Advances in Imaging X Philips Tests Live 3D Holographic Visualisation X GE’S New Revolution CT Scans Heart in One Beat X Siemens’ Symbia Intevo Integrates SPECT & CT

January-February 2014 www.MiddleEastHealthMag.com Advances in Imaging X Philips tests live 3D holographic visualisation X GE’s new Revolution CT scans heart in one beat X Siemens’ Symbia Intevo integrates SPECT & CT

60th WHO EMR MERS-CoV found in camels conference highlights Death toll from coronavirus continues to rise in Gulf States • Polio outbreak in Syria • Shocking road death stats In the News • Dubai makes expat health insurance mandatory Houston Methodist Global Health Care Services – • EU launches universal flu vaccine research project Middle East Heath Roundtable looks at improving • New HIV strain leads to faster AIDS development healthcare workforce education in the region • Add bone deterioration to diabetes complications

Bahrain BD3, Egypt £E40, Iran IRR75, Iraq IQD9,400, Jordan JD5, Kuwait KD3, Lebanon LBP12,000, Oman RO3, Qatar QR30, Saudi Arabia SR30, Syria £S400, UAE Dh30, Yemen YR1,600

MIDDLE EAST HEALTHI1 2 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI3 4 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI5 6 IMIDDLE EAST HEALTH Prognosis

Tech Evolution January-February 2014

We have another bumper issue, thanks to all the advertising support. From Publisher Michael Hurst the publisher and the editorial team – we wish you all a healthy, happy [email protected] and prosperous 2014. Editor This is always an interesting time of year as we see what new technology Callan Emery is being introduced by the major medical device manufacturers who often [email protected] wait for the three large medical expos, Medica (in November), RSNA (in Editorial and Production Trident Media - Middle East December) and Arab Health (in January) to launch their new products on www.tridentmedia-me.com the market. In this issue, in the focus on Cardiology, Computed Tomogra- Editorial Consultants phy and in the extensive Product News section, we look at some of these Dr Gamal Hammad, Dr Peter Moore, Harry Brewer innovative products. It is always impressive to witness this evolution in Middle East Editorial Office technology on show at these exhibitions year on year. Advances appear to PO Box 825, Dubai, UAE come in two spheres – either improvements in the technology to enhance Telephone: (+9714) 334 6609 [email protected] its capability, Philips’ holographic visualisation is a good example, or developments that enable the technology to be manufactured at lower cost, Marketing Manager Foehn Sarkar which then enables greater access to these devices. Telephone: (+9714) 391 4775 n Fax: (+9714) 391 4888 The WHO Eastern Mediterranean Region held their annual meeting in [email protected] Muscat at the end of October where a number of important public health Subscription & Admin Manager issues affecting the region were raised – in particular the polio outbreak in Savita Kapoor Telephone: (+9714) 391 4775 n Fax: (+9714) 391 4888 Syria, which could have wider regional implications. We look at this is- [email protected] sue, the new road trafﬁc safety report – with it shocking regional statistics Advertising Sales – and the MERS coronavirus, which continues to take its toll across the PO Box 72280, Dubai, UAE Gulf States, albeit slowly. [email protected] Also in this issue we speak to the head of the Thalassaemia Interna- Americas, France Jay Franco, tional Federation about the little known non-transfusion dependent thal- 3 Erinlea Crescent, Scarborough, assaemia. We do this on the occasion of an online initiative – NTDT Ontario M1H 2S8, Canada Tel: 1-416-439-5100 n Fax: 1-416-439-0770 Voices – to raise aware of the condition. And we speak to Professor Heinz [email protected] Josef Lenz, an eminent cancer research specialist, about colorectal cancer Japan and whether it can be prevented. Mr Katsuhiro Ishii Each year we partner with Houston Methodist Global Health Services Ace Media Service Inc 12-6, 4-chome, Adachi-ku, Tokyo 121-0824, Japan to host a roundtable discussion on a pertinent issue in regional healthcare. Tel: +81-3-5691-3335 n Fax:+81-3-5691-3336 The 2013 roundtable talks looked at improving health workforce educa- Email: [email protected] tion. A summary of the talks appears in this issue. China Miss Li Ying Medic Time Development Ltd, Good Heath Flat 1907, Tower A, Haisong Building, Tairan 9th Road, Futian District, Shenzhen, China 518048 Tel: +86-755-239 812 21 n Fax: +86-755-239 812 33 Callan Emery Email: [email protected] Editor Taiwan Larry Wang [email protected] Olympia Global Co Ltd 7F, No.35, Sec 3, Shenyang Rd, Taichung Taiwan 40651 n P O Box: 46-283 Taichung Taiwan 40799 Tel: +886- (4)-22429845 n Fax:+886- (4)-23587689 Email: [email protected]

Middle East Health is published by Hurst Publishing FZE, Creative City Fujairah, Licence Number: 3910/2013 FBCC.

Middle East Health website www.MiddleEastHealthMag.com

MIDDLE EAST HEALTHI7 January-February 2013 contents

134

NEWS 12 Middle East Monitor 20 Worldwide Monitor 28 The Laboratory 36 The Gene Pool

NEWS FEATURES 38 WHO EMR 60th annual conference 41 Polio in Syria 42 Universal Health Coverage 44 2.3 billion beneﬁt from anti-tobacco programmes 46 MERS-CoV found in camels 41 48 AIDS in the Middle East: Only 1 in 5 with HIV get treatment 50 Global health workforce shortage to reach 12.9 million by 2035 52 Global malaria mortality rates down 45%

FEATURES 54 Cardiology: Siemens introduces new devices for diagnosis & treatment of cardiovascular diseases 60 Cardiology: Philips tests live 3D holographic visualization 66 Computed Tomography: GE’s new CT scanner captures motion-free image of heart in one beat 70 Computed Tomography: CT imaging proves as accurate as invasive tests to assess heart blockages 72 Oncology: Is colon cancer preventable? An interview with Prof Heinz-Josef Lenz 76 Oncology: New ﬂuorescent camera ‘paints’ tumours for more accurate surgical excision 54

8 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI9 January-February 2013 contents

FEATURES 92 Pharmaceuticals: Sanoﬁ celebrates 90 years of insulin 66 production 94 Pharmaceuticals: Upping the ante in the battle against counterfeit criminals 98 Healthcare Economics: Reducing adverse events in hospitals 104 Roundtable Talks: Improving healthcare workforce training in the Middle East

INTERVIEWS 80 Dr Androulla Eleftheriou, executive director of the Thalassaemia International Federation, and Prof Ali Taher, Professor of Hematology & Oncology, American University of Beirut – on non-transfusion dependent thalassaemia

CONFERENCES & EXPOS 134 Arab Health, UAE 136 The Brain Forum, KSA 138 MEDICA, Germany 80 144 RSNA, USA

CONFERENCES & EXPOS 150 Durbin

THE BACK OF THE MAG 162 On the Pulse 182 The Back Page 183 Agenda 104 92

Cover image Philips Healthcare recently announced that they have completed a clinical study that has demonstrated the feasibility of using an innovative live 3D holographic visualization and interaction technology to guide minimally-invasive structural heart disease procedures. See full story on page 60.

10 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI11 middle east monitor Update from around the region

grams and also serve as cameras in the classrooms whereby the a model lab for other teachers can be connected with Yale while centres. As cognitive, they are interacting with the children.” physical, behavioural The Centre of Excellence was formally and learning develop- launched on 6 October at a Muntada fo- ment are largely defined rum that included talks by Dr Salvatore as 0-3 years of age, early LaSpada; Fatima Al Bastaki, Senior Ad- childhood develop- visor, Shamsa bint Mohamed Al Nahyan ment is a crucial period Fellowship in Early Childhood Develop- in the human development, Abu Dhabi; and Dr Walter Gilliam, ment cycle and is the Associate Professor of Child Psychiatry determining factor for and Psychology and Director of The Ed- social and emotional ward Zigler Center in Child Development stability throughout an and Social Policy at the Yale University individual’s life. Child Study Center. Artist impression of a classroom at the Salama bint Hamdan Al Nahyan Further, the Foun- Center of Excellence in Early Childhood Development dation’s ECD program Dubai makes expat health Reem Island, Abu Dhabi to get new aims to develop and nurture a team of insurance mandatory childhood centre of excellence well-trained professionals. As a result, it Dubai’s ruler has approved a law requir- The Salama bint Hamdan Al Nahyan has established the Shamsa bint Moham- ing all employers in the emirate to pur- Foundation has announced the establish- med Al Nahyan Fellowship in Early Child- chase health insurance for their expatriate ment of The Salama bint Hamdan Al hood Development, in collaboration with staff, a move expected to boost healthcare Nahyan Center of Excellence in Early Yale University. Currently enrolled in the spending by its 2.2 million residents con- Childhood Development at Reem Island fellowship is a pool of eight women, of siderably, Arab News reported. in Abu Dhabi aimed at facilitating further whom seven are Emirati, who are either The law will be rolled out within three research and learning on Early Childhood educators or paediatricians. years and will make employers responsible Development (ECD). While revealing the vision on the fel- for providing at least an “essential benefits A crucial component of the foundation’s lowship program at the Muntada, Dr package” for every worker. It will be rolled Early Childhood Development (ECD) pro- Salvatore LaSpada, Executive Director, out in several phases by 2016, the Dubai gramme for the UAE, the model early child- Salama bint Hamdan Al Nahyan Founda- Health Authority said in a statement. hood education centre will have a capacity tion commented, “For the benefit of our The government will remain responsible for around 80 children of up to three years children and the society as a whole, our for the coverage of local citizens, who are of age, as well as a kindergarten centre for fellows will be supported in the develop- estimated to make up less than a fifth of children from 4 to 5 years of age. There will ment of their projects and work with ex- the population. Insurance companies will be an auditorium that can accommodate up perts in ECD. The centre will be a base for need to secure a special permit from the to 150 guests, a Parents Resource Center, the fellows to learn, share, and disseminate Health Authority in order to issue policies. and a retail store selling organic foods, de- their knowledge to other professionals and According to official estimates, only 40- velopmentally appropriate toys and materi- educators, as well as parents. Our aspira- 50% of Dubai’s residents are covered by als for young children and families. tion is to invest in the capacity of ECD government and private health insurance The Centre of Excellence will be a new leaders within the country who can take schemes currently. research-based facility that serves as a hub ECD forward.” Although it is unclear how much the for early diagnosis and detection of learn- Dr Walter Gilliam, Associate Professor required insurance policy will cost, Dubai- ing challenges. It will likewise be open to of Child Psychiatry and Psychology and based Arqaam Capital estimates patient university students who focus on ECD or Director of The Edward Zigler Center in claims in Dubai will more than triple by related fields to conduct observations to Child Development and Social Policy at 2016 to AED4.8 billion (US$1.3 billion) aid their research. Moreover, the centre the Yale University Child Study Center, from AED1.3 billion a year ago. will host seminars, workshops and discus- commented: “In collaboration with the “We see a medium-term positive for NMC sions to equip parents, educators and pro- Foundation, we have incorporated a Long Health, Al-Noor Hospitals, and to a lesser fessionals to develop necessary skills and Distance Centre within the centre of ex- degree insurance underwriters in Dubai,” knowledge in ECD practices and policies. cellence whereby the fellows and staff will Arqaam Capital said, adding, however, that The Early Childhood Centre of Excel- be able to connect with Yale University. it was not changing its ratings for the com- lence will create awareness among the UAE For training purposes, there will also be panies’ shares, which are “buy” for NMC citizens about quality ECD learning pro- 12 IMIDDLE EAST HEALTH Health and “hold” for Al-Noor Hospitals. “We currently have around 17,000 Saudi to provide better healthcare services to its Dubai’s neighbour Abu Dhabi introduced students studying at various colleges and people as per the ninth development plan. mandatory health insurance in 2007, with universities in Canada,” he added. “We have adopted an integrated and patient claims quadrupling as a result. comprehensive system for healthcare and Arqaam Capital said the move could KSA buys more state-of-the-art will increase the development potential also spur growth in hospital bed capacity: ambulances of research and education in the King- the UAE has 1.9 beds per 1 000 residents Health facilities across the Kingdom of Sau- dom,” the minister said, adding that the while the global average is 3.0 beds and for di Arabia are expected to receive 400 state- new training institute to be set up at the developed countries it is 5.5. of-the-art ambulances within 11 months, King Fahd Medical City, would be a ma- the Ministry of Health announced recently. jor breakthrough for building new skills Saudi and Canada to work A senior official from the ministry said among the ministry’s medical staff. closer in healthcare that the purchase order for these ambu- The Kingdom of Saudi Arabia and Canada lances has been approved by the Health Doha to host world paediatric congress plan to increase co-operation in the health Minister Dr Abdullah Al-Rabeeah at a cost Sidra Medical and Research Center and sector over the next six months, according of SR130 million (about US$34 million). the Pan Arab Association of Pediatric Sur- to the Saudi deputy health minister, Mo- Mohammed Al-Sibeiri, head of the pro- geons (PAAPS) have been chosen to co- hammed Hamzah Kosheim. curement department at the ministry, said host the 6th World Congress of the World Kosheim said details of the plan were the ministry has updated its ambulance Federation of Associations of Paediatric outlined during a meeting with Simon fleet by 1,700 vehicles over the past five Surgeons (WOFAPS) in 2019, to take Kennedy, the Canadian deputy minister of years, and that these ambulances are avail- place at the National Convention Center international trade, and his accompanying able 24 hours a day on toll-free number in Doha, Qatar. delegation at his office in Riyadh. Thomas 937 from any part of the Kingdom. The It is the first time in its 40-year history MacDonald, the Canadian ambassador, ministry has been providing 300 vehicles that WOFAPS will be hosted in the Mid- was also present during the discussions. each year for the past three years. dle East North Africa (MENA) region. “Canada is a highly developed country He added that the ambulances would be Doha was chosen over Kuala Lumpur, Is- in the health sector. We are happy to ex- distributed among the 20 health regions tanbul and Sydney. change expertise for the benefit of the two spread throughout the country for emer- “The selection of Doha as the host city nations,” Kosheim said. gency services. for WOFAPS 2019 continues the orga- Kennedy said his visit was a follow-up Meanwhile, the Ministry of Health nization’s focus on improving the surgical to the agreement signed between the two signed a Memorandum of Understand- care of children in emerging and develop- countries recently: “We discussed the de- ing (MoU) with GE Healthcare recently ing countries. The region, and Qatar spe- tails of some of the future projects that are to train medical professionals within the cifically, have invested heavily in building to be undertaken by the two parties.” ministry. The accord will address current world-class medical institutions and devel- The agreement was signed recently by healthcare challenges in the area of train- oping innovative infrastructure, making Peter van Loan, the Canadian minister ing and clinical expertise and focus on a visit to Doha an exceptional experience for international trade, and Abdullah Al- transforming healthcare delivery via col- from colleagues from across the world,” said Rabeeah, the Saudi health minister. laborations, partnerships and regional sup- WOFAPS President Dr Richard Azizkhan. Loan said co-operation between the two port from public and private sectors. Co-chairs of the regional organizing com- countries goes back three decades. “The According to the agreement, some 600 mittee, Sidra’s Clinical Chief of Surgery Dr agreement will create new opportunities to technologists from the Ministry of Health David Sigalet and Hamad Medical Corpora- enhance and increase co-operation in the would be trained in the fields of Magnetic tion’s Head of Paediatric Surgery Dr Mansour health and medical fields and enable the Resonance (MR), Computed Tomography Ali, were in Berlin at this year’s WOFAPS kingdom to benefit from Canada, which is (CT) and X-ray. The ministry’s profession- conference when the bid was announced. recognized as having one of the best health als will also undergo clinical training and Dr Sigalet, who also serves as president care systems in the world,” he said. engage in leadership and decision-making elect of WOFAPS and will take over as According to Al-Rabeeah, the agree- programs. Attendees will exchange top- president in 2017, said: “Qatar sits at the ment would allow the two countries to notch practices in modern medicine and intersection of a growing, youthful popula- share medical expertise and exchange phy- hold learning sessions on change acceleration dedicated to learning and improving sicians and healthcare professionals. tion, in addition to shedding light on six lives, which makes Doha, Sidra and our re- Kennedy said that some 4,000 Saudi sigma methodologies and processes. gional partners ideal hosts for a WOFAPS doctors have graduated from various uni- Al-Rabeeah said that the government conference. Over 1,000 paediatric surgeons versities and medical colleges in Canada. is keen on developing its human resources from all over the world will contribute to

MIDDLE EAST HEALTHI13 learning opportunities for the attendees by tor of the Center for Prospective Clinical Mafraq Hospital launches taking part in training sessions and panel Trials at the Children’s Mercy Kansas City breast-feeding program discussions, expanding the regional knowl- Hospital Dr Shawn St. Peters. In celebration of the UAE’s National edge bank through access to international Breastfeeding Week held from 10-14 No- expertise, as well as the latest techniques DHA launches Smart Community vember, Mafraq Hospital has committed to and technologies.” All screening results of health campaigns enhanced levels of support for breastfeeding The MENA region has a young and ex- organized by the Dubai Health Authority mothers and to implementing the WHO/ panding population and consequently a (DHA) will be entered electronically us- UNICEF Baby-Friendly Hospital Initiative’s growing need for paediatric surgical care and ing the new ‘Smart Community Health ‘10 Steps to Successful Breastfeeding’. expertise. Sidra and its partners are commit- Service,’ said a top DHA official recently. One of the largest tertiary referral treat- ted to support education for these physicians Dr Ahmad bin Kalban, CEO of Prima- ment hospitals in the United Arab Emir- and will sponsor 100 surgeons from low- and ry Healthcare at the DHA, said the new ates, Mafraq Hospital, which opened in middle-income countries to attend WO- system would provide a boost to commu- 1982, has 451 licensed beds, and is owned FAPS 2019, who would not otherwise have nity health campaigns and help to ana- and operated by the Abu Dhabi Health had the opportunity to attend to take part. lyze vital data. Services Company PJSC (SEHA). Sidra Medical and Research Center, cur- “The community health section at the The hospital is fully committed to Emi- rently under construction in Doha, Qatar, DHA carries out more than 200 health ratization and has developed a comprehen- will be a fully digital facility with advanced campaigns annually, targeting different sive plan to attract more Emirati talent. It information technology applications, pro- sections of society. We provide free screen- has been recognized twice by the Sheikh viding world-class care for women and ing services for blood pressure sugar, cho- Khalifa Excellence Awards for outstand- children regionally and globally. Sidra will lesterol, etc. during these campaigns.” ing efforts in improving medical standards, initially have 400 beds with infrastructure “Previously all this data was entered providing exceptional patient care and its to enable expansion to 550 beds. Sidra rep- manually and analysis was a labour-inten- adherence to business best practice. resents the vision of Her Highness Sheikha sive and time-consuming process. With Based on the premise that breastfeed- Moza bint Nasser who serves as its Chair- this system, all the data will be entered and ing and mother-baby bonding contribute to person, and will be funded by a US$7.9 bil- analyzed electronically, which improves healthy growth and development of babies, lion endowment from Qatar Foundation, efficiencies, minimizes errors and is in line the Baby-Friendly Initiative launched by the one of the largest of its kind in the world. with our smart e-health initiatives.” World Health Organization (WHO) and the Sidra staff and the medical and research Dr Hanan Obaid, Head of Community United Nations Children’s Fund (UNICEF) center will also play a major role in making Health Services, Primary Healthcare Sec- in 1991 recommends breastfeeding exclusive- WOFAPS 2019 a key educational event for tor at the DHA, said the system would help ly for the first six months of a baby’s life to op- the region by holding instructional courses revolutionise the manner in which surveys timize these benefits. Thereafter, mothers can in conjunction with the congress through are conducted at the DHA. “With the im- continue to breastfeed for two years or more, the use of its simulation center and access plementation of this system, we tailor-make as is mutually desired by mother and baby, and to the latest surgical technology. our screening questionnaires electronically to complement this with solid foods such as The theme of the 2019 conference will depending on the target audience. Respon- mashed fruits and vegetables. be “Arabian Pearls of Paediatric Surgery,” dents need to register themselves using an Babies who are not breastfed are at in- and a number of high-profile speakers from Emirates ID, drivers’ licence or any other of- creased risk of infant morbidity and mor- North America and Western Europe have ficial form of identification.” tality, adult obesity, diabetes, cardiovascu- already agreed to take part in the event, “Once they electronically register them- lar disease and osteoporosis, and breastfed including Chief of Pediatric Surgery at the selves, their details are captured onto our babies and their mothers have less risk of Rocky Mountain Hospital for Children Dr system and doctors electronically fill out pre-menopausal breast cancer and ovar- Steven Rothenberg; European Paediatric all the information including blood sugar ian cancer. For mothers, breastfeeding also Surgeons’ Association President Dr Jean- levels etc. on their smartphones. The re- helps lower the risk of breast and ovarian Michel Guys; Senior Associate in Surgery, sults can then be seen electronically by the cancer, uses up to 500 calories a day, is Surgical Director at Center for Advanced family physician and respondents are pro- cost-efficient and can help build a stronger Intestinal Rehabilitation at the Boston vided with free counselling. Respondents bond between mother and baby. Children’s Hospital Dr Tom Jaksic; As- can later log on to the DHA website and Themed “Breastfeeding Support: Close to sistant Professor in Surgery at the North- view their results as well as health educa- Mothers”, the UAE’s National Breastfeeding western University Feinberg School of tion materials online at any point in time.” Week campaign focused on the support need- Medicine Dr Katherine Barsness; Director “The paperless process speeds things up ed to enable new mothers to initiate, establish of the Colorectal Center at the Cincinnati for both patients and healthcare profes- and maintain proper breastfeeding practices. Children’s Hospital Dr Marc Levitt; Direc- sionals,” explained Obaid. Dr Laila Obaid, Pediatrics Neonatol-

