Ophthalmic imaging is an integral part of the work of all ophthalmic departments as it is essential to the diagnosis, treatment, and long-term monitoring of many ocular conditions. Also, it plays a central role in ophthalmic disease screening, teaching, clinical trials and in virtual clinics and telemedicine.

According to Dr. Ammar Safar, who is the medical director and consultant vitreoretinal surgeon at Moorfields Eye Hospital Dubai, imaging has played a significant role over the decades in expanding our understanding of the disease process of many eye conditions.

“Similar to when a general practitioner detects abdominal pain and orders an imaging study to investigate it, an ophthalmologist frequently encounters a similar situation where if an abnormality is detected on the eye examination in the cornea or retina, for example, the imaging study becomes instrumental in giving the ophthalmologist the needed information to make the diagnosis,” he explains.

Imaging modalities in ophthalmology range from plain films radiography where images of radiopaque tissues are obtained by exposure of special photographic plates to ionizing radiation, to Computed Tomography (CT) and Magnetic Resonance Imaging (MRI).

According to Safar, ophthalmology is rich in imaging tools, depending on the structure that is studied. Ultrasonography has been used for decades in imaging the internal parts of the eye, especially when there is internal bleeding and direct visualisation is difficult to achieve. Ultrasonography was instrumental in following and assessing intraocular tumours and helped set the guidelines for managing those rare tumours. Another imaging modality is Optical Coherence Tomography (OCT), which creates a cross-sectional image of the structure of interest that adds a wide range of information to the decision-making process.

“Angiography of the vessels of the retina (using fluorescein dye) and choroid (using ICG dye) have also been the gold standard used for years for diagnosing common and potentially blinding conditions such as diabetic retinopathy and age-related macular degeneration among others,” Safar says.

Direct photography of different parts of the eye has been long used to document and categorise disease stages. Angiography of the retinal vessels after injecting a dye into a patient’s arm has been a benchmark for decades. Dr. Safar explains that with the turn of the century, two major developments were introduced to the clinical practice of ophthalmology that truly revolutionised the practice.

The first breakthrough is OCT that uses light scans of different eye structures (the retina for example) to create a 3D cross-sectional image of that structure offering an unprecedented look at that structure, which opened so many doors to a better understanding of the disease process and also allowed for better surgical intervention as well as better medications.

The second breakthrough is the ability to utilise the OCT technology to image the retinal vasculature in its entirety without the injection of any dye into a patient. This imaging device is called OCT Angiography.

“Much to the surprise of scientists and researchers, this new technology discovered the presence of new networks of retinal vessels that were not known to be present before using the traditional dye-based angiography. This new discovery will, no doubt, result in major advancement in understanding the pathophysiology and the exact causes of the blinding conditions and, based on that, new and more precise treatments will be designed and introduced to help re-gain vision for helpless patients,” Dr. Safar highlights.

In modern ophthalmology practices, several imaging tools help an ophthalmologist make an accurate diagnosis and also deliver effective treatment to his or her patient.

According to Dr. Safar, one of the most widely available imaging tools is an OCT scanner, which have now become an essential tool for any eye hospital or clinic. OCT angiographies are newer tools and may likely be also readily available soon.

“Another technique that is commonly found in every practice is a corneal topography machine that creates a map of the cornea and allows the ophthalmologist to determine the weak or thin areas of the cornea, which helps design the treatment around any potential problem area. Fluorescein angiography remains present in every practice as it offers a wealth of information,’” he adds.

In addition, Dr. Safar highlights that ultrasound machines for the eye are invaluable in detecting eye problems when there is internal bleeding in the eye that prevents direct visualisation of the internal eye structure, or in the case of an intraocular tumour.

Case studies

Dr. Safar outlines two clinical case studies to illustrate the changing role of imaging in ophthalmology.

The first is a 42-year-old woman presented for a routine eye examination as she wore glasses for the last 15 years. Upon examination, the patient was discovered to have slightly elevated intraocular pressure in the right eye from which she had absolutely no symptoms. OCT of the optic nerve was ordered, and it illustrated the presence of reduced nerve fibre layer thickness, which is a sign of possible glaucoma: a potentially blinding condition if left undiscovered and untreated. Further imaging and testing were carried out to rule out any other possible causes. After establishing the diagnosis, the condition was discussed with the patient and treatment was started.

The second is the case of a 39-year-old computer programmer presented with a history of recurrent episodes of intermittent blurring of the vision that would come and go. The blurring lasted a few days and then would get better spontaneously. He visited the Moorfields Eye Hospital in Dubai on one occasion as it had been over three weeks and the left eye had not yet improved, although it usually did before.

The examination of the retina showed some mild pigmentary changes which, along with the given history, was consistent with a diagnosis of central serous retinopathy. What was unusual was the severity of vision loss in the left eye despite the lack of fluid on the direct visualisation of the retina. Imaging study was ordered, and when the results came, the condition was clear, and there was no room for any error or doubt. The patient had new abnormal vessels growing under the retina and oozing fluid, which was only discovered using the latest OCT angiography technique.

According to Dr. Safar, this result changed the entire approach for the management of this condition, from mere observation to full intervention with medications injected into the eye to dissolve the abnormal vessels, which resulted in saving this programmer’s vision.

“Stories like the ones presented above are crucial in order to understanding why it is exceedingly important to couple the doctor’s examination with the results of the imaging technology; this way the treating physician has a complete and deep understanding of all the factors involved in the loss of vision,” says Dr. Safar. “This is the only scientific and acceptable way to practice ophthalmology in the 21st century. Patients need to understand that an ophthalmologist orders imaging studies purely to be complete in their assessment, and make sure that no effort has been spared before a treatment regimen has been recommended.”

In the event of the woman with glaucoma, the peripheral vision and eventually, the central vision could have been lost in a matter of several years without the detection and management that was applied. Dr. Safar believes that the case of the 39-year-old programmer is even more acute, as the presence of those abnormal blood vessels could have become explosive at any minute and the results would have been disastrous had the vessels bled into the space below the retina.

Innovation is key to improving healthcare outcomes more quickly and effectively. This is where Malaffi (Arabic for ‘my file’), the region’s first Health Information Exchange (HIE) platform, will facilitate the making of better-informed and more efficient clinical decisions, as well as enhance coordination and transition of care. The platform allows healthcare providers to better coordinate patient care, reduce the duplication of procedures, and prevent medical and medication errors. Ultimately, with the help of the platform, healthcare providers will have more information about their patients enabling them to deliver higher healthcare quality. This reliable sharing of patient health information will support the management of chronic diseases and the provision of emergency care.

