At the Artificial Intelligence in Healthcare conference at the recently concluded Arab Health, Professor Rachel Dunscombe, CEO, NHS Digital Academy, London, UK, shed light on the skills required to embrace the changes in care that data and technology will enable. 

In an interview with Daily Dose, she said: "It really is a skills emergency because we need to educate and train 90 per cent of our workforce so that they have significant digital skills in the next 15 years. We need to start that journey quickly so that people can understand the toolset they have to deliver care differently and redesign it."

Related: AI has arrived in medical imaging

She also discussed Artificial Intelligence and governance. If digital technologies are going to go at scale and pace safely, there must be ways of monitoring, managing, and leveraging AI, she stressed.

When asked about how doctors can prepare for an AI-powered future, Dunscombe said that several of the doctors she has worked with have chosen to go for training programmes around data analytics and AI. "I worked with a cohort of doctors who did a postgraduate in data science. Some doctors are readying themselves by taking study leave and investigating further. I would encourage any doctor to find out more about what AI, automation and data can do for them. I would also encourage them to become proactive in engaging with it rather than being passive about it because AI can help improve the safety and quality of care. Augments are wonderful doctors. So, it's not about replacing but augmenting. I would urge doctors to become curious about how technologies can augment and assist their practice and allow them to do more of what they need to do well," she shared.

What can AI solve?

Related: How post-COVID radiology will be shaped by data-driven insights powered by AI

According to Dunscombe, different people have different definitions of AI. One of the simple things considered part of the AI family is automation and robotic processes. For example, it can replicate data across other systems saving precious time for doctors. Other things in the AI space include algorithms that can pick up unusual patterns and detect when something may not be right, and assist in making decisions.

"I think that we will see AI assisting doctors in spotting exceptions and bringing to light the most important information about the patient. It will almost serve as a heads-up display seen in aircraft. So, I think we are going see some of this emerging in the coming five years," she added. 

AI also has a role to play when it comes to personalised care. For instance, if a patient's blood pressure says it's 140 over 85, that may be fine for some. But for certain patients with pre-existing conditions such as diabetes or renal failure, that may trigger a need to see somebody. This is where personalised care kicks in. By having the digital twin of the patient, it is easy to compare what is known about the patient and if they require immediate care. It allows for monitoring those exceptions on a personal basis. This also allows to use resources better and doctors to see patients when needed and drive efficiency.

Some other technology trends that are coming to the fore include those out of the hospital, where people are self-caring and self-managing in their homes. This is typically where data is being created by sensors or the Internet of Things and creates an ecosystem for patient enablement. Together, these will enable different models of care in the home and in the community.

Professor Rachel Dunscombe

Another upcoming growth area is the smart routing of clinicians outside of the hospital. This involves smart placement of medical devices in the community and the movement of medicines in the community, which Dunscombe describes as "non-hospital" logistics. She gave the example of the UK, where this has improved nursing efficiency between 20 and 26 per cent by matching the patient's needs to the skills of the nurse and routing them efficiently.

"The capacity and demand in the community and the smart use of resources is a new horizon that I find exciting. This is backed by smart algorithms and cloud-based processing of capacity and demand. Powerful analytics are providing the optimal way of dealing with what we need to do in the community with the workforce we've got," she highlighted. 

Like any other industry, the future of AI in healthcare, said Dunscombe, will take several decades to leverage fully. But she stressed that it's essential to have a complete understanding of how it will be leveraged and governed. 

"I sometimes see AI as a junior doctor or nurse. It's something you need to audit, supervise, and look at the performance of. But, this is something that we can harness and leverage using good governance. I think that is the way that we move forward together. In the future, AI is something that augments our healthcare system and supports us to do better. I am very optimistic that if we tackle this with the right speed, this will enable us to be more efficient and effective," she concluded.

NHS Digital Academy

The NHS Digital Academy educates healthcare professionals to be ready to redesign the healthcare system and enable digital processes. Participants learn about AI, analytics, and patient-centred design. "It's about preparing them as transformational change leaders with evidence and a rigorous academic curriculum, based in the workplace, so they're doing as they learn. It's creating t transformational leaders catalytically. We work with them for a year and a half say, and then they are ready to self-sustain their transformational learning journey in their organisation. The Academy is creating the people that will lead the change," said Dunscombe.

Musculoskeletal conditions were the leading cause of disability in four of the six WHO regions in 2017. It has been estimated that approximately 1.5 per cent of the world’s population needs assistive devices to alleviate suffering but only 5–15 per cent of this affected population has access to these devices. Foot related problems and pain are common in approximately 24-30 per cent of the adult population. This is reportedly one of the top 20 reasons for seeing a doctor by people of age 65 or over. In addition, foot problems are associated with reduced mobility, decreased leg strength and an increase in the incidence of falls in frail adults. Foot pain and pathology can be disabling, eventually leading to more complex orthopaedic complaints and footwear is often viewed as a significant factor in the development and persistence of foot pain.

Footwear can alter human gait and the physical characteristics of footwear often impact on dorsal and plantar pressure. Footwear advice is a critical part of patient care and should be considered for every clinical assessment. Individual needs should be matched to the footwear style as well as the physical characteristics. Consideration should also be given to the role footwear has in self-awareness, image, and fashion in addition to its function.

Related: What you need to know today about protective footwear and COVID-19

Assessment of current practices of footwear advice provided by healthcare professionals shows that often the advice is based on the clinician’s experience and training as well as a personal preference rather than original research.

