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Articles from 2020 In January


Daily Dose

UAEGDA paves the way for the future

Article-UAEGDA paves the way for the future

The United Arab Emirates Genetic Diseases Association (UAEGDA) was established with the aim to increase awareness programmes in order to prevent the occurrence of common genetic disorders in the UAE and throughout the region. Daily Dose caught up with HE Dr Maryam Matar, Genetic Scientist, Founder and Chairperson, UAEGDA, ahead of the show to find out the different initiatives being carried out by the association.

She said: “The UAE Genetics Disorders Association (GDA) started with blood disorder initiatives, however, it is currently working on several others such as Familial hypercholesterolemia, G6PD, sickle cell, and thalassemia, among other. One of them is also the fragile x chromosome, which is related to autism. There is a specific mutation that increases the risk of that child to have autism.”

The association also has a breast cancer initiative along with two international centers with which they are able to identify 21 new mutations for breast cancer, which is very essential for the management. “Previously, a patient with cancer, would be screened only for BRCA1 and BRCA2,” she explained. “With our exercise, we are able to specify mutations specific to our ethnicity such as people coming from Middle East, Africa, India, Philippines, Pakistan, etc.”

For instance, if there is any patient diagnosed with breast cancer in the Middle East in these ethnicities, healthcare institutions can check for the 21 mutations, which are specific to the ethnicity. The impact of that would be that their medication and chemotherapy can be modified. “We have a complete circle of chain – prevention, counselling, early detection and management. We don’t do it ourselves, but have a partner who is helping us to achieve this,” she added,

One of the other initiatives that makes UAEGDA unique is that under its umbrella they host the GCC Genomic Society. As part of the society, doctors from member GCC countries gather once every year at a conference, where they decide what type of project and priority of mutation needs to be focused on. Furthermore, UAEGDA is also a member of the Global Rare Diseases Commission.

She concludes: “We are working on an Epigenetics project and focusing on the impact of sleep and gene expression of common non-communicable disorders such as diabetes, hypertension etc. Epigenetics tries to address the relationship between the environmental factor and genetic make-up.

“My advice to people is that if you cannot change your lifestyle, at least try to modify your sleeping pattern. If you have better quality of sleep, you will help your body to maintain itself during the night so that it will switch off all those mutations that can increase the risk of obesity, hypertension, cancer etc.”

Daily Dose

OKI: Meeting printing needs of hospitals

Article-OKI: Meeting printing needs of hospitals

Medical imaging equipment such as x-ray, ultrasound and scanners, provide clinicians with diagnostic quality images directly to their computer screens using a special DICOM (Digital Imaging and Communications in Medicine) protocol. OKI, a printer solution provider, provides high-end medical printers to meet diverse requirements and are showcasing their range of printers at the show.

The company also specializes in printers for graphic arts, and indoor and outdoor applications, among others.

Carine Haddad, Healthcare Manager, OKI Euope Limited, tells Daily Dose: “We are one of the only companies to have DICOM embedded software inside the printer. This allows users to connect it directly to the modalities such as ultrasound machines. It has been specifically designed for the medical sector and is sold to hospitals, clinics, etc.”

Furthermore, the company also sells a compact printer for ultrasound devices. She says, “Our printers are being used to serve as back up to print directly in emergency cases.

"For example, we are selling the PRO9431 to hospitals, which is the biggest in the range and allows you to connect it to an unlimited number of devices.”

Haddad highlights that hospitals also need to ensure that patient needs are met. For instance, patients visiting private hospitals in the UAE are often asked for print outs of their various documents, as some hospitals don’t accept soft copies and need hard copies for proof.

This is where OKI’s efficient range of printers come to the rescue. The company’s medical printers can also, therefore, multi-task and can be used across the various healthcare departments, to fulfill basic needs such as patient registration to providing high-quality images that enable efficient diagnosis.

“One of the next steps for us as a company is to complement our product with medical solutions. For example, we intend to provide full Hospital Information System (HIS) solutions, which provide customers a bundle offer that includes software’s, printers and modalities.” she comments.

The UAE is a very important market for OKI, says Haddad, as the country has established itself as a hub and all the people in and around the region refer to it as the “source of innovation”.

“It is essential for us to have the UAE as a strategic market. This also makes Arab Health an important event for us as this is where we start our year and see how we can generate more business and partnerships with dealers and sellers. We promote our products here first and then take it across the Middle East,” she concludes.

Daily Dose

Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension

Article-Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension

Spontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid (CSF) leaks and is known for causing orthostatic headaches. It is an important cause of new headaches in young and middle-aged individuals, but initial misdiagnosis is common.

Typically, a patient presents with a new headache that occurs shortly after assuming an upright position and is relieved by lying down. Although such a positional headache pattern is well-known following a diagnostic lumbar puncture, the spontaneous onset of an orthostatic headache is not well recognized and the patient may be diagnosed with migraine, tension headache, viral meningitis, or malingering. This has been a typical scenario for many patients experiencing spontaneous intracranial hypotension. But an initial misdiagnosis remains the norm.