Having an Emirate-wide HIE system allows for the exchange of significant amounts of data. Soon, this will provide a great opportunity for advanced technologies to process and analyse monumental amounts of data in record time with unmatched efficiency. As an electronic platform, Malaffi will help pave the way for the introduction of artificial intelligence (AI) and machine learning technologies to further improve care coordination, system planning and public health management.

Atif Al Braiki, Chief Executive Officer, Abu Dhabi Health Data Services told Omnia Health Magazine: “Malaffi was established as part of the strategic priorities of the Department of Health – Abu Dhabi (DOH) as a key component of the digital transformation of the healthcare system in the Emirate.

“The surge of chronic diseases and the growing and ageing population put increasing strain on the healthcare system in Abu Dhabi and worldwide. To optimise the delivery of healthcare, safely and securely sourcing medical information is vital. As a result, there is a healthcare imperative to create a central database of patient health data that can be accessed by healthcare providers. Medical information shared electronically and securely can improve the speed, quality and safety of patient care.”

The platform is operated by the Abu Dhabi Health Data Services – Sole Proprietorship LLC (ADHDS), established as Public-Private Partnership (PPP) between the Department of Health – Abu Dhabi (DOH) and Injazat Data Systems, a subsidiary ultimately of Mubadala Investment Company. The first six providers joined Malaffi by signing the Participant Agreement in December 2019, and the official Malaffi operations started in January 2019. The platform is set to connect almost 2,000 public and private healthcare facilities in Abu Dhabi. To date, around 400 facilities have been onboarded.

How does it work?

Malaffi is fully integrated with the Electronic Medical Records of the providers that have onboarded the platform and is accessible over a safe and secure connection. This means that users do not have to log into a separate platform and that they have real-time instant access to the most important information of the patient’s medical history. These include demographic data, encounters, diagnosis, problems, allergies, laboratory and radiology results, past procedures, clinical notes, among other information. “The initial feedback has been very positive; although the platform contains robust information, it is built in a way that makes it very easy to use and the information can be located quite effortlessly,” Al Braiki added.

From a provider perspective, Malaffi has been well-received by the industry in Abu Dhabi. By the end of December 2019, more than 1,700 facilities joined Malaffi by signing the Participation Agreement, out of which around 400 have already onboarded the platform, and close to 15,500 users from those facilities have access to the platform, which contains more than 38 million patient records for more than three million patients. Some of the providers that have already onboarded Malaffi include Abu Dhabi Health Services Company (SEHA), United Eastern Medical Services (UEMedical) group, Mediclinic Al Noor Hospital and Kanad Hospital (formerly known as Oasis Hospital) and Cleveland Clinic Abu Dhabi.

Al Braiki highlighted: “According to a recent public survey, we know that more than 90 per cent of surveyed Abu Dhabi residents are proud that their Emirate is the first to have an advanced Health Information Exchange platform like Malaffi. 82 per cent are also aware of the benefits of Malaffi and believe it will improve the overall patient experience.”

Mohammed Ali Al Shorafa Al Hammadi, CEO and Managing Director of United Eastern Medical Services (UEMedical), was quoted saying: “We are already starting to see the benefits of Malaffi amongst our clinicians and patients. The real-time exchange of information through Malaffi enables all our facilities, including Danat Al Emarat Hospital, Moorfields Eye Hospital Abu Dhabi and HealthPlus Network of Specialty Centers, to exchange information, which is very important for the continuum of care we provide at UEMedical Group. This improves our business process and allows our teams to focus on treating and healing our patients.”

Population health

One of the key benefits of the platform is that Malaffi will provide the DOH with invaluable population health information, which will help identify public health risks, launch health awareness campaigns and prevention programmes specific to the needs of the population for a healthier Abu Dhabi.

“Malaffi supports the DOH by providing robust population health data,” said Al Braiki. “The information around the broader trends in the population’s health enables the surveillance and management of chronic diseases, which can and will help drive and support public health policies and programmes in Abu Dhabi. This helps promote better health across the Emirate’s population.

“A healthy community is a happy community that can make greater contributions to create a prosperous society. This data is also invaluable for the swift identification of public health risks and for the Emirate’s emergency preparedness, in the event of an outbreak for example.”

He concluded: “By providing access to a centralised database, Malaffi allows the safe and secure exchange of patient health information in real-time. This plays a major role in improving quality healthcare and patient outcomes and elevates healthcare in Abu Dhabi.

“As a result, this will help further reinforce Abu Dhabi’s place on the international medical tourism map and attract regional and international patients to the Emirate. Furthermore, the platform will serve as a catalyst for the digital transformation of the Abu Dhabi healthcare industry, by establishing a solid repository of data for future AI predictive analytics and public health.”

Malaffi app to debut at Arab Health 2020

This year, Malaffi will be launching a patient mobile application. On downloading the app, patients will have access to their medical information at their fingertips. Malaffi will be providing a sneak peek of the app at this year’s edition of Arab Health, at the stand of the Department of Health – Abu Dhabi. The app will bring a myriad of benefits for the patient, including enhancing the patient experience by making all health information accessible in a mobile way. Through the app, patients can check their Malaffi file anytime, anywhere, even if they are traveling. Thanks to its patient-friendly interface, the app will engage patients in the management of their health and support prevention efforts, for a healthier Abu Dhabi.

Atif Al Braiki

The healthcare of the future will be unique, convenient and on our own terms,” says Dr. Shamsheer Vayalil, Chairman & Managing Director, VPS Healthcare. In an interview with Omnia Health Magazine, the healthcare pioneer discusses the changing healthcare landscape in the region and how, as data becomes more extensive, providers such as VPS Healthcare will be able to use this information to enhance the overall patient experience.

VPS Healthcare has become one of the most dynamic healthcare companies in the region, spanning six countries, 24 hospitals, over 125 medical centres, more than 15,000 employees and one of the largest pharmaceutical U.S. Food and Drug Administration (USFDA)-certified manufacturing plants in the UAE.

 Dr. Vayalil said: “As emerging markets achieve growth, there is a pressing need for them to build sustainable healthcare systems. World-class economies like the UAE need the best health services to cater to populations who potentially face increased lifestyle and wellness issues. In this new landscape, there is an urgent need for affordable and accessible services, without compromising on quality.” Excerpts from the interview:

Connectivity for better healthcare delivery is the theme of Arab Health 2020. What would you say is the current impact of connectivity on the delivery of healthcare?

With the increased use of technology and data, we are seeing the emergence of new trends that have the potential of changing the medical experiences for patients and providers. In this fast-paced, and increasingly connected world, on-demand is becoming a habit rather than a feature. The availability of reliable, efficient and affordable services will help strengthen trust in the healthcare system. As an example, the use of telemedicine technology, including teleradiology can allow doctors to engage with patients and provide services, irrespective of their geographic location. This not only reduces the need for in-person services, but also drives efficiency across the medical ecosystem.