Also, little is known about the impact of everyday footwear choice on foot biomechanics and the development of pathologies. Our collection of work assesses the impact of footwear choice on foot biomechanics. The novel work on the subject of gaining consensus on where flexibility and support should be given on school shoes for 6 to10-year-olds yielded interesting insights into the current understanding of clinical experts in the field of paediatric footwear. It highlighted the lack of knowledge and confidence in the effects of children's footwear. Our further inter-disciplinary work examining modern footwear and their association with the development of foot pain and pathology in the ageing adult clearly showed that foot health issue does not alter young women’s footwear purchases. 162 teenage girls were questioned regarding shoes purchased over six months. The results indicated that footwear choices are activity-specific, and participants chose the style and design of shoes for the image they wanted to portray.

Related: Orthobiologics – scientific or just hype?

Association of footwear choice to foot health was not found to influence their choice of footwear. In older adults, pressure-related skin lesions on the digits cause significant discomfort. Most foot pain related to ill-fitting shoes occurs in the forefoot or the digital areas and has been associated with poor shoe fit, reduced toe box volume, as well as the contour and shape of the shoe. Off-the-shelf medical-grade footwear is designed as an intervention for chronic lesions on the digits. Our research investigated the effect of an off-the-shelf, medical-grade shoe on dorsal digital pressure and perceived comfort when compared to the participant's preferred shoe. Our work showed medical-grade footwear to be a viable alternative to custom-made prescription footwear and more suitable than a regular everyday shoe when treating digital lesions associated with pressure. One of the key pressure associated complications is related to the diabetic foot. Currently, diabetes is a major cause of lower limb amputation, and it is a significant global challenge. Every 30 seconds a lower limb is amputated somewhere in the world as a consequence of diabetes, and people with diabetes are six times more likely to undergo an amputation because of a non-healing ulcer than people without diabetes. Footwear and orthotic interventions are designed to reduce these ulcer incidences in the foot that is at risk of ulceration.

Whilst, inappropriate or ill-fitting footwear increases foot pain, reduces balance, impedes clinical rehabilitation, and increases hyperkeratotic lesions, they are also the front-line treatment for many of these issues along with orthoses. Anecdotal reports from patients and clinicians suggest foot orthoses achieve much success in alleviating discomforts and symptoms. Yet, the scientific community has not reached a consensus on their biomechanical effects. The core objective of our research is to study the external factors impacting foot orthoses and to assess biomechanical effects. Our previous work established the effect of simple non-moulded flat-based insoles on three-dimensional foot motion during normal walking. Factors such as casting and practitioner variability, the type of device (custom-made orthoses vs. prefabricated orthoses) and the midsole composition have been the focus of further work. Using a single patient clinically assessed by 11 different foot-care specialists, inter-practitioner variability was assessed, finding a large amount of variation introduced by the practitioners themselves. Consequently, we suggested taking great caution, when transferring or generalising results on the biomechanical effects of custom-made foot orthoses.

Also, clinicians need a good understanding of the properties and characteristics of materials used to manufacture orthoses to make informed decisions on the most appropriate material to meet their patients’ needs. Given that there are no standardised testing methods for assessing materials used in orthoses and that much of the research examining materials are outdated, our research has addressed some of the pertinent clinical questions. Our research has influenced the development of materials performance indexes to show that flat insoles made from medium density PU were superior to the other materials for pressure off-loading and when constructed into an orthotic PU provided similar off-loading capabilities as the EVA materials. This work has also resulted in the development of shoe and orthotic designs for foot at risk. Significant changes in the orthotics industry are anticipated shortly due to advances in both material science and technology. While traditionally orthoses were handcrafted recent advances initiated the use of CAD/CAM manufacturing and more recently additive manufacturing/3D printing has started to be utilised in orthoses production. The use of additive manufacturing results in the use of different materials in the production of orthoses.

Many external factors influence the effects foot orthoses have on patients, especially those factors present before the orthoses are dispensed to the patients. Nevertheless, orthotic interventions should take as many factors as possible into account to allow accurate, appropriately defined, and predictable outcomes. It is particularly important that children and young people needing orthotic intervention get it quickly and that the orthoses are well fitted and of good quality. If they have to wait many months to obtain the correct orthoses, most will have outgrown them before they are fitted and endured unnecessary pain and immobility. It also undermines the work of the rehabilitation team and sometimes results in the need for further surgery and dependency on a wheelchair. This affects not only their physical health but also their mental health resulting in a compromised psychological, emotional and social status.

References available on request

Nachiappan Chockalingam

COVID-19 is continuing to wreak havoc in India. According to a recent World Health Organization (WHO) report, hospitals in India were fighting for beds and oxygen in April and May in response to the deadly surge in infections. The country accounted for nearly half the coronavirus cases reported worldwide and a quarter of the deaths. 

In an interview with Daily Dose, Dr Nirmal Surya, Consultant, Neurologist, Surya Neuro Centre; Founder Trustee & Chairman, Epilepsy Foundation of India, Mumbai, India, said that the situation started getting bad for India in March where significant number of cases were reported as the virus became much more virulent. The other complications included Mucormycosis or black fungus. "That's a major problem. High mortality rates were reported, along with a rise in neurological problems. We also saw more younger people getting affected," he explained. 

Related: Decoding India’s COVID-19 crisis

Due to the wide-ranging lockdowns in the country in 2020, rehabilitation services came to a complete standstill. For outpatient services, therapists started adopting telemedicine and tele-neurorehabilitation. By the time the second wave hit, the therapists were better prepared as most of them had received both the vaccination doses and had sufficient PPE kits to feel confident to continue going to the hospitals. So, while rehabilitation services were affected, the situation was not as bad as when the first wave hit. 

