giving it to anyone else— Epitaph of an Athenian Physician, 2AD

By adhering to this advice, a surgeon could achieve clarity of purpose and focused attention—the essence of excellence.

Professor Ali Al Dameh is the Conference Chair of the Surgery Conference scheduled to be held from 29th January to 1st February 2018 at the Arab Health Congress.

During the past decade, we have witnessed a paradigm shift in the use of radiology in medical practice. While radiology continues to provide a cornerstone of advanced diagnostics and quality care, increasingly, medical imaging is being used for follow-up and monitoring a large spectrum of medical conditions. Thanks to the development of new technologies, we have entered into an era in which imaging techniques contribute to our fundamental understanding of physiological processes in health and disease. In particular for disorders of the central nervous system, new imaging and post-processing techniques (perfusion imaging, diffusion weighted imaging, diffusion tensor imaging, diffusion kurtosis imaging, spectroscopy, etc), have made a significant impact on clinical patient management, therapeutic decision-making, and outcome prediction.

But, despite cutting-edge scientific developments and expanded clinical applications, radiologists still rely mainly on visual assessment (“eyeballing”) to interpret radiology examinations. The traditional process of “visual image interpretation” by radiologists has remained essentially unchanged for over a century. And while this approach may be more or less ‘good enough’ to suggest an initial diagnosis, it is definitely not acceptable for the interpretation of follow-up examinations. Radiologists encounter great difficulties when comparing current images with previous studies. It is extremely difficult to accurately assess subtle changes from one examination to the next (for example in the shape, size and structure of a tumour). This is due to variations in patient positioning, sequence, equipment, protocols and parameters, window settings, etc. In addition to these technical limitations, visual assessment is also prone to subjective interpretation variations, failures of perception, lack of knowledge and human error. These factors lead to significant inter-observer, and also intra-observer variations in the visual inspection of imaging data.

Fortunately, things are changing, due to the introduction of “imaging biomarkers” in research and, even more importantly, in daily clinical practice. The word “biomarker” implies a measurable parameter that can be used as an indicator of a particular disease or some other physiological state of an organism. In a “white paper”, the European Society of Radiology (ESR) stated that the development of new imaging biomarkers has a high impact in terms of patient management, assessing risk factors and disease prognosis. In particular, “imaging biomarkers” are of great value to extract quantitative, objective, reproducible parameters, thus improving the value of imaging in clinical practice.

The advent of imaging biomarkers to clinical neuroimaging is a game changer. They provide innovative ways to explore new research avenues, and approach clinical questions. Both the pharmaceutical industry and the regulatory bodies are increasingly relying on imaging studies to provide surrogate end points in clinical trials (a surrogate end point is defined by the National Institutes of Health as “a biomarker intended to substitute for a clinical endpoint”). It is important to find out what works, and what doesn’t, quickly, cheaply and efficiently. Quantitative imaging biomarkers are helping drug companies to make “go/no-go” decisions about new products; in many cases, this obviates the need for more expensive and time-consuming exploratory trials, and it saves time and money. Healthcare is progressing towards evidence-based and personalised medicine, and doctors are rapidly adopting decision-support tools, all of which require the input of quantitative data and objective metrics.

There is a strong need for objective biomarkers in clinical practice. Basically, any feature that can be detected on an imaging study can now be used to quantify specific biological processes. Examples of quantitative neuroimaging biomarkers include: volume measurements (hippocampus, gray matter, whole brain, etc), apparent diffusion coefficient (ADC), fractional anisotropy (FA) or mean diffusivity (MD), cerebral blood volume and flow (CBV & CBF), etc. Radiologists are adopting imaging biomarkers in combination with advanced image processing techniques. Table 1 shows an overview of clinically relevant biological parameters and the quantitative imaging tools to study them.

Table 1. Overview of quantitative imaging techniques
Type of information		Acquisition technique	Imaging biomarker
Anatomical	CT, MR		# of lesions, volume, (local) atrophy, …
Structural	DWI, DTI		cellularity, axonal/myelin damage, …
Functional	fMRI, rs-fMRI		(task specific) brain activation
Dynamic	perfusion MRI (DSC, DCE), ASL, perfusion CT		vascularity, CBV, CBF, MTT, capillary permeability, …
Molecular	PET, SPECT, MRS		receptors, metabolism, biochemistry, …