14 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI15 ogy Consultant at Mafraq Hospital said, complications from other “Breastfeeding success begins in the hospi- eye diseases and for those tal. At Mafraq Hospital, we are committed who have a complication to adopting maternity practices that are sup- following previous surgery. portive of breastfeeding. We are also strong Moorfields is a referral cen- advocates of the social support required to tre for the management of increase a mother’s confidence in her abil- complications following ity to breastfeed beyond the early weeks and previous refractive sur- months. Therefore, we believe that the key gery. The new technology, to the best breastfeeding practices is con- which is very compact and tinued day-to-day support for the nursing patient friendly, is already mother within her home and community.” Moorfields Eye Hospital Dubai invests operational and the patient results have been As part of the week-long awareness cam- in advanced eye laser technology very good.” paign, invited members of the La Leche Moorfields Eye Hospital Dubai, the first Clinical studies have documented League (LLL), a UAE-based non-profit or- overseas branch of the world renowned the treatment quality achieved with the ganization, provided breastfeeding counsel- Moorfields Eye Hospital in London, has Schwind Amaris technology, with visual ling and encouraged new mothers through invested in the most advanced technology acuity of 10/10 (100 percent) or better a series of interactive activities. A special used for laser refractive surgery for vision achieved in nearly all cases. This means booth was set up at Mafraq Hospital to hand correction, providing improved perfor- that a high percentage of treated patients out informative brochures to visitors and mance for patients in terms of speed, preci- could see even better than before treat- give away prizes to nursing mothers who sion, safety and comfort, and often allow- ment with their glasses or contact lenses. have been breastfeeding their babies for two ing faster visual recovery. Patients can also The study also shows that patients had im- years or more. The team also counselled benefit from a special offer on vision cor- proved contrast vision. mothers at the Bawabat Al Sharq mall. rection surgery until the end of the year. The Schwind Amaris 750S has two Mafraq Hospital’s trained lactation consul- The Schwind Amaris 750S uses an ex- energy levels, a high energy level rapidly tants offer support to breastfeeding mothers ceptionally small diameter laser beam with removes around 80 percent of the tissue from the moment of birth until after moms a customised ablation map, which matches to be removed and then a gentler beam and babies have left the hospital to go home. the shape of the patient’s cornea. The result- removes the remaining 20 percent, creat- The Baby-Friendly designation is award- ing vision for the patient can be an improve- ing the smooth surface required for im- ed after a rigorous on-site survey is com- ment on pre-treatment eyesight with glasses proved vision. Since the patient’s eyes can pleted, and maintained by continuing to or contact lenses. Moorfields, in Dubai, is involuntarily move for milliseconds while practice 10 crucial program elements. The among the first private hospitals in the Mid- fixating on the laser light, the Schwind comprehensive program includes initiat- dle East to invest in the new technology. Amaris 750S compensates for this with its ing breastfeeding in the first hour of life, The Schwind Amaris 750S is the lead- advanced 6 dimensions eye tracker that “rooming-in” with mums and babies in the ing technology for laser treatment and monitors the position of the eye with ap- same room, educating staff and patients, operates with a very fast repetition rate: proximately 1050 measurements per sec- and fostering breastfeeding support groups. 750 tiny light flashes per second shape the ond and detects all these eye movements “We have a powerful and experienced corneal surface quickly resulting in patient and compensates for them, instantly. team at the hospital coming together to re- comfort and better vision correction, cor- write policies and procedures, undergo con- recting one dioptre (a measure of the opti- Dubai doctor develops new method siderable training, extend skills to all levels cal power of a lens) of myopia within 1.5 to reconstruct abdominal wall of staff, and establish auditing to ensure that seconds, and eight dioptres are removed Dr Marwan Al Zarouni, head of plastic quality is maintained,” added Obaid. within 13 seconds. surgery and wound care at Rashid Hos- Meanwhile, SEHA announced that in Dr Edmondo Borasio, Consultant Corneal pital, Dubai, announced recently that order to service the growing regional com- and Refractive Surgeon at Moorfields Eye his novel two-step technique (TST) to munity, it is investing US$750 million Hospital Dubai, said: “Patients should only reconstruct the abdominal wall had been to build a new Mafraq Hospital campus have this eye correction treatment done once published by the International Wound which is due to open in 2015. The new fa- and so they want to have the safest and most Journal on March 15, 2013. cility will serve as the community hospital effective treatment. The Amaris 750S really is He said the procedure is used to manage for one of the fastest growing areas in the the state of the art in laser vision correction – complex abdominal wall defects that occur Emirate of Abu Dhabi, whilst continuing very fast and accurate, whilst providing infor- due to trauma, multiple re-operations, her- to align its goals with those of the Execu- mation of the cornea on screen in real time. nia, abdominal compartment syndrome, tive Council and Abu Dhabi Vision 2030. It is especially valuable for patients who have obesity and other problems.

16 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI17 He said he had successfully operated on During the trip, the Fellows 50 patients using the technique and its will meet with the Yale faculty novelty lay in ensuring a quick, hassle- who are specialists in issues re- free and lasting recovery, unlike an earlier lated to young children and their three-stage process where patients come assigned mentors. The Fellow- back for repair. ship also allows for visits to com- The TST uses the same vacuum-assisted munity-based early childhood or non-invasive wound closure system to education centres and health promote healing as the earlier procedure, facilities. but there’s a difference when covering the “We are excited to host the exposed intestine. first group of the Shamsa bint “Unlike the earlier procedure which Mohamed Al Nahyan Fellows used a skin graft to temporarily cover the in ECD. The commitment and bowel, I flipped over the skin surrounding engagement of the Fellows in the bowel to create the missing abdomi- search and policy formation. the program so far has been exceptional, nal wall. I stitched the flipped skin from Seven Emirati professionals and one and we are confident that their participa- either side to ensure the bowel remains UAE resident and professional were cho- tion at the national conference on ECD firmly inside,” explained Al Zarouni. sen by the Foundation and Yale University at San Antonio along with their visit to “With the skin grafts used earlier, the to learn more about ECD. The Fellowship Yale University will enrich their knowl- intestine would bulge out and there is a one-year program for young profession- edge and allow for further discussions on would be pressure on the patient when als with the central aim of building the ca- the importance of ECD on a global level”, he walked or moved, often requiring pro- pacity of the UAE workforce by training said Dr Walter Gilliam, Director of The tection with a binder. The patient would a select group of promising early and mid- Edward Zigler Center in Child Develop- also have to come back in six months or career leaders to practise ECD in order to ment and Social Policy at the Yale Uni- so for another repair procedure. Now that improve early childhood services and sup- versity Child Study Center. will no longer be required.” port in the UAE. The Foundation’s role is to increase Al Zarouni said the first trigger for the “The strategic partnership between awareness and raise the ECD discussion technique occurred when a complicated the Foundation and Yale University will levels in Abu Dhabi, UAE and the region trauma case involving a labourer was re- increase the skill-set of our Fellows, and in general. The family foundation, founded ferred to him in 2008. “I realised that this therefore contribute to the larger ECD by Sheikha Salama Bint Hamdan Al Na- man would not come back to me for fol- community in the country,” said Sheikha hyan in 2010, will work closely with UAE low-up in six months’ time as his company Shamsa bint Mohammed Al Nahyan, experts such as Karima Al Mazrouie, Cur- would probably send him back to his home leader and founder of the fellowship pro- riculum Division Manager P-12 at ADEC; country.” gram. “While Yale University will provide Dr. Hossam Al Tatari, Division Chief Necessity being the mother of invention, international expertise to our Fellows, the PEDS-Infectious Disease at Tawam Hos- he invented the TST which puts patients Foundation will support them in imple- pital; and Fatima Al Bastaki, Director of back on their feet in five weeks. While the menting the ideas they develop during the Early Childhood Learning Center at Zayed first two steps are performed over a period Fellowship and over the long term support University as Senior Advisers of the Sham- of three weeks, an additional two weeks are the leadership roles they will play in this sa bint Mohammed Al Nahyan Fellowship required for follow-up as an outpatient. important field.” in Early Childhood Development. Having spent a week in October work- Since the inception of the program in Yale to mentor UAE fellows on early ing with Yale in Abu Dhabi, the first October, the Fellows have been encour- childhood development group of the UAE-based Fellows will aged to work on projects that have posi- The Shamsa bint Mohamed Al Nahyan set off for the Zero to Three National tive and meaningful effects on the com- fellowship, a crucial component of the Conference (www.zerotothree.org), the munity. The end of the fellowship year is Salama bint Hamdan Al Nahyan Founda- world’s largest professional conference May 2014. tion’s holistic Early Childhood Develop- devoted solely to child development in The next group of Fellows is expected ment (ECD) program, has selected eight the first three years, on 10 December to recommence in October 2014 with the of its fellows to train at Yale University’s 2013. This will be followed by a trip to same vigorous selection process entailing Edward Zigler Center, which trains future Yale University in New Haven, Con- nominations, applications, and interviews generations of professionals whose work necticut. They were expected to return conducted by the Foundation and Yale influences both child development re- by 20 December. University.

18 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI19 worldwide monitor Update from around the globe

Othmar Engelhardt, principal investigator These are: at the National Institute for Biological l Exclusive breastfeeding for six months Standards and Control, United Kingdom. and continued breastfeeding complemented The research team expects to achieve by nutritious solid foods up to age 2; better protection against epidemic l Vaccination against whooping cough influenza through the devel- (pertussis), measles, Haemophilus influen- opment of a vaccine that zae type b (Hib) and pneumococcus; would not only offer the l Safe drinking water, sanitation and advantage of eliminating handwashing facilities; Improved cooking the need for a seasonal stoves to reduce indoor air pollution; vaccine every year, but l Treatment, including amoxicillin dis- could also reduce the persible tablets and oxygen; need for costly annual vac- Recognizing that child mortality cannot cination campaigns. be addressed in a vacuum, but only through Odile Leroy, Executive Di- integrated efforts, in April 2013, WHO and rector of the European Vaccine UNICEF released an Integrated Global Ac- Initiative and co-ordinator of tion Plan for the Prevention and Control of EU launches universal flu EDUFLUVAC, says: “Low and middle- Pneumonia and Diarrhoea (GAPPD). vaccine research project income countries currently have mini- The GAPPD presents an innovative A newly launched European project is set mal influenza vaccination programmes. framework bringing together prevention, to take a major step towards the develop- Thus, the development of a vaccine that protection and control of both pneumo- ment of a universal flu vaccine. It aims to elicits broad long-lasting defence would nia and diarrhoea – two of the world’s counter the emergence of new strains and facilitate vaccination campaigns and leading killers of children under 5 – to seasonal epidemics. confer protection against influenza in make more efficient and effective use of The viral infection usually strikes in hitherto untargeted groups with limited scarce health resources. colder months with seasonal influenza health care.” To mark 5th World Pneumonia Day, being responsible for around 3 - 5 mil- The four-year project is co-ordinated Mauritania and Papua New Guinea intro- lion cases of severe illness and 250,000 to by the European Vaccine Initiative head- duced the pneumococcal vaccine, which 500,000 deaths worldwide. quartered in Germany and was awarded a protects against one of the leading causes Due to its rapid spread, particularly grant of EUR 4.6 million in EU funding. of pneumonia. With support from the among high-risk population groups, in- GAVI Alliance, more than 50 countries fluenza remains a serious public health Pneumonia – the single biggest will introduce this vaccine by 2015. problem. To date, the most effective way cause of child mortality “The GAVI Alliance is helping to ac- to prevent the disease or severe symptoms Pneumonia remains the single biggest kill- celerate the fight against pneumonia by is annual vaccination, but current vac- er of children under five globally, claiming increasing access to pneumococcal vaccines only offer limited protection against the lives of more than one million chil- cines, thanks to GAVI’s innovative Ad- evolving strains of the infection. dren every year. vance Market Commitment (AMC), but To overcome these weaknesses, a public- To celebrate World Pneumonia Day on also to the five-in-one pentavalent vaccine private partnership comprising seven re- 12 November, the GAVI Alliance, UNI- which protects against Haemophilus influ- nowned organisations from Europe joined CEF and the World Health Organization enzae type b, another major cause of pneu- forces under the EDUFLUVAC project (WHO) launched an “Innovate to End monia,” says Dr Seth Berkley, CEO of the to develop a broad-spectrum, long-lasting Child Pneumonia” campaign to highlight GAVI Alliance. vaccine. EDUFLUVAC aims to take a essential actions to help end child deaths Since the launch of the GAPPD seven novel approach by ‘educating’ the immune from this entirely preventable disease. months ago, several countries have taken system to cross-recognise common regions “Tackling pneumonia doesn’t necessar- this forward. For example, Bangladesh and within multiple influenza virus strains. ily need complicated solutions,” said Dr Zambia are translating the GAPPD into “Developing a universal flu vaccine has Mickey Chopra, Chief of Health, UNI- local implementation plans in some dis- become a global health priority for pre- CEF, proposing five simple but effective tricts. Program managers responsible for venting the spread of the virus and the interventions, which will help reduce the immunisation, child health, nutrition and emergence of new strains, and we are con- burden of the disease that is responsible for water and sanitation have joined forces to vinced that EDUFLUVAC will be a ma- almost one-fifth of all child deaths around accelerate progress and eliminate prevent- jor step towards achieving this goal,” says the world, if implemented properly. able deaths from pneumonia and diarrhoea.

20 IMIDDLE EAST HEALTH In addition, in October 2013, the WHO- sue for further data analysis. about having a mammogram. updated guidelines on the treatment of “Digitization of pathology will enable us “It is of great concern that women in pneumonia, recommending simpler antibi- to keep momentum going to accelerate can- newly industrialized countries are reluc- otic regimens, and published a handbook on cer research and, in the end, improve patient tant to get checked out until it is too late. how to introduce the pneumococcal vac- care,” says Xavier Sastre-Garau, director of the This is why GE is working with a number cine for staff, in line with the GAPPD. Biopathology Department of Institut Curie. of governments and health ministries in “To achieve the vision and goals of the “Philips’ digital pathology solution is em- these regions to expand access to screening integrated plan – to end preventable deaths powering Institut Curie to realize a single vir- and improve consumer awareness. Some from pneumonia and diarrhoea in the next tual laboratory that offers new opportunities of these initiatives are making excellent generation – the children of the world need for intensive collaboration,” says Guido du progress,” said Claire Goodliffe, Global to see political will, co-ordinated efforts, and Pree, vice-president of Marketing & Sales for Oncology Director for GE Healthcare. increased resources at the global and nation- Philips Digital Pathology Solutions. The study draws some interesting con- al levels to fight these stubborn killers,” says To support its cancer research, Insitut clusions about the impact of breast cancer Dr Elizabeth Mason, Director of WHO’s De- Curie has completed installation of the fully on sufferers’ lives. According to the most partment of Maternal, Newborn, Child and integrated Philips Digital Pathology Solu- recent published data, 15 million years of Adolescent Health. tion with ultra-fast scanners at its locations ‘healthy life’ were lost worldwide in 2008 in Paris and St. Cloud, which are connected due to women dying early or being ill with Cancer tumour analysis to be digitized on-line through an image management sys- the disease. ‘Healthy life lost’ is defined Philips has announced that it is collaborat- tem that provides an interface to commu- by years lost due to premature death and ing with Institut Curie, in order to digitize nicate with commercially available Labora- incapacitation due to the effects of breast tumour analysis research, with the aim of tory Information Systems (LIS). cancer. Women in Africa, China and the speeding up and improving cancer diagno- USA lost the most years of healthy life. sis and treatment. Developing world faces Furthermore, of the 15 million years lost While pathologists today view tissue breast cancer surge globally, more than three times as many sample images manually using a micro- Rising breast cancer incidence and mor- years were lost due to dying than being scope, by using Philips Digital Pathology tality represent a significant and growing ill with the disease. For women in Africa, Solution, Institut Curie hopes to increase threat for the developing world, accord- Russia, Mexico, Turkey and Saudi Arabia, workflow efficiency and consolidate its pa- ing to a new global study commissioned the number of healthy years lost due to thology activities at multiple sites into one by GE Healthcare. death were up to seven times greater than single virtual laboratory. Report co-author Bengt Jönsson, Profes- elsewhere in the world. In addition to the diagnosis of tissue sor in Health Economics at the Stockholm Jönsson said: “The report findings suggest from patients with cancer indications, the School of Economics, explained: “Breast that a worryingly high proportion of women pathology department at Institut Curie cancer is on the rise across developing na- are still dying from breast cancer across the evaluates thousands of test samples from tions, mainly due to the increase in life world and this seems to correlate strongly experimental cancer research programmes expectancy and lifestyle changes such as with access to breast screening programmes worldwide to gain a better understanding women having fewer children, as well as and expenditure on healthcare.” of the causes and mechanisms of diseases hormonal intervention such as post-meno- He highlighted the distinct lack of ac- at both cellular and molecular level. These pausal hormonal therapy. In these regions, curate and current data in areas like breast new insights may give rise to new diagnos- mortality rates are compounded by the later cancer incidence and mortality, the eco- tic approaches and therapeutic treatments. stage at which the disease is diagnosed, as nomic burden of the disease, and detailed Currently, Institut Curie produces and well as limited access to treatment, present- patient-linked data on outcomes in relation diagnoses more than 200,000 glass pathol- ing a ‘ticking time bomb’ which health sys- to treatment patterns and stage of diagno- ogy slides every year using a microscope. tems and policymakers in these countries sis. “This limits analyses of how changes Digitization of the pathology workflow need to work hard to defuse.” in clinical practice affect patient outcomes could ease this logistical burden and enable The report on “the prevention, early and needs to be addressed,” he said. new ways of working, such as real-time col- detection and economic burden of breast As breast cancer incidence rates have laboration with peers and creation of a vir- cancer” suggests that consumer under- steadily increased in developed countries tual network across the globe. Moreover, standing about breast cancer and screen- over the last 50 years, it is no surprise that in cancer research, digital histopathology ing methods is putting lives at risk in the the main focus of treatment has been sur- information can now, for example, be add- developing world. For example, a recent vival. However, as more women are now lived to biology data and this opens up new survey in Mexico City indicated many ing with the disease, the report suggests that ways to mine information from tumour tis- women feel uncomfortable or worried quality of life is becoming a growing issue as

MIDDLE EAST HEALTHI21 survival rates improve. As a result, doctors tries and regions with high levels of immi- are urged to focus on measuring the impact of gration, such as the US and Europe, the diagnosis and treatment on survivors’ quality trend is towards an increasingly mixed and of life to identify what problems patients may complex HIV flora, unlike in the begin- have and how these can be mitigated. ning of the epidemic when a small number Goodliffe said: “This report finds a direct of non-recombinant variants of the virus link between survival rates in countries and novative ideas aimed at preventing disease dominated. There is, therefore, reason to the stage at which breast cancer is diagnosed. development and progression in healthy, be wary of HIV recombinants in general. It provides further evidence of the need for at-risk and early-stage populations. These “HIV is an extremely dynamic and vari- early detection and treatment which we calls aim to harness the necessary expertise able virus. New subtypes and recombinant welcome, given current controversies about across Europe and globally to address these forms of HIV-1 have been introduced to the relative harms, benefits and cost-effec- needs in the fight against these diseases.” our part of the world, and it is highly likely tiveness of breast cancer screening.” The following neurodegenerative dis- that there are a large number of circulat- eases are included for both calls: ing recombinants of which we know little EU funds new research for strategies l Alzheimer’s disease and other dementias or nothing. We therefore need to be aware to prevent neurodegenerative diseases l Parkinson’s disease and PD‐related of how the HIV-1 epidemic changes over The EU Joint Programme - Neurode- disorders time”, said Patrik Medstrand, Professor of generative Disease Research (JPND) - is l Prion disease Clinical Virology at Lund University. launching two calls for proposals aimed at l Motor neurone diseases The research is based on a unique long- encouraging research teams across Europe l Huntington’s disease term follow-up of HIV-infected individu- to investigate the cross-disease pathways l Spinocerebellar ataxia (SCA) als in Guinea-Bissau, a project run by Lund in neurodegenerative diseases such as Al- l Spinal muscular atrophy (SMA) University. In future research, Angelica zheimer’s and Parkinson’s, and to identify Palm and her colleagues hope to be able new, innovative preventative strategies for New HIV strain leads to to continue researching the characteristics these debilitating conditions. faster AIDS development of recombinant viruses and the presence of “Neurodegenerative Diseases such as A recently discovered HIV strain leads to sig- these among HIV carriers in Europe. Alzheimer’s and Parkinson’s are a global nificantly faster development of AIDS than For health services, the new research re- health, economic and social emergency currently prevalent forms, according to new sults mean a need to be aware that certain with numbers affected expected to double by research from Lund University in Sweden. HIV-1 types can be more aggressive than 2030 and more than triple by 2050,” accord- The period from infection to the devel- others, according to the research team. ing to Professor Philippe Amouyel, Chair of opment of AIDS was the shortest reported the JPND Management Board. “With this among HIV-1 types, at around five years. Frost & Sullivan issues predictions in mind, JPND-participating countries have There are over 60 different epidemic for global healthcare market identified two further areas of greatest need strains of HIV-1 in the world, and geo- Frost & Sullivan has released its three big for targeted investment in order to improve graphic regions are often dominated by predictions for the global healthcare market understanding of the underlying links be- one or two of these. If a person becomes for 2014 and beyond: mHealth, Cloud in tween different diseases, and to encourage infected with two different strains, they Healthcare and Regulatory Environments. new ideas on preventative strategies.” can fuse and a recombined form can occur. “Insights from a ‘2013 Search for Professor Amouyel added: “This invest- “Recombinants seem to be more vigorous Growth’ survey which involved 1835 ex- ment is part of a series of JPND funding and more aggressive than the strains from ecutives in more than 40 countries world- initiatives, aimed at addressing priority which they developed”, explained Angelica wide has also been essential in unveiling areas identified in our European Research Palm, a doctoral student at Lund University. the business outlook for Pharmaceuticals, Strategy. This year’s calls will see over 23 The recombinant studied is called Biotechnology, Clinical Diagnostics and million euro made available to applicants A3/02 and is a cross between the two most Medical Devices, as well as to provide a from 18 different countries.” common strains in Guinea-Bissau, West global perspective on the industry’s geo- According to Professor Thomas Gasser, Africa - 02AG and A3. It has previously graphical hot spots,” explains Frost & Sul- University of Tübingen and Chair of the been described by Joakim Esbjörnsson, a livan Partner, Dorman Followwill. JPND Scientific Advisory Board, “Neu- post-doctoral fellow at the University of mHealth expansion has been fuelled by an rodegenerative diseases currently cannot Oxford, who is a co-author of the study. unprecedented spread of mobile technolo- be cured, prevented, or even substantially So far, the new strain has only been gies, as well as advancements in their inno- slowed. In order to tackle these diseases identified in West Africa, but other studies vative application to address health priori- together, we need greater thinking across have shown that the global spread of dif- ties. It is largely supported by mobile phones, traditional clinical boundaries and new, in- ferent recombinants is increasing. In coun- patient monitoring devices, personal digital