What different innovative products and solutions will you be bringing to the show?

We are planning to present a unique healthcare platform that combines a Software as a service (SaaS) model and approach for critical services like electronic health records and revenue cycle management, among others. This pay-per-use service will reduce the financial and technical barrier of entry for many hospitals and clinics for these cost and resource-intensive services. Our purpose is to provide patients and providers access to reliable healthcare round-the-clock. We are confident that our solutions will help support an efficient and integrated delivery system that avoids unnecessary wastage of healthcare resources.

What, according to you, are the healthcare trends to watch out for in 2020?

The healthcare of the future will be unique, convenient and on our own terms. As data becomes more extensive, providers such as VPS Healthcare will be able to use this information to enhance the overall patient experience. These types of technologies offer safer, faster and more tailored treatments. They harness the power of collective data for the individual, achieving a far greater degree of personalisation in medicine than has ever been possible before. Our challenge will be to make these innovations affordable and accessible.

Could you shed light on your future plans.

Earlier last year, LIFEPharma, VPS Healthcare’s pharmaceutical manufacturing facility in Jebel Ali, which is the country’s sole facility certified by the USFDA, signed a 10-year contract worth AED 200 million to produce a billion pills for export to North America. This represents an important milestone in the strategy to make the UAE a global hub for knowledge-based, sustainable and innovative industries. We believe that this is a stepping stone for us to produce complex therapeutics right here in the UAE for local and international markets.

Dr. Shamsheer Vayalil

State-of-the-art facility

VPS Healthcare will also soon be launching the 400-bed Burjeel Medical City (BMC) that is designed to be a hub for tertiary and quaternary oncology treatment for adult and paediatric subspecialties, long-term and palliative care (including immunotherapy and molecularly targeted therapies). It is being positioned to be a world leader in cancer genomics research and its translation into actionable clinical tests and for biomarker-driven drug development. The hospital is equipped with advanced radiotherapy and radiosurgery equipment. This includes two linear accelerators and Brachytherapy facility, with space for a Gamma Knife. In addition, the hospital will have advanced Radiology Diagnostics that include SPECT CT, two CT scanners and a simulation CT in radiotherapy department. To complete the diagnostics, there are two advanced MRIs, with an intraoperative MRI that will be another unique system in BMC. This will facilitate minimal invasive stereotactic biopsies and ensure complete surgical removal of tumours. To achieve these goals, the hospital is supported by advanced laboratory and diagnostic facilities. These include advanced molecular and genetic testing, Stem Cell preparation and therapy, apheresis and HLA matching.

Coronary Heart Disease (CHD) is the leading cause of death and morbidity worldwide, with a high socioeconomic burden and one million deaths in the U.S. About 50 per cent of acute myocardial infarctions occur in previously asymptomatic patients, pinpointing at the major weakness of current strategies for screening of CHD.

Conventional assessment based on cardiovascular risk factors (EuroSCORE or ASCVD) allows for a 10-year cardiac event prediction, but fails to accurately diagnose CHD at early stages, in which fatal outcomes would be still preventable by initiating medical therapy and risk factor intervention.

Coronary computed tomography angiography (CTA) is a novel non-invasive imaging technique, enabling a direct visualisation of the coronary arteries at high resolution in submillimetre range (<0.3mm), hence CTA creates new horizons for screening of CHD.

Early stages of atherosclerosis, such as non-calcified fibroatheroma can be detected with high accuracy, even in the absence of coronary calcification. These non-calcified lesions can be further characterised by their specific x-ray absorption, the CT-attenuation (Hounsfield Units, HU) by value of less than <160 HU. Non-calcified plaque can be stratified by their specific tissue components into lipid-necrotic core (<30HU), and fibro-fatty lesions (30-160HU). Both have been liked with adverse outcomes, especially the necrotic core plaque (LAP<30HU) (5-9) but also fibro-fatty (LAP<60HU) and specific imaging features such as the hyperdense rim “Napkin Ring” sign (Fig 1b).

Comparative studies with OCT and pathohistology have identified four major criteria for plaque “vulnerability”: Beyond LAP and Napkin Ring Sing, spotty calcification of less than 3mm and positive remodelling (Remodelling Index>1.1) are regarded as markers for “high-risk” plaque. These criteria define a precursor (culprit) lesions for later acute coronary syndromes.

During the natural course of atherosclerosis over decades, noncalcified fibroatheroma transforms into a dense- compact calcified lesions at later stages, which may narrow the vessels (Fig 1c) up to severe >70 per cent stenosis, and require treatment with percutaneous transarterial coronary angioplasty (PTCA) and STENT implantation (Fig 1d), in order to prevent adverse outcome.

Newest data from the ICONIC registry have shown that CTA enables monitoring of lesions, and revealed that the denser the plaque, the less likely the chance of ACS. In lesions with more than 350 HU compactness, the number of ACS decreased, and above 1000 HU (“1 K”, syn. marble plaque”) a significant decline was observed.

This effect can be obtained by medication such as statins, which act anti-inflammatory and reduce blood cholesterol (c-LDL) hence, the transformation of fibrous into stable calcified lesions. During statin therapy, the total plaque volume progression, and especially the necrotic core, fibrous and fibrofatty lesions growth was significantly lower – in large international multicentric study registry (PARADIGM) enrolling 1241 patients over a mean period of two years.

Of note, these lesions may be found even in patients without coronary calcification (calcium score zero), in about a quarter (25.9 per cent), while the rate of significant >50 per cent coronary stenosis was with 5.1 per cent low but not negligible.

The coronary CT calcium score is another imaging tool for quantification of coronary calcium and risk stratification based on total calcium volume and density (Agatston Score), however it misses the chance to detect early fibroatheroma. 

Data from CONFIRM registry, a large international multicentric trial, have shown that coronary stenosis and plaque burden by CTA improve risk stratification as compared to calcium scoring.

Beyond, the strength of CTA lies in the excellent false negative rate (90-99 per cent NPV) for exclusion of CHD, ensuring a safe and reliable exclusion of CHD in individuals, in whom CHD is already suspected by regular clinical work-up exams. Such patients are those with atypical chest pain symptoms, and low-to-intermediate ASCVD risk.

Most recently, two prospective randomised multicentric trials in the U.S. and Europe (PROMISE and SCOT-HEART), have proven the safety and efficacy of coronary CTA for patients with stable chest pain. The SCOT HEART trial has even shown favourable outcomes in patients undergoing CTA, as compared to standard of care (SOC), in terms of a lower event rate in the CTA group (2.3 vs 2.9 per cent, p=0.004).