Multiple Sclerosis as a model for the rational use of MRI Biomarkers

To illustrate the growing importance of neuroimaging biomarkers, let us focus on patients with Multiple Sclerosis (MS). When doctors need to compare MRI examinations of the same patient, obtained at different time points, from different institutions, on different MRI machines, it is nearly impossible to accurately detect changes in the number of white matter lesions (‘lesion load’), or to identify and count new and enlarging lesions. It is like trying to count the black spots on a Dalmatian dog running at full speed. Moreover, in addition to changes in the number, shape and activity of demyelinating plaques, the brains of patients with MS also undergo subtle modifications in brain volume. These small changes are impossible to detect by visual inspection, and yet, they have important clinical consequences. Fortunately, today, for patients with MS, imaging biomarkers provide the neuroradiologist and neurologist with key information on how the disease is progressing and whether the patient is responding to the treatment. Several imaging biomarkers, such as volumetric assessment of brain structures (tissue segmentation), have been shown to have excellent sensitivity and specificity for diagnosis or prognosis of various neurological diseases.

A prerequisite for the adoption of neuroimaging biomarkers is standardisation of image acquisition, data processing and analysis and image interpretation (i.e. generating a report). MRI protocols and sequences must be reproducible, accurate and sensitive; quality assessment should be an integral part of this process. Methods used for analysis should be adequate and observer-independent. Ideally it should be possible to compare a biomarker in a single patient to a healthy control group (reference values). The key words in this chain of production are “standardisation” and “validation”. Individual radiologists need to rely on computers, which are able to handle large data sets, perform centralised analysis and automated quantification.

Neuroimaging biomarkers for measuring volumes and changes in volume

Two types of neuroimaging biomarkers can be distinguished: cross-sectional and longitudinal. In the cross-sectional approach, we extract and measure volumes in a 3-dimensional MRI dataset of a single subject. The volume of the whole brain, or part of the brain (grey matter, white matter, cerebrospinal fluid, hippocampus, …), can be computed through segmentation techniques. These methods rely on “segmenting” brain tissue from the surrounding scalp and other extracerebral tissues. The probabilistic modelling of voxel intensities exploits the fact that different tissue types have different MR image characteristics. Volumes in millilitres for each class can be computed, by simply multiplying the sum of the tissue segmentation over all voxels by the voxel volume. For example, in patients with MS, it becomes possible to perform volume measurements of, for example, total brain volume or FLAIR white matter hyperintensities.

Longitudinal neuroimaging biomarkers take into account two (or more) MRI scans of the same subject, obtained at different time points, to calculate volume changes in brain volume. This makes it possible to evaluate MS patients for progressive brain shrinkage (atrophy), a parameter reflecting neuro-axonal and myelin loss, and which is increasingly being used as an outcome measure in MS treatment trials. Longitudinal methods for brain atrophy typically match two MRI scans using registration techniques and directly extract small changes in brain volume from this process. A similar approach can be used for the longitudinal segmentation of white matter lesions.

Adding quantitative MRI biomarkers takes clinical neuroimaging to the next level. But in order to successfully introduce quantitative biomarkers in the clinical imaging pipeline, several important elements should be taken into account:

1. Accuracy and reproducibility: Many software applications offering cross-sectional brain volume measurements, based on a single MRI scan, have errors in the range of 1 – 1,5 %, which is too much if the expected yearly rate of volume loss is far less than 1%. In other words, measurement errors should be small enough to be reliable in individual patients, and the results should be clinically meaningful. Fortunately, there are now certain softwares such as MSmetrix (CE marked) or icoBrain (FDA cleared), which were developed especially for monitoring MS and provide measures for atrophy and lesion load with measurement errors as low as 0,13% for whole brain atrophy. It is only when measurement errors are so low that meaningful conclusions for individual patients can be drawn.

2.  Scan time is money. Currently, the average MRI protocol for MS patients represents about 20 to 35 minutes of scan time. Typically, such an optimal scanning protocol would include a 3D-FLAIR sequence, diffusion-weighted imaging, T2-weighted sequence, 3D-T1-weighted images before and after Gadolinium-chelate injection. Biomarkers will only be successful if they can be derived from the standard imaging protocol for MS, without the need for additional (lengthy) sequences.

3. Integration into the standard workflow: The idea is that biomarkers should help doctors, and not generate extra work. Radiologists and neurologists alike don’t have time to perform additional post-processing for every patient. Ideally, the post-processing should be linked to the patient informatics, to automatically generate reports that include biomarker information about the lesions and cerebral atrophy. The radiologist should report back to the neurologist, qualitatively if not quantitatively, about the lesion status and the atrophy of MS patients, covering the following points: comparison with previous scan(s); evidence of new disease activity; number of new lesions (T2/T1); lesion size; overall assessment, including presence (definite/probable) and extent (number of new/enlarging lesions or gadolinium-enhancing lesions) of disease activity; change in T2 lesion volume; and evidence of brain atrophy.