Tech to the rescue

Before COVID-19 hit, telemedicine was not legal in India. However, in March 2020, the Government of India came up with guidelines about how telemedicine can be practised. Dr Surya explained that telemedicine could be done for people who require follow-ups. So, any patient who might have been treated in the past can opt for telemedicine, and the therapist can keep track of the status of their medicines. Also, there has to be an emergency where there is an urgent need to see the physician. 

Related: How technology is reshaping rehabilitation in the Middle East

"We have developed various platforms for telemedicine," he said. "Several IT companies in India have created platforms where therapists can conduct only audio or video consultations. The payment gateway is linked, and the situation can be reported immediately, and a prescription can be given if certain requirements are met."

Dr Nirmal Surya

However, he stressed that while some doctors have been consulting through Whatsapp videos, they need to be careful and maintain reports. 

"There are some challenges, but there are guidelines in place that will keep on improving the various organisations who have started the training. In my organisation, we have been doing systematic training programmes. Recently, we conducted these for paediatric telemedicine and looked at how paediatric patients will be examined," he added.

Some other challenges that telemedicine poses include issues with bandwidth. For instance, patients in villages might not have a smartphone or a carer next to them who understand the rehabilitation exercises being taught. 

Dr Surya emphasised: "Telerehabilitation needs to go hand in hand with the family. In the long term, the family person at home does exercises for the patient under their supervision. For 10 years, I have been talking about this, but people were not accepting. But COVID has changed this, and both the patients and families see the benefit." 

Another challenge, according to him, is that with telerehabilitation, how does the therapist assess the muscle? How can they assess the various activities available? "We are working on developing various acts of the exercises, which can be accessed through the mobile phone and can be done with the home. We are currently working on learning the exercise protocols for stroke, Parkinson's, and neck and back pain," he added.

Dr Surya stressed that rehabilitation is changing, and multidisciplinary teams will have to plan out similar treatment programmes for patients at home. The family will become a key point along with telemedicine and telerehabilitation, he stressed. 

"We need to develop long-term mobile apps with proper exercise protocols, which is easy to follow. So that patient need not travel to the hospital unnecessarily. They should come only for a specific reason and when they require urgent care. But once they improve from their condition and go home, the therapy should change and incorporate home care," he concluded.

His Excellency Nicola Lener, Ambassador of Italy to the UAE, officially inaugurated the Italian Trade Agency pavilion at Arab Health, along with Giuseppe Finocchiaro, Italian Consul-General in Dubai and Amedeo Scarpa, Italian Trade Commissioner, Dubai Office/UAE, Oman and Pakistan, Italian Trade Agency (ITA). Fifty-one Italian companies, including eight innovative start-ups, were selected by ITA in its official pavilion to be present at Arab Health.

In an interview with the Daily Dose on the sidelines of the show, Lener said: "Italy is showcasing its innovation capacity in the health sector at Arab Health, which is exciting. Italian companies are investing a lot in healthcare, and the government is supporting them. As a result, we have a very innovative ecosystem in Italy with more than 14,000 start-ups supported by the government who plan to invest 1 billion Euros. Italian healthcare start-ups are some of the most innovative in the world. We are showcasing the ideas, projects, and products of eight start-ups here. There are also other 51 Italian companies showcasing their products, equipment and technologies."

Related: Italy brings innovative SMEs and start-ups to Arab Health 2021

He stressed that COVID-19 has turned out to be a significant catalyst for innovation in Italy, not just in healthcare but also in other sectors. These include mobility, environment, technologies such as cybersecurity, artificial intelligence, and energy use. "We are showcasing and investing a lot of resources to foster the use of technology and digitalisation. In fact, digitalisation has been one of the main pillars of our national recovery and resilience plan."

According to Lener, the UAE and Italy have traditionally had very strong economic relations. The trade exchange between the two countries was more than 8 billion Euros in 2020 and increased across all sectors.

Related: Special Report: Private healthcare in Italy

Italy is renowned internationally for its excellence in the Biotech, Pharma and Medical Devices sectors, the three major life science sectors. There are currently 4,323 Italian companies operating in the Medical Devices sector with a total value of 16.7 billion Euros, of which 5.7 billion Euros of this were exported in 2020, a 1.2 per cent increase compared to 2019. On the other side, the UAE's Medical Devices market is expected to reach AED 5.6 billion (US$1.5bn) by 2025, with an annual compound growth rate (CAGR) of 4.4 per cent from 2020, and our manufacturers are in a strong position to support the county's growth.

Scarpa shared that even during the pandemic, the trade relations between Italy and the UAE witnessed significant growth. Highlighting the healthcare sector, he shared that the demand is expected to grow 4.4 per cent each year from now until 2025, specifically for medical devices. Growth will also be seen in the life sciences sector in pharmaceuticals and biotech. "That's why we're here. The demand is there; the Italian offer too, demonstrating the good trade relations between the two countries," he added.

When asked about future plans, Scarpa said that Italy is getting ready to participate at Expo 2020 Dubai, where the theme is "Beauty connects people". "When you say beauty, it is related to healthcare, good food, good style and strong relations. So, we are preparing a great programme for Expo 2020."

He also said that ITA is looking forward to Gitex Future Stars and engaging with the considerable number of incubators in the UAE and want to involve them in the incubation and developing innovative programmes for SMEs and start-ups.

He concluded: "For the first time, Arab Health has made an area dedicated to start-ups from all over the world. Out of these, eight start-ups are from Italy, which means 25 per cent of the total start-ups exhibiting at Aran Health are Italian!