A new field is currently emerging in cardiovascular imaging: artificial intelligence (AI)/machine learning. AI based–deep learning tools provide three promising potentials. First, they improve risk prediction, when combining CTA imaging parameters with conventional risk factors. Second, “radiomics” based analysis allows for assignment of a voxel into texture and feature based parameters and hence a more detailed sub-analysis of images. And third, automated feature recognition allows for a more accurate segmentation of both calcium and of coronary vessels from CTA.

Therefore, they provide the potential to improve diagnostic accuracy and efficacy in clinical practice, for example, the quantification of global plaque burden, a predictor for adverse outcomes and ischemia or automated extraction and interpolation of calcium load from standardised chest CT. Machine learning tools also allow for complex analytics such as quantification of flow, as recently shown for computation of the fractional flow reserve (FFR) by CTA (20).

Importantly, early risk factor management, such as by reducing c-LDL by medication such as statins or eztemibe or PSK 9 inhibitors have shown reduction in plaque burden progression and initiate the transformation of vulnerable lesions into stable. Only as little as 39 mg/dl c-LDL reduction results in a 25 per cent lower ASCVD risk. Total plaque burden is one of the main drivers for ischemia and adverse outcomes, even in patients with non-obstructive lesions (ANOCA), especially “vulnerable” low attenuation plaques with positive remodelling.

Also, lifestyle modifications play a key role: regular exercise, weight control, smoking cessation and blood pressure control are crucial factors to prevent progression of atherosclerosis and adverse outcome.

Conclusion

Coronary CTA is a promising novel technique for accurate screening of coronary heart disease. CTA enables early detection and consecutively, the initiation of preventive actions with a great potential to reduce global burden of CHD, and most importantly, fatal outcome with personal tragedies affecting all age groups including even young or middle-aged individuals.

References available on request.

The pain in Sara Llibre’s right hip was so severe, the triathlete could barely walk, much less train for a race. Hip preservation surgery at the University of Chicago Medicine returned her to Ironman form.

After running her first marathon in 2009, Llibre joined a triathlon team in the suburbs of Chicago. She competed in her first Ironman (2.4-mile swim/112-mile bike/26.2 mile run) in 2012.

Over time, though, heavy training took a toll on Llibre’s right hip. An MRI showed joint damage caused by femoroacetabular impingement, or FAI — a condition in which the hip bones rub together abnormally. After one orthopaedic surgeon told Llibre she’d never run again, a fellow athlete encouraged her to get a second opinion.

Members of Llibre’s triathlon team recommended UChicago Medicine orthopaedic surgeon Sherwin S. W. Ho, MD, a sports medicine expert. Ho specialises in minimally invasive arthroscopic procedures for conditions of the shoulder, elbow, hip, knee and ankle.

“I could tell that Dr. Ho knew from my description of the pain exactly what I was dealing with,” Llibre said.

FAI occurs in individuals whose hip bones did not form normally during childhood growth and development. Structural defects result in the hip ball and socket hitting against each other. Because athletes work the hip joint frequently and vigorously, they may have damage and experience pain earlier in life than less active people.

Just a decade ago, Ho said patients with FAI were diagnosed with tendonitis or arthritis and lived with pain until the condition was advanced enough to warrant hip replacement surgery.

“Today, with better imaging tests and more sophisticated minimally invasive tools, we can diagnose patients who have impingement and tears related to FAI and treat them before they get arthritis,” Ho said. “If we treat these patients early enough, we can save the hip and allow them to continue an active, healthy lifestyle. Our job as hip preservation specialists is to maintain our patient’s natural hip and avoid the need for hip replacement later in life.”

“For athletes like Sara who want to do triathlons later in life,” he added, “the surgery can give them additional miles and years on their hips.”

Llibre said Ho didn’t promise her anything but told her the chances of her running again were good. “And he was right.”

Ho performed Llibre’s 90-minute hip preservation procedure in January 2014. She started swimming three weeks after the surgery and biking at two months. By April, she was running again.

“I got such good advice from Dr. Ho about how much I could do and when to back off,” she recalled, adding, “and I didn’t have to back off a lot.”

Today, the 60-year-old trains every day. Since her surgery, she has completed seven Ironman races, including the Ironman World Championships in Kona, Hawaii.

“I can’t tell you how many times I thanked Dr. Ho for his expertise,” she said.” I look forward to many more years of training and competing.”  

For more info visit: https://www.uchicagomedicine.org/global

Mental ill health affects more than 450 million people worldwide and encompasses a variety of conditions such as depression, anxiety and low self-esteem. Reports highlight how, in the last 20 years, mental health problems and diagnoses have been on the rise, specifically among the younger generation whose daily lives are increasingly influenced by technology and, in particular, social media.

While today’s ‘wired world’ has propelled them in a direction that is quite phenomenal in terms of opportunities and experiences, studies show it is also taking its toll on their ability to cope with the pressures of life. While the rapid development of technology on growth, development, socialisation, and society can be exhilarating and present unprecedented opportunities, there are also accompanying downsides, no matter our age. For example, while social media channels such as Instagram and Facebook can enable us to stay connected and share our thoughts and experiences with a ‘ready-made’ online community, they can also lead to many living a virtual life where face-to-face interaction is limited, avoidance is supported, and reality is misconstrued. This can create unrealistic and unattainable expectations of life, which fuels anxiety and can trigger depression, low self-esteem and a loss of individual value and confidence. There are 7.7 billion people in the world, with a massive 3.5 billion of us online. It’s therefore key that we are all aware of the risks that can accompany the technology-driven world we now live in.

The Priory Group is one of the leading independent providers of behavioural care in the UK, supporting more than 30,000 people a year. Its world-class experts treat more than 70 different conditions through a UK-nationwide network of more than 450 facilities that support individuals’ mental health, care, education and specialised needs. Within the Middle East, the Priory Group operates a Wellbeing Centre in Dubai; in Abu Dhabi, it has teamed with the Abu Dhabi Department of Education and Knowledge (ADEK) to run the first dedicated autism school for Emirati students.

According to the Center for Strategic and International Studies (CSIS), depression and anxiety disorders are by far the most common mental illnesses in the Middle East. A 2009 study that screened 1,552 adolescents in Saudi Arabia found that the most common mental health problem was anxiety.

While the prevalence of depression in the Arab and Gulf regions varies substantially between published studies – ranging between 13 to 18 per cent – they all consistently highlight the prevalence of higher rates of depression among women than men – in some cases the rates among women are double that of men. While worrying, this is typical of the global average. According to the World Health Organization (WHO), the rate of depression is 50 per cent higher for females than males. Associated links are drawn to societal factors and the greater likelihood of women experiencing sexual and physical abuse.

Cultural beliefs tend to affect people’s attitudes toward mental illness and their willingness to come forward and seek help. In fact, reports reveal how nearly two-thirds of people with a known mental disorder never reach out for support from a health professional. The underlying cause of this can be attributed to stigma, discrimination and neglect – factors which exist in many communities and prevent an open and honest conversation about mental ill health.