Clinical background and epidemiology

Spontaneous intracranial hypotension is caused by single or multiple spinal CSF leaks. Once considered an exceedingly rare disorder, recent evidence suggests that spontaneous intracranial hypotension is not that rare and has to be considered as an important cause of new daily persistent headaches, particularly among young and middle-aged individuals. In the past, our knowledge regarding spontaneous intracranial hypotension was derived from case reports only, and no epidemiologic data were available.

In a community-based study conducted in 1994, the prevalence of spontaneous intracranial hypotension was estimated at 1 per 50 000. In a more recent emergency department–based study (2003-2004), spontaneous intracranial hypotension was half as common as spontaneous subarachnoid hemorrhage, for an estimated annual incidence of 5 per 100 000. Spontaneous intracranial hypotension affects women more frequently than men, with a female-male ratio of approximately 2:1. Onset of symptoms typically is in the fourth or fifth decade of life, with a peak incidence around age 40 years, but children and elderly persons also may be affected.

Comprehensive population-based epidemiologic studies, however, are not yet available. In the past, spontaneous intracranial hypotension was probably more frequently underdiagnosed than it is now, and it is unlikely that there has been an actual increase in its incidence, although that possibility cannot be entirely excluded.

Because spinal CSF leaks generally do not cause any local symptoms, they remain undetected unless actively looked for in a patient suspected of spontaneous intracranial hypotension. Also, unlike CSF rhinorrhea or otorrhea, there is no risk of meningitis because the CSF is directly absorbed into the sterile spinal epidural venous plexus or paraspinal soft tissues and is therefore not exposed to the external milieu.

The precise cause of spontaneous spinal CSF leaks remains largely unknown, but an underlying structural weakness of the spinal meninges generally is suspected. A history of a trivial traumatic event preceding the onset of symptoms can be elicited in about one third of patients, suggesting a role for mechanical factors as well. The dural weakness predisposes to the formation of dural defects that allow CSF to leak into the epidural space. A wide variety of dural defects may be observed at the time of surgery, ranging from simple dural holes or rents to complex fragile meningeal diverticula or even complete absence of the dura that normally covers the spinal nerve root. The volume of the CSF leak is quite variable as well, ranging from a minimal amount of seeping CSF only detectable when applying a Valsalva maneuver to large amounts of CSF spontaneously pouring out into the paraspinal soft tissues.

There is good evidence to suggest that a generalized connective tissue disorder plays a crucial role in the development of spontaneous spinal CSF leaks. In fact, based on physical examination alone, evidence for an underlying generalized connective tissue disorder is found in about two thirds of patients. This group of connective tissue disorders is heterogeneous, possibly affecting different components of the dural extracellular matrix, and include Marfan, Ehlers-Danlos syndromes, among many others.

Mechanical factors combine with an underlying connective tissue disorder can cause the CSF leaks. An orthostatic headache is the prototypical manifestation, but other headache patterns occur as well, and associated symptoms are common.

Clinical presentation and diagnosis

Positional headache: The prototypical manifestation of spontaneous intracranial hypotension is an orthostatic headache. Such a headache generally occurs or worsens within 15 minutes of assuming the upright position, as reflected by the revised International Classification of Headache Disorders criteria, but in some patients, this lag period may be as long as several hours. Improvement of the headache after lying down is less variable and occurs within 15 to 30 minutes. The headache may be diffused or localized to the frontal, temporal, or—most commonly—the occipital or suboccipital regions. The headache may be throbbing or non-throbbing and is rarely unilateral. Some patients use descriptive terms for their headaches, such as the feeling of “an ice cube in an empty glass” or a “pulling sensation from my head down to my neck,” offering a clue to the diagnosis. Additional clues may be the patient's recumbent position in the physician's office or a pillow they carry along to allow them to lie down comfortably. The initial onset of headache generally is gradual or subacute, reaching maximal intensity in several minutes to hours, but it may be instantaneous. Patients with such a “thunderclap” headache often will be suspected of having a subarachnoid hemorrhage and may undergo invasive testing, such as cerebral angiography. The severity of the headache varies widely; many mild cases probably remain undiagnosed, whereas other patients are incapacitated and unable to engage in any useful activity while upright.

Diagnostic criteria for headache due to Spontaneous Spinal CSF Leak and Intracranial Hypotension according to the International Classification of Headache Disorders:

• Diffuse and/or dull headache that worsens within 15 minutes after sitting or standing, with 1 of the following:

1. Neck stiffness

2. Tinnitus

3. Hypacusia

4. Photophobia

5. Nausea

• And at least 1 of the following:

1. Evidence of low CSF pressure on MRI (e.g., pachymeningeal enhancement)

2. Evidence of CSF leakage on conventional myelography, Computed Tomography myelography, or cisternography

3. CSF opening pressure <60 mm H2O in sitting position

4. No history of dural puncture or other cause of CSF fistula

5. Headache resolves within 72 hours after epidural blood patching

The headache is a direct result of the downward displacement of the brain due to loss of CSF buoyancy, causing traction on pain-sensitive structures, particularly the dura. An alternative mechanism involves compensatory dilation of the pain-sensitive intracranial venous structures.

It should be noted that not all orthostatic headaches are caused by spontaneous spinal CSF leaks, and other diagnoses should be considered.

