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Daily Dose

Acute Cholecystectomy: Better than the Alternatives

Article-Acute Cholecystectomy: Better than the Alternatives

In addition, with the increase in obesity rates and diabetes, the problems associated with gallstones and their complications is steadily increasing.

The burden on emergency surgical services is significant. This has driven the need for more defined surgical pathways to be developed in order to deal effectively with acute patients.

This need has been recognised by many centres around the world, but uptake of acute cholecystectomy has been unequal. This is especially relevant in an age of increasing subspecialisation, where the necessary skill-set for safe operative intervention in the acute setting might not be available.

Over the last 25 years we have seen a move away from open cholecystectomy and conservative treatment for acute gallstone disease. Traditionally, patients presenting with acute cholecystitis are managed by the general surgery emergency service. Resuscitation, management of sepsis and analgesia remain the mainstays of initial treatment. Clearly, these can be managed by non-specialist surgeons.

However, controversy exists around the best time for intervention to remove the gallbladder containing the troublesome stones. In the past, surgical teaching was to allow the inflammatory process to ‘settle’ for 6-8 weeks, then proceed with elective (or ‘cold’) cholecystectomy.

Increasingly, this approach is being shown to be both inefficient and potentially dangerous for patients at risk of further complications of their gallstones.

Since the advent of specialised upper gastrointestinal services, the development of acute cholecystectomy for the ‘hot gallbladder’ has matured into a realistic option for the majority of patients presenting acutely. Data from around the world have started to define the standard of care that would be applicable for the majority of acutely presenting patients.

Guidelines from the World Society of Emergency Surgery (WSES) recommend that early laparoscopic cholecystectomy should be performed as soon as possible but can be performed up to 10 days from symptom onset. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommend that patients with acute cholecystitis should receive cholecystectomy within seven days of diagnosis.

Evidence Base

A recent observational study comparing the practice of acute cholecystectomy in the U.S. and UK has given some interesting insights. National hospital data for a 14 year period (1998-2012) was analysed for the diagnosis of acute cholecystitis. In the U.S., 1,191,331 patients were admitted, in England 288,907 patient. Emergency cholecystectomy was performed in 53 per cent of U.S. patients, but only 16 per cent of UK patients.

The rate of emergency cholecystectomy increased over the time period in the U.S. (50 to 55 per cent) but remained relatively static in the UK (14 to 16 per cent). The rate of laparoscopic procedures was 89 per cent in the U.S., but only 38 per cent in the UK. The incidence of bile duct injury reduced over the time period in both subsets to 0.4 per cent at the study end.

The low proportion of acute cholecystectomy in the UK permitted an analysis of delayed cholecystectomy surgery in this patient group. Within the first year of index admission, 40 per cent of the delayed surgery group were readmitted as emergencies with a further attack of acute cholecystitis, in addition to gallbladder colic (9.4 per cent), biliary obstruction (3.2 per cent), pancreatitis (1.3 per cent) and ascending cholangitis (0.6 per cent).

A mean of 2.7 emergency re-admissions admissions was recorded in the first year for this group. After the first year, more than half this group had not received definitive cholecystectomy. The main reason for the delayed management in the UK group was lack of healthcare resource provision. Many patients were subsequently lost to follow-up. This study clearly demonstrates the unnecessary burden of a ‘delayed cholecystectomy’ policy, which imposes increased costs in the healthcare system and the patient.

Further sub analysis of the UK patient group undergoing index cholecystectomy showed that in high-volume centres undertaking cholecystectomy within three days of presentation, patients had reduced complications, incidence of conversion to laparotomy and hospital stay. Larger hospitals with specialist upper GI units had better outcomes.

The Cochrane review of seven randomised trials of acute vs delayed cholecystectomy found that early cholecystectomy reduced hospital stay, and the risk of later emergency surgery for unresolved cholecystitis or complications. No increased complications or surgical conversions were seen in the early surgery group.

The London-based CholeS study group, in which my Unit participates, has identified further insights into the UK population series admitted to hospital with acute cholecystitis. High volume centres (>300 total cholecystectomy procedures per annum) performed more procedures within three days and less after eight days than low volume centres (< 170 total cholecystectomy procedures per annum). Patients with delayed cholecystectomy tended to be older and more co-morbid, perhaps pointing to a clinical reason for delay. Multi-variate analysis showed that bile duct injury was associated with age >70yrs, high comorbidity index and delay in surgery to eight days (HR 2.76). High volume centres had lower bile duct injury rates.

Our specialised Upper GI centre performs approximately 850 cholecystectomy procedures per annum. We have the benefit of laparoscopic nurse practitioners who can mediate the emergency cholecystectomy pathway and navigate patients swiftly through to discharge. Of those presenting as an emergency (appx 30 per cent), 70 per cent are treated with cholecystectomy within three days, and 50 per cent are discharged within 24hrs of the procedure.

Recommendations

The Royal College of Surgeons of England is completing a national quality improvement project via the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC). This aims to develop and disseminate a viable model for the provision of emergency cholecystectomy services within the National Health Service. Healthcare systems with a financial incentive to early treatment have been identified as having a higher provision of early treatment services.

Patients presenting with acute gallstone disease should be able to access urgent laparoscopic cholecystectomy to resolve the cause of the acute episode and prevent the occurrence of further complications and emergency presentation. This makes good clinical sense and is cost effective. Increasingly, patients will seek out those services which provide one-stop care for their acute presentation with gallstone disease.

References available on request.

Daily Dose

3D Breast Imaging: Improving Accuracy in Daily Practice

Article-3D Breast Imaging: Improving Accuracy in Daily Practice

She says: “When you do the 2-D mammogram, breast density can hide something underneath. But when you do the 3-D mammogram you can more carefully analyse what’s inside the density, slice by slice. And at that time, you may notice finding a true cancer.

“I first experienced 3-D mammography in 2016 with Siemens MAMMOMAT and over the years, 3-D has quickly becoming the standard of care.”