22 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI23 24 IMIDDLE EAST HEALTH assistants (PDAs) and other wireless devices. for 13% of the total reported cancers and The penetration prospects of mHealth affecting over 1.6 million people annually. technologies are significant in the following areas: wireless vital signs monitoring, loca- Tapping into spinal cord injury tion-aware telemonitoring systems and Blue- As many as 500,000 people suffer a spinal tooth wireless technology-enabled health cord injury each year, and are two to five trackers. It is an exciting area of opportunity times more likely to die prematurely, with for healthcare growth and will provide inno- World lung organisations call worse survival rates in low- and middle- vative solutions for healthcare providers and for better lung health policies income countries, according to the WHO. patients alike, across the board. Experts from the world’s leading lung or- A new WHO report, International Per- In addition, as more healthcare IT and pa- ganizations have come together for the spectives on Spinal Cord Injuries, summarizes tient monitoring tools are integrated, every first time to call for a worldwide effort to the best available evidence on the causes, hospital facility will eventually have to ac- improve healthcare policies and systems prevention, care and lived experience of quire a full-enterprise wireless solution. The to make a positive difference for the lung people with spinal cord injury. most innovative mobile healthcare solutions health of the world. Males are most at risk of spinal cord in- that best meet pressing healthcare needs will Produced by the Forum of International jury between the ages of 20-29 years and be adopted as the gold standard. Respiratory Societies (FIRS), the report was 70 years and older, while females are most Enterprise-wide healthcare informatics launched on 20 November, COPD (Chron- at risk between the ages of 15-19 years and will also improve the quality of medical ic Obstructive Lung Disease) Day. Entitled 60 years and older. Studies report male to services and efficiency of operations while Respiratory Diseases in the World: Realities female ratios of at least 2:1 among adults. reducing expenditure. Implementing cloud of Today – Opportunities for Tomorrow, the Up to 90% of spinal cord injury cases computing technologies appropriately will report features five major disease areas that are due to traumatic causes like road traffic help healthcare providers improve the are of immediate and greatest concern, in- crashes, falls and violence. Variations ex- quality of medical services and the efficien- cluding COPD, which is the fourth-leading ist across regions. For example, road traffic cy of operations, share information world- cause of death worldwide. crashes are the main contributor to spinal wide and manage budgets. The concept “This report aims to heighten awareness cord injury in the African Region (nearly can be applied in a variety of ways, includ- of lung disease throughout the world. We 70% of cases) and the Western Pacific Re- ing data storage and data loss prevention, hope that this collaboration will help to shed gion (55% of cases) and falls the leading maintaining patient information records light on the pervasiveness of these conditions cause in the South-East Asia and Eastern and authorized sharing of information. and diseases and will be a call to action for Mediterranean Regions (40% of cases). As for Regulatory Environment, recent health-care professionals, policy makers, pa- Non-traumatic spinal cord injury results healthcare reforms and policy initiatives in tients, and advocates,” said Michael H. Bau- from conditions such as tumours, spina many countries have emphasised the impor- mann, MD, MS, FCCP, President, American bifida, and tuberculosis. A third of non- tance of quality of care over quantity. In the College of Chest Physicians. traumatic spinal cord injury is linked to absence of sufficient proof of clinical benefit, Some of the key issues highlighted in tuberculosis in sub-Saharan Africa. reimbursements may pose a major hurdle. this publication include the following: Most people with spinal cord injury ex- Overall, three big predictions may be l COPD affects more than 200 million perience chronic pain, and an estimated formulated based on the survey’s results: people and is the fourth-leading cause of 20-30% show clinically significant signs of – As healthcare is geared towards a per- death in the world. depression. People with spinal cord injury sonalized medicine model, companion di- l Asthma affects about 235 million also risk developing secondary conditions agnostics will alter drug development and people worldwide, is one of the most fre- that can be debilitating and even life- the commercialization process of drug can- quent reasons for hospital admissions threatening, such as deep vein thrombosis, didates. Combining biomarkers and drugs among children, and leads to approximate- urinary tract infections, pressure ulcers and will make for safer, more efficient therapy. ly 180 000 deaths each year. respiratory complications. – The healthcare and life sciences indus- l Respiratory infections account for Spinal cord injury is associated with lower try will consolidate further in this decade, over 4 million deaths annually, dispropor- rates of school enrolment and economic par- with many big pharma companies seeking tionately in children, and are the leading ticipation. Children with spinal cord injury alternatives to the blockbuster model. cause of death in low-income or middle- are less likely than their peers to start school, – The rise of new technologies capable income countries. and once enrolled, less likely to advance. of integrating medical devices into a con- l TB kills around 1.4 million people with Adults with spinal cord injury face similar nected platform will improve function of about 8.7 million new cases of TB annually. barriers to socio-economic participation, devices, reduce the manpower burden and l Lung cancer is the most commonly with a global unemployment rate of more minimize errors. diagnosed cancer in the world, accounting than 60%. Spinal cord injury carries sub-

MIDDLE EAST HEALTHI25 stantial individual and societal costs. ployment and educational settings. zation (WHO), the US Agency for In- Many of the consequences associated l Vocational rehabilitation to optimize ternational Development (USAID) and with spinal cord injury do not result from the chance of employment. its implementing partner, the Maternal the condition itself, but from inadequate l Micro-finance and other forms of and Child Health Integrated Program medical care and rehabilitation services, self-employment benefits to support alter- (MCHIP). and from barriers in the physical, social and native forms of economic self-sufficiency. “Virtually all women who have just had policy environments that exclude people l Access to social support payments a baby are not ready to have another one with spinal cord injury from participation. that do not act as disincentives to return right away; but too often they don’t have Full Implementation of the Convention to work. access to family planning,” says Dr Marleen on the Rights of Persons with Disabilities is l Correct understanding of spinal cord Temmerman, director of the Department urgently required to address these barriers. injury and positive attitudes towards peo- of Reproductive Health and Research at “Spinal cord injury is a medically com- ple living with it. WHO. “Many women are not even aware plex and life-disrupting condition,” notes that they can become pregnant within 12 Dr Etienne Krug, Director of the Depart- International Perspectives on months of giving birth.” ment of Violence and Injury Prevention Spinal Cord Injuries Demographic and Health Survey and Disability, WHO. “However, spinal www.who.int/disabilities/policies/ (DHS) data from 27 developing countries cord injury is preventable, survivable, and spinal_cord_injury show that 95% of post-partum women need not preclude good health and social want to avoid a pregnancy for at least two inclusion.” New resource expands years, yet 65% do not use contraception. Essential measures for improving the sur- access to family planning In Ethiopia, a similar analysis shows 81% vival, health and participation of people A new resource for health program man- of post-partum women are not using any with spinal cord injury include: agers and policy makers released recently contraception. l Timely, appropriate pre-hospital man- aims to improve access to family planning “There are many obvious, although of- agement: quick recognition of suspected for women after childbirth and during the ten missed, opportunities to inform post- spinal cord injury, rapid evaluation and first 12 months of motherhood. partum women on their options for healthy initiation of injury management, including Closely spaced and unintended preg- birth spacing and offer them an effective immobilization of the spine. nancies are a health risk to both mother method of contraception,” said Patricia l Acute care appropriate to the level and child: spacing pregnancies at least two MacDonald, Senior Technical Advisor, and severity of injury, degree of instability years apart can avert 10% of infant deaths Office of Population and Reproductive and presence of neural compression. and about one out of five deaths in chil- Health, USAID. “Antenatal care givers, l Access to ongoing health care, health dren aged 1 to 4. birth attendants, child health providers and education and products such as catheters Launched in Addis Ababa, the ‘Interna- vaccinators should all take the time to ask to reduce risk of secondary conditions and tional Conference on Family Planning for a woman whether she is interested in fam- improve quality of life. Postpartum Family Planning Full Access, ily planning to protect herself from having l Access to skilled rehabilitation and Full Choice’ provides interventions at all another pregnancy too soon. This critical mental health services to maximize func- levels of health care to expand access to window may be the only chance to offer tioning, independence, overall well-being scientifically-sound family planning meth- post-partum women the information they and community integration. ods for new mothers. need for safe and healthy motherhood.” l Access to appropriate assistive de- The plan identifies three critical areas “This document demonstrates the global vices that can enable people to perform of work for countries to ensure successful health community’s response to the grow- everyday activities, reducing functional implementation of the strategies: ing demand for post-partum family plan- limitations and dependency. l Close tracking of post-partum contra- ning,” according to Koki Agarwal, MCHIP l Specialized knowledge and skills ceptive use to ensure a steady supply and Director and moderator of the launch among providers of medical care and reha- distribution of contraceptives; event. “Today we call on stakeholders bilitation services. l High quality, easy-to-understand in- across the spectrum – from health exten- Essential measures to secure the right to formational materials about family plan- sion workers to midwives, nurses, medical education and economic participation in- ning options to help women and families doctors and policy makers – to ensure that clude legislation, policy and programmes make informed choices; and every mother, every couple, is better able that promote: l Health worker training of recom- to safely plan their families.” l Physically accessible homes, schools, mended practices so services are consistent workplaces, hospitals and transportation. with global standards of care. Programming Strategies for l Inclusive education. Programming Strategies is being Postpartum Family Planning l Elimination of discrimination in em- launched by the World Health Organi- http://tinyurl.com/p7gjhfh

26 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI27 the laboratory Medical research news from around the world

Mayo Clinic: Add bone deterioration nology may help in studying other condi- “Playing a musical instrument is a to diabetes complications tions where fractures occur at higher than multi-sensory and motor experience that The list of complications from Type 2 dia- expected bone density, says co-author and creates emotions and motions – from betes is long: vascular and heart disease, rheumatologist Shreyasee Amin, M.D. finger tapping to dancing – and engages eye problems, nerve damage, kidney dis- She says this will be especially relevant pleasure and reward systems in the brain. ease, hearing problems and Alzheimer’s to many forms of auto-immune arthritis It has the potential to change brain func- disease. Physicians have long thought where glucocorticoids are used, such as in tion and structure when done over a long of osteoporosis as another complication. rheumatoid arthritis. period of time,” said press conference Based on a Mayo Clinic study published in The team says more research needs to be moderator Gottfried Schlaug, MD, PhD, the Journal of Bone and Mineral Research, done, as this was a small study in a limited of Harvard Medical School/Beth Israel that’s confirmed: You can definitely add population. Deaconess Medical Center, an expert skeletal problems to the list. on music, neuro-imaging and brain plas- “This is the first demonstration – us- Musical training influences ticity. “As these findings show, intense ing direct measurement of bone strength brain anatomy and function musical training generates new processes in the body – of compromised bone ma- New findings show that extensive musi- within the brain, at different stages of life, terial in patients with Type 2 diabetes,” cal training affects the structure and func- and with a range of impacts on creativity, says Sundeep Khosla, M.D., Mayo Clinic tion of different brain regions, how those cognition, and learning.” endocrinologist and senior author of the regions communicate during the creation study. “Clearly, the skeleton needs to be of music, and how the brain interprets and High-voltage electric fields recognized as another important target of integrates sensory information. The find- may aid scar tissue research diabetes complications.” ings were presented at Neuroscience 2013, High voltage, short-pulsed electric fields, Previous studies in the field showed that the annual meeting of the Society for Neu- used for disinfection and solid tumour patients with diabetes experienced frac- roscience and the world’s largest source of destruction, selectively damage cell tures at levels of bone density above that of emerging news about brain science and membranes, while preserving overall tis- the regular population, hinting that some- health. sue structure, a phenomenon that may thing was different about the “quality” of These insights suggest potential new be a key factor in scarless tissue regen- their bone. The Mayo researchers validat- roles for musical training including foster- eration. ed that assumption in a clinical study of 60 ing plasticity in the brain, an alternative Any organ or tissue after serious in- postmenopausal women, 30 of whom had tool in education, and treating a range of jury forms a scar, an enigma which has Type 2 diabetes. Using a new tool (Osteo- learning disabilities. puzzled humans for thousands of years. Probe), the researchers performed micro The new findings show that: The mechanism by which scars form is indentation testing of the tibia (actually l Long-term high level musical train- not known, and there are very limited causing a microscopic crack) to measure ing has a broader impact than previously therapies available to block scar forma- bone material strength. thought. Researchers found that musicians tion. Now, a team based at the Center Compared to the control group of wom- have an enhanced ability to integrate sensory for Engineering in Medicine at the Mas- en, aged 50 to 80, the group with Type 2 information from hearing, touch, and sight. sachusetts General Hospital report that diabetes had significantly lower bone ma- l The age at which musical training high-voltage short electric fields appear terial strength. There was no difference begins affects brain anatomy as an adult; to destroy all cells in skin tissue but lead between the microarchitecture of the bone beginning training before the age of seven to full regeneration with no scars. These or bone density between the two groups. has the greatest impact. strong but short-pulsed electric fields se- The study showed that diabetic women l Brain circuits involved in musical im- lectively kill the cells, while preserving with lower bone material strength had also provisation are shaped by systematic train- the extracellular matrix tissue structure experienced higher levels of hypoglycae- ing, leading to less reliance on working including the local blood supply, which mia over the previous 10 years, suggesting memory and more extensive connectivity are needed for healthy tissue growth and potential detrimental effects of poor glu- within the brain. functional regeneration. cose control on bone quality. Some of the brain changes that occur “It is a fascinating finding,” says Al- The resounding message: Conventional with musical training reflect the automa- exander Golberg, PhD of MGH, the measurements under-estimated the risk of tion of task (much as one would recite a paper’s first author. “We compared this fracture among patients with Type 2 dia- multiplication table) and the acquisition technique with thermal burns and found betes and loss of bone material strength, of highly specific sensorimotor and cogni- many different aspects post-injury both or bone quality, is a clear, downstream tive skills required for various aspects of in terms of the extent of damage and the consequence of the disease. The new tech- musical expertise. dynamics of recovery”.

28 IMIDDLE EAST HEALTH Currently, pulsed electric fields are primarily used for disin- ogy by scientists from Oregon State University and four other uni- fection and solid tumour ablation. Pulsed fields selectively kill versities or research institutes. cells in the tissue presumably by a mechanism called irreversible “We’ve known for some time of many medications that can in- electroporation. After exposure to the fields, large pores appear teract with statins, but only now is it becoming clear that this is in cell membranes that eventually lead to cell death. a significant contributor to the side-effects, and often the reason “Previously, scarless regeneration has only been observed some patients stop taking statins,” said Matt Ito, a professor in the in adult amphibians and early in mammalian fetuses, both of OSU College of Pharmacy and president of the National Lipid As- which do not have an adaptive immune response. Even though sociation, which funded this study. our rodents had an intact adaptive immune system, we were able “This issue is something physicians, pharmacists and patients all to generate scarless skin regeneration in these adult mammals. need to be more aware of,” Ito said. “There’s a lot we can do besides Further study of this technique will help us better understand discontinue use of these valuable medications. You can change dos- the mechanism of scarring,” says Martin L. Yarmush, MD, PhD, ages, use drugs that don’t cause interactions, use different types of director of the MGH Center for Engineering in Medicine, the statins. Patients need to be proactive in understanding this issue senior author of the paper. and working with their health care providers to address it.” “This development not only holds a great promise for unrav- Besides drug interactions, statin side-effects are also more com- elling many aspects of the complex wound healing process but mon in women and associated with increasing age, history of also to potentially lead to new therapies,” Golberg says. “We be- cardiovascular disease, and some other conditions. Statin discon- lieve that this model will enable other laboratories to learn and tinuation has also been associated with increased cardiovascular uncover new aspects of adult tissue growth and development.” morbidity and death. The paper is published in the inaugural issue of the new journal Technology. l doi: 10.1142/S233954781320001X

Drug interactions cause significant impact on statin use A new study has found that many people who stopped taking cholesterol-lowering statin drugs were also taking an average of three other drugs that interfered with the normal metabolism of the statins. The other drugs can contribute to a common side-effect of taking statins – muscle pain – and often led people to discontinue use of a medication that could otherwise help save their lives, researchers learned. The interactions of many drugs with statins have been known of for some time, researchers said, but are not being adequately managed by physicians and pharmacists, who could often choose different medications or adjust dosages to retain the value of statin drugs without causing this side-effect. The research, done as part of a survey of more than 10,000 current and former statin users, found that use of medications which interfere with statin metabolism almost doubles the chance that a person will discontinue statin use due to muscle pain. The issue is of growing importance because statin drugs are some of the most widely used medications in the world, proven to lower LDL, or “bad” cholesterol, and decrease the risk of heart attacks, heart disease, strokes and death. About 20 million people in the US now take statins, and new guidelines have just been issued to further expand the types of health conditions for which statins may be of benefit. Based on those guidelines, the number of statin users could increase to more than 30 million. The findings were published in theJournal of Clinical Lipidol-

MIDDLE EAST HEALTHI29 New research findings may aid tion correlated with dementia. They pre- observed 21 patients that tested all three early detection of Alzheimer’s dicted that people with low scores that diets in a randomized order. During each Using scores obtained from cognitive tests, were evenly distributed were not likely test day, blood samples were collected at Johns Hopkins researchers think they to develop dementia. But those with six time points. have developed a model that could help clearly lopsided test score distributions The low-fat diet had a nutrient com- determine whether memory loss in older on the 13 measures administered were position that has traditionally been rec- adults is benign or a step on the way to Al- already experiencing varying levels of ommended in the Nordic countries, with zheimer’s disease. dementia. about 55% of the total energy from carbo- The risk of developing dementia in- “Departures from the normal bell-shaped hydrates. The low-carbohydrate diet had creases markedly when a person is diag- pattern of variability on cognitive tests might a relatively low content of carbohydrate; nosed with mild cognitive impairment, a determine which people with low scores de- approximately 20% of the energy was from noticeable and measurable decline in in- velop dementia,” says David J. Schretlen, carbohydrates and about 50% of the total tellectual abilities that does not seriously Ph.D., a professor of psychiatry and behav- energy came from fat. The Mediterranean interfere with daily life. But physicians ioral sciences at the Johns Hopkins Univer- diet was composed of only a cup of black have no reliable way to predict which sity School of Medicine and leader of a study coffee for breakfast, and with all the ca- people with mild cognitive impairment published online in the November 2013 is- loric content corresponding to breakfast are likely to be in the 5 to 10% a year who sue of the journal Neuropsychology. and lunch during the other two test days progress to dementia. Since these declines can be subtle, the accumulated to one large lunch. In a proof-of-concept study, the Johns researchers also increased the precision of Furthermore, the total caloric content Hopkins investigators analyzed records cognitive testing by accounting for the ef- included energy from 150 ml (women) to of 528 people age 60 and over, who were fects of age, sex, race and education on test 200 ml (men) of French red wine to ingest referred to the Johns Hopkins Medical performance. with the lunch. The food in the Mediterra- Psychology Clinic for cognitive testing The challenge for doctors, Schretlen ex- nean diet had an energy content from car- as part of a dementia work-up between plains, is that most normal, healthy people bohydrates that was intermediate between 1996 and 2004. The results were compared will produce a few low scores on cognitive the low-fat and the low-carbohydrate to those of 135 healthy older adults who testing. That makes it nearly impossible to meals, and sources of fat were mainly ol- participated in a study of normal aging. know at the outset whether a patient who ives and fatty fish. Both groups completed tests of memory, reports forgetfulness and produces one or “We found that the low-carbohydrate language, attention, processing speed and two low scores has a benign form of mild diet increased blood glucose levels much drawing abilities from which 13 scores cognitive impairment, or is in the earliest less than the low-fat diet but that levels were recorded. stage of dementia. As a result, doctors of- of triglycerides tended to be high com- Since each person is naturally more skil- ten tell such patients to return for follow- pared to the low-fat diet,” says Dr Hans ful in some areas than in others, the scores up testing in a year or two. Guldbrand, who, together with Professor of healthy adults showed a symmetrical, But if future research confirms it, this Fredrik Nystrom, was the principal inves- bell-shaped range. Most of their scores were new statistical model could help doctors tigator of the study. high, some were a bit lower, and a few were get the prognosis right earlier in the dis- “It is very interesting that the Mediter- even lower. By grouping the patients into ease, at the first visit, and start treating pa- ranean diet, without breakfast and with a cohorts based on the severity of their de- tients accordingly. massive lunch with wine, did not induce mentia, the researchers found a trend in the higher blood glucose levels than the low- test scores that is likely to mimic the dete- New research finds Mediterranean diet fat diet lunch, despite such a large single rioration of an individual’s scores over time. without breakfast best for diabetics meal,” says Professor Nyström. At the outset, he says, Alzheimer’s dis- For patients with diabetes, it is better to “This suggests that it is favourable to ease subtly disrupts some mental abilities, eat a single large meal than several smaller have a large meal instead of several smaller while leaving others intact. Thus, well meals throughout the day. This is the re- meals when you have diabetes, and it is before a person develops clear cognitive sult of a current dietary study done at surprising how often one today refers to impairment, his or her performance de- Linköping University in Sweden. the usefulness of the so-called Mediter- clines slightly on a few measures. When In the study, the effect on blood glucose, ranean diet but forgets that it also tradi- shown on a graph, these changes cause the blood lipids and different hormones after tionally meant the absence of a breakfast. healthy symmetric, bell-shaped curve to meals were compared using three different Our results give reason to reconsider both shift and become asymmetrical. macronutrient compositions in patients nutritional composition and meal arrange- Regardless of how low a person’s test with Type 2 diabetes. The three diets were ments for patients with diabetes,” says Pro- scores were, the researchers determined a low-fat diet, a low-carbohydrate diet fessor Nystrom. that lopsidedness in their score distribu- and a Mediterranean diet. The scientists l doi: 10.1371/journal.pone.0079324