 ​​​Contact between a medical device or surgical tool and a patient's sterile tissue or mucous membranes occurs in all invasive procedures. The introduction of harmful microorganisms that might cause infection is a major concern of operations of this kind. Breach of the host barriers might occur if reusable medical equipment is not thoroughly disinfected or sterilised. The level of disinfection or sterilisation required depends on the object's intended use: critical items (such as surgical instruments that come into contact with sterile tissue), semicritical items (such as endoscopes that come into contact with mucous membranes), and noncritical items (such as stethoscopes that only come into contact with intact skin) all require sterilisation, high-level disinfection, and low-level disinfection, respectively.

Cleaning must always come before disinfection and sterilisation at a high level. When choosing a disinfection or sterilisation procedure, users must weigh the benefits and drawbacks of various approaches. Following these guidelines could enhance disinfection and sterilisation methods in healthcare institutions, lowering the risk of illnesses caused by contaminated patient-care items. Reduced processing times and greater capacities for instrument reprocessing have come from further advances in low-temperature sterilising systems. As the link between environmental surface pollution and health-care-associated illnesses has become clearer, novel techniques for surface disinfection have evolved, including area disinfection systems and antimicrobial surface technologies.

Recent advancements in sterilization technology for use in healthcare institutions have followed a two-and-a-half-decade pattern of concentrating on low-temperature sterilization systems. Shorter cycles, greater materials compatibility, extended instrument capabilities, environmental friendliness, and lower prices are the market's driving forces. Low-temperature sterilization systems that are already on the market have been improved, and at least two other technologies are on their way to the market. The steam sterilization method now has new biological indicators (BIs) with faster readout times.

Furthermore, there have been tremendous developments in technology, specifically in surface disinfection. According to a publication by the American Journal of Infection Control, a growing body of evidence suggests that environmental surface contamination in health care facilities is directly related to healthcare-associated infections (HAI). Existing surface disinfection technologies have been enhanced to overcome respective limitations and create viable alternatives for surface decontamination/disinfection in room-sized regions. These "area decontamination systems" are meant to enhance cleaning and disinfection methods in health care facilities, which studies have demonstrated to be lacking inefficiency. The use of materials having intrinsic antimicrobial characteristics, in the fabrication of common surfaces seen in healthcare institutions is also gaining traction as a way of preventing environmental surface contamination.

The necessity to enhance the cleaning and disinfection of environmental surfaces in healthcare institutions has garnered considerable attention and momentum, and it's now a rising topic in the fight against HAI. While it has always been obvious that disinfecting environmental surfaces is an important practice, current scientific data indicating a clear relationship between these environmental bacteria and HAI has raised awareness of its importance.

This awareness, along with the expenses of HAI, along with the potential loss of reimbursement, has prompted the development and commercialisation of area decontamination/disinfection systems, as well as the use of antimicrobial surface technology. The trend toward microbial control inpatient environments is predicted to continue, and novel materials with intrinsic antimicrobial characteristics for environmental surface applications are likely to emerge.

  

In just 42 months, Millennials will make up 75 per cent of the workforce, according to U.S. Department of Commerce statistics. As consumers and patients, they are already triggering changes, reforms, and innovation in healthcare. It is timely for clinical lab administrators and pathologists to understand how and why Millennials expect to experience healthcare services in a very different way than Generation X and Baby Boomers. Here’s a look at key developments.

Consumers are becoming a powerful force of change as the healthcare system in the United States and other nations continues to transform. This has profound implications for those medical laboratories that want to stay at the cutting edge of clinical care with their diagnostic testing services.

Related: Arab Health and Medlab Middle East generated over AED767 million of deals during the four-day live, in-person event

As consumers radically alter the way they access medical services, medical laboratories will need to reconfigure key aspects of their services to properly serve the “new healthcare consumer” and meet the very different expectations this younger generation has for service, for quality, and for price.

For example, as more patients grow comfortable using telehealth to do virtual office visits with their physicians, how will clinical labs get access to that patient to collect the samples needed to perform the lab tests ordered by that physician as a result of the virtual office examination?

Related: Entering the RNA era of therapeutics

Today, specifically in the United States, the medical laboratory profession is oriented around the primary specimen collection model of:

a) having phlebotomists in physician offices, and,

b) maintaining a network of patient service centres, typically located in physician office buildings.

Will this existing infrastructure of specimen collection sites be viable if a greater number of patients stop traveling to their doctors’ offices and instead see their caregiver using a telehealth service? Labs should ask this question in their strategic planning and develop new approaches to collecting specimens from those patients using telehealth services to consult with their physicians.

Millennials—Generation Y (born between 1981 and 1996)—are the front wave in this change in the way healthcare is accessed and delivered. They are comfortable accessing their physicians via telemedicine and virtual office visits, especially if it saves time.

Similarly, the Millennials want to use their smartphones and digital devices to have immediate access to their health records. A high proportion of Millennials also track their own health metrics with a fast-growing product category known as “wearable fitness technology.” These devices range from FitBits and Nike Fuelbands to Apple watches.

The consumer revolution in healthcare is not limited only to Millennials. Growing numbers of Gen X’ers and Baby Boomers are becoming comfortable seeing their physicians virtually, having 24/7 digital access to their health records, and using wearable devices to monitor their diabetes, deliver insulin, and track the function of their heart, among other uses.

Insurers support telehealth

Private health insurers are jumping on the virtual physician visit trend. Not only do telehealth services meet the wants of Millennials for quick access to their doctors, but telehealth sessions are a way for payers to reduce healthcare costs without compromising the quality of care. Just this year in the United States, Oscar Health, UnitedHealthcare, and Kaiser Permanente launched or expanded virtual-first care plans.

Humana started similar health plans in the Southeast U.S. two years ago that require the patient to start a care encounter with a virtual physician visit in exchange for very low monthly premiums. Last year, Humana invested US$100 million in telehealth company Heal specifically to help the insurer expand into new markets.