What 3-D offers, she says, is the ability to see certain anomalies that just aren’t apparent on 2-D screens. Further, sometimes a 2-D image will show something suspicious, but when looking at the image in 3-D it ends up being an overlap of tissue and not a cause for concern.

“A situation like that, creates a lot of anxiety for a woman who is called back for additional testing,” she explains. “She’s assuming it’s cancer, but it might be a non-cancerous or benign finding. Using 3-D technology dramatically reduces the number of false alarms.”

Dr. Albastaki added that standard 2-D digital images are provided even when 3-D is used, giving physicians a complete picture of the breast architecture.

“3D definitely has a clinical advantage,” she highlights. “The 3-D scan is an additional sweep that takes 1-milimeter slice pictures through the breast. It opens the structure of the breast, allowing us to see more cancers.”

In her experience, Dr. Albastaki shares that the 3-D scan typically adds just one to two minutes more to the screening.

Furthermore, research has also shown that cancer detection rates have improved by 40 per cent when 3-D imaging is used in addition to 2-D. That’s because breast cancer outcomes notably improve, the earlier the cancer is detected.

The downsides to 3-D breast imaging are minimal. The doctor pointed out that 3-D scans do come with a greater radiation exposure than 2-D scans, about the same as a film X-ray. The only time she doesn’t do 3-D scans is because of patient preference or fatty parenchyma.

“The benefits definitely outweigh the downsides of it,” Dr. Albastaki said. “3-D is the newest technology available in mammography. It’s a huge clinical benefit and we have it readily available right here in Mediclinic Airport Road. It improves accuracy and overall visualisation for the physicians, and provides greater peace of mind and reduced anxiety for patients.”

A recent study titled “Effectiveness of Digital Breast Tomosynthesis Compared with Digital Mammography: Outcomes Analysis From 3 Years of Breast Cancer Screening,” saw researchers analyse 44,468 screening mammograms of 23,958 women who had never been diagnosed with breast cancer. From September 2010 to August 2011, all the women were screened with digital 2-D mammograms only. For the next 3 years, the women were screened with 3-D mammograms.

The researchers compared differences in screening outcomes between each 3-D mammogram year and the 2-D digital mammogram year. They also compared the differences in outcomes between women who had one, two, or three 3-D mammograms.

The rates of women who had to come back for more testing increased slightly each year for women who had 3-D mammograms:
– year one recall rate: 88 per 1,000 women screened
– year two recall rate: 90 per 1,000 women screened
– year three recall rate: 92 per 1,000 women screened

Still, these rates were much lower than the recall rate of 104 per 1,000 women screened for 2-D mammograms. This difference was statistically significant, which means that it was likely because of the difference in screening technique rather than just due to chance.

The rate of cancers found in women who were called back for more testing went up in women who had 3-D mammograms compared to women who had 2-D mammograms – meaning that 3-D mammograms found more cancers than 2-D mammograms. Rates of cancer detection in women who were called back for more testing were:
– 4.4 per cent in women who had 2-D mammograms
– 6.2 per cent in year one of 3-D mammograms
– 6.5 per cent in year two of 3-D mammograms
– 6.7 per cent in year three of 3-D mammograms

When the researchers compared recall rates between women who had one, two, or three 3-D mammograms, they found that these rates went down as women had more 3-D mammograms. Recall rates were:
– 130 per 1,000 women screened for women who had one 3-D mammogram
– 78 per 1,000 women screened for women who had two 3-D mammograms
– 59 per 1,000 women screened for women who had three 3-D mammograms

Interval cancers are cancers that are found within 12 months after a normal mammogram. Rates of interval cancers went down slightly from 0.7 per 1,000 women screened with 2-D mammograms to 0.5 per 1,000 women screened with 3-D mammograms.

“These results and further studies with exciting outcomes along with my personal experience show that 3-D mammography has become an essential part of routine breast cancer screening,” Dr. Albastaki concludes

Daily Dose

Partner for Innovation and Networking in Pharma

Article-Partner for Innovation and Networking in Pharma

Whether you are looking for sourcing new business or getting the latest market insight, with its co-located events, the exhibition is a one-stop–shop pharmaceutical platform in the Middle East & Africa region. The next edition will take place between September 16 to 18.

In an interview with Daily Dose, Cara Turner, Brand Director, CPhI Middle East & Africa, discusses the impact innovation is driving in the healthcare arena, especially technology that is transforming the pharma industry, and sheds light on the agenda for the upcoming event. Excerpts.

Innovation in healthcare is the theme of Arab Health this year. What would you say is the impact innovation is having on the delivery of healthcare?

Innovation has become crucial to the delivery of healthcare. Already we’ve seen the incredible impact technologies such as Artificial Intelligence (AI), Virtual Reality (VR), wearable technologies, 3D printing, and drones have had on the transformation of the healthcare landscape. The wearable medical device market is worth billions of dollars annually and this is expected to continue to increase year-on-year according to the latest research. It’s not only the wearables market either; across-the-board strong growth is predicted with healthy lifestyle apps, telehealth, and, greater patient engagement through technology resulting in cost saving and quality improvement.

What according to you is the potential of Blockchain and Artificial Intelligence in improving patient care?

If we look at the healthcare sector over the last few years, there have been several buzzwords dominating the discussion. However, it appears Artificial Intelligence (AI) could be the one that will have the most impact on the sector as we move forward. Computer-assisted robotic technology or AI one day superseding medical professionals are just a couple of examples being looked at and discussed. As we move into 2019, these will become even more pertinent, as the industry prepares to implement the technology.AI might be a relatively new term, but this is something that a lot of businesses, particularly those involved in the healthcare sphere, have been exploring for a long time.

What are your thoughts on the UAE’s healthcare industry? According to you, what are some of the current healthcare trends being seen in the GCC region and what do you see as the growth areas going forward?

Innovation is driving the healthcare industry forward and advances in technologies are creating vast new possibilities and opportunities for the UAE healthcare sector. Healthcare facilities, medical device manufacturers and service providers across the globe are constantly innovating to remain competitive and offer new and improved treatments to patients.