30 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI31 NIH launches trial of investigational key proteins from the vaccine virus so that lational Medicine, could greatly accelerate genital herpes vaccine it cannot multiply to cause genital herpes. the development of new drug and cell Researchers have launched an early-stage The clinical trial is expected to enrol 60 therapies for people suffering from brain clinical trial of an investigational vaccine adults ages 18 to 40, who will be divided injuries or disease. designed to prevent genital herpes disease. into three groups of 20 participants each. Human pluripotent stem cells (hPSCs), The US National Institute of Allergy and The first group will be of people who have including human embryonic stem cells Infectious Diseases (NIAID), part of the been previously infected with HSV-2 and (hESCs) and human induced pluripotent National Institutes of Health, is sponsor- HSV-1 or solely with HSV-2; the second stem cells (hiPSCs), show great promise in ing the Phase I trial, which is being con- will have individuals who had been in- regenerative medicine due to their ability to ducted at the NIH Clinical Center in fected with HSV-1 only; and the third will be “coaxed” into becoming different specific Bethesda, Maryland. consist of those who have not been infect- types of cells. These cells can theoretically Genital herpes is one of the most com- ed with HSV-1 or HSV-2. The investiga- then go on to help the body heal itself by mon sexually transmitted infections in the tional vaccine is being tested among study replacing or repairing damaged or dead cells. United States. Most genital herpes cases participants who have previously been However, the current methods for in- are caused by infection with herpes sim- infected with HSV to determine if it may ducing neural stem cells involve time-con- plex virus type 2 (HSV-2); however, her- pose any safety issues. suming, multiple labor-intensive steps that pes simplex virus type 1 (HSV-1) can also Within each of the three groups, re- cannot be easily automated or made GMP cause genital herpes. An estimated 776,000 searchers will randomly assign participants (good manufacturing practice) compliant people in the United States are infected to receive three doses (0.5 milliliters each) for clinical grade manufacture. In addition, with HSV-2 or HSV-1 each year. There is of the investigational HSV529 vaccine not many of the neural stem cells produced no vaccine to prevent genital herpes. (15 participants) or a saline-based placebo this way can be expanded and coaxed into “Although genital herpes is treatable, vaccine (five participants). The three vac- becoming different neural subtypes specific it is a lifelong infection that can exact a cinations will occur at study enrollment to the brain regions responsible for control- substantial psychological and physical toll and again one month and six months ling different functions. on infected individuals and places them at later. Participant safety will be monitored “Towards this critical need, we have higher risk of acquiring HIV,” said NIAID throughout the course of the trial, and re- developed a simple one-step protocol Director Anthony S. Fauci, M.D. “Fur- searchers will follow participants for six with a GMP-manufactured medium that thermore, mothers with active genital her- months after they have received their last is rapid and efficient in the derivation of pes infection at time of delivery can trans- dose of vaccine. Blood samples will be used neural stem cells (from hPSCs) that remit the virus to their newborns, which can to evaluate the candidate vaccine’s ability tain the cues to differentiate into differ- lead to severe illness and death.” to stimulate immune system responses to ent disease relevant neurons. By starting “A protective vaccine would help to HSV-2, including production of virus- with a million pluripotent stem cells, it reduce significantly the spread of this all- specific antibodies and T-cell responses. is possible to get approximately 40 to 50 too-common sexually transmitted infec- The study is expected to be completed by million neural stem cells in seven days,” tion,” Fauci added. October 2016. said Mohan C. Vemuri, Ph.D., director Led by principal investigator Lesia K. HSV-2 is generally transmitted through of research and development for Cell Dropulic, M.D., of NIAID’s Laboratory of sexual contact and can spread even when Biology and Stem Cell Systems at Life Infectious Diseases, the trial will test an the infected individual shows no symp- Technologies, Frederick, Md. He was lead investigational HSV-2 vaccine candidate, toms. Although HSV-1 commonly in- author of the study done in conjunction called HSV529, for safety and the ability fects the mouth and lips, it can also cause with researchers from Buck Institute for to generate an immune system response. genital herpes. Once in the body, HSV Age Research, Novato, California, the The investigational vaccine manufactured migrates to nerve cells and remains there Methodist Hospital Research Institute in by Sanofi Pasteur was developed by David permanently, where it can reactivate to Houston and the National Institutes of Knipe, Ph.D., professor of microbiology cause painful sores and blisters. Health, Bethesda, Maryland. and immunobiology at Harvard Medical “This method sets the stage for produc- School, Boston. New way to grow neural stem ing neural cells that potentially could lead Pre-clinical testing of the candidate cells may aid brain therapy to new therapies for diseases such as Par- vaccine involved a 10-year collaborative Researchers have discovered a new, high- kinson’s,” he added. effort between Dr. Knipe and Jeffrey Co- ly efficient way to produce neural stem “Whether the intended use is drug dis- hen, M.D., chief of NIAID’s Laboratory cells from human pluripotent stem cells covery or cell therapies for neurological of Infectious Diseases. The experimental that can then go on to form neurons in diseases, it is essential to develop efficient product is a replication-defective vaccine, the brain. The discovery, reported in the and reproducible differentiation methods meaning that scientists have removed two November 2013 issue of Stem Cells Trans- for neurons,” said Anthony Atala, M.D.,

32 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI33 editor of Stem Cells Translational Medicine ability to make brown fat or find novel of recruiting normal alpha-synuclein and and director of the Wake Forest Institute ways to directly implant the brown fat adding it to the deposit. for Regenerative Medicine. “This study stem cells into patients. For this reason, many researchers ad- reports on a new method for the robust vocate that the alpha-synuclein of the and reproducible production of neural Researchers find two aggregates should be considered as an in- stem cells.” forms of Parkinson’s fectious protein, in other words a prion. l doi: 10.5966/sctm.2013-0080 Why can the symptoms of Parkinson’s Highly toxic, the alpha-synuclein deposits disease vary so greatly from one patient end up by triggering a process of apoptosis, Newly discovered brown fat cells to another? A consortium of research- i.e. cell death. may help treat diabetes, obesity ers, headed by a team from the Labora- The researchers have shown that there Obesity and diabetes have become a global toire CNRS d’Enzymologie et Biochimie is not just one single type of aggregate. epidemic leading to severe cardiovascular Structurales, is well on the way to provid- They succeeded in producing two types of disease. Researchers at the University of ing an explanation. aggregate that only differ in how the pro- Utah believe their recent identification of Parkinson’s disease is caused by a protein stacks up. At the millionth of a mil- brown fat stem cells in adult humans may tein known as alpha-synuclein, which limetre scale, the first form of aggregate lead to new treatments for heart and endo- forms aggregates within neurons, killing resembles spaghetti, whereas the second crine disorders, according to a new study them eventually. The researchers have form is long and flat, recalling the shape of published in the peer-reviewed journal succeeded in characterizing and produc- wider pasta such as linguine. The team of Stem Cells. ing two different types of alpha-synuclein scientists then tried to determine whether The study was led by Amit N. Patel, aggregates. Better still, they have shown these structural differences result in func- M.D. M.S., director of Clinical Regen- that one of these two forms is much more tional differences. erative Medicine and Tissue Engineering, toxic than the other and has a greater ca- To find out, they placed the two types of and associate professor in the Division of pacity to invade neurons. aggregates in contact with neuronal cells in Cardiothoracic Surgery at the University This discovery takes account, at the culture. They discovered that the capacity of Utah School of Medicine. molecular scale, of the existence of alpha- of the “spaghetti” form to bind to and pen- Prior to Patel’s study, it was thought that synuclein accumulation profiles that differ etrate cells is notably greater than that of brown fat stem cells did not exist in adults. from one patient to the next. These results, the “linguine” form. The “spaghetti” form Children have large amounts of brown fat published October 10 in Nature Communi- is also considerably more toxic and rap- that is highly metabolically active, which cations, represent a notable advance in our idly kills the infected cells. This form has allows them to eat large amounts of food understanding of Parkinson’s Disease and shown itself to be capable of resisting the and not gain weight. Patel notes, adults pave the way for the development of spe- cell mechanisms responsible for eliminat- generally have an abundance of white cific therapies targeting each form of the ing it, whereas the “linguine” form is, to a fat in their bodies, which leads to weight disease. certain extent, controlled by the cell. gain and cardiovascular disease but this is Parkinson’s Disease, which is the second The researchers are convinced that the not seen in brown fat. As people age, the most frequent neurodegenerative disease existence of at least two forms of alpha- amount of white fat increases and brown after Alzheimer’s, affects some 150,000 synuclein aggregates explains why doctors fat decreases which contributes to diabetes people in France. According to those suf- are faced with different Parkinson’s Diseas- and high cholesterol. fering from the disease, it can manifest it- es depending on the patient. Experiments “If you have more brown fat, you weigh self in the form of uncontrollable shaking on mice are currently under way to confirm less, you’re metabolically efficient, and you (in 60% of patients) or by less localized this hypothesis. Furthermore, the scientists have fewer instances of diabetes and high symptoms such as depression, behavioural consider that analysis of the type of ag- cholesterol. The unique identification of and motor disorders. These differences in gregate could lead to an efficient diagnosis human brown fat stem cells in the chest symptoms point to different forms of Par- method, which would make it possible, in of patients aged from 28 to 84 years is pro- kinson’s disease. particular, to assess the virulence of the dis- found. We were able to isolate the human This condition, for which no curative ease for each patient. stem cells, culture and grow them, and im- treatment currently exists, is caused by the Finally, they hope that by refining the plant them into a pre-human model which aggregation in the form of fibrillar deposits characterization of the structure of the has demonstrated positive effects on glu- of alpha-synuclein, a protein that is natu- aggregates, it will be possible to develop cose levels,” said Patel. rally abundant at neuron junctions. These targeted therapeutic strategies for each The new discovery of finding brown fat misfolded alpha-synuclein aggregates variant in order to slow down the propa- stem cells may help in identifying poten- propagate between neurons. When they gation of abnormal alpha-synuclein with- tial drugs that may increase the body’s own invade a new neuron, they are capable in the brain.

34 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI35 gene pool Genetic research news from around the world

ing the originally deleted gene with the the thousands of strains in the collection. gene that was secondarily mutated gave For each strain, they generated six sub- us a list of gene interactions strains, each derived from a single yeast that were largely unknown cell from the “parental batch.” before.” They then put each sub-strain through a Hardwick says the find- “stress test” designed to detect sub-strains ings call researchers with behaviours that varied from the be- to greater scrutiny in haviour of the parental batch. All of the their genetic analyses sub-strains grew indistinguishably without because they could stress, but when the temperature was grad- unwittingly attribute ually raised for only a few minutes, some a phenomenon to a sub-strains died because they could not gene they mutated, when it handle the stress. is actually due to a second- When the Hardwick team examined ary mutation. their genes, they found that, in addition to “This work has the po- the originally knocked-out gene, each of tential to transform the the sub-strains that faltered also had a mu- field of cancer genetics,” tation in another gene, leading the team Hardwick says. “We had been to conclude that the cells in each strain of thinking of cancer as progress- the single-gene knockouts do not all share ing from an initial mutation in a the same genetic sequence. Gene mutation research calls for tumour-suppressor gene, followed by ad- They then tested all 5,000 of the origi- rethink on cancer gene analysis ditional mutations that help the cancer nal single-gene knockout strains to find Johns Hopkins researchers report that thrive. Our work provides hard evidence sub-strains that could overgrow when the deletion of any single gene in yeast that a single one of those ‘additional given low-nutrient food – a trait that tu- cells puts pressure on the organism’s ge- mutations’ might come first and actively mour cells often possess. This was another nome to compensate, leading to a muta- provoke the mutations seen in tumour- stress test designed to detect differences tion in another gene. Their discovery, suppressor genes. We hope that our find- between the individual cells taken from which is likely applicable to human ge- ings in yeast will help to identify these the parental batches. They identified 749 netics because of the way DNA is con- ‘first’ mutations in tumours.” such knockout strains and showed that served across species, could have signifi- The beauty of working with yeast, Hard- their growth differences were often due to cant consequences for the way genetic wick says, is that it is easy to delete, or secondary mutations. analysis is done in cancer and other areas “knock out,” any given gene. Her team In total, the team’s evidence indicates of research, they say. started with a readily available collection that 77% of all the knockout strains have Summarized in a report published No- of thousands of different yeast strains, each acquired one or two additional mutations vember 21, 2013 in Molecular Cell, the with a different gene knockout. that affect cell survival and/or excessive team’s results add new evidence that ge- At their preferred temperature, each of growth when food is scarce. nomes, the sum total of species’ genes, are these strains of yeast grows robustly even Hardwick believes that stressing yeast like supremely intricate machines, in that though they each have a different gene in other ways may lead to an even higher the removal of a single, tiny part stresses missing. Hardwick’s team first asked a fun- percentage of double-mutant strains. In the whole mechanism and might cause an- damental question: Within a given strain fact, she said she believes that “essentially other part to warp elsewhere to fill in for of yeast, does each cell have the same ge- any gene, when mutated, has the power to the missing part. netic sequence as the other cells, as had alter other genes in the genome”. Delet- “The deletion of any given gene usually generally been presumed? ing the first gene seems to cause a biologi- results in one, or sometimes two, specific “We know, for example, that within a cal imbalance that is sufficient to provoke genes being ‘warped’ in response,” says J. given tumour, different cells have differ- additional adaptive genetic changes, she Marie Hardwick, Ph.D., the David Bo- ent mutations or versions of a gene,” ex- explains. dian Professor of Molecular Microbiology plains Hardwick. “So it seemed plausible Furthermore, in all of the strains that and Immunology at the Johns Hopkins that other cell populations would exhibit they examined, they found that the sec- Bloomberg School of Public Health and a a similar genetic diversity.” ondary mutations that appeared after a professor of pharmacology and molecular To test this idea, her team randomly given knockout were always in the same sciences at the school of medicine. “Pair- chose 250 single-knockout strains from one or two genes as in their earlier ob-

36 IMIDDLE EAST HEALTH servations. Unexpectedly, Hardwick said, find out more about how cells control L1 the altered growth of the sub-strains was and what tricks the jumping gene uses to usually due to the secondary mutations, get around these defences, Dai and others not the original knockout, and many of in the laboratory of Jef Boeke, Ph.D., first those secondary mutations were in genes induced lab-grown human cells to make that are known to be cancer-causing in large amounts of the proteins for which humans. L1 contains the blueprints. As expected, l doi: 10.1016/j.molcel.2013.09.026 the two types of L1 protein joined with human proteins and genetic material Two human proteins found called RNA to form so-called ribonucleo- to affect “jumping gene” protein particle complexes, which L1 uses Using a new method to catch elusive to “jump”. “jumping genes” in the act, researchers To find out which human proteins in- have found two human proteins that are teract with ribonucleoproteins – and are used by one type of DNA to replicate it- therefore likely to have a role in either self and move from place to place. The tamping down its activity or helping it discovery, described in Molecular Cell along – Boeke’s team collaborated with in November 2013, breaks new ground, researchers at The Rockefeller University they say, in understanding the arms race who had developed a technique for fast- between a jumping gene driven to colo- freezing yeast with liquid nitrogen, then nize new areas of the human genome and grinding it up for analysis with steel balls cells working to limit the risk posed by and very rapidly pulling out the ribonu- such volatile bits of DNA. cleoproteins with tiny magnetic particles. Jumping genes, more formally known “It’s a good way of preserving the interac- as transposons or transposable elements, tions,” Dai says. are DNA segments with the blueprints Adapting this powerful technique to for proteins that help to either copy the human cells, the team found 37 proteins segment or remove it, then insert it into that appear to interact with the ribonu- a new place in the genome. Human ge- cleoprotein, and they selected two for nomes are littered with the remnants of further analysis. One of these, UPF1, is says PCNA seems to have been co-opted ancient jumping genes, but because cells known for its role in quality control; it into helping the jumping gene, perhaps by have an interest in limiting such trespass- monitors the RNA transcripts that car- repairing gaps left in human DNA after L1 es, they have evolved ways to regulate ry instructions from DNA to the cell’s splices itself into a new spot. them. Most jumping genes have mutated protein-making machinery and destroys Dai notes that these discoveries would and can no longer move, but these “rust- those with mistakes. In this case, Dai not have been possible without two ing hulks” are still passed down from gen- says, UPF1 binds to the L1 ribonucleo- methods pioneered in this study: growing eration to generation. protein, probably because L1 RNA con- large quantities of human cells and in- One exception is a jumping gene called tains instructions for two proteins rather ducing them to make ribonucleoprotein, L1, which has been so successful that cop- than one – a red flag for UPF1. When the and adapting the fast-freezing technique ies of it make up about 20% of human researchers disabled the UPF1 gene, cells to study interactions in human cells. He DNA. While many of these copies are now produced more L1 RNA and protein. But expects that these methods will enable mutated and dormant, others are still ac- they still haven’t figured out exactly how biologists to greatly increase their under- tive and thus the subject of much interest UPF1 interacts with the ribonucleopro- standing of L1, a jumping gene that has by geneticists. tein, Dai says. played a key role in the evolution of the “Human cells have evolved ways of The other human protein, PCNA, helps human genome and whose activity has limiting jumping genes’ activity, since to copy DNA strands before a cell divides been implicated in some cancers. the more frequently they move, the more into two. The researchers found that “Our study shows how the jumping gene likely they are to disrupt an important PCNA interacts with a critical segment of tries to be smart and get around the host gene and cause serious damage,” says Lix- one of the ribonucleoprotein’s L1 proteins; cell’s control mechanisms, and how the in Dai, Ph.D., a post-doctoral associate at when they tried altering that section, host tries to minimize its activity,” Dai the Johns Hopkins Institute for Basic Bio- L1 could no longer jump. In contrast to says. “We’re looking forward to learning medical Sciences, who led the study. To UPF1’s role in suppressing L1 activity, Dai more about this arms race.”

MIDDLE EAST HEALTHI37 Public Health

Access to healthcare, polio and road traffic safety among key issues highlighted at 60th WHO EMR annual meeting

The Sixtieth Session of the WHO Region- vealed the huge differences in the response al Committee for the Eastern Mediterra- of health systems, and the need to take ur- nean was held in the Omani capital Mus- gent measures to bridge the gaps. cat from 27-30 October 2013. The session “Strengthening health systems and mak- looked at a number a public health issues ing them more efficient is a fundamental and passed several resolutions pertinent to strategy to promote comprehensive devel- the region, including universal health cov- opment [in public health].” erage, polio and road traffic safety. A number of resolutions were passed at In his opening speech, Dr Ala Alwan, the meeting. Importantly, one of the reso- WHO Regional Director of the World lutions addresses the escalation of polio Health Organization for the Eastern in the region, declared the circulation of Mediterranean, praised the advances that the polio virus in the region as an emer- Oman has made in health and social de- gency for all Member States. It called on Dr Ala Alwan, WHO Regional Director of the World Health Organization for the Eastern velopments Oman over the past four de- Pakistan to take necessary steps to ensure Mediterranean, addresses the meeting cades, through its sustained commitment all children are assessed and vaccinated as to health and social development and a matter of utmost emergency to prevent careful planning. further international spread and requested “The excellent collaboration between the Syrian Arab Republic and adjoining WHO and Oman is a model that we aim countries to coordinate, and if possible, to for with all Member States, and I extend my synchronize, intensified mass vaccination particular appreciation to Oman for this ad- campaigns using the most appropriate tac- mirable achievement,” said Dr Alwan. tics and vaccines to stop this new outbreak The Regional Director highlighted a num- within six months. ber of issues, such as strengthening health Another resolution addresses universal systems, universal health coverage, maternal health coverage. In this context the Re- and child health, international health regu- gional Committee called on Member States lations, polio, non-communicable diseases to ensure sustained political commitment and the challenges faced by the Region re- to universal health coverage in order to en- HRH Princess Muna Al-Hussein, the WHO Patron of nursing and midwifery in the Eastern Mediterranean garding health and the environment. sure that all people have access to essential Region, called for a stronger public health system In her opening remarks HRH Princess health services that are of sufficient quality Muna Al-Hussein, the WHO Patron of without the risk of financial hardship. nursing and midwifery in the Eastern Med- The Regional Committee also endorsed iterranean Region, stressed the importance the Dubai Declaration: Saving the lives of of strengthening public health by prioritis- mothers and children: rising to the challenge. ing the promotion of public health. Committee Members urged high-burden Dr Mohammed bin Ahmed Al Saidi, countries to strengthen multisectoral part- Minister of Health of Oman, concluded nership in order to implement their national the opening ceremony saying the emer- acceleration plans and allocate the necessary gence of several health issues as priorities human and financial resources and mobilize makes it obligatory for all of us to do more additional resources as necessary. for the health of our communities. There The Regional Committee also endorsed was an urgent need for more commitment the regional strategy for the improvement especially with the profound political, so- of civil registration and vital statistics sys- Dr Mohammed bin Ahmed Al Saidi, Minister of cial and economic changes in a number of tem 2014–2019.; urging Member States to Health of Oman, said more must be done for the countries in the region. give priority to the strengthening of their health of communities Dr Saidi said: “The past two years has re- national systems and develop multisectoral

38 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI39 Public Health

strategies to improve civil registration and gional strategy and to build partnerships gional Committee requested the Regional vital statistics systems based on the find- with United Nations agencies and other Director to support Member States in de- ings of an in-depth assessment and guided relevant stakeholders veloping and implementing strategies and by the regional strategy. Adopting the Annual Report of the self-delivery approaches for rapid scale-up Another strategy endorsed by the Regional Director for 2012, the Regional of HIV treatment to improve the quality Regional Committee was the Regional Committee urged middle income coun- of the planning cycle by building capacity strategy on health and environment tries to participate in the pooled vaccine at the three levels of the Organization and 2014-2019 and its framework for ac- procurement system and to sign a memo- improving monitoring mechanisms. tion. It requested the Regional Director randum of understanding with WHO and to provide technical support to Member UNICEF to complete the participation WHO EMRO RC 60 States to adapt and implement the re- process before the end of 2013. The Re- www.emro.who.int/about-who/rc60 WHO EMRO releases global status report on road safety 2013 Road traffic crashes are Eastern Mediterranean Region accounts the leading cause of death for 10% of the world’s road traffic deaths among people aged 15- The Global status report on road safety Worldwide the total number of road 29 years in the Eastern 2013: supporting a Decade of Action was traffic deaths remains unacceptably high Mediterranean Region. released at the 60th WHO Eastern Med- at 1.24 million per year. iterranean Regional Committee. The real policies and enabling environments port provides an update of the road safety Eastern Mediterranean Region to encourage walking and cycling or to situation in countries across the world. Data from the Eastern Mediterranean Re- separate vulnerable road users. More importantly it sets the baseline for gion show that it accounts for 10% of the Laws on key risk factors are available monitoring action through the Decade world’s road traffic deaths and has the sec- in the majority of the Region’s coun- of Action for Road Safety 2011–2020. ond highest road traffic fatality rate among tries, but are mostly not comprehen- The report presents information from WHO regions after the African Region. sive. This, together with inadequate 182 countries – including 19 countries Middle-income countries of the Region ac- enforcement, limits their effective- from the Eastern Mediterranean Re- count for over 85% of its road traffic deaths. ness. And although most countries gion – accounting for almost 99% of the On the other hand high-income countries have post-crash care systems, these world’s population or 6.8 billion people. in the Region have road traffic death rates need strengthening both in terms of Among other important information, that are double the rates in high-income trauma care and rehabilitation. the report shows that only 28 countries, countries in other regions of the world. The 2013 Global status report is the covering 7% of the world’s population, This clearly shows that road traffic inju- second in a series analysing the extent have comprehensive road safety laws on ries pose a grave problem for all countries in to which countries are implement- five key risk factors: drinking and driv- the Region regardless of their income level. ing a number of effective road safety ing, speeding, failing to use motorcycle More alarming is that the younger pro- measures. In addition to the five risk helmets, seat-belts and child restraints. ductive age groups are hardest hit. About factors noted above, it highlights the It indicates that, among other measures, 60% of those who are killed in road traffic importance of issues such as vehicle the pace of legislative change needs to crashes are between the ages of 15 and 44 safety standards, road infrastructure rapidly accelerate if the United Na- years, and over 75% are male. This is in line inspections, policies on walking and tions Decade of Action for Road Safety with the most updated Global Burden of cycling and aspects of pre-hospital 2011–2020 is to meet its target of saving Disease Data 2010, which shows that road care systems. It also indicates wheth- 5 million lives. traffic crashes are the leading cause of death er countries have a national strategy The report also documents that be- among those aged 15-29 years in the East- which sets measurable targets to re- tween 2007 and 2010, 88 countries ern Mediterranean Region. duce the number of people killed and managed to reduce the number of Of all road traffic victims in the Eastern seriously injured on the roads. deaths on their roads, showing that Mediterranean Region, about 45% are vul- improvements are possible. However, nerable road users. The highest toll is among Global status report on road the number of deaths increased in 87 pedestrians followed by motorcyclists and bi- safety 2013 countries during the same period. cyclists. Yet only a few countries have nation- http://tinyurl.com/cls2cjy