However, despite this, there is also a growing awareness of the signs and symptoms of mental ill health and the need to seek help early, which is having a positive effect on diagnoses and treatment and bodes well for the future.

In the UAE, steps are being taken to both recognise and tackle the magnitude of mental health disorders in the region and ensure its prominence in its health agenda. The Dubai Health Authority (DHA), for example, launched the first comprehensive mental health strategy for Dubai in 2018. The strategy, entitled ‘Happy Lives, Healthy Communities’, is a major step towards raising community awareness and removing the stigma attached to mental health. Such initiatives can help to normalise people’s attitudes towards mental health and highlight the importance of seeking timely care. Anxiety disorders, for example, often begin in early life, and therefore prompt intervention is key to combatting the long-term repercussions.

Treating depression and anxiety

While the definitions of depression and anxiety do not change according to geography, gender or across age groups, studies show that they differ in clinical presentation. Anxiety, for example, is more prevalent in females and symptoms include a higher prevalence of co-morbid depression with the anxiety. Patients tend to display more agoraphobia (a type of anxiety disorder in which you fear and avoid places and situations that might cause you to panic and make you feel trapped) and usually present in a chronic state. Additionally, while studies show how men tend to seek psychiatric help at an earlier stage, they also tend to participate in higher rates of substance use to ease their symptoms.

Depression – identified by WHO as the leading cause of disability and ill-health worldwide – manifests in various ways. While sadness is an emotion that everyone experiences, there are some individuals who experience such overwhelming feelings of sadness that it affects their ability to function in their daily lives. If ignored or left untreated, symptoms such as decreased energy, feelings of low self-worth and disturbed sleep, can become chronic or recurrent over time. At its worst, depression can convince people that they shouldn’t continue to live, leading to suicide, which claims close to 800,000 lives every year.

Depression also causes symptoms of anxiety, a mental disorder resulting from a complex display of biological and social factors. There are many types of anxiety disorders, ranging from generalised anxiety disorder, panic disorder, post-traumatic stress disorder, and social anxiety. Where stress comes and goes with the external factor causing it, such as work stress, financial difficulties and relationship issues, anxiety can persist irrespective of its cause. Symptoms can be physical, such as an increased heart rate, hyperventilation and increased perspiration. There are also behavioural and psychological implications which can cause feelings of detachment and fear.

Depression and anxiety can be treated and monitored using various techniques of mediation and therapy, and therefore access to the most relevant healthcare and support services is absolutely crucial to ensure recovery.

At our facility, experts provide various treatments for mental health conditions, including Cognitive Behavioural Therapy, EMDR (eye movement desensitization reprocessing) ACT (acceptance and commitment) Therapy, Relationship Therapy, Mindfulness, Dialectic Behavioural Therapy, and Family Based Treatment. Our teams consist of psychiatrists, psychologists, counsellors and behavioural analysts from various parts of the world, speaking a diverse range of languages, including English, Arabic, French, German, Dutch, Hindi, and Punjabi to meet the differing cultural needs of our patients.

While medication and therapy have proven effective for many, some patients may require alternative treatments such as, for example, repetitive transcranial magnetic stimulation (rTMS). This is a non-invasive brain stimulation that provides an innovative drug-free approach to treating depression and is available at the Priory’s Wellbeing Centre in London. It offers patients an effective, evidence-based, alternative biological treatment, approved by the National Institute of Clinical and Health Care Excellence (NICE) and the U.S. Food and Drug Administration (FDA). rTMS has been tested in several hundred clinical studies worldwide and evidence shows a high and positive response rate in patients suffering from depression.

Destigmatising mental health

It is vital that the impact of mental ill health on both the individual, and society, is recognised. Thankfully we have seen an increase in awareness and understanding in recent years, which has helped to both destigmatise and normalise mental health conditions among cultures, genders and age groups. In turn, this has encouraged more people to reach out for help. It has also been encouraging to see insurance companies responding by increasing their provision for mental health treatment – financial constraints are a key obstacle, which prevent many people from seeking professional support.

Despite the progress made in recent years, there is still much more work to be done to banish many of the common misconceptions about mental ill health. Importantly, we need to create a common understanding that treatment is available, and that it works – action is the key to preserving our positive mental health and well-being.

References available on request

Although imaging of the biliary tree was introduced as early as 1922, it was the introduction of percutaneous trans hepatic cholangiography by the ultrathin needle in the late 1960s in Japan and the subsequent use of cholangiography without the need for surgical intervention by Okuda in 1974 that heralded the involvement of radiologists in the image-guided management of liver and biliary tree conditions and which developed rapidly with the introduction of modern imaging tools like ultrasound, CT and MRI. The specialty of Interventional Radiology developed alongside the availability of image-guidance and the manufacturing of various devices that are designed to meet the challenge of the various clinical conditions.

The modern multi-disciplinary approach to many of the conditions that affect the hepatobiliary system encompasses the collaboration of internists, interventional radiologists, endoscopists, surgeons and oncologists to achieve the best outcome.

Image guided biopsies and simple drainage procedures

This is mostly done through a percutaneous approach under Ultrasound (US) or computed tomography (CT) guidance (Fig 1). Occasionally Magnetic resonance (MRI) guidance is required. In patients in whom clotting abnormalities exist, a transjugular approach provides a safer method with lower risk of significant haemorrhage.

Management of portal hypertension

Cirrhosis of the liver and the subsequent elevation of portal pressure is more prevalent in areas where hepatitis is common and also where alcohol abuse is present. The development of oesophageal varices frequently leads to recurrent episodes of bleeding, which can be quite severe and life threatening. Surgical measures to reduce the portal pressure such as porto-caval shunts have long been practiced however the bulk of management is now based on the use of beta blockers, local treatment of bleeding by endoscopists and the formation of intrahepatic shunts under image guidance. Transjugular intra hepatic porto-systemic shunt (TIPS) is now the treatment of choice for uncontrollable variceal bleeding and other manifestations of portal hypertension and liver disease such as persistent ascites. This procedure is performed, as its name indicates, by advancing a catheter from the right jugular vein into the hepatic vein and then creating a track through the liver into the portal vein followed by dilatation of the track and the insertion of a covered stent across the track that connects the systemic circulation with the portal circulation (Fig 2). The size of the stent is chosen according to the clinical situation and the level of portal pressure. Generally, a gradient of less than 12mmHg is required across the shunt to achieve a satisfactory outcome. There are other medical measures to reduce the incidence of encephalopathy that can happen after any form of porto-systemic shunt creation. The varices may be embolised through the shunt that provides access to the portal system and its tributaries. One of the main advantages of TIPS in addition to the minimally invasive non-surgical approach, is that it does not prevent future liver transplantation.