This trend of expanded acceptance and use of telehealth and virtual office visits was intensified by the outbreak of COVID-19 in the winter of 2020. From the start of the pandemic, even senior citizens proved willing to see their doctors virtually.

The American Medical Association published a report quoting Jared Augenstein, a Director at Manatt Health. He said that “between mid-March and mid-October of last year, nearly 25 million Medicare beneficiaries received services via telehealth, while Medicaid and CHIP beneficiaries received nearly 35 million services via telehealth last year.”

Convenience as a driver

Another important driver of change in healthcare shared by all consumers—regardless of their generation—is the desire for convenience. Today’s healthcare consumer wants a smooth, fast, and easy experience with any retailer or service provider.

That is why patients are increasingly frustrated with how they are forced to interact with hospitals, doctors’ offices, clinical laboratories, and other providers. It is still common for a patient with an appointment for a health service to walk into the facility and be handed a clipboard with a form to fill out with pen or pencil. Patients must sit in the lobby and fill out forms before they can access their doctor or have a procedure performed.

This example shows why patients—as consumers—are frustrated with the healthcare system. They understand that, if they are buying from Amazon, eBay, or any number of other web retailers, they may be just two clicks away from completing a purchase. That is not true for healthcare.

Medical laboratories emulating Starbucks?

Similarly, these patients know they can walk into a Starbucks, give the barista the order, and then hold their smartphone up to the reader to complete the transaction wirelessly and instantly. Furthermore, digitally connected consumers can use the Starbucks app on their smartphone to order and pay before they even entered the store! This allows them to walk through the door and find their order ready and waiting to be picked up.

Imagine how different the experience of your lab’s patients would be if your team streamlined and automated as much of the specimen collection process as possible. Your lab would create a loyalty bond with each patient that would be difficult for competing laboratories to break. It could be the ultimate competitive advantage.

Different generations

Changes in healthcare and other segments of business attributed to the different interests and needs of Millennials can be better understood when compared to earlier generations.

For example, the “Greatest Generation” (those Americans who fought World War II and parented the Baby Boomer generation) were typically recognised to be compliant patients. They usually accepted their doctor’s diagnoses and recommendations with few questions.

This is generally not true of Baby Boomers. They are the generation of patients who do deep-dive research into their health conditions. They then arrive for their appointment carrying a stack of published clinical studies and press the doctor to absorb this information and incorporate it into their treatment plans.

Then came Generation X

Generation X continued the research trait of the Boomers, but also began adapting to new models of primary care. The rapid growth and popularity of urgent care centres that opened early in the morning and stayed open late and on the weekends in the United States could be considered a response to Gen X patients who want 24/7 access to healthcare whenever they have earaches, sore throats, and sniffles. Urgent care centres provided consumers with a friendlier place with faster treatment for many minor conditions, compared to emergency departments and A&E departments found at local hospitals.

So much of healthcare and medicine is changing because of Millennials—who grew up with computers, mobile communication devices, and the Internet. Millennials tend be more demanding consumers of healthcare.

Thus, medical laboratory leaders would be well-served to understand Millennial lifestyle preferences and meet those expectations.

Identifying other forces shaping healthcare

Fortunately for the medical laboratory profession, the pace of healthcare’s transformation will allow adequate time for labs to identify and understand key trends, then develop appropriate strategies in response to those changes.

Healthcare’s transformation in the U.S. includes discrete elements. These are elements that The Dark Report tracks regularly. They include:

• New emphasis on proactive care, compared to the reactive care of past decades.

• Continued efforts to shift care from inpatient to outpatient settings because hospitals are the most expensive sites for medical care.

• Tighter integration of both clinical services and the organizations that provide those services.

• Digital health records that are truly interoperable, allowing data to move freely across all classes of providers.

• Emphasis on reducing variation in care provided by different doctors so that the treatment delivered to every patient is consistent with the care protocols for their health conditions.

• Telehealth/Virtual physician visits.

• Value-based payment to providers.

• Consumer-driven change.

• Primary care’s move toward clinics based in retail pharmacies and in neighbourhood shopping centres.

• For labs, what The Dark Report describes as distributed testing, enabled by a coming generation of small, miniaturised instruments that deliver accurate results inexpensively at the point of care and in near-patient settings.

Four ways that consumers are encouraging change and transformation in healthcare 

If medical laboratories groups want to continue to meet and exceed the expectations of con­sumers and their patients, they need to recognise how consumers are changing many aspects of healthcare. Below are several primary trends in consumerism as they relate to how consumers want to be served by their healthcare providers, including hospitals, physician offices, and laboratories.

Convenience: Consumers want fast access to personal services. In healthcare, think of the growth of medical clinics in retail stores, the big shift to put laboratory patient service centres in retail pharmacies and grocery stores.

Examples: Walmart’s healthcare supercentres, branded as “Walmart Care Clinic.” CVS Pharmacies’ “Health Hubs” and “Minute Clinics.”

In the United States and other nations around the world, healthcare is being reinvented so as to meet the needs of the Millennial Generation and other consumers who want faster access to care, personalized service, and low prices. WalMart, known for its low-price leadership, is now building what can be described as “healthcare service hubs” that are located near where consumers live. Shown above is one of the early clinics Walmart opened in Georgia. Not only does this clinical provide primary care, but it offers lab tests, x-ray/imaging, optometry, dental, hearing, and mental health counseling. (Photo copyright WalMart.)

Personalisation: Consumers turning to the web for information before seeing their physicians and to find providers; they want their doctors and care providers to know them and their unique needs.