There will be a wealth of opportunities for healthcare start-ups, thanks to an increase in interest in new products and innovations — it will be the manufacturers and service providers who are able to innovate and remain competitive who will experience the greatest growth.

Could you tell us about CPhI’s upcoming events? What is the agenda for these?

CPhI Middle East & Africa focuses exclusively on pharma manufacturing across the region and is this specific community’s regional partner for innovation and networking, across the entire pharma supply chain. As such, our content this September will be shaped around encouraging government to industry initiatives, exploration of the latest trends within manufacturing, but more importantly, taking a closer look at innovation; where it’s coming from and what it means to the pharma manufacturing across the region.

What according to you are the opportunities available to healthcare and trade professionals who attend CPhI events?

CPhI is all about making connections that propel businesses within pharma manufacturing forward. At our events, we work hard to ensure a mix of trending content, high-level exhibitor interactions, and multi-level networking opportunities; from pre-arranged mutually beneficial meetings to informal networking events. If your business is within any aspect of the pharma manufacturing supply chain, then CPhI events are a must-attend!

For more information visit www.cphi.com/mea.

Trends in KSA healthcare market

Article-Trends in KSA healthcare market

The Saudi economy has witnessed dramatic changes, especially in the last few years. The new Vision 2030 for Saudi Arabia, announced on April 24, 2016, has enforced various economic reforms to decrease the country’s dependence on oil sources. In assembly with that, the healthcare sector in the Kingdom of Saudi Arabia (KSA) has witnessed several transformations, which will redefine the delivery of healthcare in Saudi Arabia.

KSA is considered to be one of the largest countries in the Middle East with an area of 2.15 million sq. m. The country’s population was 33.4 million in 2018 of which 62 per cent are nationals and 38 per cent are expats. Over the last 3 years, the country has witnessed a growth rate of 2.2 per cent, typically regarded as high when compared to the average population growth in the world (1.09 per cent).

A number of significant trends currently drive demand for KSA’s healthcare market. This includes a rising ageing population. According to the Ministry of Health, the age bracket of 65 years and above is expected to grow from 1.96 million in mid-2018 to 4.63 million in mid-2030. This is mostly attributed to an improvement in the quality of healthcare coupled with awareness programmes, increased accessibility to healthcare facilities and other governmental initiatives.

Another significant trend driving the healthcare market is the rise in the prevalence of non-communicable diseases (NCDs). According to a report published by the World Health Organization (WHO), the prevalence of obesity is expected to rise to above 45 per cent by 2025. As a result, these factors eventually put the Saudi population at higher risk of NCDs such as diabetes, and hypertension, in addition to other diseases pertaining to cardiac, kidneys and other body systems.

Additionally, high injury rates due to road traffic accidents are another key demand driver for the Kingdom’s healthcare sector. Despite considerable government efforts in an attempt to decrease accidents, road traffic injury was the second most common cause of death in the Kingdom between 2007 and 2017.

The aforementioned factors are key demand drivers for both primary and preventative services, as well as secondary and tertiary care. More importantly, however, these factors have highlighted a need in the market for specialised extended healthcare services, such as rehabilitation and long-term care.

The need for extended care, which includes comprehensive rehabilitation services, along with home and long-term care is expected to grow significantly. It is estimated that the demand for the number of beds for extended care in the top three most populated regions of KSA will reach more than 8,000 beds in 2030, further highlighting a paradigm shift. Care is evolving; shifting from three to four-day in-patient hospital stays on average, to more options in the out-patient care sphere. Examples of this include one-day procedures or tailored home care. Further supporting this paradigm shift is the stance of physicians, who are now advocating the practice of “fewer nights in hospitals”.

Various studies have showcased a positive direct relationship between patient outcomes and shorter inpatient stay, due to decreased risk of hospital-acquired infections and a lower dependency on hospitals, which helps rehabilitate patients faster. Additionally, shorter hospital inpatient stays increase the ability of hospitals to better utilise resources, leading to cheaper overall costs on patients and insurance. Improved resource utilisation combined with a consequent high turnover will eventually lead to higher levels of profitability for healthcare players. Also, the aforementioned results will ultimately have an impact on the wider macroeconomic environment. With an increase in the overall health of individual patients, their levels of productivity and utilisation at work also improve, translating to a positive impact on the overall economy.

It is expected that demand for hospital and specialised beds will increase by an additional ~5,000 beds by 2020, and ~20,000 more by 2035. Coupled with a new focus on involving the private sector in 12 major areas of healthcare including diagnostics and laboratory services, extended and primary care, this creates a good opportunity for entry and expansion in the market.

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How is the government creating an attractive ecosystem for investors?

The government, in turn, has created several initiatives making it more attractive to invest in the Saudi healthcare market. Those include the National Transformation Programme (NTP) as part of the 2030 Saudi Vision. Also, the Saudi Arabian General Investment Authority (SAGIA) has opened the door for 100 per cent ownership of foreign investment in various fields, and healthcare is among them. Increasing the number of internationally accredited hospitals is one of the focus areas of the NTP. Insurance became mandatory for all private-sector employees. Also, a national insurance programme is being launched to transform the delivery of healthcare to nationals through private and public hospitals. The Ministry of Health (MOH) has adapted a new partnership with the private sector (Private Sector Participation). “This partnership empowers the private sector to shape its future role in the Saudi economy and enhance its ability to meet short and long-term requirements in achieving the goals of the future vision by participating in the financing, operation and management of service projects, selecting suitable models for its contribution and identifying priority sectors and achieving financial sustainability,” a MOH statement said. Those are creating key opportunities for expansion and a new entry into KSA’s healthcare market.

On a side note, healthcare budget is being expanded, which reflects a strong indication of potentially high demand as the government may be willing to spend and embrace improvement and growth within the sector.