Diagnosis

Typical magnetic resonance imaging findings include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain (mnemonic: SEEPS). Myelography is the study of choice to identify the spinal CSF leak.

Primary diagnosis methods include:

• Cranial MRI

• Cranial Computed Tomography

• Myelography

• Radionuclide Cisternography

• Spinal MRI

• Lumbar Puncture

Treatment and outcome

Although data are lacking, it is often stated that many cases of spontaneous intracranial hypotension resolve spontaneously without any specific therapy. Fortunately, several options are available to treat patients with spontaneous intracranial hypotension who seek medical attention. However, none of the treatments have been evaluated by randomized clinical trials. A purely conservative approach consists of bed rest, oral hydration, a generous caffeine intake, and use of an abdominal binder. Given enough time, this treatment is probably effective in many patients. However, symptoms may be debilitating, and more timely results may be desired. Administration of steroids, intravenous caffeine, or theophylline all have been advocated as specific treatments for spontaneous intracranial hypotension, but their effectiveness is limited.

The mainstay of treatment is the injection of autologous blood into the spinal epidural space, the so-called epidural blood patch. Relief of symptoms often is instantaneous, thereby also serving a diagnostic purpose, and this is likely due to replacement of lost CSF volume with blood volume within the spinal canal. Initially, about 10 to 20 mL of blood is used, and this is effective in relieving symptoms in about one third of patients, presumably by forming a dural tamponade, thereby sealing the leak. Another mechanism of action may be restriction of CSF flow within the spinal epidural space, thereby interfering with CSF absorption. If the epidural blood patch is unsuccessful it can be repeated, and consideration should be given to a large-volume (20-100 mL) epidural blood patch.

Given the potentially high volume of injected blood, a minimum of 5 days between blood patches is advised. The volume of blood that can be injected is mainly limited by local back pain or the development of radiculopathy. I prefer to place the blood patch at 2 separate sites, first at the thoracolumbar junction and then in the lower lumbar area, after which the patient is placed in the Trendelenburg position, either supine, prone, and/or lateral for 30 to 60 minutes, depending on the location of the CSF leak. This allows blood to travel over many spinal segments toward the site of the leak.

If epidural blood patches fail to provide relief, a directed epidural blood patch or percutaneous placement of fibrin sealant is recommended. These therapies require that the exact site of the CSF leak be known, and placement of fibrin sealant probably provides the best chance of alleviating symptoms. In my experience, about one third of patients for whom epidural blood patching has not been effective experience relief with the percutaneous placement of fibrin sealant, thereby avoiding surgery.

Surgical treatment is reserved for those patients in whom these nonsurgical measures have failed. Surgical repair of CSF leak is safe and often succeeds in providing relief for those patients in whom a structural abnormality or focal CSF leak is identified. Leaking meningeal diverticula can be ligated with suture or a metal aneurysm clip, while dural rents, holes, or other defects are repaired either directly with suture or, more commonly, by placement of a muscle pledget along with gelfoam and fibrin sealant. Rarely, intradural exploration may be required.

Intrathecal infusion of saline or artificial CSF should not be expected to seal a CSF leak but may be required as an effective temporizing measure to restore CSF volume until the leak can be permanently repaired in patients who require urgent treatment, such as those with a decreased level of consciousness.

A recurrence of headache following successful treatment of spontaneous intracranial hypotension may indicate a recurrent CSF leak, but if the pattern of headache has changed, rebound transient intracranial hypertension or dural venous sinus thrombosis should be considered.

Data on long-term outcomes are scarce, but in my experience, recurrence of a spinal CSF leak is seen in approximately 10% of patients, regardless of treatment. Outcome studies have shown that patients with abnormal brain MRI findings and a focal spinal CSF leak have an excellent prognosis, while those with normal initial MRI findings and a diffuse multilevel spinal CSF leak have a poor prognosis. Some patients have persistent symptoms following treatment, despite documented resolution of CSF leakage. Such patients may have residual altered CSF dynamics or small residual CSF leaks below the level of detection of current imaging techniques.

Conclusions

Spontaneous intracranial hypotension is not rare, but it remains underdiagnosed. The spectrum of clinical and radiographic manifestations is varied, with diagnosis largely based on clinical suspicion, cranial magnetic resonance imaging, and myelography. Numerous treatment options are available, but much remains to be learned about this disorder.

References

1. Shievink WI. Spontaneous Spinal Cerebrospinal Fluid Leaks and Intracranial Hypotension. JAMA. 2006;295(19):2286-2296. doi:10.1001/jama.295.19.2286

2. Shievink WI. Lateral decubitus digital subtraction myelography to identify spinal CSF-venous fistulas in spontaneous intracranial hypotension. J Neurosurg Spine September 13, 20194

3.Shievink WI. A classification system of spontaneous spinal CSF leaks. Neurology Aug 2016, 87 (7) 673-679; DOI: 10.1212/WNL.0000000000002986

Daily Dose

Getting to the root of poor oral hygiene

Article-Getting to the root of poor oral hygiene

After her grandmother suffered a stroke due to poor oral hygiene, Dr. Emily Stein, CEO of Primal Health, decided to take the matter into her own hands. Armed with her microbiology and rheumatology knowledge, she started the company to make people healthier by focusing on promoting oral hygiene.