Examples: Amazon Prime Members recognised at log-in and have just two clicks to purchase. Starbucks mobile app handles the order and payment before customer gets to the store.

Technology: Consumers want to track their own exercise and health factors in real time. Think consumers using wearable monitors for exercise, monitoring blood glucose levels (for diabetics), using remote monitoring devices prescribed by their physician; digital access to health information that alerts them digitally to test results, etc.

Examples: Fitbits, Apple Watches, Abbott Laboratories’ FreeStyle Libre device, cardiac rhythm remote monitoring devices.

Transparency: Consumers, particularly those with high-deductible health plans, want to know the price of service before choosing a provider.

Examples: Growth of benefit investigation (BI) for expensive genetic tests, prices posted publicly at Walmart’s healthcare supercentres, CMS Medicare website with provider prices, Castlight Health’s website with provider prices.

Robert L. Michel

The article was published in Arab Health Daily Dose Day 1. Read all the issues here.

Copyright 2021, The Dark Report. Reprinted by Permission.

Over the last year and a half, the pandemic has shown a remarkable rise in thrombosis (blood clots blocking blood vessels) in relation to the COVID-19 infection. It raised many questions about anticoagulation treatment indications within and outside the hospital. Some countries were using aspirin to reduce the risk of thrombosis, while some others were using oral anticoagulants, which was causing a bleeding accident due to overuse.

At Medlab Middle East, Dr Kayane Mheidly, Consultant Haematology, Clemenceau Medical Center, Dubai, UAE, discussed the risk factor of thrombosis with COVID-19. She shed light on the physiopathology of thrombosis, how it can be prevented, and which patients require anticoagulation.

Related: Blood availability and safety during COVID-19

In an interview with Daily Dose, she highlighted: "I discussed several important points. Haematological manifestations of the COVID-19 infection are various. The most frequent are thrombocytopenia and lymphopenia. There were also some cases of aplastic anaemia and activation of macrophages caused by COVID-19. In our hospital, we had the case of an elderly patient with rheumatological disease with pancytopenia and severe infection, she developed a secondary hemophagocytic lymphohistiocytosis syndrome and, unfortunately, she passed away due to severe infection.

“I also spoke about vaccination and complications post-vaccination, notably atypical thrombosis such as thrombosis and the recent observation about cerebral thrombophlebitis divided fluid etc."

Related: Spotlight on improving quality in haematology

However, she stressed that vaccination is recommended for all patients and that the benefits of vaccination outweigh the risk. For instance, the immunosuppressed population is at high risk of catching severe COVID-19, and it's better to vaccinate these patients. For patients at an increased risk of thrombosis, physicians can manage the choice of vaccine and suggest which vaccination is the safest. The International Society of Thrombosis and Haemostasis also recommends that all patients should be vaccinated.

Dr Mheidly explained that the risk factor of thrombosis increases with age, inflammation for a patient with malignancies, post-surgery, with reduced mobility, pregnancy, use of oral contraception, hormonal replacements, history of thrombosis in the family. The most frequent type of thrombosis is deep vein thrombosis (DVT) and pulmonary embolism. The other types of thrombosis are rare such as splanchnic vein thrombosis (SVT)and cerebral veins thrombosis

Dr Kayane Mheidly

Impact on blood safety

Dr Mheidly said that blood donors have become quite rare due to the pandemic as people are afraid to go to the hospital and give blood. However, some COVID-19 patients have anaemia and thrombocytopenia, which has increased the need for blood transfusions.

When asked about the quality considerations that need to be kept in mind, she said that the hospital staff needs to ensure those blood donors are not infected. Blood banks should ask donors to fill out questionnaires about details such as if the patient has fever etc. If the donor is symptomatic, the blood bank should wait until they are asymptomatic before taking blood.

"COVID-19 has taught us a lot about technology," she said. "We held a lot of virtual meetings and virtual scientific workshops. It helped us, doctors, to have a continuous learning process.

“Moreover, due to COVID-19, we learnt a lot about other diseases and their interaction with this disease. It was a good learning process.”

She concluded: "My message is for people to please take the vaccination to stop the pandemic. People should continue to take care and stay safe by practising social distance, putting their masks on and washing their hands."

The article was published in Arab Health Daily Dose Day 1. Read all the issues here.

Dystonia is a brain condition where there is an abnormal control of muscles because of changes in the brain, which leads to excessive muscle contraction. Some people can have it without any known cause or due to a genetic condition where they have an abnormality in a gene that affects the brain control of muscles. It can also occur due to damage in the brain, such as a stroke or tumour or inflammation.

Shedding light on the disorder today is Danish Bhatti MD FAAN, Associate Professor; Co-Director Comprehensive Multidisciplinary Parkinson's Disease Clinic; Director, International Neurology Program; Associate Director, Movement Disorders Fellowship Program, Department of Neurological Sciences, University of Nebraska Medical Centre (UNMC), Omaha, Nebraska, U.S. He will mainly focus on the aspects of rehabilitation in dystonia.

In an interview with Daily Dose, he explained that while some conditions are similar to dystonia, what separates it from others is that the contractions of the muscles are very patterned. There are specific muscles that are always involved. It's also dependent on the activity of the person. The overactivity of muscles is more in certain positions and particular tasks.

Types of dystonia

Bhatti said that dystonia is underdiagnosed and is often missed. It could present as a muscle spasm in the jaw, feet, hand, or neck, leading to an abnormal posture of any part of the body. Or if one feel's certain muscle tightness or that their posture is unusual, or there is an excessive tilting of the head, clenching the jaw or curling toes in. Anytime there is any unusual muscle tightness or posture, one should be concerned about dystonia.