40 IMIDDLE EAST HEALTH Syria Report

Polio outbreak in Syria prompts massive immunization campaign across Middle East The largest-ever immunization campaign in the Middle East is under way, aiming to vaccinate more than 23 million children under the age of five against polio in Syria Children at Atme and neighbouring countries. camp for displaced The campaign, launched by the World people in northern Health Organization and UNICEF, is a Syria, near the border with Turkey. crucial part of the response to an outbreak Children in Syria of the disease in Syria, where 17 cases, are at risk of getting caused by wild poliovirus type 1 (WPV1), polio following an outbreak of have so far been confirmed (December the disease in the 2013), and to the detection of the virus in country. environmental samples in other parts of the Middle East. Fifteen of these children © Jodi Hilton/IRIN are in the contested governorate of Deir Ez Zour, one is in Aleppo and another in dren in Syria remain inaccessible, particu- viding awareness sessions on issues relating Douma, near Damascus. Prior to this out- larly those trapped in sealed off areas or to polio and other health-related issues, in break, no polio cases had been recorded in living in areas where conflict is ongoing. one month the number of children attend- Syria since 1999, but vaccination efforts A surveillance alert has been issued for the ing the centre rose from 46 to 1 357. So far, have suffered during the last three years of region to actively search for additional po- throughout Al Hassakeh province, 87,728 conflict. tential cases in addition to implementing children have been vaccinated, including Genetically-related polio viruses, which the recommended supplementary immu- 7,676 children who were vaccinated by originated in Pakistan, have also been de- nization activities with oral polio vaccine. UNHCR-supported volunteers. tected in sewage samples in Egypt in De- UOSSM (Union of Syrian Medical Re- “All Syrian children should be protected cember 2012, and in Israel and the West lief Organizations) has asked the WHO from disease,” noted Dr Ala Alwan, Re- Bank and Gaza Strip earlier in 2013. In a and UNICEF to extend their vaccination gional Director, WHO Eastern Mediterra- joint resolution, all countries of the WHO campaign against polio to areas under op- nean Region. “To eradicate polio, we need Eastern Mediterranean Region have de- position control. In one report, Dr Khaled to eradicate any reason for failing to reach clared polio eradication to be an emer- Almilaji reported that in the rebel-con- children.” gency and called on Pakistan to urgently trolled areas, “the virus is spreading faster, Over the coming months, UNICEF is access and vaccinate all of its children to where millions of people are displaced planning to deliver 10 million doses of stem the international spread of its viruses. and living in dire conditions. Families polio vaccine to Syria. The first ship- Organizers aim to vaccinate, repeatedly are drinking directly from the rivers, de- ment of two million vaccines arrived in over the next few months, all children un- pendent on contaminated water, which Damascus on 29 November. All coun- der the age of five, whether they are liv- can carry the virus. The opposition’s Po- tries of the WHO Eastern Mediterranean ing at home or displaced by conflict. The lio Task Force charge that the Damascus- Region have united in calling for support WHO has said the vaccinations would based program is not reaching all the vul- to negotiate and establish access to those take place in Egypt, Iraq, Jordan, Lebanon, nerable children in rebel areas.” children who are currently unreached the West Bank, Gaza Strip and Turkey. Despite the gaps in coverage, however, with polio vaccination. It is anticipated Depending on the area, vaccination will initial information suggests that vaccine is that the outbreak response will need to be offered at fixed sites at populous loca- getting to more areas of Syria than has so continue for at least six to eight months, tions or by going from house to house. The far been the case for health interventions depending on the area and based on activities are carried out by national and delivered as part of the larger ongoing evolving epidemiology. In Syria, these local health authorities supported by UNI- humanitarian effort. In parallel with the campaigns will be carried out at monthly CEF, WHO, the Syrian Arab Red Cres- vaccination effort, work is ongoing to bol- intervals until April this year. cent and other partners. ster systems for verifying coverage data in The total cost to UNICEF and WHO Inside Syria, the campaign aims to reach upcoming campaigns inside the war-torn of supporting the seven-country polio re- 2.2 million children, including those who country. At one public health centre in Al sponse from November through April is live in contested areas and those who were Hassakeh in eastern Syria, where 23 UN- US$39 million, based on a strategic plan missed in an earlier campaign. Many chil- HCR-supported health volunteers are pro- developed for the Middle East.

MIDDLE EAST HEALTHI41 Healthcare Economics

Dubai meeting of policymakers calls for better universal health coverage The World Health Organization, in collaboration with the Ministry of Health of world, as well as members of scientific cir- the United Arab Emirates, organised a re- cles, academia and concerned nongovern- gional meeting on accelerating progress mental organisations. towards universal health coverage: global The purpose of the meeting was to re- The high share of direct experiences and lessons for the Eastern flect on the latest thinking with regard to Mediterranean Region, in Dubai from 5 to7 addressing the challenges in pursuing uni- payment limits people’s December 2013. versal health care and to share the lessons access to much needed Universal health coverage is emerging as learned from countries that have succeeded health services and exposes a global health priority which is likely to oc- in reforming their national health systems those in need of health cupy a significant place in any future global so as to move towards universal health cov- development agenda. erage. care to a higher risk of Universal health coverage means that all At the opening of the meeting Dr Ala financial catastrophe and people have access to good quality health Alwan, WHO Regional Director for the impoverishment care, without running the risk of financial Eastern Mediterranean, reiterated the im- ruin. This means without having to pay portance of the meeting and its expected re- from their own pocket excessive amounts sults: “We will discuss the strategic roadmap that would either limit their spending on that was endorsed by the Regional Com- other essential services or push them into mittee and how to implement it through a poverty. Universal health coverage focuses framework for action in the Region. This need to be identified and adapted to coun- on all types of health service and not just will then need to be followed by develop- try needs,” Dr Alwan emphasized. treatment. ment of country-specific roadmaps, starting The focus on universal health coverage with generating evidence and engaging in Political commitment is not new. The aspiration goes back to the national policy dialogue.” He stressed that political commitment to WHO Constitution of 1948 and the Alma- universal health coverage is essential and Ata Declaration of 1978. However, the Out-of-pocket can be achieved by: world is not there yet. Every year, millions “In some low-income countries in the Re- l providing a national vision, strategy of people in the world and in the Eastern gion, people still pay for more than 70% of and roadmap Mediterranean Region are still deprived health expenses out of their own pocket,” l devising evidence-based healthcare of health care, and millions others experi- Dr Alwan said. financing strategies ence financial hardship because of the way “The high share of direct payment limits l expanding the provision of integrated health services are organized, delivered and people’s access to much needed health ser- people-centred health services financed. vices and exposes those in need of health l progressively expanding coverage to Recently, the move towards universal care to a higher risk of financial catastrophe all population groups health coverage has gained momentum. It and impoverishment. It is estimated that Advancing the achievement of univer- was the focus of many global reports. The each year, up to 16.5 million people in the sal health coverage also requires the avail- subject was also presented before the last Region encounter financial ruin, and up to ability of the necessary health workforce; two sessions of the WHO Regional Com- 7.5 million individuals become poor due to the accessibility of essential medicines and mittee for the Eastern Mediterranean. Hav- out-of-pocket payments for health services. technologies; the presence of good gover- ing a comprehensive vision, evidence-based “While population coverage has reached nance and leadership; the provision of good strategy and a well-laid out roadmap, and close to 100% for nationals in several high- quality services; and the production of ap- associated framework of action, remain es- income countries of the Region, the cover- propriate information for decision-making. sential for making progress towards univer- age of non-nationals has yet to reach the The challenges and opportunities for uni- sal health coverage. same level. For most middle-income coun- versal health coverage have been found to The Dubai meeting brought together tries the population coverage ranges be- be common to all countries in the Region, high-level policy-makers, health profes- tween 40-90%, whereas it continues to lag although to varying extent, which reflects sionals, representatives of civil society and at around 25% for low-income countries. the need for efforts to enhance universal development partners from all parts of the “Solutions to address these challenges health care across the entire Region.

42 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI43 WHO tobacco report

2.3 billion people benefit from anti-tobacco programs The number of people worldwide covered spiratory diseases. “Unless we act, tobacco by at least one life-saving measure to limit will kill more than eight million people tobacco use has more than doubled to 2.3 every year by 2030,” says Dr Alwan. “More billion in the past five years, according to than 80% of these preventable deaths will the WHO Report on the Global Tobacco be among people living in low- and mid- Epidemic, 2013. dle-income countries”. The number of people covered by bans Tobacco companies are spending tens of on tobacco advertising, promotion and billions of dollars each year on advertising, sponsorship, the focus of this year’s report, promotion and sponsorship. increased by almost 400 million people, re- “As tobacco use decreases in many siding mainly in low- and middle-income countries, partly due to restrictions on countries. marketing and use,” explains Dr Alwan, Furthermore, the Report shows that 3 “the tobacco industry is switching its fo- billion people are now covered by national cus to the developing world where there anti-tobacco campaigns. As a result, hun- are large and growing markets and fewer dreds of millions of non-smokers are less restrictions. In particular, as potential cus- likely to start. tomers, young people and women present However, the Report notes, to achieve a major marketing opportunity for the to- the globally agreed target of a 30% reduc- bacco industry”. tion of tobacco use by 2025, more coun- Other key findings of the report include tries have to implement comprehensive – in the past five years: tobacco control programs. l A total of 20 countries with 657 mil- Bans on tobacco advertising, promotion lion people put strong warning label re- and sponsorship are some of the most pow- quirements in place. erful measures to control tobacco use. To l More than half a billion people in date, 24 countries with 694 million people nine countries have gained access to ap- have introduced complete bans and 100 propriate cessation services. more countries are close to a complete ban. l There are 32 countries that passed In the Eastern Mediterranean Region, complete smoking bans covering all work only six out of 23 countries are fully pro- places, public places and public transporta- tected from exposure to the tobacco in- tion means, protecting nearly 900 million dustry advertising, promotion and spon- additional people. sorship tactics. In 2008, WHO identified six evidence- “We know that tobacco advertising, based tobacco control measures that are promotion and sponsorship are critical the most effective in reducing tobacco to the industry’s continued physical and use. Known as “MPOWER”, these mea- * Raise taxes on tobacco. political expansion”, says Dr Ala Alwan, sures correspond to one or more of the This year’s report is the fourth in the WHO Regional Director for the Eastern demand reduction provisions included in series of WHO reports on the status of Mediterranean. “That is why the tobacco the WHO Framework Convention on To- the MPOWER measures. These mea- industry continues to fight bans through bacco Control (WHO FCTC): sures provide countries with practical minimum concessions, half measures, vol- * Monitor tobacco use and prevention assistance to reduce demand for to- untary self-regulation, claims of corporate policies, bacco in line with the WHO FCTC, social responsibility and numerous other * Protect people from tobacco smoke, thereby reducing related illness, dis- innovative ways”. * Offer help to quit tobacco use, ability and death. Tobacco is the leading cause of prevent- * Warn people about the dangers of to- The WHO FCTC entered into force able death globally, killing six million peo- bacco, in 2005 and, with 177 parties today, is ple every year. It can cause cardiovascular * Enforce bans on tobacco advertising, a powerful tool to combat the deadly disease, cancer, diabetes and chronic re- promotion and sponsorship, and tobacco epidemic.

44 IMIDDLE EAST HEALTH Syria Report

MIDDLE EAST HEALTHI45 MERS-CoV Update

MERS-CoV found in camels The International Health Regulations sity of Minnesota reports (December 12 - European researchers reported that 11 of Emergency Committee held their fourth http://tinyurl.com/nhsb5t3) that reports that 11 camels tested in Jordan had MERS- meeting to discuss the latest develop- dromedary camels in Jordan and Saudi CoV-like antibodies. The second study ments with MERS-CoV on December 4. Arabia were found to have antibodies to found that 280 of 310 dromedary camels The Committee concluded that it saw no the virus or one closely related to it. from various parts of Saudi Arabia had an- reason to change its previous advice to the CIDRAP cites two studies published in tibodies to MERS-CoV or a very similar Director-General that the conditions for a Eurosurveillance* in which Jordanian and virus. In both studies tests in goats, sheep, Public Health Emergency of International Concern (PHEIC) have not at present been met. However, the Committee stated MERS-CoV cases by that situation continues to be of concern, country – 185 cases in total (18 Dec 2013). in view of ongoing cases and of new in- NOTE: The Epidemic formation about the presence of the virus website points out that in camels. The Committee plans to meet the list of cases has been gathered from various again in March. sources including WHO As of December 17, the WHO states it bulletins and media re- has been informed of a total of 165 labo- ports. It contains some cases that were not lab- ratory-confirmed cases of infection with oratory-confirmed (but MERS-CoV, including 71 deaths. are extremely likely). CIDRAP, the Center for Infectious Dis- ease Research and Policy at the Univer- Epidemic - http://epidemic.bio.ed.ac.uk MERS-CoV FAQ

The World Health Organisation an- have been reported in France, Germany, patients have had pneumonia. Many have swers some frequently answered ques- Italy Jordan, Qatar, Saudi Arabia, Tunisia, also had gastrointestinal symptoms, includ- tions about MERS-CoV. the United Arab Emirates, and the United ing diarrhoea. Some patients have had kid- Kingdom. All cases have had some con- ney failure. About half of people infected n What is coronavirus? nection (whether direct or indirect) with with MERS-CoV have died. In people with Coronaviruses are a large family of viruses the Middle East. In France, Italy, Tunisia immune deficiencies, the disease may have that cause illness in humans and animals. and the United Kingdom, limited local an atypical presentation. It is important to In people, coronaviruses can cause illness- transmission has occurred in people who note that the current understanding of ill- es ranging in severity from the common had not been to the Middle East but who ness caused by this infection is based on a cold to Severe Acute Respiratory Syn- had been in close contact with laboratory- limited number of cases and may change as drome (SARS). confirmed or probable cases. we learn more about the virus. The novel coronavirus, first detected in April 2012, is a new virus that has not n How widespread is MERS-CoV? n What is the significance of the been seen in humans before. In most cas- How widespread this virus may be is still recent finding of MERS-CoV in camels? es, it has caused severe disease. Death has unknown. WHO encourages Member On 11 November, the Ministry of Health occurred in about half of cases. States to continue to closely monitor for of Saudi Arabia announced that MERS- This new coronavirus is now known as severe acute respiratory infections (SARI) CoV had been detected in a camel linked Middle East respiratory syndrome coro- and to carefully review any unusual pat- to a human case in Saudi Arabia. This navirus (MERS-CoV). It was named by terns of SARI or pneumonia. WHO will finding is consistent with previously pub- the Coronavirus Study Group of the In- continue to share information as it be- lished reports of MERS-CoV reactive ternational Committee on Taxonomy of comes available. antibodies in camels, and adds another Viruses in May 2013. important piece of information to our n What are the symptoms of MERS-CoV? understanding of MERS-CoV ecology. n Where are MERS-CoV infections occurring? Common symptoms are acute, serious re- However, this finding does not necessar- Nine countries have now reported cases of spiratory illness with fever, cough, shortness ily implicate camels directly in the chain human infection with MERS-CoV. Cases of breath and breathing difficulties. Most of transmission to humans. The critical

46 IMIDDLE EAST HEALTH Epidemic - http://epidemic.bio.ed.ac.uk Epidemiology of MERS-CoV (18 Dec 2013) and cows were negative. Earlier last year East have been exposed to the pathogen”. infection control and prevention. researchers found MERS-CoV like anti- At the December 4 meeting the IHR * Reusken CB, Ababneh M, Raj VS, et bodies in camels in Oman, Egypt, and the Emergency Committee emphasized he al. Middle East respiratory syndrome coro- Canary Islands. need for: navirus (MERS-CoV) serology in major The research centre points out, however, l investigative studies, including in- livestock species in an affected region in that “it remains unclear whether camels are ternational case-control, serological, en- Jordan, June to September 2013. Eurosur- a source of MERS-CoV in humans, because vironmental, and animal-human interface veill 2013 Dec 12;50 (18): pii=20662 no one has yet demonstrated a close ge- studies, to better understand risk factors Hemida MG, Perera RA, Wang P, et al. netic match between a camel MERS-CoV and the epidemiology; Middle East respiratory syndrome (MERS) isolate and a human isolate”, but adds that l further review and strengthening of coronavirus seroprevalence in domestic “the new findings seem to strengthen the such tools as standardized case definitions livestock in Saudi Arabia, 2010 to 2013. evidence that many camels in the Middle and surveillance and further emphasis on Eurosurveill 2013 Dec 12;50(18):pii=2065

question that remains about this virus is question. It is unlikely that transmission of which transmission occurred in all of these the route by which humans are infected, the MERs-CoV to people occurs through cases, whether respiratory (e.g. coughing, and the way in which they are exposed. direct exposure to an infected camel, as sneezing) or direct physical contact with Most patients who have tested positive for very few of the cases have reported a camel the patient or contamination of the envi- MERS-CoV had neither a human source exposure. More investigations are needed ronment by the patient, is unknown. Thus of infection nor direct exposure to ani- to look at the recent exposures and activi- far, no sustained community transmission mals, including camels. It is still unclear ties of infected humans. WHO is working has been observed. whether camels, even if infected with with partner agencies with expertise in MERS-CoV, play a role in transmission animal health and food safety, including n Is there a vaccine or to humans. Further genetic sequencing FAO, OIE and national authorities, to treatment for MERS-CoV? and epidemiologic data are needed to un- facilitate these investigations. Many tech- No. No vaccine is currently available. derstand the role, if any, of camels in the nical organizations are offering their ex- Treatment is largely supportive and should transmission of MERS CoV to humans. pertise to assist ministries responsible for be based on the patient’s clinical condition. human health, animal health, food, and n How do people become agriculture. Investigation protocols and n Are health workers infected with this virus? guidelines for dealing with new cases are at risk from MERS-CoV? We do not yet know how people become available on the WHO website. Yes. Transmission has occurred in health- infected with this virus. Investigations are care facilities, including spread from pa- underway to determine the source of the n Can the virus be transmitted tients to health-care providers. WHO virus, the types of exposure that lead to from person to person? recommends that health-care workers infection, the mode of transmission, and Yes. We have now seen multiple clus- consistently apply appropriate infection the clinical pattern and course of disease. ters of cases in which human-to-human prevention and control measures. transmission has occurred. These clusters n How is the virus being have been observed in health-care facili- MERS-CoV infections update (WHO) transmitted to humans? ties, among family members and between www.who.int/csr/disease/coronavirus_ We still do not know the answer to this co-workers. However, the mechanism by infections

MIDDLE EAST HEALTHI47 AIDS Report

Less than 1 in 5 who have HIV in Middle East receive treatment WHO moves to expand access to antiretroviral therapy

World AIDS Day was marked on 1 De- efforts to rapidly expand access to good cember with events around the world. quality HIV treatment and care services”. An estimated 80% of The World Health Organisation Eastern To Treat More people living with HIV, people living with HIV Mediterranean Regional Office (WHO WHO urges partners to expand access to in the region are still EMRO) released a statement saying that treatment to ensure that all people who not aware that they are not even one in five people living with need it actually receive it, regardless of HIV in the Eastern Mediterranean Re- their age, gender, risk behaviour, race or carrying HIV. gion and in need of treatment is actu- any other reason. There is a need to reach ally receiving it. Although the number of out to those most at risk, and to address treatment are receiving it, making it the people living with HIV and receiving an- stigma and discrimination in healthcare region with the lowest HIV treatment tiretroviral therapy (ART) in the Region settings. To Treat Better, WHO stresses coverage in the world. has increased over the past five years, the the need to use more potent, less toxic, An advocacy document entitled, “Ac- number of new infections is increasing at and easy-to-take medicines and to ensure celerating HIV treatment in the WHO a faster pace. better monitoring of patients’ response to Eastern Mediterranean and UNAIDS In addition, the WHO says, most peo- treatment. Middle East and North Africa regions” ple living with HIV do not know that “HIV treatment works,” emphasized was launched at the meeting, which a they have acquired the infection because Dr Alwan. “I am certain that with strong analyses the regional context and offers a they have never taken the HIV test. ownership, political will and the right tailored regional framework for a signifi- To address this situation, the WHO policies and strategies in place, countries cant scale-up in treatment coverage. It is launched, on World Aids Day, a new can treat more, and treat better.” built on four pillars: creating demand for regional campaign to expand access to testing and treatment; investing in sus- good quality treatment and care – titled: Lowest HIV treatment tainable systems for HIV care; delivering “Treat More, Treat Better”. The cam- coverage in the world results in an equitable manner; and com- paign which aims to expand access to Meanwhile, at the 60th session of the mitting to urgent action. ART is in line with the global theme: WHO Regional Committee for the “The treatment crisis in the region is “Getting to Zero: Zero new infections. Eastern Mediterranean held in Muscat, reversible,” said Dr Yamina Chakkar, Di- Zero deaths from AIDS-related illness. Oman in October last year, the WHO rector UNAIDS-Regional Support Team Zero discrimination”. and the Joint United Nations Programme for the Middle East and North Africa. Dr Ala Alwan, Regional Director, on HIV/AIDS (UNAIDS) initiated a “We are eager to join forces with our part- WHO Eastern Mediterranean Region, joint campaign to accelerate HIV testing ners and with regional leaders to renew said the campaign is “a plea to all of us and treatment coverage in Eastern Medi- the commitment and bring HIV testing – governments, civil society groups, tech- terranean Region, where, they say, only and treatment services to the people who nical partners and donors to redouble our 15% of the estimated people in need of need them.”