In an interview with Daily Dose, she shares: “My grandmother was living in a senior healthcare facility in the U.S. and her rheumatoid arthritis was so bad that she couldn’t brush her teeth. She had significant decay, gum disease, had a couple of tooth extractions and eventually suffered a stroke. Turns out that there is a huge link between cardiovascular events and poor oral hygiene.”

She says that she was a post-doc at Stanford when the incident occurred and she flew to meet her grandmother, grabbed her microbiome fluid, bio-hacked it in her apartment and figured out what ingredients worked to stop the bacteria that lived in her mouth from causing inflammation, tooth decay and gum disease.

“We came up with a novel approach and patented it. It has broad applications elsewhere as well such as for skin, agriculture or wherever microbes are causing harm. We figured out a way to tune outcomes based on going after metabolism. We are focused on dental hygiene because 80 per cent of humans have dental disease,” she explains. “We all eat carbohydrates and certain bacteria can immediately convert those carbohydrates into harmful things called organic acids and other molecules that can cause leaky gums. That bacteria then escape from the mouth and go into the body, which is why oral hygiene is linked to cardiovascular disease, dementia, arthritis, and even pancreatic cancer.”

To fight the disease at its root, Primal Health developed pHossident, a Proudct of USA, that is a clinically proven prebiotic dental lozenge that promotes dental health. “I made the pHossident breath mints for my grandmother, as she couldn’t brush her teeth but could suck on the mints and that helps dynamically change which bacteria lived in her mouth. In our clinical work, we have shown that it can eradicate salmonella, etc., and help maintain a healthy level of bacteria that are actually protective. The goal was to combat it through an easy way,” she adds.

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Dr. Emily Stein

Primal Health also has a programme for animals, as cats and dogs tend to encounter similar dental issues. In animals, poor oral hygiene can strip away about a third of their lifespan and they can die prematurely.

She further emphasised that a lot of people are just lazy and don’t realize that they need to brush often. A U.S.-based study found that if you brush your teeth only twice a day, you can lose about 10 years of lifespan. It can also significantly impact quality of life and social interactions.

Dr. Stein highlights that the company has been getting a good response and will also be doing some work with the UK and received some interest from Greece to perform clinical work.

She says: “A lot of countries are struggling with oral disease and it is all a matter of being able to meet these people and figure out ways to work together. I looked at the statistics in the UAE and noticed that a high number of children have dental disease here. Cavities can disrupt their ability to learn but these are problems with that can be solved by just practicing good oral hygiene.”

Daily Dose

How is Malaffi transforming patient lives through connected healthcare systems?

Article-How is Malaffi transforming patient lives through connected healthcare systems?

Technology has an impact on all our lives: from how we consume food, shop, and interact with one another. For the healthcare sector, technology is helping people beyond convenience, it is helping save lives.

One way it does so is by utilising the abundance of data in the form of patient health information to empower providers and patients to make better-informed healthcare decisions. This ultimately has an impact on improving patient experience, outcomes and efficiencies. Understanding this, Malaffi, the region’s first Health Information Exchange (HIE) platform, was launched in the Emirate of Abu Dhabi in 2019; established as part of the strategic priorities of the Department of Health – Abu Dhabi.

Malaffi allows providers from across Abu Dhabi to electronically, safely and securely exchange and access crucial patient information accessible in real-time. Reducing information-sourcing admin, this allows medical providers to focus more of their time on treating and healing their patients; resulting in the delivery of better-quality healthcare and improved patient outcomes. Ultimately, Malaffi places patients at the heart of care.

Enhancing the patient experience

During their healthcare journey, patients often undertake unnecessary tests, multiple doctor visits and repeat procedures for the same health issue. This is often due to the non-availability of past patient health information, such as test results or diagnoses – all of which are not shared between healthcare providers and remain inaccessible to the attending doctor and care team.

Through Malaffi, patients can rest assured that their provider has all their necessary health information, which will ultimately reduce any inconvenience for patients and their loved ones. Crucially and importantly this significantly improves their patient experience.

Malaffi will reduce the unnecessary duplication of services and the amount of time doctors and care teams spend on administrative tasks to source important patient information from other healthcare providers. It will improve patient safety by reducing medication errors; enhance patient journeys. By ensuring providers have access to key patient health information, they will be able to best coordinate care. This is especially important for those with chronic or malignant diseases who need to see multiple doctors on a regular basis.

Providing better patient outcomes

Through Malaffi, each patient in Abu Dhabi will have a unified medical file. This file will bring together patient data, including medication, allergies, laboratory and radiology results, procedures and more. Every time a patient seeks medical support – from consultation to emergency treatment – their Malaffi file will be updated in real-time to facilitate faster and better-informed decisions and more reliable diagnoses. With 80% of serious medical errors involving miscommunication between healthcare providers during the transfer of patients from one provider to the next, healthcare providers will now have instant access to all the health information they need which can reduce misdiagnosis.