Private investment in healthcare is being guided and governed by SAGIA. More mature models are expected to be formed to guide entrance and investments into KSA’s healthcare market.

In the medium to long term, the healthcare market in Saudi Arabia presents itself as a sector with high growth opportunities. To expand or enter the market and achieve long term success, it is important to carefully study the gaps between supply and demand, understand international best practices and embrace digital and technological advances. 

References available on request.

The gateway to the healthcare sector in Saudi Arabia

Global Health Exhibition and Congress, held under the patronage of the Saudi Ministry of Health, brings together 15,000+ key healthcare professionals from KSA and across the globe to meet, learn and do business in the Kingdom of Saudi Arabia. Learn more about the comprehensive range of healthcare products and services being showcased by the world’s most innovative and prevailing companies.

Discover Global Health Exhibition and Congress

Inspiring Innovation in the Spotlight at Arab Health 2019

Article-Inspiring Innovation in the Spotlight at Arab Health 2019

A new feature being launched at the show this year is the Innovation Hub, located within the central Plaza Hall, that will prominently focus on technologies transforming healthcare. Working alongside government entities such as the UAE Ministry of Health and Prevention, Dubai Health Authority, Department of Health Abu Dhabi and SEHA, the Innovation Hub is a dedicated area for visitors to immerse themselves in the latest healthcare innovations and discover trending start-ups and SMEs creating an impact in the healthcare arena.

Plus, a dedicated seminar theatre will be a key feature in the Innovation Hub for the inaugural Innov8 Talks that will host 8 pitches, each 8-minute-long. Here you can listen to start-ups and entrepreneurs present their healthcare innovations to a panel of industry experts and potential investors.

Below is a deeper dive into some of the companies that are a part of the Innovation Hub and looking at how their innovations are shaping the future of healthcare.

Improving Paediatric Care with AI

At the Innov8 talks today, Nolan Rome, engineer and healthcare design director for WSP in the U.S. and co-chair of WSP’s Global Healthcare initiative, will be showcasing a paediatric care innovation that the company has been working on to determine how Artificial Intelligence (AI) can help deliver a better experience for patients and staff.

He shares: “We’re discovering whether using AI to interpret temperature, lighting controls, etc., is effective to achieving better wellness environments and reduce the procedural information the clinicians need direct from patients. The approach we are taking is to empower the children and give them the ability to control their environment, then using this data to provide the clinicians with unspoken cues as to what the patients level of wellness is. We believe this would reduce anxiety and stress on the patient, potentially helping them to recover more quickly, and allow the clinicians to have less scripted interactions with patients.”

Access to Everyone Everywhere

Participating at Arab Health for the second consecutive year is Okadoc, which is based in Dubai Health Care City and is a first of its kind platform in the region that connects healthcare providers and doctors instantly with their patients, bringing a way to quickly make confirmed booking appointments.

Fodhil Benturquia, CEO and Founder of Okadoc highlights: “We are making our official international debut at the show, showcasing our unique proprietary digital platform designed to provide instant and interactive healthcare access to everyone everywhere.

“The platform shows real-time doctors’ calendar availability, which allows hospitals, clinics and practitioners to take online appointments by patients who can search and select the doctor they need according to specialty, experience, education, location, insurance, language spoken and availability.”

Okadoc’s aim is to help the healthcare sector introduce significant efficiencies while reducing cost and maximising revenues and profitability. For example, hospitals and clinics connected to it can reduce no-shows by 75 per cent. From a patient experience standpoint, its user-friendly and device-agnostic platform drastically improve patient satisfaction giving them the functionality to find their preferred doctor who matches their precise requirements, book a confirmed appointment in less than 40 seconds, reschedule in 10 seconds and cancel in just five seconds; and all that without any human intervention. In fact, artificial intelligence enables Okadoc’s platform reduce toxic calls hospitals and clinics receive by 30 per cent.

When asked about future plans, Benturquia shares: “Okadoc’s high-adoption platform and highly scalable business model are at the core of the digital transformation of the UAE’s healthcare market, which is expected to be worth US$20 billion by 2020. Looking across the region, this year we have concrete plans to launch our presence in key regional markets across the GCC, a market expected to be worth a total US$71.3 billion by 2020.”

Effectively Managing Diabetes

Nicolas Babin is the co-founder of MirambeauAppCare and co-founded the company in France in 2017 with his associate Benoit Mirambeau. The company manages diabetes protocol for patients and at the show they are showcasing DiabiLive, their flagship product, an EU class 2b medical device application.

Babin explains: “DiabiLive allows insulin management and tele-consultation for patients and doctors. Everything is based on the doctor’s protocol. This application is unique as it is the only technology on the market that can calculate the precise amount of insulin the patient needs to inject by integrating their glycaemic level with medical protocol, food intake and physical activity.”According to Babin, innovation in healthcare today means having the patient at the centre of everything. Furthermore, the use of AI and smart algorithms allow patients to feel safe and doctors to manage them efficiently on-site or at a distance.

When asked about future plans, he shares: “We are currently focused on our diabetes protocol management application using all new technology. Our next step is to apply our technology to other illnesses that require strict and challenging protocols. Also, we are looking forward to starting our business in the UAE shortly.”

DiabiLive will be pitching at the Innov8 talks on Tuesday, January 28.

Machine Learning to the Rescue

Brainscan.ai is showcasing a software that uses machine learning to analyse computed tomography images of the head to detect and evaluate brain changes. Thanks to this solution, the Radiologist is able to give an opinion on a case faster, more accurately and with easy access to similar cases, in order to make a more informed decision. It hopes to generate savings for the hospitals and lower the queues for radiological interpretation.

Dariusz Wiśniewski, International Relationship Manager, Brainscan.ai says: “As software is not prone to be tired, it’s a tool that can actively help to lower the risk of misdiagnosis, which is a major problem.”Brainscan.ai is continuing to further develop the software by improving its accuracy and by polishing functionalities.

“Our team of developers is working to ensure that the final version of the software is available on the market in October 2019. When we have an established presence on the market, we want to get into MRI scans,” Wiśniewski adds.