48 IMIDDLE EAST HEALTH Adolescents falling through gaps in HIV services More than 2 million adolescents be- treat HIV,” says Craig McClure, Chief The region is one of two tween the ages of 10 and 19 years are of HIV programmes for UNICEF. in the world where new living with HIV, and many do not re- “About one-seventh of all new HIV HIV infections are still on ceive the care and support that they infections occur during adolescence. the rise. In 2012, 347,000 need to stay in good health and prevent Unless the barriers are removed, the transmission. In addition, millions more dream of an AIDS-free generation will people in the region were adolescents are at risk of infection. never be realized.” living with HIV, a 127% The failure to support effective and increase over the number acceptable HIV services for adoles- Making it easier to know HIV status living with HIV in 2001. cents has resulted in a 50% increase in Furthermore, many young people do reported AIDS-related deaths in this not know their HIV status. For ex- group compared with the 30% decline ample, in sub-Saharan Africa, it is The region is one of two in the world seen in the general population from estimated that only 10% of young where new HIV infections are still on 2005 to 2012. men and 15% of young women (15-24 the rise. In 2012, 347,000 people in the years) know their HIV status and, in region were living with HIV, a 127% in- Addressing the needs of adolescents other regions, although data is scarce, crease over the number living with HIV The WHO recommendations “HIV access to HIV testing and counselling in 2001. However, in other parts of the and adolescents: Guidance for HIV by vulnerable adolescents is consis- world antiretroviral therapy has trans- testing and counselling and care for tently reported as being very low. formed the global HIV response, mitigat- adolescents living with HIV” are the WHO recommends governments ing the human costs of HIV and playing first to address the specific needs of review their laws to make it easier a vital role in slowing the further spread adolescents both for those living with for adolescents to obtain HIV testing of the virus. HIV as well as those who are at risk of without needing consent from their Across the region, HIV testing and infection. parents. The guidelines also suggest treatment services are available, but “Adolescents face difficult and often ways that health services can improve several factors limit access for people in confusing emotional and social pres- the quality of care and social support need: lack of awareness; fear of stigma sures as they grow from children into for adolescents. And they highlight and discrimination in families, work- adults,” says Dr Gottfried Hirnschall, the value of involving this age group to places, communities and in health care director of WHO HIV/AIDS Depart- create an adolescent-centred approach facilities prevent people from taking an ment. “Adolescents need health ser- to the services that work for people of HIV test; and seeking care. As a result, an vices and support, tailored to their their age. estimated 80% of people living with HIV needs. They are less likely than adults in the region are still not aware that they to be tested for HIV and often need Better equipping adolescents are carrying HIV. more support than adults to help them “Young people need to be better The good news is that some countries maintain care and to stick to treat- equipped to manage their HIV in- have achieved considerably higher HIV ment.” fection and take ownership of their testing and treatment coverage than the Across sub-Saharan Africa, many health care,” says Dr Elizabeth Ma- regional average. Countries that have who were infected at birth are becom- son, Director of WHO Maternal, decentralized and integrated HIV service ing adolescents. In addition to the Newborn, Child and Adolescent delivery into the health system and en- many changes associated with adoles- Health Department. “We have seen gaged civil society and private providers cence, they also face the challenges of for example in Zimbabwe that, by de- have succeeded in achieving much better living with a chronic infection: dis- veloping adolescent friendly services, coverage than those that have not. closing the news to friends and family it is possible to achieve good treat- This initiative calls upon leaders to and preventing transmission to sexual ment outcomes among adolescents. commit to urgent action to increase ac- partners. We urge others to be inspired by these cess to HIV treatment in the region. “Adolescent girls, young men who examples.” “Treatment is fundamental to achieving have sex with men, those who inject To help health workers put these an AIDS-free generation, in addition to re- drugs or are subject to sexual coercion recommendations into practice WHO ducing morbidity and mortality, HIV treat- and abuse are at highest risk. They face has developed a new online tool (to ment also reduces transmission. We cannot many barriers, including harsh laws, be launched in January 2014). It uses let this opportunity remain untapped. We inequalities, stigma and discrimination practical examples from country pro- must do more to garner both the individ- which prevent them from accessing grammes that are working closely with ual and the public health benefits of treat- services that could test, prevent, and adolescents on HIV issues. ment,” emphasized Dr Ala Alwan.

MIDDLE EAST HEALTHI49 Human Resources

Global health workforce shortage to reach 12.9 million in coming decades

The world will be short of 12.9 million ing corroded in front of our very eyes by fail- healthcare workers by 2035; today, that fig- ing to match today’s supply of professionals The foundations for a ure stands at 7.2 million. A World Health with the demands of tomorrow’s popula- strong and effective health Organization (WHO) report released in tions,” says Dr Marie-Paule Kieny, WHO November warns that the findings - if not Assistant Director-General for Health workforce for the future addressed now - will have serious implica- Systems and Innovation. “To prevent this are being corroded in front tions for the health of billions of people happening, we must rethink and improve of our very eyes by failing across all regions of the world. how we teach, train, deploy and pay health to match today’s supply The report, A Universal Truth: No health workers so that their impact can widen.” without a workforce, identifies several key While the report highlights some en- of professionals with the causes. They include an ageing health couraging developments, for example, demands of tomorrow’s workforce with staff retiring or leaving for more countries have increased their health populations better paid jobs without being replaced, workforce, progressing towards the basic while inversely, not enough young people threshold of 23 skilled health professionals are entering the profession or being ad- per 10,000 people, there are still 83 coun- interventions, but those countries still face equately trained. Increasing demands are tries below this basic threshold. But it is significant challenges linked to the distri- also being put on the sector from a growing the future projections that raise the loudest bution of professionals, their migration and world population with risks of noncommu- alarms. In a stark assessment, the report says appropriate training and skills mix. nicable diseases (e.g. cancer, heart disease, the current rate of training of new health “Training of health professionals must stroke etc.) increasing. Internal and inter- professionals is falling well below current be aligned with the health needs of the national migration of health workers is also and projected demand. The result will be country,” adds Dr Etienne. exacerbating regional imbalances. that in the future, the sick will find it even All countries are urged to heed the sig- The findings were released at the Third harder to get the essential services they nals of shortages. For example, in devel- Global Forum on Human Resources for need and preventive services will suffer. oped countries, 40% of nurses will leave Health together with recommendations Whilst the largest shortages in numeri- health employment in the next decade. on actions to address workforce shortages cal terms are expected to be in parts of With demanding work and relatively low in the era of universal health coverage. Asia, it is in sub-Saharan Africa where the pay, the reality is that many young health The main recommended actions include: shortages will be especially acute. On edu- workers receive too few incentives to stay 1. Increased political and technical cation and training, for example, in the 47 in the profession. leadership in countries to support long- countries of sub-Saharan Africa, just 168 The publication also identifies maternal term human resource development efforts. medical schools exist. Of those countries, and child health as an urgent health work- 2. Collection of reliable data and 11 have no medical schools, and 24 coun- ers’ action area. Around 90% of all mater- strengthening human resource for health tries have only one medical school. nal deaths and 80% of all still births oc- databases. “One of the challenges for achieving cur in 58 countries, largely because those 3. Maximizing the role of mid-level and universal health coverage is ensuring that countries lack trained midwives. Also, community health workers to make front- everyone – especially people in vulnerable of the 6.6 million under-five year olds line health services more accessible and communities and remote areas – has access who died in 2012, most deaths were from acceptable. to well-trained, culturally-sensitive and treatable and preventable diseases. Again, 4. Retention of health workers in coun- competent health staff,” says Dr Carissa more health workers would prevent most tries where the deficits are most acute and Etienne, WHO Regional Director for the of those unnecessary young deaths. greater balancing of the distribution of Americas. “The best strategy for achieving The Third Global Forum for Human Re- health workers geographically. this is by strengthening multidisciplinary sources for Health is the largest event ever 5. Providing mechanisms for the voice, teams at the primary health care level.” held on human resources for health, with rights and responsibilities of health work- Universal Health Coverage aims to en- more than 1300 participants from 85 coun- ers in the development and implementa- sure that all people obtain the health ser- tries, including 40 Ministers of Health. tion of policies and strategies towards Uni- vices they need without suffering financial versal Health Coverage. hardship when paying for them. In the A Universal Truth: No health “The foundations for a strong and effec- Americas, 70% of countries have enough without a workforce tive health workforce for the future are be- health care workers to carry out basic health http://tinyurl.com/otx455h

50 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI51 WHO Malaria Report 2013

Global malaria mortality rates down 45% Global efforts to control and eliminate 2010. The new WHO report notes a slow- This remarkable progress is malaria have saved an estimated 3.3 mil- down in the expansion of interventions to no cause for complacency: lion lives since 2000, reducing malaria control mosquitoes for the second succes- mortality rates by 45% globally and by sive year, particularly in providing access absolute numbers of malaria 49% in Africa, according to the World ma- to insecticide-treated bed nets. This has cases and deaths are not laria report 2013 published by the World been primarily due to lack of funds to pro- going down as fast as they Health Organization (WHO). cure bed nets in countries that have on- could. The fact that so many An expansion of prevention and control going malaria transmission. measures has been mirrored by a consis- In sub-Saharan Africa, the proportion people are infected and tent decline in malaria deaths and illness, of the population with access to an insec- dying from mosquito bites is despite an increase in the global popula- ticide-treated bed net remained well under one of the greatest tragedies tion at risk of malaria between 2000 and 50% in 2013. Only 70 million new bed nets of the 21st century. 2012. Increased political commitment and were delivered to malaria-endemic coun- expanded funding have helped to reduce tries in 2012, below the 150 million mini- incidence of malaria by 29% globally, and mum needed every year to ensure everyone adding billions of dollars to economies by 31% in Africa. at risk is protected. However, in 2013, about that nations can use in other ways.” The large majority of the 3.3 million 136 million nets were delivered, and the lives saved between 2000 and 2012 were pipeline for 2014 looks even stronger (ap- Global funding gap in the ten countries with the highest ma- proximately 200 million), suggesting that International funding for malaria control laria burden, and among children aged less there is real chance for a turnaround. increased from less than US$100 million than five years – the group most affected by There was no such setback for malaria in 2000 to almost $2 billion in 2012. Do- the disease. Over the same period, malaria diagnostic testing, which has continued mestic funding stood at around $0.5 bil- mortality rates in children in Africa were to expand in recent years. Between 2010 lion in the same year, bringing the total reduced by an estimated 54%. and 2012, the proportion of people with international and domestic funding com- suspected malaria who received a diagnos- mitted to malaria control to $2.5 billion But more needs to be done. tic test in the public sector increased from in 2012 – less than half the $5.1 billion “This remarkable progress is no cause for 44% to 64% globally. needed each year to achieve universal ac- complacency: absolute numbers of malaria Access to WHO-recommended artemis- cess to interventions. cases and deaths are not going down as fast inin-based combination therapies (ACTs) has Without adequate and predictable fund- as they could,” says Dr Margaret Chan, also increased, with the number of treatment ing, the progress against malaria is also WHO Director-General. “The fact that so courses delivered to countries rising from 76 threatened by emerging parasite resistance many people are infected and dying from million in 2006 to 331 million in 2012. to artemisinin, the core component of mosquito bites is one of the greatest trag- Despite this progress, millions of people ACTs, and mosquito resistance to insecti- edies of the 21st century.” continue to lack access to diagnosis and cides. Artemisinin resistance has been de- In 2012, there were an estimated 207 quality-assured treatment, particularly in tected in four countries in south-east Asia, million cases of malaria (uncertainty in- countries with weak health systems. The roll- and insecticide resistance has been found terval: 135 – 287 million), which caused out of preventive therapies – recommended in at least 64 countries. approximately 627,000 malaria deaths for infants, children under five and pregnant “The remarkable gains against malaria (uncertainty interval 473.000 – 789,000). women – has also been slow in recent years. are still fragile,” says Dr Robert Newman, An estimated 3.4 billion people continue “To win the fight against malaria we Director of the WHO Global Malaria to be at risk of malaria, mostly in Africa must get the means to prevent and treat Programme. “In the next 10-15 years, the and south-east Asia. Around 80% of ma- the disease to every family who needs it,” world will need innovative tools and tech- laria cases occur in Africa. says Raymond G Chambers, the United nologies, as well as new strategic approach- Nations Secretary General’s Special En- es to sustain and accelerate progress.” Universal access to prevention voy for Financing the Health MDGs and and treatment for Malaria. “Our collective efforts are not World Malaria Report 2013 Malaria prevention suffered a setback af- only ending the needless suffering of mil- www.who.int/malaria/publications/world_ ter its strong build-up between 2005 and lions, but are helping families thrive and malaria_report_2013

52 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI53 Cardiology

Siemens introduces new devices for diagnosis and treatment of cardiovascular diseases l New cardiac catheter for volumetric intracardiac echocardiography l Full cardiac MR possible in less than 30 minutes l New cardiology information system for faster reporting

To support patients, physicians and clinical staff, Siemens has developed products and solutions especially tailored to the diagnosis and treatment of cardiovascular diseases. These include a new cardiac catheter, clinical IT, applications for computed tomography and magnetic resonance imaging and a new system for cardiac molecular imaging. The World Health Organization (WHO) estimates that the number of people dying of cardiovascular diseases will increase to about 23.3 million world-wide by 2030. These diseases, which include coronary heart disease (CHD) and stroke, are already the no. 1 cause of death world-wide. Siemens demonstrated these new products at the European Society of Cardiology (ESC) congress in Amsterdam, the Nether- lands, in September last year.

New intra-cardiac catheter for echocardiography Siemens’ intra-cardiac catheter Siemens is the first to offer real-time volumetric intra-cardiac echocardiography ment (TAVR) surgery – a high-risk pro- patient is under conscious sedation rather (ICE) with the Acuson AcuNav V ultra- cedure often performed on patients who than general anaesthesia. This potentially sound catheter. Real-time ICE delivers cannot tolerate the risks and complica- saves up to two hours in total procedure high quality, radiation-free imaging during tions associated with general anaesthesia time and improves patient outcomes with interventional procedures. The Acuson and mechanical ventilation. By using the faster recovery. The Acuson AcuNav V AcuNav V catheter is particularly useful volumetric ICE catheter, the physician catheter is also useful during electrophysi- during transcatheter aortic valve replace- can perform TAVR procedures while the ology (EP) ablation procedures.

54 IMIDDLE EAST HEALTH New release of Acuson SC2000 cludes breathing tests, pulse monitoring, ner offers a further major benefit for older System with HD transducers planning the examination and adjusting and weaker patients in particular. They Siemens’ high-end Acuson SC2000 ultra- the volume of contrast agent to the pa- often suffer from impaired renal func- sound system enables new abdominal vas- tient’s weight and age. The standardized tion and may experience renal failure in cular imaging capabilities. The Abdominal examination protocols make the results a worst-case scenario if relatively large Vascular Release of the echocardiography highly reproducible. This means that a doses of contrast agent are used. With the platform is equipped for the first time with full heart examination can be performed Somatom Definition Flash, a scan using a high-density curved array probe – the in less than 30 minutes, compared to the only 40 ml of contrast agent is enough to 6C1 HD. This new feature combines the usual hour. The AutoAlign Heart expan- provide the cardiologist with all necessary benefits of HD transducers and IN Focus sion in the new version of the Cardiac information. coherent imaging technology to provide Dot Engine plans diagnostically relevant Traditional scanners may require more high-quality images with enhanced detail sectional planes through the longitudinal than one scan and up to 150 ml of contrast resolution and ease of use in abdominal axis of the heart fully automatically. agent. Contrast agent can also be saved by vascular imaging. In combination with To enable efficient diagnosis of vascular using preliminary CT examinations when Clarify vascular enhancement (VE) tech- diseases based on MR angiography datas- determining the approach angle. If the nology, the transducers improve image ets, Syngo.via offers the new application cardiologist has the information needed to quality in tissue boundary detection and Syngo.MR Vascular Analysis. It enables determine the best angle before surgery in contrast resolution. The available NTEQ physicians to identify vascular diseases the cardiac catheterization laboratory, less technology automatically and intuitively such as stenoses, automatically quantify contrast agent has to be injected to find optimizes the image for easier, more con- the vascular changes and thus diagnose the correct annulus plane. The Syngo CT sistent images. Furthermore, new work- them swiftly and efficiently, with just three Cardiac Function - Valve Pilot application flow enhancement features are available clicks of the mouse. offers a further advantage here, since it on the latest version of Acuson SC2000 automatically determines the ideal angle, system. The Trace Assist Tool enables us- CT scanner software improves which can be transferred directly to the ers to easily trace spectral waveforms for accuracy for TAVI procedures catheterization laboratory. quick vascular measurements. The sys- Computed tomography provides support tem’s workflow applications and automat- for minimally invasive Transcatheter Aor- New cardiology information ed measurement tools, including eSie Left tic Valve Implantation (TAVI). Siemens system for faster workflow Heart (LH) measurement package, can Healthcare has developed new software A new version of the Syngo Dynamics now be quickly accessed through the new that helps physicians determine the right cardiology information system supports eSie Access menu. valve size for the patient and establish the physicians in streamlining the workflow Shown for the first time at ESC Amster- precise angle at which the new valve must and making improvements in clinical use. dam was the improved 4V1c transducer. be inserted even before the intervention Whereas a report previously had to be fully Featuring a significantly smaller contact in the cardiac catheterization laboratory. completed before another user could access area than the previous model, the 4V1c This saves time and reduces the dose of it, Syngo Dynamics now allows numerous transducer enables easier access to rib contrast agent required for the patient dur- users to call up the documentation on a spaces for faster exams on difficult-to-im- ing the intervention, since the important single study simultaneously. This means age patients. information is already available. that physicians, medical staff and techni- To select an appropriate artificial heart cians can work more effectively together, Full cardiac MRI exam possible valve, the physician must determine the which benefits the patient, since reports in less than 30 minutes precise dimensions of the target location, can now be completed more quickly than Magnetic resonance imaging of the heart, the aortic annulus. This elliptical struc- was previously the case. Users now have or cardiac MRI (CMR), supplies detailed ture was previously measured manually access to new, additional documentation information about the morphology and using ultrasound, which was subject to an options that cover the entire reporting function of the heart. It also provides a elevated risk of error. The Syngo CT Car- process, e.g. earlier studies. This saves a visualization of myocardial blood supply, diac Function – Valve Pilot application, step in the process. edemas or scar tissue in the context of di- in combination with 3-D CT imaging, As soon as the documentation is com- agnosing coronary heart disease or various automatically detects the annulus plane pleted, improvements included in the myocardial inflammations. and determines the precise measurements new version of the software ensure that The Cardiac Dot Engine enables physi- of the annulus as the case is opened. The reports can be completed in a shorter cians to examine the heart thoroughly in cardiologist can then select the correct time than before. Using Syngo Dynamics a very short period. It provides standard- size for the implant. This further estab- also permits physicians to better monitor ized clinical examination protocols that lishes TAVI as a lower-risk alternative to the radiation dose. It thus warns physi- are adapted to suit each individual patient open thoracic surgery. The combination cians automatically about excessive doses to shorten the examination time. This in- with the Somatom Definition Flash scan- when they are planning an examination.

MIDDLE EAST HEALTHI55 Cardiology

The new “Automatic Study List” feature from Syngo Dynamics helps draw up reports more quickly. Physicians can thus navigate through the clinically relevant information to complete their reports. A simple dropdown menu replaces the need to call up patient data and older additional information one item at a time.

New system for molecular imaging Myocardial perfusion scintigraphy is a typical exam in the field of molecular imaging. Questions such as ‘How healthy is the heart tissue?’ and ‘How efficiently it is pumping blood to the rest of the body?’ are crucial here. The new positron emission tomography/computed tomography (PET/CT) scanner, Biograph mCT Flow, comes with two features to support cardiovascular care. Siemens’ Biograph mCT Flow The feature HD-Cardiac enables physi- searches the scan data for waves created non-respiratory motion corrected images. cians – for the first time – to correct for by respiratory motion and corrects it to ac- The feature One-Click phase-matched both respiratory and cardiac motion in count for lung movement motion without gating provides automatic accurate phase the heart using single-trigger dual gating. the use of a second trigger. The result is re- registration and quantification of PET HD-Cardiac relies on an electrocardiogra- duced respiratory motion blur, which can and CT cardiac phases. This software phy (ECG) lead to account for the heart provide physicians with improved visual- aligns and synchronizes PET and CT im- motion, while software using a special ex- ization of myocardial tracer distribution, ages with just one click even when ani- traction algorithm developed by Siemens, wall thickness and defect definition over mated.