Management of venous occlusion (Budd-Chiari Syndrome)

Budd Chiari Syndrome is related to venous obstruction either inside the liver or at the level of the large hepatic veins or the vena cava. Patients can present with an acute liver failure or develop symptoms gradually and ultimately go into liver cirrhosis and failure. Reducing the pressure emanating from liver congestion at an early stage may prevent progression into advanced cirrhosis and ameliorate the clinical symptoms. The interventional radiologist may perform one of two main treatment procedures depending on the clinical scenario; TIPS or restoration of major vein patency. The latter may require a complex procedure combining percutaneous and transjugular approach in cases where the veins are totally occluded (Fig 3,4,5). A stent is generally required to maintain patency of the re-opened major vein.

Biliary obstruction

This is commonly related to tumours such as cholangiocarcinoma and may happen at different levels in the biliary tree. Endoscopic management of obstruction is preferred when the level of obstruction is in the common hepatic or common bile duct. Obstruction at the level of the hepatic ducts or the confluence is better managed through percutaneous drainage. Biopsies can be obtained from inside the obstructed ducts to confirm the diagnosis. The drainage procedure starts with cholangiography performed by insertion under ultrasound or fluoroscopy, of an ultrathin needle into the bile duct and injecting contrast material to outline the ducts and level of obstruction. Subsequently a wire is introduced into the bile ducts and manoeuvred through the obstruction. A drain may be inserted to decompress the system (Fig 6). Alternatively, a metal stent may be placed across the point of obstruction depending on the clinical scenario.

Tumour management

Liver tumours, whether primary like hepatocellular carcinoma or metastatic may be treated locally after, or in conjunction with, systemic chemotherapy or surgical resection. The interventional radiologist has many tools at his disposal:

• Injection of chemotherapeutic or radioactive material directly into the blood vessels supplying the tumour (chemoembolization and radioembolization) via a catheter inserted and advanced through the arterial system into the hepatic artery and then selectively into the feeding artery (Fig 7)
• Percutaneous tumour ablation is done using a variety of methods such as radiofrequency ablation, microwave ablation and electroporation. These methods are particularly suitable for localised disease preferably in the 3 cm range (Fig 8,9)
• Portal vein embolization may be performed to allow the normal part of the liver to grow and permit surgical resection of the diseased lobe

Arterial conditions

Post-traumatic aneurysm formation can be life threatening. Control of the bleeding point is usually possible by trans-catheter embolization of the point of bleeding. Similarly, other causes of bleeding, particularly post-surgery or intervention and from rupture of vascular tumours, can be handled by catheter-based intervention (Fig 10,11). Finally, post liver transplant vascular problems such as stenosis of the artery at the anastomosis requires rapid action. Frequently, balloon dilatation alone or in conjunction with stent insertion can save the precious transplant.

Conclusion

The interventional radiologists have a pivotal role in the management of a wide range of conditions that affect the liver and biliary tree.

Cosmetic Gynaecology, the fastest-growing speciality globally, is an area of special interest that covers a variety of procedures that includes both cosmetic procedures to enhance the aesthetic appearance of the vulvo/vaginal region, as well as functional vaginal repairs to enhance or help restore sexual function following the changes that may occur following childbirth and/or ageing.

This includes labiaplasty or labia minora reduction with or without excess prepuce reduction, labia majora reduction or augmentation, vaginoplasty, vaginal introital repairs as well as reduction of lipodystrophy in the mons pubis region, and, G-spot amplification; and others. New non-surgical techniques are now available to enhance the labial and vaginal region (Vaginal Rejuvenation).

Cosmetic gynaecology is now on the high tide and the average age of females requesting a procedure is steadily decreasing. The demand for these is now on the rise secondary to the globalisation effect and more women taking to social media. People learn beauty standards within the sociocultural context and the sociocultural standards are inarguably established online.

Social media provides users the opportunity to present the best versions of themselves. A study published last year found that increased engagement in social media correlated with increased consideration for cosmetic surgery, and more so with the use of certain applications that uses visual nature as Instagram and Snapchat. 

Overall, it is a significant driver of cosmetic interventions. There are potential societal benefits, such as dissemination of knowledge, the potential for exchange of ideas, and community building. These aspects are used to the advantage of both doctors and patients in the realm of cosmetic surgery. Many physicians use their own websites/social media applications to publish educational materials regarding procedures. The availability of this information online ultimately leads to a shared vision and more alignment of patient and physician goals and expectations.

Labiaplasty procedures have been reported to be the largest growing trend (up 45 per cent year-on-year, a survey by International Society of Aesthetic Plastic Surgery [ISAPS] found) of cosmetic surgery procedures for women throughout the world, other than vaginoplasty. The increase in labiaplasty is not isolated to the U.S. In Australia, labiaplasty procedures performed four-fold over a 13-year period.

This even more pronounced in the United Kingdom, with a five-fold increase in over a 10-year period. Middle Eastern countries also follow suit in these statistics. Most surgeons agree that there is no predominant reason why vaginal cosmetic surgery is on the rise. Instead, change in grooming practices, air-brushed images on social media, distorted view of “normal” genitalia, and growing focus on athleticism are factors identified. This procedure empowers women and helps them achieve a better quality of life through increased comfort and sexual confidence.

Medical professionals typically only recommend surgery if the enlarged labia begin to interfere with everyday life or cause problems during sexual intercourse. A 2008 study reported that 32 per cent of women underwent the procedure to correct a functional impairment; 31 per cent to correct functional impairment and for aesthetic reasons; and 37 per cent for aesthetic reasons alone.

Though what essentially started as enhancing cosmesis of the female genitalia in the 90s that gave birth to this specialty, the past decade has seen a surge in technological advancements with the invention of tools and modalities for tissue functional restoration, to reverse age-related tissue remodelling (as an anti-ageing modality) that has opened up a completely new dimension and has also bridged the gap between cosmetic indications of this new field and those of conventional gynaecology.

As women age, physiologic changes in the genital region occur due to variation in the hormones. In an ageing vagina, there is laxity and loss of tone in pelvic floor.

Other factors that influence the tissue remodelling include genetic predisposition, radiation, diet, exercise, smoking, and surgery. The extra cellular matrix (ECM) of vaginal tissue largely determines its tissue tensile strength, and its mechanical stability is remodelled and maintained by fibroblasts. It is the delicate balance between production and degradation of ECM proteins in connective tissue that is critical to the pelvic floor integrity.