Driving the Future of Medicine

One of the world’s first bioink companies and leading 3D bioprinter provider, CELLINK, is present at the show and will be pitching at the Innov8 talks today. The company focuses on the development and commercialisation of bioprinting technologies. Its innovative and patent pending bioinks are biomaterial innovations that enable human cells to grow and thrive such as they would in the natural human body environment.

The company’s disruptive technology platform is being used in over 600 labs to print tissues such as cartilage, skin, and even fully functional cancer tumours that can then be used to develop new cancer treatments. At the show, CELLINK is showcasing its latest 3D Bioprinter, BIO X.

Johan Berthag, Head of Global Sales, CELLINK says, “At CELLINK we take great pride in being one of the companies that are driving the future of medicine. To be able to be a part of and collaborating with some of the world’s best scientists doing ground-breaking research that will totally change how we develop new pharmaceuticals or patient-specific treatments, that is truly exciting.“One of the big goals is of course to be able to bioprint a full-size organ and transplant this into a patient!”  

Tapping into Telemedicine

TruDoc24x7 has been operating since 2011 and is one of the UAE’s leading 24x7 Population Health Management Delivery System that combines next-generation telemedicine, telemonitoring and home health to provide patients with immediate access to highly trained, DHA licensed doctors and wellness experts for healthy, acute and chronic condition management and advice via voice/video calls. The one-of-a-kind solution consists of a 24x7 Call Centre, Integrated and Interactive Mobile Application, 24x7 On-site Virtual Clinic Booth, On Site Clinics, Disease Management Programs and Hospital at Home Program, which is licensed by Johns Hopkins University.

Raouf Khalil, Founder & CEO, TruDoc24x7 highlights: “Our full-time, non-incentivized doctors will tell you the truth about what you need, not what you can afford. As a trusted partner to over 5.1 million paid subscribers, we provide consumers with a true concierge service based on 24x7 Population Health Management and a guaranteed savings model for payers through the practice of true evidence-based medicine."

At Arab Health, the company will be showcasing its new 24x7 On-site Virtual Clinic Booth. Through the innovative technology included within the clinic, patients are able to take their readings using easy-to-use, integrated smart devices, which relay the readings directly to the call centre where TruDoc’s doctors are available 24x7 to assess the readings and provide advice back to the patient.

Daily Dose

Diagnosing and Treating Latent Autoimmune Diabetes in Adults

Article-Diagnosing and Treating Latent Autoimmune Diabetes in Adults

Differently from type 2 diabetes (T2D), all forms of autoimmune diabetes are characterised by the presence of specific autoantibodies directed against pancreatic β-cells islets such as islet cell-related autoantibodies (ICA), glutamic acid decarboxylase (GAD) autoantibodies.

Classically, when this form occurs in children or young adults, insulin therapy is needed right up, due to the impairment of β-cell function, defining the well-known type 1 diabetes (T1D). However, the clinical onset of autoimmune diabetes is extremely heterogeneous, and it can develop at any age. Eepidemiological studies have demonstrated that approximately 30 per cent of cases of T1D occur after 30 years of age, showing that adult-onset T1D is less rare than previously deemed.

On the other hand, it has been estimated that among people with a clinical diagnosis of T2D, the occurrence of the same diabetes autoantibodies vary between 3 per cent and 12 per cent. Some of these subjects may experience a progressive loss of insulin-secreting β-cells due to the reactivity of activated T-cells, developing insulin-dependent diabetes.

In this regard, these subjects are wrongly diagnosed with T2D and are actually affected by “latent autoimmune diabetes in adults” (LADA), a slowly progressive insulin-dependent diabetes, characterised by initially non-insulin requiring, slower course through β-cells failure and, in most cases, a subclinical onset. Nonetheless, established guidelines for diagnosis of LADA are currently unavailable due to the great heterogeneity that is inside the definition of LADA itself and the lack of well-designed randomised controlled trials. Therefore, a great effort has been made in order to well-characterise these individuals. The overlap for genetic, immunological features between LADA and classical T1D as well as the lack of pathogenetic studies that are exclusive for this form of diabetes, make it difficult to draw a clear dividing line between them.

According to the Immunology of Diabetes Society (IDS), subjects affected by LADA are diagnosed with diabetes after the age of 30 years old and are insulin independent for at least six months after diagnosis, despite the presence of T1D-related circulating autoantibodies. Therefore, any adult who does not require insulin and who is positive for at least one diabetes-associated autoantibody, regardless of number, could be diagnosed as having LADA. This definition reveals the heterogeneity of LADA. For instance, not all subjects found to be positive for circulating autoantibodies develop the need for insulin therapy.

Thus, LADA remains often unnoticed in clinical setting and a high misdiagnosis rate (5-10 per cent) still occurs among people with T2D, leading to inappropriate therapies that could worsen diabetes control and could accelerate the loss of insulin producing capability by β-cells.

As a consequence, one of the main issue concerns is how to identify LADA patients at an early stage, before insulin therapy is needed. LADA should be suspected in adults newly-diagnosed with insulin-independent diabetes, who have few signs of metabolic syndrome (such as obesity, high blood pressure and cholesterol levels), uncontrolled hyperglycaemia despite using oral agents and familiar and/or personal history of autoimmunity. Testing islet autoantibodies, glutamic acid decarboxylase autoantibodies (GADA) especially, in these patients should be advised in order to ensure a closer monitoring of those with autoantibody positivity. However, it is important to clarify that a state of insulin resentence, which is typical of T2D, does not exclude LADA.

In fact, patients affected by LADA encompass a broad spectrum of phenotypes from prevalent insulin deficiency to variable degrees of insulin resistance, sharing features of both T1D and T2D and make it difficult to correctly identify LADA, just on the basis of metabolic phenotype. Consequentially, islet-cell antibodies measurement remains essential to diagnose LADA and routine GADA screening have been previously proposed. Nonetheless, testing for LADA with a full autoantibody panel in all patients with newly diagnosed T2D, irrespective to the clinical suspicious, is not recommended because of high costs, low test specificity and difficulties in interpreting the results. Risk scores based on clinical parameters should be considered before requiring islet-cell autoantibodies tests in patients with recent evidence of diabetes in order to increase the efficiency of a screening programme for LADA.