Benefits of Malaffi

Dr. Gareth Goodier, Group Chief Executive Officer, SEHA, said: “This initiative will bring enormous benefits for our patients. As Malaffi evolves to onboard more providers and include more clinical information, we anticipate increased efficiencies within the healthcare sector over the coming years.”

David Hadley, CEO of Mediclinic Middle East, said: “Mediclinic Middle East is happy to join Malaffi, as a strategic priority of the Department of Health - Abu Dhabi. Following its implementation, Abu Dhabi will benefit from a more efficient healthcare system through the resulting reduction in medication errors and duplicate tests, as well as the introduction of emirate-wide health initiatives made possible by the centralisation of information.”

Heightened data protection

Patient privacy and the security of digital health information are top priorities for the Department of Health - Abu Dhabi and Malaffi. By connecting the electronic medical records (EMR) systems of all providers in Abu Dhabi, Malaffi and providers adhere to the strict government rules and regulations around data protection and patient rights, and must comply with Emirate and federal health privacy laws that protect patient health  information. These include different measures, such as ensuring that only authorised users can access patient data, and that data is encrypted and exchanged over a secure network. This ensures that a standard for the security and protection of personal health information and privacy is upheld.

Placing patients at the centre of care

To help patients better manage their health, in 2020 Malaffi will be launching a patient mobile application. As soon as they download the app, patients will have their own medical information at their fingertips. With 55% of all medical malpractice cases due to miscommunication that happens between a provider and a patient, this patient app will facilitate better communication and allow patients to be more fully engaged in their care. Patients can check their Malaffi file anytime and anywhere through the app, which also supports prevention and early detection of illnesses; in addition to providing peace of mind for them and their families. This reassures them that they are receiving the best possible care, anywhere – and at any time – in Abu Dhabi.

Not only does Malaffi deliver a variety of benefits for everyone, but also assists in improving healthcare for the whole population. It does so by providing invaluable information to the Department of Health - Abu Dhabi to help monitor the quality of care, launch health awareness and prevention programmes; and identify public health risks.

References available on request.

Daily Dose

Orthotics: Is it Science or a Sham?

Article-Orthotics: Is it Science or a Sham?

Foot pain is very common among all populations, with estimates that 13% to 36% of people suffer from some form of foot pain. Consultations with primary care physicians in the UK identified that overall foot pain ranked the 5th most common cause for seeking medical help. That same study also identified the most common complaint among children (less than 14 years of age) was foot pain, forcing patients to seek medical help. Risk factors for developing foot pain include female gender, obesity and increasing age. Some of the most frequent causes of foot pain include Plantar Fasciitis, Metatarsalgia, Hallux Valgus, Arthritis (including Rheumatoid Arthritis), Hallux limitus and rigidus, Morton’s neuroma, posterior tibialis tendon disorders and stress fractures. For people with these conditions, the resulting foot pain and associated disability can have large, negative impact on their comfort, mobility and quality of life. Further still, foot pain can decrease balance and strength and is a contributing factor to falls. Since we rely on the use of our feet to work and exercise, good foot health is crucial in leading an active and fulfilling life.

Why is foot pain disability so high?

Evolutionarily, the human foot was designed to navigate on soft ground, for instance sand or grass. Soft ground has the ability to give way and mold around the foot, allowing for a larger area to be in contact with the ground. This larger area of contact decreases the peak pressures passing through the foot. However, fuelled by the invention of wheel, things have changed. Wheels roll efficiently on hard surfaces and, in order to accommodate this, most of our habitable locations have been converted to hard surfaces. The roads and pavements in our cities and the tiled floors in our homes are just a few examples of the firm and flat surfaces our feet now navigate. Additionally, even the majority of modern footwear has flat footbeds, further exposing the soles of our feet to flat, solid surfaces. This is where orthotics can help. Orthotics provide contoured surfaces, often with substantial arch support, which allows a wider area of contact to be made with the sole of the feet. This wider area of contact decreases peak plantar pressures. In addition, foot orthotics also change muscle activation and reduce joint loading. Both these effects in conjunction with each other and independently aid in the reduction of foot pain. These orthotics can also be placed within normal, fashionable shoes, enabling the wearer to enjoy their favorite pair in comfort.

Orthotics for specific conditions

Plantar Fasciitis

Plantar Fasciitis is a common cause of heel pain. The plantar fascia connects each of the toes to the heel bone. In plantar fasciitis, this tissue becomes inflamed. The pain is normally felt in the heel, and the first step early in the morning can be severe. 

A systematic review conducted by Lewis and colleagues revealed that, within 1 to 3 months orthotics can improve the pain levels and functionality for individuals with plantar fasciitis. A randomized clinical trial, the SOOTHE trial by Whittaker, et al, studied a comparison between steroid injections and orthotics and concluded that, whilst steroid injections provided temporary relief, orthotics provided a more sustainable and longer-term benefit.

Metatarsalgia

Metatarsalgia affects the forefoot, causing pain directly beneath the metatarsal heads at the ball of the foot. The metatarsal heads contain joints which connect the toes to the foot and provide support when we run, walk or stand. These joints are therefore often under intense pressure, making them prone to pain and inflammation.