How to transmit this information to the clinician

Today, MRI biomarkers are already an important factor for making therapeutic decisions. Efficient patient follow-up requires effective and consistent communication between the neurologist and radiologist. Unfortunately, most MRI reports are still written in prose, and do not make use of the full potential embedded within the MRI data sets. I strongly believe that communication regarding MRI findings between the (neuro)radiologist and the neurologist can be improved with automatically computed, quantitative values for the relevant imaging biomarkers. To this end, the (neuro)radiologist should have easy access to approved tools for calculating these biomarkers. Furthermore, when following the evolution of changes in an individual patient, comparisons could be made of biomarker values against relevant populations (e.g., healthy controls, MS patients that respond well to therapy, etc). Obviously, relevant confounding factors (such as age and sex) should be taken into account.

Conclusion

The introduction of (neuro)imaging biomarkers has led to a significant improvement in the diagnosis, management and follow-up of patients with MS. Standardisation of MRI acquisition protocols, and improvement of quantitative reporting tools provides a better understanding of the natural history of MS, and allows accurate treatment monitoring, for the greater benefit of patients.

Three-dimensional (3D) printing has significant advantages over other imaging techniques because it can represent anatomical structures inside the body. As the complexity of procedures in medicine has increased and become minimally invasive, the need for realistic representations of human anatomy is becoming increasingly important. The heart is a complex organ which has valves, chambers, and vessels of which, especially in congenital heart disease, can be difficult to represent using conventional imaging techniques. 3D printing can be used for surgical planning, patient education, and student teaching. 

Creating a 3D printed model first starts with 3D data sets usually obtained by computed tomography (CT), magnetic resonance imaging (MRI) and 3D echocardiography. This initial step called “segmentation” allows specific heart and vascular imaging information to be extracted from the original raw data, which comes in Digital Imaging and Communication in Medicine (DICOM) format. Unfortunately, DICOM files cannot be utilised by 3D printers. Therefore, they have to be converted into Standard Tessellation Language (STL) format and will need further post-processing to optimise the form for printing (Figure 1).

A variety of 3D printing techniques and materials are available, some of which are well suited to the needs of cardiovascular medicine and surgery. The most useful are sterolithography, selective laser sintering, binder jet, poly jet technology, and fused deposition.

• Stereolithography represents an early technique based on a layer by layer photopolymerisation. This technique reveals transparent or non-transparent but rigid printouts and is therefore not ideal for purposes in cardiovascular medicine.
• Selective Laser Sintering (SLS)considered an outclassing technology uses laser as a power source to sinter powdered material. This technique enables 3D printing of delicate cardiac structures, e.g. native valves. Its dissemination is still limited owing to high production costs.
• Binder Jetting is a technique that creates artifacts through inkjet printing of binder into a powder bed of raw material, provides with rigid and non-transparent printouts. It is capable of printing substructures, e.g. ventricles, atria and large vessels in different colours.
• PolyJet Technologyprovides with dual-material printouts combining smooth, soft and transparent material with hard and non-transparent components. The advantage of this technique is its capability of printing pathology or implants being visible through surrounding native tissue.
• Fused Deposition Modeling also known as Fused Filament Fabricationor Plastic Jet Printing utilises melted thermoplastic material being supplied layer by layer as the material hardens immediately after extrusion from a nozzle which can turn the flow on and off.

Similar to printing on paper, 3D printing deposits a small amount of material onto itself, making many passes to grow the form. The time to complete a 3D printing varies from three fours for distinct cardiac or vascular structures to a full day for complete hearts. Because 3D printing is relatively new the costs are still considerable and usually start around $1000 but depend much on the quality of equipment and the institutional volume.

3D printing can be used for preprocedural preparation of complex interventional procedures. Tangible benefits resulting from 3D printing have been shown for transcatheter aortic valve replacement (TAVR), percutaneous mitral valve repair and device closure of interatrial communications. Device selection, sizing of defects and solid structures as well as general 3D conceptualization are clearly shown in the 3D models. Accurate imaging of pathology including its anatomic features and spatial relation to the surrounding structures is critical for selecting optimal approach and evaluation of procedural results. For example, a high-frequency ablation procedure for treatment of atrial fibrillation using 3D printing allows patient specific optimisation (Figure 2) importantly including optimal catheter selection which can be tested in the 3D model prior to the procedure. Similarly, physicians-in-training can also practice and develop adequate skills on dedicated 3D models before translating them into optimal procedural accomplishments. 