Once LADA is diagnosed, another critical issue is how to recognise subjects who have a higher risk of progression to insulin treatment. In this regard, authors suggest that insulin requirement in LADA may be linked to the degree of autoimmunity, explaining the heterogeneity observed in LADA. On that note, recent studies investigated this heterogeneity by comparing phenotypes of LADA with high-titre GADA versus those with low-titre GADA, finding that individuals with high-titre GADA are clinically more similar to those affected by T1D, being younger, thinner and showing faster progression towards insulin treatment. By contrast, low-titre GADA subjects show more pronounced traits of insulin resistance and slower rate of β-cells destruction as compared with high-titre GADA.

Furthermore, even the type of antibody positivity seems to influence clinical features of LADA. The Non Insulin Requiring Autoimmune Diabetes (NIRAD) group demonstrated that IA-2A, that are less frequent than GADA, increase in frequency with increasing BMI in a population affected by T2DM, becoming the most prevalent antibody in patients with BMI > 30 kg/m2. In the Arab population, it was observed that the number of positive autoantibodies is also associated with the risk of developing insulin-dependence. These findings support the hypothesis that pathogenesis of LADA should be linked with both immunological factors, which may act as the principal trigger in subjects with normal BMI and high-titre GADA, and chronic inflammation, which could lead to the development of less severe islet autoimmunity in people with obesity and with increased risk of T2D, as testified by the presence of IA-2A. Testing for C-peptide may also be helpful to identify LADA subjects at higher risk of developing insulin-dependency.

Another outstanding question concerns treatment strategy. In fact, due to the wide heterogeneity among patients with LADA it is difficult to establish a priori algorithm for treatment and a tailor-made therapeutic approach is needed to improve glycaemic control and insulin sensitivity, taking into account clinical and biochemical features of each patient. Considering the autoimmune pathogenesis of LADA, evidence shows that patients with LADA should be treated with insulin at an earlier stage. On the contrary, data on sulfonylureas discourage their use in patients with LADA, because these agents might stimulate β-cell and enhance the antigen expression of β-cells, exacerbating the autoimmune process. However, there is a wider window of other therapeutic interventions that may be of some clinical benefits when added to insulin treatment.

Insulin sensitizers have been shown to be helpful in subjects with autoimmune diabetes who share more pronounced insulin-resistant traits. Moreover, as LADA subjects generally show some degree of residual β-cell function, treatment should aim at both protecting and stimulating β-cell regeneration. Thus, combined therapies to target different pathways could be a proper strategy. Based on the newest evidences, DPP-4 inhibitors and GLP-1 receptor agonists might be tested in LADA as an add-on therapy to insulin to sustain residual β-cell function, slow down β-cell loss and improve glycemic control in autoimmune diabetes, especially in patients with a relative maintenance of C-peptide secretion. Therapeutic strategy in LADA should focus on the preservation of residual β-cell function as long as possible since its preservation is associated with reduction of long-term diabetic complications. Further studies in this field of interest are strongly encouraged.

References available on request.

Dr. Maddaloni will be speaking on ‘Latent autoimmune diabetes of the adulthood’ as part of the Diabetes conference, 

Daily Dose

Novaerus Presents the Future of Infection Control with Defend 1050

Article-Novaerus Presents the Future of Infection Control with Defend 1050

Participating at Arab Health for the fourth time this year, Novaerus, a leading Irish firm that specializes in the most effective technology for air dis-infection, continues on its mission to reduce indoor airborne pollutants by showcasing its latest product, Novaerus Defend 1050 (NV 1050), that combines rapid air dis-infection and purification to kill pathogens and trap particulates to control infection.

Globally, nosocomial infection is a serious and widespread problem with an estimated 1 in 10 patients acquiring an infection during a hospital stay. Airborne pathogens spread infection through inhalation and surface contamination. New research data points out that in Europe alone, healthcare acquired infections lead to 16 million additional days of hospital stay and 7 billion euros in direct costs.  

Athough all hospitals have air handling and air filtration systems, what makes Novaerus different, explains Kieran J. McBrien, Senior Vice-President, International Business Development, “is that our systems go above and beyond conventional systems to get into confined indoor spaces and add another level of air sterilisation and air cleaning. It works on two levels: one, it prevents direct transmission from person to person, and second, it also reduces contamination on surfaces by taking pathogens out of the air.”

“Every human is a bio bomb,” he adds. “We carry bacteria, we shed bacteria, and we pass on bacteria through contamination of surfaces and hands, thereby causing infection, allergies and irritation. Novaerus systems use ultra-low energy plasma technology that has been independently tested and proven to deactivate airborne bacteria and viruses, neutralise VOCs and reduce particulate such as mould spores, dust mites, pollen, etc.”

The newly launched Novaerus Defend 1050, he adds, “uses this unique patented plasma technology in combination with a triple-stage Camfil filter system – a leading Swedish manufacturer of premium clean air solutions – to give a powerful, compact and manoeuvrable air sterilisation device that provides an effective solution for both air dis-infection and particle removal.”

Designed for rapid remediation in large spaces and situations with high risk of infection, what makes Novaerus Defend 1050 superior is that “it offers much higher air volumes, improved ergonomics and ease of use.” The all-in-one Defend 1050 can be operated continuously around patients and staff to kill airborne pathogens, adsorb odours, neutralise volatile organic compounds (VOCs), and trap particulate as small as 0.12µm, he adds.