Orthotics with metatarsal pad supports have been found to reduce the pressure on the ball of the foot by shifting the weight away from high pressure areas. Manniko from Finland identified a metatarsal pad reduced pain in 84% of the participants in the study. Pain decreased by an average of 3.2 points on a 10 point numeric rating scale in all patients.

Hallux Valgus

The most frequent deformity of the forefoot, Hallux Valgus (bunion) is the malformation of the joint at the base of the big toe. Often caused by narrow toe boxes, bunions occur when the big toe turns inwards, pointing towards the other toes. As a result, the first metatarsal and the connecting joint are forced to protrude outwards, causing the surrounding bursa to become enlarged, painful and stiff.

In patients with Hallux Valgus, total contact orthotics have been found to significantly reduce pain and improve contentedness. Orthotics have also been highlighted as an effective prevention technique. An independent study by Budiman-Mak and colleagues found that using orthotics reduced the rate of developing Hallux Valgus by 73%, in patients with Rheumatoid arthritis.

Rheumatoid Arthritis (RA)

Rheumatoid arthritis is an auto-immune disease, which causes malformation, pain and inflammation in joints. The condition occurs when the body’s immune system attacks the joints and damages the cartilage. RA is the most common form of inflammatory arthritis.

A study by Kavlak et al found that patients with ankle rheumatoid arthritis who used orthotics for three months reduced their pain levels and energy expenditure while increasing their stride length and step.

Diabetes and Diabetic Foot: A rising concern in the Arab Nations?

Diabetes is a significant medical burden throughout the world. The condition affects 382 million people globally (5%) and the prevalence is rising in every country year on year. In the Arab nations, the incidence and prevalence are higher than the global average. For instance, in Saudi Arabia the prevalence is reported to be as high as 31.6%, ranking the country as the 7th highest in the world for T2DM occurrence. Additionally, Oman and Kuwait are also reported to have high prevalence rates of 29% and 25.4% respectively. When compared to the average prevalence reported in the UK, which stands at 6%, and the global average of around 5%, a stark contrast between the statistics is observable. In the International Diabetes Federation global fact sheet 2019, Sudan, Egypt, UAE, and Bahrain were also listed within the top 20 nations for diabetes prevalence, indicating that a diabetes epidemic is taking place within the Arabian nations.

Peripheral Sensory Neuropathy (PSN)

Diabetes can result in peripheral sensory neuropathy. Neuropathy is when the nerves do not function normally, and numbness and loss of sensation can occur. When sensation is lost, the protective reflex from pain is lost. The body fails to recognize constant pressure and the skin cover fails. This leads to diabetic foot ulcerations (DFU) and infection. It is estimated that peripheral sensory neuropathy is found in 82% of diabetic patients in Western Saudi Arabia (one of the highest rates in the world).

Diabetic Foot Ulcerations

Diabetic foot ulcerations (DFU) occur in 15% of all diabetics and it is estimated that 15% of these patients will have to have an amputation as a result of their ulcers.

A systematic review of nine papers found that the average prevalence of diabetic foot ulcerations within the diabetic population in Saudi Arabia was 11.85% [20]. This is almost double the global average of 6.4%.

Amputation in diabetics unfortunately leads to death. In a meta-analysis of 31 studies, the 5-year mortality rate was found to range between 53% to 100%.

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Orthotics for diabetic foot ulcerations?

In a 2013 study by Fernandez et al, 117 diabetic participants, each with a history of DFU’s, were prescribed custom-made orthotics. The participants were given therapeutic insoles and footwear to reduce plantar pressure, based on a detailed biomechanical study. The orthotics aimed to disperse the pressure to the whole of the sole of the foot. Prior to the treatment, ulceration recurrence was 79% and the amputation rate was 54%. After 2 years of orthotic therapy, the reulceration rate had significantly dropped to 15%. The amputation rate was also reduced to 6%.

If an ulcer is subjected to pressure, it will remain an ulcer. Relieving this pressure will allow the healing of ulcer. Relieving the pressure is called off-loading. Modern studies have reinforced the concept that total contact casts are the most effective methods for off-loading pressure from a pre-existing diabetic foot ulcer. A systematic review by Elraiyah and colleagues contained 19 interventional studies, including the data from 1605 participants with DFU’s. The study found that total contact casting benefited patients in the treatment of diabetic foot ulcers. Furthermore, various forms of orthotic shoes and insoles were found to significantly reduce ulcer recurrence.

Conclusion

Foot pain is an ever-increasing medical burden throughout the world. The symptoms of painful foot conditions including Plantar Fasciitis, Hallux valgus, Metatarsalgia and RA have all been found to be reduced through the use of orthotics. Additionally, diabetes and diabetic foot ulcers are becoming a significant concern throughout the world. This is more so in the Arab nations where the epidemic of diabetes and its associated conditions is becoming an increasing social, medical and financial burden. Review of the literature shows the benefits of orthotics in prevention and avoiding recurrence. Decreasing the incidence of ulcers will decrease the incidence of amputation which should also decrease the mortality associated with it. In conclusion, prefabricated orthotics seem to be a value-based, effective treatment for many conditions affecting the foot.

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References available on request.