Through preoperative tactile and visual experience, the opportunities of simulating surgery with 3D models show promise and a vast yet unrealised future of this technology in medicine. More research is needed to demonstrate improved safety and better long-term results, and cost reduction. Nevertheless, even reduction in medical costs from reduction of complications from a surgeon knowing the anatomy precisely before making an incision will likely outweigh the time and expense to prepare the 3D model. Future perspectives of this method derive from standardisation of segmentation of the 3D imaging and optimal printing substrates (i.e. hard vs. soft) 3D printing appears to be most beneficial in highly specific procedures with complex anatomy. Prospective, multicenter clinical trials as well as standardisation of 3D modeling are needed to verify accuracy of this approach and clinical benefits in order to justify insurance reimbursement.

In conclusion, 3D models derived from conventional CT, MRI, and echocardiographic imaging is helpful for individualised treatment of complex cardiovascular anatomy. 3D printing provides users with the ability to manipulate the model and to simulate and test how the procedure will be performed and how a catheter or device responds to the unique cardiovascular anatomy. Although more research is needed, 3D printing has all the necessary elements to provide high quality patient specific treatments, utilising both a visual and tactile experience. As 3D printers become more commonplace, it is anticipated that it will integrate into quality management and payment systems necessary for its continued growth in medicine.

Bartel T, Rivard A, Jimenz A, Mestres CA, Müller S. Medical three-dimensional printing opens up new opportunities in cardiology and cardiac surgery. European Heart Journal 2017, doi:10.1093/eurheart/ehx016

References available on request.

Dr Thomas Bartel speaks on ‘3D printing in cardiology and cardiac surgery: New opportunities’ at the 3D Medical Printing Conference scheduled to be held on 29th January 2018 at the Arab Health Congress.

In the cardiovascular domain, these imaging technologies that include 3D-echocardiography/ultrasound, 3D-rotational angiography (3DRA), computer-tomography (CT) and magnetic resonance (MR) imaging provide accurate direct information of the anatomy and indirectly of the hemodynamic consequences. 3D-multimodality image integration grossly improves reliability, accuracy and resolution of these modalities, however, as images are not acquired in real-time, three limitations persist: (1) any change in the position of patient or equipment can cause misalignment of the registration; (2) static models do not account for cardiac and respiratory motion; and (3) 3D-models are in projected in two-dimensional plane of the visual screen. 3D-printed anatomical models remain static, but they are different and offer interactivity and hands-on approach. Personalised imaging and modelling of anatomy presents surgeons with a range of advantages, e.g. better understanding of complex anatomy, preoperative planning and virtual surgery, manufacturing of intraoperative aids and prostheses, ability to assess expected result, improved communication within the multidisciplinary team and with patients.

3D-printing processes, manufacturing of patient-specific prototypes

3D-printing consists of consecutive steps of pre-processing (digital data acquisition, segmentation), production (actual stereolithographic printing, a.k.a. additive manufacturing) and post-production (processes similar to chiselling and refinement in sculpture). First, digital data from imaging sources (CT-angio, MRI and echocardiography) are obtained. Most commonly ECG-gated breath-held contrast-enhanced CT-angiography is used that can reach a spatial resolution of 0.3–0.7 mm. Dataset is processed by a special 3D-software [Mimics, Materialise, Leuven, Belgium] and a rotatable digital (virtual) 3D-model is segmented. Accuracy of segmentation depends on the completeness and clarity of raw data and appropriate selection of segmentation values. Areas and structures of interest are exposed while others (temporarily) removed. All this requires intimate knowledge of anatomy. Thus, involvement of the surgeon/morphologist is advised; segmentation is also time-consuming, laborious and – at present – it is not feasible for automation.