Although hand hygiene and surface cleaning are the norm in healthcare organisations, these have only limited effects due to low compliance and the ongoing presence of pathogens in the hospital environment, says McBrien. “The Defend 1050 is therefore a safe, continuous and effective air disinfection solution to augment hygiene protocols and reduce the transmission of infection in operating theatres, ICUs, hospital wards, emergency rooms, labs and other critical areas.”
 
Novaerus is taking advantage of its presence at the 2019 Arab Health Exhibition & Congress to re-enter the UAE market, following its relaunch in the country in October 2018.  “Arab Health is an important platform for us to extend our reach not only in the GCC region but also enter the rapidly growing markets of India and Africa. It also serves as a great opportunity to meet our distributors from both the GCC and other parts of the world.”

Arab Health, he adds, is a great venue to showcase new products and learn about innovations in other markets and product segments. “It is an exciting show, very well organized, and we always look forward to coming back.”

Keen on making a firm foothold in the region, Novaerus is supporting its partners in the MENA region by working with them in close cooperation in their respective markets. “These include making hospital visits, conducting training and seminars,” he concludes. 

Healthcare at your fingertips

Article-Healthcare at your fingertips

Recently, His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice-President and Prime Minister of the UAE and Ruler of Dubai, declared the Fifty-Year Charter, which includes nine articles that aim to shape the future of Dubai and enhance the city’s quality of life. One of these pillars is to have a doctor for every citizen.

An initiative that could help fulfil this vision is Okadoc, an app that was launched in 2018. It is a 24-hour medical calendar system that helps patients search and select doctors by specialty, location, language and insurance coverage. With the app, patients can instantly book appointments based on availability.

The app is the brainchild of Fodhil Benturquia, Founder & CEO, Okadoc, who was previously the CEO of Noon.com, a founding member of the regional e-commerce site MarkaVIP and former general manager of Souq.com’s operations in Saudi Arabia.

Benturquia shares: “The stresses of daily life can lead to falling sick quite often. Once, when I wanted to book an appointment with a doctor, I faced a tough time. I am used to ordering my food or booking my taxi or airline tickets or even a car wash in less than 30 to 60 seconds. But when I was sick and wanted to get a doctor’s appointment, it took me 15 minutes and even then, I couldn’t get a confirmed appointment. I had to hold the line, listen to recorded music and eventually got told that nobody can pick up and to call back later. I found it extremely shocking, as healthcare is the most important need of life.”

The second thing that caught Benturquia’s attention was the fact that in e-commerce when somebody calls, the rule is to attend it in 20 seconds. “We know that if you don’t pick up the phone in 20 seconds, you lose 50 per cent of clients. In e-commerce, people call for retention purposes – in case there is a delay in delivery or to request for cancellation. But in healthcare, the primary purpose is an acquisition. Somebody is sick and wants to spend in your clinic, but they are kept waiting. For instance, on a Friday, most of the time the phone won’t get answered and if you or your child are sick, how do you manage to get an appointment? You end up going to the emergency ward. It costs a lot of money and nobody wants to go there as it’s scary, specialists might not be available and you could wait a couple of hours before getting treatment,” he explains.

When the CEO did a quick search on the Internet, he found that there were a couple of companies that offered online booking, but soon realised that none of them offered an instant confirmation. With these platforms, you could book a date and time and receive a call from the clinic to confirm the appointment, a few hours later or maybe even the next day. “Also, when a clinic calls, you might not pick up the call,” says the CEO. “This is not the experience I am expecting as a patient or a user. I don’t need somebody to call me back. When it’s booked it should be confirmed, just like any other digital experience,” he adds.

However, he also chanced upon websites such as ZocDoc in the U.S. and Doctolib in Europe that offered instant booking solutions. “I found that patients and healthcare providers loved these platforms as they solved so many problems for everybody,” he stresses. “That’s when I decided it would be a great idea to bring it to the UAE.”

Making an appointment with a doctor on Okadoc takes 20-30 seconds. If you are not logged in, it will take 40 seconds. It can be cancelled in 5 seconds, which is two clicks, and rescheduled in 7 seconds, which is three clicks. A user will also get reminders by SMS, push notifications, emails and within the reminders, there is an option to cancel or reschedule.

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Fodhil Benturquia

Problem-solving

Moreover, Okadoc can tackle the discovery issue. This means that the app allows the user to search for doctors by spoken languages, filter by gender, search by availability and insurance policy.

Benturquia highlights that healthcare facilities often have a high no-show, and this is a big problem in the region. In the U.S., the no-show rate is around 23 per cent but in the UAE, it is 37 per cent, while in Saudi Arabia it is 50 per cent.

He says: “No-show is kind of a disease of the clinic or the hospital. Almost 4 out of 10 patients are not turning up. Our research found that the reason for these numbers is because 50 per cent of people forget about their appointment; 40 per cent of the people want to cancel or reschedule but when they want to do so, it is outside working hours or the waiting time to cancel/reschedule is very long. Then there is 10 per cent of the people who don’t care about cancelling or rescheduling. With our platform, we have been able to reduce no-shows by 75 per cent!”

Almost 14,000 doctors in the UAE are listed on the platform, but out of that 1,000 are instantly bookable. Institutions such as Zulekha Hospital and Emirates Speciality Hospital, among others, are already a part of it.

Geographically, it caters to users in Dubai, Sharjah, Abu Dhabi, Ajman, Fujairah and Ras Al Khaimah. The app is also available as a website, on Android and iOS, and as widgets. Also, when a booking is made, the user can request for earlier availability, so if someone cancels, they can be moved to that spot.

“We are hosted in the UAE and are compliant with every global standard such as the Health Insurance Portability and Accountability Act (HIPAA). We are a step ahead when it comes to security, encryption, and follow best practices. By regulation, the data needs to be hosted in the UAE,” he explains.

When asked about future plans, he concludes: “We are currently touching 10 per cent of online bookable doctors. Our goal is for the UAE to become the first country with the highest number of online bookable doctors per capita by 2021.

“We are soon going to launch in Saudi Arabia. It is a great opportunity for us, as the no-show is even bigger there. We are also looking at launching in one more country by the end of the year. Our expansion plans are in the GCC, but also beyond.”