Among the different types is task-specific dystonia, where the abnormal muscle contraction is only seen in specific specialised tasks such as musician's dystonia and writer’s cramp.

Bhatti explained: "For example, if you play the piano, violin, or flute, then you may develop a dystonia where when you try to play the piano there is an excessive muscle contraction in the fingers, creating a spasm or a cramp due to which you can't play."

Although few people have genetic dystonia, many develop it without any apparent cause. This is referred to as primary dystonia or idiopathic dystonia. That dystonia may occur due to excessive repetitive activity, using the same motor system in your brain, which might trigger dystonia due to abnormal organisation.

He shared: "I remember seeing a patient who once developed dystonia of the right hand for handwriting. He needed to write since that was a big part of his job, so he learned to write with his left hand. Ten years later, he developed dystonia in the left hand. So those kinds of examples make us think that dystonia stems from repetitive activities. I have seen patients who have developed dystonia of typing and voice dystonia in actors acting voiceovers. There could be sports dystonia in people who play golf. The single common theme here is that when someone does repetitive tasks or activities, that puts them at a higher risk of developing dystonia."

Dr Danish Bhatti

Rehabilitation and treatment options

When asked about what sort of rehabilitation can help patients with dystonia, he said it can be in the form of a training programme with either general training through different exercises or specialised training based on what actions are bringing out the dystonia. Some programmes look at feedback or biofeedback, where some information can be given back to the patient on their muscles either visually or through electrical stimulation. There is also a therapy that combines some form of brain stimulation or neuromodulation. One example would be to put a device on top of the skull, which creates a large magnetic field that can alter the brain's activity. It can be focused on specific areas of the brain. This can be used in combination with other exercises as one form of therapy.

"There is not a lot of research on dystonia and rehabilitation, as it is not a very common condition. It will be hard to find enough patients and unless you specialise or specifically see patients with dystonia. One of the biggest challenges is that all the research out there is a very poor level of evidence due to few patients involved," he shared.

However, technology is starting to play a critical role in improving the lives of those with dystonia. For instance, some devices can be worn on arms and feet to help improve dystonia. There are smart devices that can react to the body movement and try to realign or reposition it to fight back excessive muscle contraction. The devices can provide sensor-based feedback; it gives an auditory stimulus signal or visual signal feedback on what is happening with the dystonia. This technology could also be integrated into the smartphone or wearable devices to integrate with the body and figure out what kind of benefits it provides.

Bhatti stressed: "The underlying problem with dystonia is that right now, we don't have a way to cure it. There is a microscopic restructuring in the brain that causes dystonia. Once the brain has formed new connections, you cannot undo them so far, but maybe that will change over time. All the current treatments that we have are supportive treatments that try to block the symptoms so that patients can keep on with their daily activities without being too affected by excessive muscle activity.

"This can be done with medications or pills that work about 30 per cent of the time. Or it can be done with therapy that works for about 40 to 50 per cent of the time, but it tends to wear off over time, so you must repeat it. If nothing else is working, then some sort of surgical treatment in the brain can be looked at to try and block some of the symptoms of dystonia. In select cases, that works about 60-70 per cent of the time, but it is much more invasive."

In the future, he said, therapy for dystonia would combine neuromodulation. This would involve altering the brain circuitry through either magnetic field or electric field, along with therapy that uses some of these technologies that give a more accurate assessment to the therapist and more accurate feedback to the patient. This would involve retraining the brain by using different tools and modalities available.

"The treatment is multidisciplinary," he emphasised. "Once the dystonia is diagnosed, therapy is started. Even if patients are taking medications or pills, it's not going to work in isolation, and they have to go to therapy. Moreover, even if they go for surgical treatment, they still need to continue therapy and rehabilitation. In the future, it will become a more integrated model where intense technology-enabled rehabilitation will work along with some of the brain modulation, which will be less invasive."

How to recognise dystonia

Bhatti highlights three common patterns of dystonia that are often missed:

1. A young female with pain in the neck, with muscle tightness. It could be neck dystonia until proven otherwise.
2. Excessive blinking. People who have trouble keeping their eyes open with any bright light and want to close it tight or have to rub their eyes could be suffering from dystonia of the eyelids. This is also known as blepharospasm, which is also very common and often misdiagnosed.
3. If there is any teeth clenching or grinding, one must consider jaw dystonia.

The article was published in Arab Health Daily Dose Day 1. Read all the issues here.

Obesity is the first pandemic of the 21st century and the most serious chronic non-communicable disease facing mankind according to the World Health Organization (WHO). According to the World Obesity Federation, obesity is defined as a chronic progressive relapsing life-threatening complex neurohormonal disease. The American Medical Association defines obesity as a medical condition in which excess body fat accumulates to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems.

In adults, it is defined by body mass index (BMI) of 30 or greater. In children and. adolescents, it is defined by a BMI for age at or above the 95th percentile of a specified reference population. BMI is calculated by dividing the weight in Kg by the squared height in meters. Figure 1 shows normal and abnormal BMI and classification of obesity.

Related: Obesity, diabetes, and fatty liver disease: Time to expand the toolbox

Figure 1

Related: Bariatric Endoscopy: From development to daily practice in obesity care

Bariatric surgery is the only durable treatment for morbid obesity and its related diseases. Over the last 50 years, many surgical operations did not survive because of the safety, durability, morbidity, and mortality. Laparoscopic Roux en Y gastric bypass (LRYGB) is one of the few surgical operations that survived for more than 50 years since its discovery by the late Dr. E Maison in 1967. It is being used as a benchmark of all bariatric surgical operations.