The virtual model (stereolithography or ‘.stl’ file) already offers indispensable insight in most instances. The actual printing process involves rapid prototyping and additive manufacturing, building parts layer by layer. In our clinical practice two prototypes are 3D-printed: a real life-sized (blood-volume) solid model provides exact dimensions of the structures; another 1.5-2.5x-magnified (or scaled) hollow model is printed in transparent, flexible material. This allows simulation of the surgical approach and steps of the operation with high-fidelity (virtual surgery). Intraoperative assessment can confirm anatomic accuracy of 3D-models. Prototyping contributes to improved patient safety and shortened operating time, leading to successful outcome.
Among the multiple benefits of 3D-printed models are the improved communication within the multidisciplinary clinical team and patient/family education. Feasibility of new procedures could be experimented with patient-specific morphological characteristics. Besides listed and documented advantages, 3D-printing presents with possible downsides: labour- and technology intensive manufacturing presents with additional costs, need for extra personnel and infrastructure (e.g. 3D-printing facility). It is expected that 3D-printing will have a major role in providing patient-specific (individually customised) implants and prostheses, especially with evolving techniques of bioprinting. Bioscaffolds seeded with progenitor cells of the recipient may develop into complex structures, tissues and ultimately organs. In cardiac surgery, all this could help in fulfilling the ultimate goal to create an ideal cardiac valve implant.

Applications of 3D-modelling and printing in paediatric cardiac surgery

Paediatric cardiac surgery deals with a wide range of patients in view of age (from neonatal to adult-congenital), acuity (from emergencies to elective and/or staged reoperations), and complexities. Most operations are performed with a special attention to the expected growth of structures and assumed transformation of pathophysiology. These aspects mark out our discipline as pioneering in embracing of new modalities, e.g. advances in 3D printing, bioprinting, utilisation of novel methods and materials.

Paediatric cardiac surgery is also a discipline where individual decision-making is key in planning of complex operative plans. Preoperative preparation starts with detailed knowledge of the general patho-morphology before contemplating on an individual surgical procedure. Historically, generations of physicians and surgeons were educated with the help of cardiac specimens that come from individuals with congenital heart disease but they also represent general features of morphology.

Dr Maude Abbott (1869-1940), founder of patho-morphology for congenital heart disease, began ‘museum demonstrations’ in 1904 that had become part of the medical school curriculum. In recent years, however, availability of these specimens has become limited due to stiffened data protection regulations, reduced number of autopsies, natural attrition of specimens and most importantly that patients with congenital heart disease survive. Source of specimens has dramatically dropped.

Transfer of specimens in the morphological archives and from clinical data onto digital platform and creation of a virtual museum could solve the problem. First, specimens are scanned with high-resolution micro-computed tomography (it can achieve a resolution of 10 micrometres). Next, digital information is segmented to create 3D-virtual models and could be 3D-printed in various materials. A virtual museum offers innumerable opportunities for training and education, pre-surgical planning and virtual surgery, patient-family education, etc.

Introduction of 2D-echocardiography enhanced the importance of anatomical knowledge in our discipline that is further emphasised by newer imaging modalities. Interactivity and hands-on approach is key in modern-day medical and postgraduate education, especially in training of the new generations of surgeons. In the meantime, the learning-curve for surgical trainees has become rather steep; no collateral morbidity/mortality is now tolerated. Access to morphological archives – as mentioned – became restricted. Simulation-based methods with 3D (virtual) models and printed prototypes (clinical case scenarios and specimens) could overcome these difficulties and meet the demands of morphological demonstration. Medical education ranges from medical students, trainees, the multidisciplinary clinical team and towards patients/families and the community.

3D-printed prototypes are regularly utilised to improve understanding of the morphology in complex re/operations. 3D-visualisation of the atrial anatomy and connections of the pulmonary and systemic veins in complex atrial baffling procedures offer unique possibility of tailoring geometrically challenging separation patches. Similarly, intraventricular tunnelling and muscle resection can be designed with the help of models. Scaled, transparent hollow-models printed in flexible materials are very suitable in planning intracardiac procedures as segments can be registered with different colours helping identification of the structures. Blood volume models are especially handy for taking measurements and planning procedures on the great vessels and their branches. Actual 3D-printed models are jointly utilized with the 3D-virtual models as these can later be opened, digitally modified, etc. Accuracy of the models is excellent, even after moderate postproduction smoothing. Familiarisation with the expected operative anatomy and planning out alternative surgical scenarios (surgical emulation, virtual surgery) results in improved safety margin. As a critical mass of experience has not yet been accumulated due to the highly individual and variable case-scenarios, no conclusion can be drawn whether 3D-prototypes are effective in saving of time, or other expenses. Personal experience identifies patient-safety and reduced occurrence of complications and ultimately improved quality of care as major advantages.   