Trinity Biotech enters cardiac diagnostics with Meritas Troponin I, a novel guideline-compliant point-of-care test

Trinity Biotech, headquartered in Bray, and WHO approved. Ireland, specializes in the develop- Following the acquisition of the for- ment, manufacture and marketing of ward-thinking Swedish company Fio- diagnostic instrumentation and test mi Diagnostics in early 2012, Trinity kits for the clinical laboratory and Biotech has recently entered the point-of-care (POC) environments in field of cardiac diagnostics. Fiomi the areas of infectious disease, auto- Diagnostics has been dedicated to immunity, haemoglobin disorders and the development of accurate and diabetes. Founded in 1992, Trinity precise cardiac biomarker tests Biotech has combined strong organic since its inception. Building on growth with a progressive acquisition- the combined talents of the two led strategy to become a world leader companies, Trinity Biotech embarked on in the international diagnostics indus- a mission to create a unique suite of prod- try. This success has been due to the ucts that would herald a new era in cardiac consistent, excellent quality of its now diagnostics. and acute care clinicians worldwide more than 400 products, which are Historically, there has been a lack of re- recognize the urgent need for labora-

ISO 13485:2003, ISO 9001:2008, FDA liable testing at the point of patient care, tory standard POC testing to ensure t

56 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI57 Cardiology the quality, reliability and accuracy ruled out, allowing the patient to be safely utes. This rapid time-to-results helps of results. Using its diagnostic instru- discharged. to improve patient management and ment expertise, Trinity Biotech’s en- The Meritas Troponin I test is a single outcomes by minimizing unnecessary trepreneurial team has solved this long- use, rapid fluorescence immunoassay for admissions and inappropriate discharge standing problem by creating Meritas, in vitro quantitative determination of of patients, generating significant cost a stateof-the-art analyzer that signals a Troponin I in human whole blood and savings through optimal use of precious new dawn in reliable, accurate point-of- plasma. The straightforward, one-step hospital resources. care testing. assay simply requires the insertion of a Tom Parenteau, Vice President of The groundbreaking Meritas POC sample test cartridge into the analyzer. Cardiovascular Products at Trinity Bio- Analyzer sets a new standard for point- Each cartridge is preprogrammed with a tech, commented: “Precise, accurate of-care testing. Its test menu includes lot number, calibration curve and expiry POC testing is essential to avoid the the pioneering Meritas Troponin I test; date – eliminating the need for manual false positive results that lead to unnec- the only high sensitivity, ESC, ACC, transcription with its associated potential essary admissions, tying up precious hos- and AHA guideline-compliant tro- for errors – and all results are traceable to pital beds, as well as false negatives that ponin assay to offer true point-of-care the NIST SRM 2921 international stan- can result in inappropriate discharge of capability. The Meritas Troponin I test dard, with built-in QC checks to ensure sick patients. The revolutionary Meritas allows rapid, cost-effective and accu- comparable data to top performing labo- is a tremendous asset to the POC envi- rate triage of patients presenting at the ratory analyzers. ronment, offering top quality laboratory emergency department with a possible The Meritas POC Analyzer’s intui- performance with all the known benefits myocardial infarction (MI), enabling tive graphical user interface guides the of point-of-care testing.” earlier diagnosis and timely initiation of operator effortlessly through performing l For more information, visit www. the correct treatment or, when an MI is the test, generating results in just 15 min- meritaspoc.com High-intensity exercise for people with heart disease – is higher better? High-intensity exercise is shown to be following the 4x4 exercise model. The there is a dose-response relationship even protective against coronary heart disease 4x4 exercise model involves 4 minutes in the 85-95% high-intensity zone. (CHD) and is well known as a popular of high-intensity exercise followed by 3 and time-saving approach to getting fit. minutes of moderate-intensity exercise, Answering practical questions But what about people who already have repeated 4 times. Moholdt says that people who start exer- heart disease? Previously, these patients cising using interval training often have were told to exercise, but only at a moder- Interval intensity important lots of practical questions. How much ate intensity to protect their hearts. More “When we compared VO2max before and incline should their treadmill have? Can recently, however, researchers have found after the training period, we found that the they shorten their lower-intensity time to that high-intensity exercise is very ben- number of training sessions, the subject’s just 2 minutes? Why 4 minutes and not 5? eficial for these patients. But how intense age or baseline fitness levels had no im- “Knowing that pushing yourself to over should these sessions actually be? pact,” says Trine Moholdt, a postdoctoral 90 % of HRmax may save you from an extra A new study from the K. G. Jebsen – fellow at the center and lead author of the training session that week encourages us to Center of Exercise in Medicine at the Nor- study. “But the intensity of the intervals investigate even the small details,” says Mo- wegian University of Science and Tech- had a significant effect, and seems to be holdt. “When people give priority to exer- nology (NTNU) in Trondheim, Norway the most important characteristic of an ef- cise in their otherwise busy lives, they want examines this question in detail. Research- fective interval session.” to know that they are doing it the right way. ers analysed data from four randomized, The intensity of the training was cat- At the same time, I want to emphasize that controlled trials conducted at the center egorized according to the participant’s all exercise is better than none! Some peo- to try to determine what characterized the heart rate zone (% of maximum heart ple are not able to exercise at high intensity most effective high-intensity training pro- rate (HRmax)). High-intensity training is because of other health problems, and one gramme for this patient group. when an individual’s HR during intensive should then look for other alternatives.” The researchers used changes in VO- periods is 85-95% of HRmax. The four studies, which were composed of 2max, which is peak oxygen uptake, as a Overall, VO2max increased by 11.9 % patients who either had acute coronary syn- measure of the effectiveness of the differ- after an average of 23.4 training sessions drome or angina pectoris, confirmed previous ent exercise regimes. The study partici- during the 12-week period for all subjects. findings that high-intensity exercise is safe, pants (n=112) were aged 18+ and all had However, when participants exercised at even for patients with CHD. Moholdt says coronary heart disease. The exercise pean intensity that was greater than 92 % it would be interesting to see if these finding riod lasted for 12 weeks. The participants of their HRmax during the high-intensity hold true for healthy subjects, as well as for either ran/walked on a treadmill, walked periods, the effect was even greater than at patients with more severe heart disease. uphill outdoors or trained in a group, all the lower intensity levels, indicating that l doi:10.1016/j.jsams.2013.07.007

58 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI59 Cardiology

In the pilot study, clinicians were able to manipulate the projected 3D heart structures by literally touching the holographic volumes in front of them. 3D holographic visualization used to guide minimally-invasive heart disease procedures Philips Healthcare recently announced during the procedure,” said Dr. Einat clinical evidence of its value for a variety that they have completed a clinical study Birk, pediatric cardiologist and Director of procedures, we are convinced that our that has demonstrated the feasibility of us- of the Institute of Pediatric Cardiology at holographic technology will further ening an innovative live 3D holographic vi- Schneider Children’s Medical Center. hance 3D imaging and, most importantly, sualization and interaction technology to Dr. Elchanan Bruckheimer, pediatric improve patient care.” guide minimally-invasive structural heart cardiologist and Director of the Cardiac Progress in image-guided therapies for disease procedures. In the pilot study that Catheterization Laboratories at Schnei- heart diseases – from the opening of ob- involved eight patients and was conducted der Children’s Medical Center, added: structed coronary arteries to catheter ab- in collaboration with the Schneider Chil- “The ability to reach into the image and lation therapy for heart arrhythmias and dren’s Medical Center in Petach Tikva, apply markings on the soft tissue anatomy catheter-based structural heart repairs Israel, RealView’s innovative visualization in the X-ray and 3D ultrasound images (for example, heart valve replacements) technology was used to display interactive, would be extremely useful for guidance of – have greatly increased the need for live real-time 3D holographic images acquired these complex procedures.” 3D image guidance, to supplement today’s by Philips’ interventional X-ray and car- Bert van Meurs, General Manager of live 2D image guidance. Live X-ray and diac ultrasound systems. Integrated Clinical Solutions and Mar- live 3D cardiac ultrasound imaging are In addition to viewing the patient’s heart keting for Imaging Systems at Philips typically used simultaneously to guide on a 2D screen, doctors in the intervention- Healthcare, said: “Our ultimate goal is to minimally invasive structural heart real team were able to view detailed dynamic create the future of healthcare by deliv- pair procedures, with the ultrasound im- 3D holographic images of the heart ‘floating ering innovative solutions that enhance ages providing detailed insights into the in free space’ during a minimally-invasive clinical capabilities and improve patient heart’s soft tissue anatomy, and the X-ray structural heart disease procedure, without outcomes. By teaming up with partners imaging providing visualization of cath- using special eyewear. The doctors were also that share our passion for innovation, we eters and heart implants. able to manipulate the projected 3D heart have been able to demonstrate the feasi- The technological advancements in structures by literally touching the holo- bility and potential value of the world’s the acquisition of live 3D images to guide graphic volumes in front of them. The study first holographic visualization technology minimally invasive procedures have demonstrated the potential of the technol- targeted at guiding minimally invasive also triggered the development of novel ogy to enhance the context and guidance of cardiac procedures.” ways to visualize the data. Following the structural heart repairs. Aviad Kaufman, CEO of RealView Im- promising results produced by this pilot “The holographic projections enabled aging Ltd, commented: “I see clear indi- study, Philips and RealView Imaging will me to intuitively understand and inter- cations that 3D medical holography will continue to explore the clinical value of rogate the 3D spatial anatomy of the pa- play an important role in medical imag- combining live 3D imaging and medical tient’s heart, as well as to navigate and ing in the near future. With the advance- holography, both in interventional cardi- appreciate the device-tissue interaction ment of live 3D imaging and increasing ology and in other clinical areas.

60 IMIDDLE EAST HEALTH Researchers show how a modified pacemaker strengthens failing hearts

Johns Hopkins heart researchers are un- In their experiments, the researchers ravelling the mystery of how a modified used an animal model of heart failure with pacemaker used to treat many patients dyssynchrony and also examined the im- These discoveries with heart failure, known as cardiac re- pact of CRT on the heart. By studying iso- potentially give us synchronization therapy (CRT), is able to lated muscle tissue and muscle cells, they new pathways to strengthen the heart muscle while making examined the relationship between con- benefit more heart it beat in a coordinated fashion. In a new traction and the calcium that triggers it. In study conducted on animal heart cells de- the hearts that beat out of sync, force from failure patients. scribed in the Journal of Clinical Investiga- the muscle cells and the level of calcium tion, the scientists show that CRT changes needed to generate contractions were very these cells so they can contract more much reduced. CRT improved contraction forcefully. The researchers also identified force more than calcium, and this led to same amount of calcium-based activation. an enzyme that mimics this effect of CRT the discovery that CRT had increased the “It had never been shown before that without use of the device. sensitivity of the muscle to calcium. GSK-3 beta could modify motor proteins “These discoveries potentially give us The next question was how this change in the heart to make them more sensitive new pathways to benefit more heart failure had occurred. Calcium sensitivity is a to calcium. It is surprising that this same patients – not only those whose hearts beat property of the proteins that form the con- type of effect can be produced by a pace- out of sync, but also those who currently do tracting “engine” of muscle, so the inves- maker therapy like CRT,” says Prof Kass. not qualify for CRT therapy yet still need tigators examined how these proteins had Nearly all existing medications for heart an effective treatment to help their heart been biochemically altered by CRT. After failure increase heart contraction by en- pump stronger,” says David Kass, M.D., pro- ruling out all the known ways this might hancing levels of calcium available to fessor of medicine and biomedical engineer- have occurred, they turned to a newer ap- muscle cells, but over time, these higher ing at the Johns Hopkins University School proach, testing for changes in more than levels can be toxic to the heart. of Medicine and senior author of the study. 150 proteins and discovered that CRT spe- Altering the calcium sensitivity of the “Understanding the inner workings of CRT cifically modified 13 of them. muscle is not the only way CRT can im- at the biological level may lead, in essence, “Once we discovered which proteins were prove heart function. In a study published to a ‘pacemaker in a bottle’.” being altered, we were able to identify an in 2011, Prof Kass and colleagues also The researchers say their ultimate goals enzyme likely responsible for these changes,” showed that CRT enables heart muscle to are to develop drugs or genetic therapies noted lead author Jonathan Kirk, Ph.D., a respond to hormones, such as adrenaline, that strengthen failing hearts and to de- post-doctoral fellow at the Johns Hopkins which stimulates pumping ability, in a sim- sign a test to identify patients who would University School of Medicine. Working ilar way to what happens during exercise. be most likely to benefit from CRT. with heart muscle and isolated cells from the The Kass Lab played a key role in devel- Prof Kass explains that while the typical same animal models, the researchers found oping CRT for use in patients in the late implanted pacemaker has only one wire that the enzyme turned out to be GSK-3 1990s. The US Food and Drug Adminis- that stimulates the right side of the heart, beta, which was able to convert the behav- tration approved CRT in 2001, and it is the CRT pacemaker has two wires. The iour of muscle cells from a heart that was widely used today to improve symptoms second wire goes to the surface of the left beating out of sync to what looked like heart and help people live longer. side of the heart to enable both sides of the cells that had received CRT, essentially In an unusual twist to the way therapies heart to be stimulated together. mimicking the effect of CRT. are usually developed, CRT was first tested CRT helps people whose hearts beat In further lab experiments, Prof Kass and in patients, but the biological mechanisms out of sync – one side is activated to his colleagues found that although GSK-3 as to why it worked were not understood. “beat” before the other, preventing the beta was inactive in muscle from a failing The new work is running the discovery muscle from pumping blood evenly. This and dyssynchronous heart, it was reac- clock backwards, revealing these mecha- condition is known as dyssynchrony. tivated by CRT. When that happened, nisms and their potential to benefit many CRT “paces” the rhythms of both sides to the enzyme altered the motor proteins so patients with heart failure. restore a coordinated beat. that they generated greater force using the l doi:10.1172/JCI69253

MIDDLE EAST HEALTHI61 Cardiology

Valve repair or replacement offers similar outcomes for severe heart valve disease Study provides first rigorous comparison of these two surgical options for leaky mitral valves

Repair or replace? Consumers often ask School of Medicine, Philadelphia, who will who had been diagnosed with severe IMR. this question when considering faulty present the results at the American Heart These patients were then evenly random- cars, appliances, or other equipment. A Association (AHA) Scientific Sessions in ized to receive surgical repair (a valve tight- new clinical study has now addressed this Dallas. “The medical community has re- ening procedure called an annuloplasty) or question for a serious medical decision: cently gravitated towards valve repair as a a prosthetic replacement mitral valve. how to treat ischemic mitral regurgitation preferred treatment option for IMR. The The participants were then monitored (IMR), a condition in which blood back- evidence this study presents does not sug- at one, six and 12 months after their flows into the heart because the mitral gest mitral valve repair is superior.” procedure. The investigators examined valve becomes leaky after a heart attack. The results of the Severe Mitral Regur- how well the surgery worked by measur- The study compared the two surgical op- gitation (SMR) trial will be published No- ing the shrinkage of the heart’s left ven- tions – re-tightening the leaky mitral tricle, which enlarges with chronic valve valve or replacing it with a prosthetic – People who have leakage. The study also measured various and found no significant differences in ischemic mitral health outcomes as well as patient-assessed patient outcomes after a year. quality of life. This was the first randomized clinical regurgitation not only After a year of follow-up, there were al- trial comparing these two approaches for have bad valves, they most no differences in ventricle shrinkage IMR. It was carried out by the Cardiotho- have bad hearts. It’s or health outcomes between the two treat- racic Surgical Trials Network (CTSN), a critical we know the ments. The only significant change was a consortium supported by the US National higher rate of recurrent regurgitation in the Heart, Lung, and Blood Institute (NHLBI) right procedure for repair group (32.6% of repair patients ver- and the US National Institute of Neuro- these patients. sus 2.3% of replacement patients). logical Disorders and Stroke (NINDS) of “The increased level of recurrent re- the US National Institute of Health, along vember 18, 2013 in the New England Jour- gurgitation falls in line with valve re- with the Canadian Institutes of Health nal of Medicine. placement offering more durable long- Research (CIHR). IMR affects over 1 million people in the term protection,” noted Annetine “This study addressed an important United States and can pose serious health Gelijns, Ph.D., CTSN investigator at question for a clinically vulnerable patient consequences. The leaky valve, by forcing the Icahn School of Medicine at Mount group,” said Michael Lauer, M.D., director the heart to pump some blood backward, Sinai in New York City, and correspond- of NHLBI’s Division of Cardiovascular Sci- makes the heart work harder, which can ing author of the study. “However, such ences. “People who have ischemic mitral eventually lead to heart failure, stroke, or regurgitation did not lead to any notice- regurgitation not only have bad valves, sudden cardiac arrest. In severe cases, re- able increases of health problems among they have bad hearts. It’s critical we know pairing or replacing the mitral valve is nec- patients in the repair group.” the right procedure for these patients.” essary. Both approaches offer benefits and Gelijns said the SMR study will continue Although the CTSN study did not find risks, but as of yet no study has rigorously to monitor the participants until they reach differences in health outcomes, the results evaluated these approaches to see if the 24 months post-procedure, to see if long- still provide implications for surgeons, noted trade-offs result in significant differences in term differences emerge, which may help CTSN investigator Michael Acker, M.D., patient outcomes. identify patient groups better suited for re- of the University of Pennsylvania Perelman The SMR study enrolled 251 patients pair or replacement.

62 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI63 Cardiology

‘Virtual heart’ helps guide defibrillator placement in children with heart disease

The small size and abnormal anatomy of other end is inserted into one of the heart’s children born with heart defects often chambers, a standard and well-tested con- force doctors to place lifesaving defibrilla- figuration. But in children with tiny or tors entirely outside the heart, rather than malformed hearts, the entire device has to partly inside – a less-than-ideal solution to be positioned externally, an often imper- dangerous heart rhythms that involves a fect setup. Such less-than-precisely posi- degree of guesstimating and can compro- tioned defibrillators can fire unnecessarily These are lifesaving mise therapy. or, worse, fail to fire when needed to shock devices, but they can Now, by marrying simple MRI images a child’s heart back into normal rhythm, with sophisticated computer analysis, a experts say. In addition, devices that are feel like a horse kick team of Johns Hopkins researchers says it not positioned well can pack a punch, to the chest and really may be possible to take the guesswork out delivering ultra-strong, painful jolts that traumatize children. of the process by using a virtual 3-D heart frighten children and could even damage model that analyzes a child’s unique anato- heart cells. my and pinpoints the best location for the “These are lifesaving devices, but they device before it is implanted. can feel like a horse kick to the chest and A description of the team’s work is pub- really traumatize children,” Dr Crosson says. lished in The Journal of Physiology. With the Johns Hopkins heart model, “Pediatric cardiologists have long sought scientists say they can find exactly where A particular advantage of the model is its a way to optimize device placement in this in relation to a patient’s heart the device true-to-life complexity. The model was built group of cardiac patients, and we believe would be best able to reset the heart by using digital representations of the heart’s our model does just that,” says lead inves- using the least amount of energy and subcellular, cellular, muscular and connec- tigator Natalia Trayanova, Ph.D., the Mur- gentlest shock. This translates into lon- tive structures – from ions and cardiac pro- ray B. Sachs Professor of Biomedical Engi- ger battery life for the device as well, Prof teins to muscle fibre and tissue. The com- neering at Johns Hopkins. “It is a critical Trayanova says. puter model also included the bones, fat and first step toward bringing computational To build the model, the Johns Hop- lungs that surround the heart. analysis to the pediatric cardiology clinic.” kins team started out with simple, low- “Heart function is astounding in its If further studies show the model has resolution MRI heart scans of a child complexity and person-to-person variabil- value in patients, it could spare many born without a tricuspid valve and right ity, and subtle shifts in how one protein children with heart disease from repeat ventricle. Based on these images, the re- interacts with another may have profound procedures that are sometimes needed to searchers developed a 3-D computer model consequences on its pumping and elec- re-position the device, says co-investigator that allowed them to simulate a danger- tric function,” Prof Trayanova says. “We Jane Crosson, M.D., a pediatric cardiolo- ous rhythm disturbance during which the wanted to capture that level of specificity gist and arrhythmia specialist at the Johns heart’s strong, regular beats degenerate to ensure predictive accuracy.” Hopkins Children’s Center. into weak quivers that, if uninterrupted, Prof Trayanova and her team also have “It’s like having a virtual electrophysi- could kill in minutes. The model predicted designed image-based models that pin- ology lab where we can predict best out- how effectively the defibrillator would ter- point arrhythmia-triggering hot spots comes before we even touch the patient,” minate this dangerous rhythm when locat- in the adult heart muscle and can help Dr Crosson says. ed in each one of 11 positions around the guide therapeutic ablation of such areas. In adults and in children with normal heart. Based on the model, the scientists The new pediatric virtual heart, howev- size and heart anatomy, one part of the de- determined that two particular positions er, is the team’s first foray into pediatric vice lies under the collar bone, while the rendered therapy optimal. cardiology.

64 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI65 Computed Tomography

GE Healthcare’s Revolution CT scans the heart in one beat with high definition, motion free imaging and low dose radiation (80kV / 500mA / 0.28sec rotation / BMI 23 / 55 bpm / 0.9mSv) GE Healthcare’s new, ultra-fast CT scanner freezes the heart’s motion in one beat without sacrificing image quality

GE Healthcare, announced at the RSNA in Chicago in November, that its 510(k)- pending Revolution CT has captured a motion free image of the human heart in just one beat. This innovative technology enables clinicians to non-invasively visualize the human heart more clearly than ever before, and diagnose more patients with erratic or high heart beats. According to published literature (the British Journal of Radiology), more than 60% of patients referred to cardiac CT were found to have heart rates higher than 60 beats per minute, and some are turned away from being scanned. With Revolu- tion CT, clinicians can clearly see specific areas of the heart that were previously compromised either by a patient’s move- tion CT converges these three technologi- ment, high heart rate, or a child’s inability cal advances into one CT system. to hold his or her breath. “This is innovation at its best and is re- gational clinical images to demonstrate the The images were captured by Dr. Ri- ally an all-in-one scanner,” said Dr Cury. capabilities of the scanner were obtained cardo C. Cury, chairman of Radiology “Diagnostic quality images are now possible in collaboration with West Kendall Baptist and director of Cardiac Imaging at Baptist in challenging patients like those with high Hospital (WKBH). Dr. Cury served as prin- Health South Florida. According to Dr heart rates, which is a significant advance- cipal investigator for this study. Cury, physicians no longer will be forced ment. The impressive ability of Revolution In a cost-constrained healthcare envi- to choose between CT systems with wide to combine coverage, spatial and temporal ronment, clinicians need one definitive coverage, high spatial resolution (clear im- resolution in a single scanner will translate test that gives them the diagnostic confi- age), or high temporal resolution (speed). to many clinical applications and potential- dence to make the right treatment decision For the first time, GE Healthcare’s Revolu- ly new applications in the future.” Investi- for their patients. GE Healthcare’s Revolu-

66 IMIDDLE EAST HEALTH tion CT makes this possible through the microns for visualizing small anatomy, This will be the first convergence of spatial resolution, tempo- and a 0.28 second gantry designed and CT scanner that’s right ral resolution, coverage, and low dose all- tested for up to 0.2 sec rotation speed. in-one, providing uncompromised image Combined with SnapShot Freeze motion for everybody in every quality and clinical capabilities. correction technology, the system deliv- clinical specialty. ers 24 msec effective temporal resolution Clinical exams for high heart rate imaging without re- as GE Healthcare is also introducing a This convergence enables the following strictions. revolutionary new user interface based advanced clinical exams: The Revolution CT continues GE’s on inputs from hundreds of clinicians l Comprehensive cardiac exams with commitment to lower CT doses, with and technologists around the world. With anatomic and functional information in innovations such as the new Gemstone Revolution, advanced imaging will now just one heartbeat, even with challenging Clarity detector, a dedicated 70kVp scan be routine, and routine imaging more ad- patients and higher heart rates mode for pediatric use, and ASiR-V, GE’s vanced. l Rapid, whole-brain stroke assessment next generation of iterative reconstruc- “This will be the first CT scanner that’s at low dose tion technology. right for everybody in every clinical spe- l Dynamic liver, kidney, or pancreas For the patient, the system provides a cialty,” said Steve Gray, president and oncology workup personalized with perfu- wider, more comfortable 80cm bore and CEO of MICT & AW for GE Healthcare. sion and vascular flow analysis. a quiet scanning experience with the new “Revolution CT is able to scan even the The Revolution CT’s technological Whisper Drive system. Ultra-fast scanning most challenging patients, day in and day advances include the 16 cm Gemstone with streamlined workflow makes it a per- out, with remarkably clear images. And, Clarity detector for whole organ cover- fect scanner for emergency rooms. we made sure that using it is productive, age, best-in-class spatial resolution at 230 Revolution CT will be easier to use logical, and intuitive.”