Daily Dose

The new frontiers in medicine

Article-The new frontiers in medicine

I want to begin by thanking everyone for working in the healthcare sector and for their hard work. People are working under challenging conditions doing their best to deliver high-quality care for their patients. The world we are in is volatile, uncertain, ambiguous, and complex (VUCA), which makes us feel unsettled whether we are doctors, nurses, therapists, managers, or patients. However, this also presents opportunities that must be seized. After all, no one can be happy with the quality of care at the current time: citizens, payers, or physicians.

Some nations have a fractured healthcare system with variable quality and rising costs. There are systemic issues with increasing demand from a tsunami of long-term conditions, an ageing population, rising costs, and the requirement for better value. Moreover, there is a rise in consumerism with discerning and empowered patients whose legitimate needs need to be met.

Moreover, there are significant patient safety issues, such as antimicrobial resistance. The scourge of modern medicine is over-diagnosis, over-investigation, lifestyle diseases such as obesity and polypharmacy. There is a reliance on super-specialisation, which, while providing brilliant care for individual patients with single conditions, does not meet the holistic needs of people or the public health challenges of global non-communicable diseases and multimorbidity. The medical profession itself is changing, wanting more autonomy, flexible working, and control of workload to deal with the damaging effects of burnout

Medicine is an unhappy place right now. So how does healthcare evolve to meet the legitimate needs of citizens? Solutions are available with new models of care that allow generalists and specialists to work together to provide high quality and safe, integrated care. Critical to this is an engaged and confident workforce that can lead and shape future health and care with a focus on wellbeing.

There are no simple answers but change and improvement are distinctly possible! It is possible to ‘bend the curve.’ The secret to success is leadership from doctors to drive forward transformation by pursuing a progressive, innovative patient-centered agenda. Conferences like Arab Health allow us to reimagine healthcare.

There are five critical components of reimagined healthcare, which I am calling the new frontiers that must be embraced. Firstly, the systematic and disruptive introduction of technology and artificial intelligence to support – not replace – doctors and nurses, especially in light of the global workforce shortage. Second, a big- data approach – including genomics to help predictive and personalised medicine. Thirdly to reverse the power balance in medicine from doctors to patients – the concept of empowered activated patients’ experts in self-care and self-management – ‘the patient will see you now doctor’! Fourthly, a relentless focus on universal primary healthcare, including the wider social determinants of health. Finally, a joined-up, connected system of healthcare where generalists and specialists’ providers work together seamlessly to focus on clinical excellence and outcomes – the focus being on teams and systems rather than individuals.

Research has clearly shown that countries with well-developed primary care healthcare systems have much better outcomes and patient satisfaction. Being a GP/family doctor is probably the hardest specialism in medicine. It is not an easy role, e.g., differentiating a viral illness from meningitis or migraine from a brain tumour or panic attacks from pulmonary disease. This requires formal training to build confidence in being a family doctor.

The WHO Alma Ata Declaration in 1978 committed to the adoption of universal primary healthcare and the importance of the social determinants of health such as sanitation, housing, education, and employment. The challenge still holds and was reconfirmed in the Almaty declaration of 2018. Underpinning all five components is the need for good governance, ethics, and collaboration. We can only earn the trust of people, patients, society, and governments by demonstrating high standards of practice with accountability. And by being kind, compassionate, and courageous.

I am confident about the future. Positive change is already happening in many parts of the world. We are in an age of progress with the advent of digital and genomic innovation and people-power. I have met many inspirational medical leaders and managers who have a vision for better sustainable healthcare. But we can all do something to help and play our part. Lots of small changes can lead to significant improvements in outcomes.

Please follow my three-point plan: Be the best doctor you can be; be on the side of patients; be a leader by shaping the future. In this way, we can get Happy Doctors, Happy Patients.

Daily Dose

Leading from the front

Article-Leading from the front

Today, a healthcare sector upgrade is recurring for most GCC countries. A lot of them are already in the process of revamping the system, preparing it for attracting investments and allowing healthy competition from the private sector. In the Kingdom of Saudi Arabia (KSA) overall, the private sector contribution to total healthcare spend currently stands at 25 per cent, which the National Transformation Programme (NTP) targets to raise to 35 per cent by 2020. Another recent trend that has emerged in the KSA is the focus of the Ministry of Health on having dedicated training centres inside every hospital. In an interview with Arab Health, Leader Healthcare Saudi Arabia’s CEO Jamal Al-Showaikhat said: “I believe in the coming 10 years Saudi Arabia will drive the world in terms of simulation”. Excerpts:

What do you think is driving the healthcare industry forward in Saudi Arabia?

Saudi Arabia is one of the biggest countries in the region. The government pays a lot of attention to healthcare. In fact, the second most important budget allocated in the government is for the health sector. I recently read an article that highlighted that by 2030 the total investment in the healthcare sector in the country is going to be more than US$100 billion. Today, many medical centres and cities are being formed in the country. Another important topic that the Ministry of Health is focusing on is that every hospital in Saudi Arabia is being asked to have their own training centre inside the hospital. I reiterate that in the coming 10 years Saudi Arabia will drive the world in terms of simulation.