Procedures

Gaining momentum is advent of energy-based devices (EBD) that apply thermal or nonthermal energy to vulvo-vaginal tissue, stimulating collagen regeneration, contracture of elastin fibres, neovascularization, and improving lubrication, and that of electromagnetic fields to restore pelvic floor and sexual dysfunction (in both women and men). These aim to address peri- and post-menopausal symptoms (genitourinary syndrome of menopause, or vulvovaginal atrophy), by stimulating increased proliferation of vaginal epithelium, neo-collagenesis, and increased vascular and neural regeneration – hence moving from pure aesthetics to functional gynaecology applications.

The minimally/non-invasive procedures include EBD such as lasers (Carbon Dioxide (CO2), Erbium:YAG (Er:YAG), Diode, or Low Level Laser Therpy (LLLT)); Radio Frequency (RF); High-intensity Focused Ultrasound (HIFU); Electromagnetic field therapy; Chemical treatments, PRP (Platelet Rich Plasma), and Labial fillers (Hyaluronic acid and Fat grafting).

Globally, laser treatments are among the most popular non-invasive procedures. They allow for delivery of light to the skin in a controlled manner. The wavelengths across the electromagnetic spectrum are differentially absorbed by different tissue chromophores, including haemoglobin, melanin, and water. Two commonly used lasers are CO2 laser and Er:YAG laser, emitting light at wavelengths of 10,600 nm and 2940 nm, respectively. RF devices use thermal energy to directly heat adjacent tissue with target temperatures at or below 45 °C. Heat causes partial denaturation of existing collagen and promotes fibroblast-mediated production of new collagen.

When absorbed in sufficient amounts, light energy can induce changes in the skin and mucosal matrix. Thermal energy delivered on vaginal wall stimulates neovascularisation, and collagen formation, and proliferation of glycogen-enriched epithelium leading to improved natural lubrication and urinary continence. Histological assessment demonstrates increased cellular thickness of the stratified vaginal epithelium and visibly greater amounts of collagen and vascular growth in the connective tissue. Visible external changes with these therapies have also been noted.

Distinct characteristics of the target tissue and technical parameters of EBD influence the tissue interactions at cellular level (laser wavelength, energy density, pulse duration, spot diameter, tissue absorption, hydration, and oxygenation, blood supply, degree of keratinization, and insulating properties of adipose tissue). For a given device, degree of ablativeness depends on multiple factors, including fluence, repetition rate, degree of coverage of device, and patient skin types and anatomic sites, whether the treatment is ablative, partially ablative, or non-ablative.

Excessive transfer of heat to dermis can lead to adverse effects such as scarring and permanent hypopigmentation. In vaginal tissue, controlled power of the energy source must be used as it varies in its water content and cellular component with age, and under hormonal influence, amongst other factors.

Fractionated lasers have become the cornerstone of laser skin rejuvenation. Fractional CO2 and Erbium Lasers have been popularly used for various indications, for both external and internal genitalia applications using specifically designed probes (either disposable/ reusable) for intravaginal or intraurethral sites. Radiofrequency devices too have etched their mark in this space with successful outcomes.

More recently, devices are being designed to accommodate dual mode of energy delivery that allows for a wider scope of clinical application and subjective computing of dose and mode delivery of the energy used.

While a typical cycle of treatment would include at least three sessions, spaced one month apart followed by a touch-up session, home-based easy to use devices using Low Level Laser Therapy (LLLT) are now out in the market that are being used for maintenance therapy to prolong the results achieved. It is important to bear in mind that one size does not fit all. A thorough understanding of interactions between light and biologic tissue is critical for selection of a laser device as well as effective and safe use of the equipment.

As one advances in their practice, they will appreciate the fact that offering the same client different modalities may in fact yield far superior results, as would a combination therapy using adjuncts in addition. It is not uncommon to see experts offering a bespoke treatment to clients that include a host of add-on therapies such as cell-based therapeutics (PRP, Stem cells), Hyaluronic acid, cosmeceuticals, add-on Bio-identical hormones, carboxytherapy, etc.

Though the initial indications were listed for the peri-/post-menopausal women for either vaginal atrophy and/or urinary incontinence, today, these EBD’s are more popularly being used as preventive measures in the younger women in the reproductive age group for functional reasons, especially in the post-natal period for the same indications, and also in those affected by chronic debilitating conditions such as Lichen sclerosus, scars, hyperpigmentation, vulvodynia, skin laxity post weight loss, side-effects following chemotherapy or hysterectomy, etc.

Further, the experts use it to craft their cosmetic work during invasive procedures such as during labiaplasty and vaginoplasty, fat-grafting procedures or simply to replace the invasive procedures with the non-invasive, such as in non-invasive labiaplasty.

EBDs are also being used to augment results of other procedures that address sexual dysfunction or enhancements such as G-spot or O-spot augmentation. One of the latest innovations of laser device is that of CO2 laser that not just offers applications for female genital rejuvenation but also extends an arm for in-office minor surgical and hysteroscopic procedures.

Mini-liposuction followed by fat-grafting too has made its way into the armamentarium of services offered in this field. The scope of services hence sees an overlap essentially not just to urogynaecology, but also to associate fields such as urology, plastic surgery, and cosmetic dermatology.

Challenges

One of the biggest changes in the past decade has been more openness about procedures, which has helped turn the cultural tide. As a result, there have been considerable investments in new technologies. Cosmetic Gynaecology Market drivers include changing women’s lifestyle, increasing adoption of non-invasive gynaecological procedure, growing medical tourism across borders, and surging demand for EBD treatments. The market restraints include social stigma associated with gynaecological treatments, stringent safety regulations for EBD procedures.

Recently, much uproar was created by the FDA published warning with the use of EBD and their false marketing promises. However, this was based on their adoption of the MAUDE database report that has failed to provide specifics regarding the quality, the quantity, and the nature of these reports. The MAUDE system does not track the number of procedures performed. It only offers an insight into the issues of reported events and has its limitations at that. The devices are exceptionally safe when properly used by trained providers, at proper settings, for clinical conditions they were designed for.  These devices are also are ranking high in consumer satisfaction.

To still remain in denial of cosmetic gynaecology’s essence in one’s practice would be to deny oneself the privilege of reaping the benefits of pure self- and patient- satisfaction in this era. In the words of Dr. Marco Pelosi III, MD, Founder of the ISCG (International Society of Cosmetic Gynaecology), “Conventional Gynecology is stuck in the Stone Age. It offers nothing for the true needs of the 21st century woman”.

Moving forward, this field is here to stay and has carved its niche. Early adopters across the globe wear their label with smile as they take pride in not just addressing to normalise the health of their patients, but to actually help women optimise their health and overall well-being. Furthermore, those that initially were sceptical, now have positively skewed their interests towards this field as they are seeing more and more feedback from patients who can’t stop bragging about its positive life-changing effects.