In this operation, a small less than 50 ml pouch “gastric pouch” is created from the stomach and separated completely from the rest of the stomach. The small intestine “jejunum” is transected around 50 -100 cm from the ligament of trietz (junction between duodenum and jejunum) to create the biliary limb and then a 100 cm from the transection to create the Roux limb. Two anastomoses are created between the jejunum and the gastric pouch called gastro-jejunal anastomosis, and another one to connect the intestine together to create the jejuno-jejunal anastomosis, as shown in figure 2.

Figure 2

The mechanism that RYGB helps the patient to lose weight and put their obesity-related diseases in remission is a complex neurohormonal one. Changing the gastrointestinal signal; to the brain, pancreas, liver through endocrine, neuronal and hormonal changes. Hormonal changes like decrease Ghrelin, decrease insulin resistance, increase in Glucagon-like peptide 1 and polypeptide YY are among many hormonal changes that have been seen after RYGB.

The minimally invasive approach “being able to do this operation laparoscopically” first done by Dr Alan Wittgrove in 1993, has changed the scope of this operation as it reduced morbidity and mortality and made it more widely used across the world.

LRYGB has been studied extensively over the past 50 years. Many studies have proven the superiority of this operation to many other surgical options. It is currently being considered the “STANDARD” surgical operation to treat morbid obesity. Any new surgical operation has to match the safety profile and provide better results to gain popularity.

Type 2 diabetes mellitus (T2DM) is one of the most important obesity-related diseases. RYGB has proven its efficacy in treating it. Many international medical associations recommend considering bariatric surgery in treating T2DM patients specially when it is not optimally controlled.

The long-term effect of RYGB on T2DM has been well stablished. Ted D Adams, and his colleagues published a study in the New England Journal of medicine in 2017, in which he showed that 51 per cent of patients with T2DM who had RYGB were on no medications 12 years after the surgery.

Two recent randomized controlled trials from Sweden “SM-BOSS” and Finland “SLEEVEPASS” trials by R Peterli and B Wolnerhanssen et al, showed that, five years after the surgery, RYGB was superior to sleeve gastrectomy in weight loss, dyslipidemia and hypertension remission. Dr. P. Schauer’s study also showed superiority of RYGB over sleeve gastrectomy in treating T2DM in the famous STAMPED trials five years after the surgery.

Bariatric surgery and RYGB in specific has been proven to reduce the predicted 10-years and lifetime cardiovascular disease risk through decreasing BMI, blood lipids in males and females, according to the study that was published in the surgery for obesity and related magazine journal (SOARD) in April 2020 on more than 1170 patients by Amanda S Hinerman and colleagues.

The durability of weight loss after RYGB has been studied, and a recent study by L Angrisani on 105 patients showed that 15 years after the surgery, patients mean excess body weight loss is more than 50 per cent. In addition, 50 per cent of T2DM patients, 61 per cent of hypertensive patients and 58 per cent of dyslipidemic patients were in remission also.

The safety of bariatric surgery, in general, has been improving over the last 20 years, as shown in figure 3. RYGB safety profile has been evaluated by Kumar and his colleagues in 2018 published in SOARD, which showed 1.6 per cent morbidity and 0.2 mortality in more the 41,000 patients who had RYGB.

Figure 3

LRYGB has proven to be an effective and safe option to treat obesity, T2DM and many other obesity-related diseases over the last 53 years. It is a technically demanding operation that requires good compliance from patients with vitamins and lifestyle like most bariatric operations. Advances in surgical knowledge, training, and techniques make the surgery easier and safer with time.

Morbid obesity is a chronic relapsing disease, and it requires life-long follow-up and commitment from patients and healthcare providers to control the disease and prevent relapse.

References available on request

Dr Mohammed Al Hadad

The article was published in Arab Health Daily Dose Day 1. Read all the issues here.

UAE-based healthtech company Group 42 (G42) and South Korean in vitro diagnostic products manufacturer Seegene signed a memorandum of understanding at Medlab Middle East recently, which cements a partnership to bring mass COVID-19 testing to the region. Seegene's latest innovation is a fully equipped mobile diagnostics and testing station, also marketed as a ‘lab on wheels’.

The mobile station is optimised for all multiplex real-time PCR testing, which helps technicians easily differentiate COVID-19 and variants. This is the first time a mass testing solution has been delivered on such a scale for real-time and accuracy. According to Seegene, the solution is adaptable for post-pandemic uses as well.

Related: Arab Health and Medlab Middle East generated over AED767 million of deals during the four-day live, in-person event

The MoU was signed by Ashish Koshy, CEO of G42 Healthcare, and James Park, Seegene Executive Director at Medlab Middle East on Monday.

“The mobile testing services will further augment our business portfolio across the MENA region and help in reaching out to various markets, ensuring swift detection, and allowing patients to benefit from the most informed decision possible, regardless of the location,” Koshy said.

Related: Novel collaborative approach among public and private sectors

The Mobile Station also includes an equipment room and an extraction room, and provides optimised molecular diagnosis and tests at any location to safeguard the health of communities.

“The Mobile Station will significantly contribute to the mitigation efforts as it will help governments to control areas where epidemics spread easily and to place the laboratory near crowded places, such as community events,” James Park, Seegene Executive Director, said.

The MoU signed means the UAE, Algeria, Morocco, Tunisia, Libya, Egypt, Sudan, Palestine, Jordan, Syria, Iraq, Iran, Pakistan, Lebanon, Kuwait, Qatar, Oman, Saudi Arabia, Bahrain, and Yemen will all have access to mobile testing.

The all-in-one platform enables 2,000 tests per day including 225 pathogens in 10 different criteria and offers a streamlined automated work­flow from pre-extraction to data analysis.