A National Centre of Excellence (COE) in 3D-printing for healthcare
The vibrant and ever-evolving sociocultural and scientific context of the United Arab Emirates demands the establishment of a Centre of Excellence (COE) in the field of 3D-printed techniques for healthcare. There are five key pillars for the success of such a venture. Most importantly, governmental leadership should embrace and support this rapidly growing and pioneering area by providing transparent legal framework and a spectrum of subsidised programmes. Programmes span from specific clinical applications in orthopaedics, maxillofacial surgery, plastic and reconstructive surgery to cardiovascular surgery to prosthetics and development of bioscaffolds, bioengineered materials, 3D-printed tissues and organs, etc.

Participation of local academic research organisations in biomedical and bioengineering sciences is also key in providing scientific leadership and proper prioritization of viable projects.

The third pillar is the involvement of clinical healthcare (professional and providing institutions) where individual projects can find their realisation, outcome and provide continuous feedback for research. Fourth, healthcare financers should be motivated and involved. Financial cover for 3D-printed models and aids remains unresolved worldwide. At present, there are no internationally established Current Procedural Terminology (CPT) codes available for insurance companies and/or healthcare financial bodies to cover expenses related to 3D-printing.

Finally, the fifth key element is the integration of local 3D-printing companies, who act as an interface with the world of rapidly-evolving technology. They are seminal in adapting new methods from 3D-printing outside of healthcare. Governance of the COE should be based on cooperation and communication among all key participants along a governmental legal framework, established scientific guidelines in research, clinical benefit to the patients, and financial sustainability.

Future prospects
Another direction of 3D-modelling technology is image-guided surgery/augmented reality. With this modality, patient-specific 3D-models or holograms are projected to a fixed point in virtual space or are directly superimposed on structures of the operative area. Thus, key landmarks of the 3D-holographic model are identified and paired with counterparts of the patient’s anatomy. In combination with robotics, optical display could revolutionise surgery: it could allow procedures in the heart with preserved perfusion/organ function while being operated. The operator performs procedures on the holographic model in the 3D-virtual reality and robotic micromanipulators would identically follow the same movements in the patients’ real surgical field. Of course, there are myriads of problems to be solved, e.g. interactivity between the holographic model and real organ – as the latter moves and changes shape and size in time with the cardiac cycle that the virtual model should exactly follow – just to mention one.  Nevertheless, such prospects in 3D-technology revive an intellectual excitement comparable to the one that established anatomy as a medical science and paved the way for modern surgical methods five hundred years ago. 

Dr Laszlo Kiraly is the Chair of the 3D Medical Printing Conference scheduled to be held from 29-30 January 2018 at the Arab Health Congress.

Profile pic caption:
Dr. Laszlo Kiraly, MD PhD FETCS, is Head of Paediatric Cardiac Surgery at Sheikh Khalifa Medical City in Abu Dhabi

MARK: Following are the captions of the Figures to be used with the article:
Fig 1: 3D-virtual (A,B) and 3D-printed (C,D) models of the aortic arch following modified Norwood-1 arch repair
 A: Digital 3D model of the aortic arch, its branches and the pulmonary arteries; left anterior oblique lateral view. B: posterior view. C: 3D-printed prototype of the aortic arch, its branches and the pulmonary arteries, life-size solid model; left anterior oblique lateral view. D: 3D-printed prototype of the aortic arch, its branches and the pulmonary arteries, 3x-magnified size, hollow model; posterior view. Sites of obstruction are denoted by *.
(Abbreviations: DAo: descending aorta; innom: innominate artery; LCA: left common carotid artery; LPA: left pulmonary artery; LSCA: left subclavian artery; neo-Ao(PT): neo-aorta; RCA:  right common carotid artery; RMBTS: right modified Blalock-Taussig shunt; RPA: right pulmonary artery; RV/PT: right ventricle to pulmonary trunk junction).

Fig 2: View of the left ventricular outflow tract obstruction (LVOTO) in a 3D-printed model and intraoperatively.
Prominent musculature significantly restricts outflow from the ventricle (black opening). Morphology on the model looks identical to the one confirmed by intraoperative exploration.

Fig 3: 3D-virtual model of tetralogy of Fallot and absent pulmonary valve
The model is opened in a horizontal plane at the level of the aortic root and viewed from above. Orifice of the left coronary artery (LCA) is flattened and obstructed by the grossly dilated right pulmonary artery (RPA). LCA is much smaller than the right coronary artery (RCA). Right-sided structures (superior vena cava: SVC and right ventricle: RV) are blue; left-sided structures (left ventricle: LV; right upper pulmonary vein: RUPV; left upper pulmonary vein: LUPV) are marked in burgundy. The opened and rotated model provides unparalleled insight into the intimate spatial relationship of the structures.