Recently, Saudi Arabia’s Minister of Health Dr. Tawfiq bin Fawzan Al-Rabiah inaugurated the Saudi Health Simulation Conference in Riyadh. Leader Healthcare was a Platinum Sponsor of the event because we believe that simulation is going to be a new era in the medical field in the coming years.

What would you say is the impact of healthcare simulation in healthcare in Saudi Arabia?

The impact of AI in the medical field is huge. For example, in simulation today, we see doctors, nurses, or people working in the medical field being trained in the new techniques through innovative devices. Another trending topic is that in many of the schools and colleges in Saudi Arabia, Leader Healthcare is leading the industry in driving this change of training and diversifying the accredited programmes. We are implementing these projects in many universities where we can integrate the latest in technology.

Today, surgeries have become the only solution for different pathologies and complex cases. Therefore, it has become more critical to have surgeons that are well educated and trained on the “Cut Suit”, a realistic way to simulate the look, feel, and smell effects of severe traumatic events on a live human casualty while allowing first respondents and physicians to safely perform real procedures – from the point of injury to treatment en route, and transition of care to surgical intervention. Trainees of surgery at most surgical residency programmes are usually under a lot of pressure to perform quick and efficient treatment to the injured individuals at an incident scene, as a life will directly depend on their performance and quick response. The Cut Suit offered by Leader Healthcare meets the various training needs, starting from psychological and emotional pressure, training the student’s psychomotor skills and achieving excellence in performing rescue tasks in a timely manner.

Another important innovation that we have today is virtual reality where we can get people trained in their daily environments and where they can practice their various medical scenarios safely. For instance, scenarios from different site locations and incidents can be brought into your facility for the purpose of training. Furthermore, our team travels all over the world to procure and bring new technology to the region such as the Interactive Immersive Classroom.

We are working on saving more lives through emergency medical training and also focus on wellness, beauty and lifestyle changes. We take complete care in understanding the latest market trends and providing clients with new surgical and diagnostic equipment devices for usage in areas such as Emergency rooms/Operating rooms, Ophthalmology, ENT, Aesthetic Dermatology, Plastic Surgery, Orthopaedic, models for simulation-based medical education and general home healthcare department.

How important is it for you to be present at Arab Health?

Our booth at Arab Health is one of the largest and also the Platinum Sponsors which highlights the importance of the show for us. We invite a number of delegates to attend this event from all over the World and make sure they have the best experience of the Arab Hospitality. The team makes sure to bring together all partners from leading innovations to the booth and we achieve to be known as a “one-stop solution provider”.

What products will you be showcasing at Arab Health 2020? Could you shed light on your future plans?

That is to be witnessed as we have something very exciting this year! Leader Healthcare is an international brand with presence all over the GCC, South Asia and APAC. We are also looking forward to expanding more in the other Middle Eastern regions such as Egypt and Iraq.

Control-X Medical commemorates 30 years

Article-Control-X Medical commemorates 30 years

Control-X Medical was established in 1990 in the U.S. with the ambition of producing word class x-ray systems at affordable prices. By now the company – still independent and managed by its Hungarian founders – is operating out of the U.S. and the EU. In the past 30 years, over 5,000 Control-X Medical systems have been installed in more than 50 countries on all seven continents, even Antarctica.

Control-X Medical’s flagship Perform-X family of x-ray suites offer automation features such as tracking, positioning and stitching to accelerate and enhance diagnostic procedures for patients and to reduce the stress and workload of busy hospital staff. With the flexibility to customise each radiographic suite, Control-X Medical can provide the highest level of quality and reliability with the personal attention customers deserve.

Control-X Medical’s philosophy is to manufacture a full range of high-quality radiographic systems and deliver top-notch service and support by partnering with strong local distributors. This offers exceptional value to hospitals and clinics worldwide, with low total cost of ownership and attentive local service.

A great example is our partnership with Tecmed Africa, a medical equipment distributor focused for 26 years on “delighting customers” in Southern Africa. Control-X Medical and Tecmed have joined forces to expand access to high quality diagnostic imaging in the region by delivering dozens of dozens of highly sophisticated Perform-X systems to hospitals in two South African provinces.

Control-X Medical is a significant player in the field of veterinary radiology too. The ZooMax family of veterinary x-ray systems is very popular in Germany, Austria and Switzerland as well as in Scandinavia, where veterinary clinics demand high quality and durable systems. Alongside solutions for small animals, the top of the ZooMax product range is a ceiling mounted telescopic system suitable for examining large animals such as horses and camels. These systems are already in use in leading German and Scandinavian veterinary university clinics.

Fulfilling the customer needs is the center point of Control-X Medical’s mission. The company is well known for its flexibility and exceptional custom-tailoring capability. Customers can rely on the technical expertise accumulated by Control-X Medical over 30 years and can be sure that the company’s solutions will match their needs exactly and serve them year after year.

For more information on Control-X Medical radiographic systems or our veterinary solutions for small and large animals, please visit www.cxmed.com.

Daily Dose 2020 Day 4

White-paper-Daily Dose 2020 Day 4

Here is a round-up of all the developments from Day 3 of the show. Plus, read more about what is on the agenda today.