With the rapid pace of change occurring in this field, it is important to have readily available resources and innovations that are critical to the advancement of the specialty. It is of tremendous benefit to be able to provide patients with a variety of options with the best possible solution to their functional and aesthetic needs. It is up to each of us to be our own investigator and our own judge of what is appropriate in our practice. That requires ascertaining whether a given procedure or technology has been truly validated as safe and effective. Any decision made by a competent woman regarding her own body and medical treatment should be respected. As for any new specialty, standards need to be set, and long-term studies undertaken.

With cosmetic gynaecology expected to continue to grow in popularity, providers must be prepared to respond to questions about vaginal rejuvenation and must possess a strong working knowledge of cosmetic gynaecology and be willing to discuss the benefits and risks. The field has established itself as a big practice changer, and it is!

Mammography has been globally adopted as the gold standard screening examination for the early detection of breast cancer since 1970. The greatest benefit of mammography has been proven by the long-term randomised controlled trials that have shown a reduction in the mortality rate by at least 20 per cent.

However, the sensitivity and specificity of mammography is lower in women with dense breasts because the x-ray attenuation is similar between the glandular tissue and non-calcified cancers, leading to “masking effect” which increases the interval cancer rate; resulting in delayed diagnosis with worse outcomes of the disease. Additionally, numerous scientific data has shown that women with heterogeneously dense and extremely dense breasts have a relative risk of two-fold and four-fold to develop invasive breast cancer compared to women with predominantly fatty breasts. Due to its clinical importance breast density has been incorporated into Tyrer-Cuzick and Breast Cancer Surveillance Consortium risk models.

In order to overpass the limitations of mammography, an improved strategy through utilisation of supplemental screening approaches has been further considered for women with dense breasts. Hand-held breast ultrasound (HHUS) and Automated breast ultrasound systems (ABUS) have been shown to improve the detection rates of small size, node negative invasive cancers, averaging 2.1–2.7 per 1,000 women screened, which would have been otherwise missed on mammography due to breast density.

Mammographic density assessment methods

Due to the clinical importance of mammographic breast density several methods have been developed that measure various aspects of fibroglandular tissue, which include visual, semi- or fully automated approaches. Visual, qualitative methods are based on human judgement and are therefore subjective with a high inter-observer variability among radiologists. In order to provide a more precise assessment of mammographic breast density for identifying women at increased risk of developing breast cancer and/or having reduced mammographic sensitivity, a fully automated breast density method have been developed. These systems provide measurement of area-based or volumetric parameters, that is objective, consistent and reproducible.

Automated Breast Ultrasound Systems (ABUS)

ABUS houses high frequency transducers that provide visualisation of a large portion of the breast within one view and produces high-resolution standardised studies. After the transverse image is acquired, the software processes and reconstructs the coronal and sagittal plane providing multiplanar volumetric images, allowing the radiologist to interpret breast lesions in different planes. Meanwhile, virtual review of data sets enables batch reading, double reading, while the coronal plane provides information on the extent of the disease and demonstrates the “retraction phenomenon sign”. Additionally, storage of ABUS volumes allows to compare examinations with priors that is expected to improve specificity in follow-up examinations and to decrease biopsy rate of benign lesions.

Implementation and performance of ABUS

Multiple studies that compared the performance of ABUS technology in breast cancer detection has shown similar results to handheld ultrasound (HHUS) studies averaging 90.6 per cent and 90.8 per cent for HHUS and ABUS respectively and in some instances ABUS appeared to be superior to HHUS, especially in the context of architectural distortion identified on the coronal reconstruction plane.

Chang et al. retrospectively evaluated the detection performance of benign and malignant masses. Overall sensitivity and specificity of three readers were, respectively, 71.9 per cent and 79.5 per cent, and the sensitivity was higher for the detection of malignant masses (87.5 – 95.8 per cent) vs. benign masses (56.3 – 66.7 per cent). Mass size, shape and surrounding tissue changes were the variables affecting detectability at ABUS. The reproducibility and consistency of breast lesions across multiple readers is important for the utilisation of ABUS in the screening setting. Chang et al showed that ABUS provided reproducible images for mass localisation, size measurement, and characterisation, which may be useful for follow-up studies.

Diagnostic accuracy in differentiation between malignant and benign lesions has been widely analysed and most studies demonstrated high values for sensitivity and specificity, as reported in a recent meta-analysis (pooled values of 92.0 per cent and 84.9 per cent, respectively). On the basis of the meta-analysis conducted by Wang that evaluated the performance of ABUS vs HHUS exhibited similar sensitivity and specificity in the differentiation of malignant and benign breast lesions. The pooled sensitivity and specificity values for ABUS were 90.8 per cent and 82.2 per cent, and these values for HHUS were 90.6 per cent and 81.0 per cent, respectively. Furthermore, volumetric measurements determined by ABUS had significantly higher accuracy than those determined by HHUS. Studies have questioned the sensitivity of ABUS in the evaluation of the area behind the nipple, the posterior aspect and the peripheral part of the breast, which have been solved with the modern equipment, while BI-RADS 3 and BI-RADS 4 lesions need further evaluation with target HHUS is needed before rendering a final assessment. The utilisation of ABUS in the preoperative setting has been further evaluated and volumetric measurements determined by ABUS had significantly higher accuracy than those determined by HHUS.

Computer-assisted detection/diagnosis

Computer-aided detection and diagnosis software can optimise the performance of ABUS. In order to improve reading time, a computer-aided detection (CAD) software for ABUS (QVCAD) have been developed and have received CE mark approval. A reader study has shown this new technology has the potential to improve the reading time with no loss in diagnostic accuracy. There has been an average of 33 per cent improved reading time among 18 radiologists in this study. The results of this study have concluded that the use of the concurrent-read QVCAD system for interpretation of screening ABUS studies of women with dense breast tissue makes interpretation significantly faster and produce non-inferior diagnostic accuracy compared to that of unaided conventional ABUS reading.

Recently, we explored the utility of Radiomic ABUS signature in the differentiation of benign from malignant breast lesions. This retrospective study included a total of 77 patients (all females) with biopsy proven lesions. Our results showed that the radiomic signature obtained from ABUS images is a promising tool in differentiating benign from malignant breast lesions, concluding that the automatic classification of these lesions could be successfully implemented using a radiomic signature extracted from ABUS images.

Furthermore, establishment of an ABUS training programme for radiologists and technicians that will provide adequate training in acquiring and interpreting 3D breast volumes data obtained by ABUS will potentially improve the sensitivity, specificity and will reduce the false negative rate.

Key points

ABUS is an emerging technology that provides an efficient, reproducible and comprehensive technique for supplemental breast screening. Novel developments of ABUS will help increase the sensitivity and specificity and will lead to more accurate diagnosis of breast cancers.

References available on request.