Ascom Showcases New Integrated Communication Solution at Arab Health 2019

Article-Ascom Showcases New Integrated Communication Solution at Arab Health 2019

Ascom, a global solutions provider focused on healthcare Information and Communication Technology (ICT) and mobile work flow solutions, is closing digital information gaps across points of care in a healthcare setting with the launch of Telligence 6.0, a new patient-centric solution that delivers advanced integration and enhances clinical decision-making.

According to Ahmed Al Jassim, Managing Director, AAA Region - Middle East and Africa, “Ascom’s Telligence 6.0 offers a higher scale of clinical solution as it collects information from multiple sources such as the patient, medical devices and monitors, healthcare applications, and other systems, to give the caregiver a more comprehensive view of the patient’s status that goes well beyond the traditional nurse call.

“By capturing and sharing information from multiple sources, it enables a more responsive patient-centric care and also empowers the patient to have control of his/her own environment.”

 In addition, Telligence is flexible, offering everything from a standalone nurse call system to a fully integrated, end-to-end patient response solution, he adds.  

One of the greatest challenges for a nurse, says Kathleen Snyder - Global Senior Product Marketing Manager, “is to get the right and reliable communication which, in turn, has a tremendous impact on a patient’s healthcare experience. A nurse needs to hear all the alarms and alerts but also filter out all the ‘noise’ so that the right information is delivered to the right caregiver at the right time for appropriate response. By enabling a seamless flow of clinical information between care teams, devices and systems, Ascom is focused on providing efficiency for clinicians while at the same time, maintaining the privacy, integrity and quality of care for the patients.”

Very often, connected medical devices produce an exhaustive amount of data, all of which may not require immediate clinical response. How do you turn this fragmented data – received from the bedside, to intensive care units, to operating rooms and more - into accessible information to support clinicians across points of care? Integration of medical devices and vital care information systems is vital to harness the power of digital clinical communication and to bridge digital information gaps, says Aage Rask Andersen, Vice President AAA Region. “This is precisely where Ascom’s strength lies. Built around three core pillars – integration, orchestration and enablement – our solutions offer actionable clinical insight across points of care for efficient, effective care, particularly in critical care and time-sensitive environments.”

Globally, the segment of senior population is growing at a rapid pace and as machines get more complex, the healthcare system across developed and developing countries is under tremendous pressure to provide the right kind of care especially with the limited resources available. “The key, therefore, is to improve efficiencies to care delivery with strategic healthcare information and communications technology and thus ensure smooth and efficient workflows leading to improved productivity and enhanced patient satisfaction in the challenging clinical environment,” he adds. “This is primarily the overall driver for Ascom’s solutions and the reason for its continued upward growth.”

Following a tremendous success last year in its key markets in Europe as well as across the Middle East and Asia, the company is now geared to repeat its success in 2019 with the launch of a new office in Singapore, says Ahmed Al Jassim. “In 2018, two of the largest hospitals in Singapore were equipped with our ICT solutions. In the UAE, Burjeel Medical City in Abu Dhabi, Dr. Sulaiman Al Habib Hospital in Dubai and Al Ain Hospital also chose Ascom to access clinical information and deliver responsive coordinated care.” 

Healthier Future With ROHA’s Natural Products

Article-Healthier Future With ROHA’s Natural Products

Established 1919 in Bremen, Northern Germany, ROHA's high-quality products help people around the world not only to become healthier but also more health-conscious, vital and productive.

During the early 1930’s the products branded Bekunis, whose active ingredients came from the indigenous senna plant, dominated ROHAs assortment. Today, Bekunis Herbal Tea is still considered a reliable natural remedy for digestive problems. The same applies to Bekunis Senna Laxative Dragees, which ROHA introduced in many countries worldwide.

Over the next few decades, ROHA expanded its portfolio with innovative brands such as Bakanasan, Sanhelios and Re-Load vital. To this day, customers from pharmacies, health food stores, and drugstores trust the high-grade herbal health products from ROHA.

Market Leader for Propolis Products
Inspired by the exceptional effects of propolis, a protective resin from bees, ROHA specialises in propolis products. With more than 40 years of experience of processing propolis, ROHA has become the market leader in Germany. In addition to the production of cosmetics and dietary supplements, ROHA holds drug approvals for products with propolis, manufactured under GMP conditions in Germany: Propolis Capsules for supporting immune system and Propolis Throat Lozenges for the throat and the respiratory tract.

beecraft: Just Bee Natural
The new beecraft brand enriches the impressive ROHA range of natural health products. The name beecraft speaks for itself: all of the natural ingredients come from the beehive. The main component is propolis, one of the oldest most-researched remedies in the world. Characteristic are the compounds of so-called phytamines, also known as polyphenols. These occur as bioactive substances in plants and significantly determine the quality of propolis. ROHA refines the newly developed beecraft brand with a standardised propolis mixture from various regions containing at least 30 per cent phytamines. With a unique combination of pure propolis from different areas of the world and the certificate Certified Phytamines 300+, ROHA ensures a highly divisive yet consistent concentration of health-promoting natural compounds.

The regular procurement of high-quality propolis is an ever-growing challenge, which is regularly attained by a dedicated ROHA sister company, one of Europe’s leading propolis importers. The extensive beecraft product assortment consists of various products for the throat and respiratory tract, immune strength, oral and dental care, and skincare cosmetics.

ROHA is Committed to Bee Health
Concerned about the decline in bee colonies, ROHA cooperates with Mellifera e.V., a German organisation, who since 1985 have devoted themselves to the protection and welfare of bees. Furthermore, ROHA supports research projects each year to combat the threat of the Varroa mite. United in all beecraft products is the distinctive expertise and dedication of the entire ROHA team who treasure the bees unique gift. Ever more ROHA employees train as beekeepers cultivating bee colonies in their free time.

MORE INFO
Visit www.roha1919.com or contact international@roha1919.com.

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