Siemens’ new Symbia Intevo fully integrates SPECT and CT data for the first time Siemens Healthcare recently introduced Symbia Intevo, the first system to fully integrate single-photon emission computed tomography (SPECT) and computed tomography (CT), thus leveraging the high resolution of CT to enable more accurate lesion characterization and early treatment follow-up. Symbia Intevo is the world’s first xSPECT system, a new modality that integrates the full data sets of both SPECT and CT. The resulting level of detail helps differentiate clinical conditions more precisely, for instance distinguishing degenerative bone loss from malignant disease. For the first time, Symbia Intevo provides quantitative images for more reliable monitoring and Symbia Intevo, the world’s first xSPECT system, is a new modality that integrates the full data sets of evaluation of treatment response. both SPECT and CT. The resulting level of detail helps differentiate clinical conditions more precisely, Until now, SPECT/CT has been for instance distinguishing degenerative bone loss from malignant disease. based on separate reconstruction of the they result from compromise: The high- enables basic anatomical localization SPECT and CT images that are then resolution CT images must be reduced of disease, the inherent misalignment mechanically fused. Those SPECT/CT to the low-fidelity frame of reference of of SPECT and CT limits a physician’s

images are inherently blurry because the SPECT image. While this method ability to characterize and follow t

MIDDLE EAST HEALTHI67 Computed Tomography

disease. Historically, physicians have bit computer, which allows high-resolution Quantification of tracer uptake used the CT images for localization image reconstruction. provides a numerical indication of a and the SPECT images to indicate The xSPECT modality deploys advanced tumour’s level of metabolic activity. metabolic activity, intuitively algorithms that leverage the attenuation With the xSPECT Quant feature, the correcting the localization of SPECT coefficients1 to index each voxel2 into physician can apply this quantitative images with the CT information. one of five classes: air, adipose, soft tissue, information as an aid in assessing a Siemens’ new Symbia Intevo xSPECT spongious bone and cortical bone. These patient’s response to therapy over system reduces the need for this provide the basis for a patient-specific linear time. “correction in the mind’s eye” with its attenuation map that can especially improve While Symbia Intevo uses more CT new technology that uses CT as the frame the resolution of bone images, which is very data than ever before, Siemens is still able of reference instead of SPECT, enabling challenging for conventional SPECT/CTs. to limit patient dose by offering combined full integration of SPECT and CT data. That way, xSPECT images show excellent applications to reduce exposure (CARE). This method is built on new hardware delineation between bone and soft tissue and Unique to Siemens, these applications and an iterative reconstruction algorithm the lesions present within, which aids the include the CARE Dose4D technique, that accounts for detector motion, physician to distinguish between cancerous which can reduce patient CT radiation gantry deflections, the sizes and shapes lesions and degenerative disorders. dose by up to 68%. of collimator holes, and the distance of The precise alignment of SPECT and 1 Indication of the level of absorption the patient from the detectors. The raw CT data with xSPECT also enables and scattering of the radiation beam data from SPECT and CT acquisitions tracer absolute quantification, which when passing a given material. are processed using a state-of-the-art, 64- was only possible with PET/CT before. 2 Data element in a 3D image. Philips introduces digital PET/CT system and Spectral CT system

At the RSNA in Chicago in November, Philips Healthcare introduced two fundamentally new developments: its Vereos PET/CT fully digital positron emission tomography/computed tomography (PET/ nosis are critical CT) imaging system, and its IQon Spec- to the success- tral CT spectral detector-based computed ful treatment of tomography (CT) imaging system. many diseases,” Philips Healthcare’s These new innovations further expand commented Pab- new Vereos PET/CT Philips’ integrated radiology product. lo Ros, M.D., Chairman of the Department injected into the patient prior to the exam, “We work closely with radiologists to of Radiology, University Hospitals Case which accumulates in the body’s tissue and understand their biggest challenges, and Medical Center and Case Western Reserve organs, and decays. The PET detector cap- incorporate these understandings in the University, Cleveland, Ohio. “With that in tures pairs of photons that are emitted from development of innovative products like mind, we are excited to have contributed to the body during this decay process and forms Vereos PET/CT and IQon Spectral CT to the development of Philips’ Vereos digital the image. Based on Philips’ proprietary meet their complex imaging needs,” said PET/CT and IQon Spectral CT systems and ‘Digital Photon Counting’ technology, the Gene Saragnese, CEO, Imaging Systems we will continue to collaborate with Philips Vereos PET/CT is the first PET/CT system at Philips Healthcare. “These innovations to realize the potential of these next genera- in the industry to use innovative digital sili- demonstrate how Philips is providing radiol- tion imaging systems.” con photomultiplier detectors instead of tra- ogists with exceptional quality and accuracy ditional analog detectors, resulting in a step in imaging at low dose rates, helping clini- Vereos PET/CT change in performance that includes an ap- cians to get answers, the first time around, PET scans are three-dimensional images proximately two-times increase in sensitivity so that they can deliver accurate and more that provide insight into what is happening gain, volumetric resolution and quantitative confident diagnoses to patients.” inside the body at the molecular and cellu- accuracy compared to analog systems. These “The timing and precision of disease diag- lar level. A small amount of radiotracer is radical improvements can ultimately be

68 IMIDDLE EAST HEALTH translated into high image quality, increased spectral imaging. It uses colour to identify ability to characterize structures based on diagnostic confidence, improved treatment the composition of an image without in- their material makeup within a single scan. planning and faster workflows. volving time-consuming protocols. In the After a spectral CT examination, clini- “Personalized medicine will require a same way that white light is made up of a cians can interpret the conventional grey- patient-specific picture of the functional spectrum of colours, the X-ray beam used scale anatomical images, and if necessary, processes associated with disease,” added in CT scanners also consists of a spectrum access the spectral information that was Pablo Ros, M.D. “Accurate quantification of X-ray energies. With the development of acquired during the same scan. The IQon of processes is therefore an important re- a fundamentally new spectral detector that Spectral CT system’s retrospective on- quirement for functional imaging in diag- can discriminate between X-ray photons of demand data analysis is made possible via nosis, therapy and research. The quantita- multiple high and low energies simultane- Philips’ iPatient platform, allowing clini- tive accuracy and remarkably clear images ously, Philips’ IQon Spectral CT adds a new cians to easily experience the benefits of that the new digital PET/CT system deliv- dimension to CT imaging, delivering not spectral CT routinely within traditional ers are a key step forward.” only anatomical information but also the radiology workflows. Philips has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) to market its digital PET/CT system in the U.S.

IQon Spectral CT Philips’ second RSNA introduction – its IQon Spectral CT system – is the world’s first spectral-detector CT system built from the ground up for

A clinical image taken with Philips Vereos PET/CT

MIDDLE EAST HEALTHI69 Computed Tomography

Advanced CT imaging proves as accurate as invasive tests to assess heart blockages An ultrafast, 320-detector computed to- other evidence. Many people in that patients having chest pain – without evi- mography (CT) scanner that shows both situation are sent to a cardiac catheter- dence of a heart attack – need an invasive anatomy within coronary arteries and ization laboratory for further evaluation procedure to open an arterial blockage,” blood flowcan accurately sort out which with angiography, an invasive test to look says cardiologist Richard George, M.D., an people need – or don’t need – an inva- for blockages in the coronary arteries us- associate professor of medicine at the Johns sive procedure to identify coronary blocking dye and special X-rays. About 30% Hopkins University School of Medicine ages, according to an international study. of people who have such catheterization and a co-author of the study. The researchers say their findings could are found to have minimal disease or no “The CTP test added significant in- potentially save millions of people world- blockage requiring an intervention to formation about the patients’ conditions wide from having an unnecessary cardiac open the vessel with a stent or bypass the and boosted our ability to identify those catheterization. vessel through surgery, says Lima. whose blockages were severe enough The study, known as CORE 320, in- The 381 patients who completed the to reduce blood flow to the heart,” adds volved 381 patients at 16 hospitals in study had traditional single-photon emis- George, who developed the CTP method eight countries. An article on the results sion computed tomography (SPECT) with Lima. was published online by the European tests and invasive angiography. Lima says The 320-detector CT provides a com- Heart Journal on November 19, 2013. SPECT, a stress test with imaging, shows plete picture of the heart by making just In the study, participants were evaluated reduced blood flow to the heart without one revolution around the body. The with a 320-detector CT and conventional indicating the number or specific location researchers say the two tests combined – tests that are widely used today. The re- of blockages. CTA and CTP – still produce less radia- searchers say 91% of those in whom the CT Study participants also had two types tion than a scan with the 64-detector CT scan ruled out blockages would not have of tests with a non-invasive 320-detec- scanner in widespread use today. required invasive treatment such as stent- tor CT scanner. In the first CT test, the “In our study, the amount of radiation ing or bypass surgery. So those patients, scanner was used to see the anatomy of exposure to patients from the two 320-de- none of whom had a history of coronary vessels to assess whether and where there tector CT tests was half the amount they artery disease, could have avoided invasive were blockages. That test is known as received as a result of the traditional tests because for them the CT scan was just CTA, in which the “A” stands for angi- evaluation methods – the angiogram and as accurate in determining who would be a ography. Then, in a second CT test with nuclear medicine stress test combined,” good candidate for revascularization as the the same machine, patients were given a says Lima. conventional tests. medication that dilates blood vessels and The researchers say they will continue “Ours is the first prospective, multi- increases blood flow to the heart in ways to follow the patients in the study for five center study to examine the diagnostic similar to what happens during a stress years, looking for any heart-related events accuracy of CT for assessing blockages test. The second test is called CTP, with such as heart attacks, as well as hospital in blood vessels and determining which the “P” standing for perfusion. admissions, procedures or operations. of those blockages may be preventing the “We found that the 320-detector CT The Johns Hopkins Hospital is among heart from getting adequate blood flow,” scanner allowed us to see the anatomy of the hospitals in the United States that says Joao A. C. Lima, M.D., senior author the blockages and determine whether the participated in the CORE 320 study, of the study and a professor of medicine blockages were causing a lack of perfu- along with hospitals in Germany, Canada, and radiology at the Johns Hopkins Uni- sion to the heart,” says lead author Carlos Brazil, the Netherlands, Denmark, Japan versity School of Medicine. “We found E. Rochitte, M.D., a cardiologist at the and Singapore. Images obtained during an excellent correlation in results when Heart Institute (InCor), University of the study were evaluated in core laborato- we compared the 320-detector CT testing São Paulo Medical School, in Brazil, “We ries at Johns Hopkins and at the Brigham with the traditional means of assessment were therefore able to correctly identify and Women’s Hospital in Boston. using a stress test with imaging and car- the patients who needed revascularization The study was sponsored by Toshiba diac catheterization.” within 30 days of their evaluation.” Medical Systems Corporation. The com- The study findings, says Lima, would “Many patients are sent for an angioplas- pany was not involved in the study de- apply to people who have chest pain but ty when they may not need it. Our ultimate sign, data acquisition, data analysis or not a heart attack based on EKG and goal is to have more certainty about which manuscript preparation.

70 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI71 Oncology

Interview Is colon cancer preventable?

Colorectal cancer is the third most common cancer in the world and its prevalence is increasing rapidly in certain regions. Middle East Health speaks to Professor Heinz-Josef Lenz, an eminent cancer research specialist based at the University of Southern California Keck School of Medicine, about the disease, its epidemiology, and options for prevention and treatment. n Middle East Health: What exactly style factors. It is also very important to is colorectal cancer? Are there known recognize the symptoms of colon cancer. If causes of its development? Can it be in- the cancer is in the left side of the colon herited? What is the risk of it spreading the symptoms are usually easy to recognize in the body? and include constipation and diarrhoea, Professor Heinz-Josef Lenz: Colon can- blood in the stool, pain with bowel move- cer is one of the most common cancers in ments and others. However, if the cancer the world and one of fasted growing cancers grows on the right side, the symptoms are in Asia. Most colon cancers develop from a less characteristic and can be like abdomi- Professor Heinz-Josef Lenz polyp which is a benign growth of the inner nal discomfort and are often mistreated as lining of the gut. The most interesting fact stomach upset. Any on-going abdominal of the development of colon cancer is that discomfort should be evaluated and a colo- position, we can successfully prevent any we can very effectively prevent it since it noscopy considered. patient in this family dying from colon is present in precancerous form, which we In addition to the lifestyle factors lead- cancer while undergoing surveillance. can, in most cases, easily spot as a polyp. ing to colon cancer, there is also a famil- Most of the colon cancer develops within ial form called Lynch Syndrome. If there n MEH: What is the epidemiology of 5-10 years, giving us a unique opportunity is any family history of colon cancer and colorectal cancer – in the World, the US, to prevent this cancer with colonoscopies possible ovarian endometrium or gastric Europe, Asia and the Middle East (for which can identify the polyp and then it cancer, the person should to be evaluated comparison)? can be easily removed. Since colon cancer for a possible genetic predisposition. Pa- HJL: The highest incidence of colon usually develops in patients older than 50 tients with a genetic predisposition devel- cancer is in the Western world, South years we recommend a baseline colonos- op colon cancer much earlier (under age America, and now also in Asia following copy at 50 years and then every 5-10 years of 50) and often on the right side without the spread of Western diet in the world. In depending on the findings. developing polyps. These patients need to the US, the incidence has been decreas- We also know very well the risk factors be seen by a genetic counsellor and un- ing mainly due to more screening with for colon cancer. The main factors are red dergo specific surveillance. We know from colonoscopies. Asia now has a higher inci- meat, alcohol, obesity and many other life- studies, if we identify this genetic predis- dence than the US – Japan has double the

72 IMIDDLE EAST HEALTH The most interesting fact of the development of colon cancer is that we can very effectively prevent it since it is present in precancerous form, which we can, in most cases, easily spot as a polyp. Most of the colon cancer develops within 5-10 years, giving us a unique opportunity to prevent this cancer with colonoscopies which can identify the polyp and then it can be easily removed. incidence of the US – because of the change of lifestyle, increasing consumption of a Western diet and less exercise, increasing obesity and more alcohol. n MEH: Is there a gender bias? If so, why? HJL: Yes there is a link to gender. We know that premenopausal women have significant decrease in the risk of colon cancer. We also know that women who take hormonal replacement have lower risk of colon cancer. This might be only effective on the right side of the colon. However, postmenopausal women have the same risk or maybe higher risk than men. We know that oestrogen plays a role in the right-sided colon cancer and the premenopausal level of oestrogen can prevent the development of disease. n MEH: What are the mortality figures for colorectal cancer? How does it rank (for mortality) compared to other diseases? HJL: Overall, colon cancer is the third most common disease and one of the most lethal (2nd) depending what statistics you look at. It is a major health problem around the world. n MEH: What do you recommend doctors tell their patients with regards prevention? HJL: My recommendation is to avoid red meat, decrease alcohol consumption, have regular exercise and eat the Mediterranean diet. Get colonoscopy at 50 and if there is any family history of the disease you may need to check for the disease earlier. If there are any on-going symptoms in the abdomen, make sure that a colonoscopy is considered. Colon cancer can be easily prevented with regular exercise 20 minutes twice a week, which reduces the risk of colon cancer by 50%. n MEH: Once diagnosed – how do you classify the different stages of progression / advancement of the cancer? HJL: Depending on the stage of the colon cancer, we do surgery, chemotherapy and radiation. For colon cancer located in the rectum, we usually – depending on the tumour size – give chemo and radiation prior to the surgery. For most colon cancers we perform surgery, but this depends on the tumour growth in the bowel wall and if the cancer travelled to the lymph nodes or spread to other organs. We stage the cancer as I, 2, 3 or 4. Stage I and II disease usually don’t require any further therapy and over 80-90% are cured. For patients with stage III colon cancer, which indicates that cancer cells were found in regional lymph nodes, patients receive six months of che-

MIDDLE EAST HEALTHI73 Oncology

Oncology Conference in Abu Dhabi in understanding of the molecular make up of November last year). Can you tell us colon cancer will not only help to select about these options? patients, but identify new treatment op- JHL: The introduction of the novel tions. We are in the middle of a molecular We are in the middle of drug regorafenib is important because it revolution and I have no doubt that we a molecular revolution gives the oncologist a new tool in their will find better therapies using our increas- fight against colon cancer. It is a ‘smart ing knowledge of the molecular pathways and I have no doubt drug’ targeting a very important genetic in this disease. that we will find better alteration in colon cancer enabling the therapies using our disease to grow and metastasize. This oral HJL: MEH: Do you have any specific increasing knowledge of medication has shown that it prolongs life recommendations for doctors and / or in patients who have exhausted the stan- health authorities in the Middle East? the molecular pathways dard therapies. This drug has a very unique JHL: I have always been impressed by in this disease. mechanism of action which explains its ef- the knowledge and training of oncologists ficacy in patients with colon cancer. It is in the Middle East. I have no doubt that also easy to give and well tolerated. the new treatments and the new molecular testing will be quickly integrated in the MEH: Is colorectal cancer curable? treatment of patients with colon cancer in Heinz-Josef Lenz is Professor of JHL: Colon cancer is a unique disease. the Middle East. We can only understand Medicine and Professor of Preventive Even when the disease has metastasized to this disease with global collaborations. We Medicine, University of Southern the liver, we still have a chance for cure. unfortunately know very little about colon California Keck School of Medicine. This is completely different to other can- cancer in the Middle East since aetiology Professor Lenz holds the Kathryn Bal- cers, such as lung or breast cancer. It has and different ethnic backgrounds may akrishnan Chair for Cancer Research, to do with the special metastatic pattern of play a role in the development, progres- and is Associate Director, Clinical the disease and the ability to remove suc- sion and outcome of patients with colon Research, Co-Chair of GI Oncology, cessful liver metastases, since liver is the cancer. It would be incredibly exciting to Co-Director USC Center for Molecu- only organ which can rejuvenate. With better understand the genetic background lar Pathways and Drug Discover at the increasing efficacy of our therapies we will and molecular make up of colon cancer in University of Southern California Keck cure more and more patients. The chal- this region. School of Medicine and USC/Norris lenge in the future will be using molecular Comprehensive Cancer Center in Los testing to identify patients who benefit the OncLive - Colorectal cancer Angeles, California. most from our therapies and the increased http://tinyurl.com/oe9co9o Global cancer burden rises to 14.1 million new cases in 2012 Data shows significant increase in breast cancers

The International Agency for Research terns of cancer in women and emphasises were 32.6 million people (over the age of 15 on Cancer (IARC), the specialized cancer that priority should be given to cancer pre- years) alive who had had a cancer diagnosed agency of the World Health Organization, vention and control measures for breast and in the previous five years. released in December the latest data on cervical cancers globally. The most commonly diagnosed can- cancer incidence, mortality, and prevalence cers worldwide were those of the lung worldwide. The new version of IARC’s on- Global burden (1.8 million, 13.0% of the total), breast line database, GLOBOCAN 2012, provides According to GLOBOCAN 2012, an esti- (1.7 million, 11.9%), and colorectum the most recent estimates for 28 types of mated 14.1 million new cancer cases and (1.4 million, 9.7%). The most common cancer in 184 countries worldwide and of- 8.2 million cancer-related deaths occurred causes of cancer death were cancers of fers a comprehensive overview of the global in 2012, compared with 12.7 million and the lung (1.6 million, 19.4% of the to- cancer burden. 7.6 million, respectively, in 2008. Preva- tal), liver (0.8 million, 9.1%), and stom- GLOBOCAN 2012 reveals striking pat- lence estimates for 2012 show that there ach (0.7 million, 8.8%).

74 IMIDDLE EAST HEALTH Projections based on the GLOBOCAN “Breast cancer is also a leading cause of 2012 estimates predict a substantive in- cancer death in the less developed countries crease to 19.3 million new cancer cases per of the world. This is partly because a shift in year by 2025, due to growth and ageing of lifestyles is causing an increase in incidence, the global population. More than half of all and partly because clinical advances to Breast cancer is also the cancers (56.8%) and cancer deaths (64.9%) combat the disease are not reaching women most common cause in 2012 occurred in less developed regions living in these regions,” says Dr David For- of the world, and these proportions will in- man, Head of the IARC Section of Cancer of cancer death among crease further by 2025. Information, the group that compiles the women and the most global cancer data. frequently diagnosed Sharp rise in breast cancer worldwide Generally, worldwide trends show that in cancer among women In 2012, 1.7 million women were diag- developing countries going through rapid nosed with breast cancer and there were societal and economic changes, the shift in 140 of 184 countries 6.3 million women alive who had been di- towards lifestyles typical of industrialized worldwide. agnosed with breast cancer in the previous countries leads to a rising burden of cancers five years. Since the 2008 estimates, breast associated with reproductive, dietary, and cancer incidence has increased by more hormonal risk factors. than 20%, while mortality has increased by Incidence has been increasing in most 14%. Breast cancer is also the most com- regions of the world, but there are huge in- treatment facilities. For example, in Western mon cause of cancer death among women equalities between rich and poor countries. Europe, breast cancer incidence has reached (522,000 deaths in 2012) and the most fre- Incidence rates remain highest in more de- more than 90 new cases per 100,000 women quently diagnosed cancer among women in veloped regions, but mortality is relatively annually, compared with 30 per 100,000 140 of 184 countries worldwide. It now rep- much higher in less developed countries in eastern Africa. In contrast, breast can- resents one in four of all cancers in women. due to a lack of early detection and access to cer mortality rates in these two regions are

MIDDLE EAST HEALTHI75 Oncology

almost identical, at about 15 per 100,000, which clearly points to a later diagnosis and much poorer survival in eastern Africa. “An urgent need in cancer control today is to develop effective and affordable approaches to the early detection, diagnosis, and treatment of breast cancer among women living © Fraunhofer IPA in less developed countries,” explains Dr Christopher Wild, Director of IARC. “It is critical to bring morbidity and mortality in line with progress made in recent years in more developed parts of the world.”

Cervical cancer, an avoidable cause of death among women With 528,000 new cases every year, cervical cancer is the fourth most common cancer affecting women worldwide, after breast, colorectal, and lung cancers; it is most notable in the lower-resource countries of sub-Saharan Africa. It is also the fourth most common cause of cancer death Left: the new camera displays colored structures by means of fluorescent dyes (blue and green areas shown here). (266,000 deaths in 2012) in women worldwide. Almost 70% of the global burden falls in areas with lower levels of develop- New fluorescent camera ‘paints’ ment, and more than one fifth of all new cases are diagnosed in India. tumours to enable more “Cervical cancer can have devastating effects with a very high human, social, and accurate surgical excision economic cost, affecting women in their prime. But this disease should not be a Cancer patients have the highest probability of recovering if death sentence, even in poor countries,” tumours are completely removed. However, tiny clusters of cancer says Dr Rengaswamy Sankaranarayanan, a lead investigator for an IARC research cells are often difficult for surgeons to recognize and remove. A project with a focus on cervical cancer new camera may ease this by making hidden cancer tissue visible screening in rural India. “Low-tech and in- during an operation. Middle East Health reports expensive screening tools exist and could significantly reduce the burden of cervical cancer deaths right now in less developed Tumour removal surgeries pose a great So what’s unique about this camera? countries.” challenge even to skilful and experienced The camera can display fluorescent In sub-Saharan Africa, 34.8 new cases of surgeons. For one thing, tumour margins molecules that “paint” the cancer tissue. cervical cancer are diagnosed per 100,000 blend into healthy tissue and are difficult These are injected into the patient’s women annually, and 22.5 per 100,000 wom- to differentiate. For another, distributed blood circulation prior to the operation en die from the disease. These figures com- domains of cancer and pre-malignancies and selectively attach onto the tumour pare with 6.6 and 2.5 per 100,000 women, are difficult to recognize. Up to now, during their trip through the body. If the respectively, in North America. The drastic doctors have depended exclusively upon corresponding area is then illuminated differences can be explained by lack of access their trained eyes when excising pieces with a specific wavelength, fluorescence to effective screening and to services that fa- of tumours. But this is set to change is emitted and the malignant tissue glows cilitate early detection and treatment. with the development of a new, special green, blue, red, or any other colour, “These findings bring into sharp focus camera system that can ‘paint’ the tumour depending on the injected dye, while the need to implement the tools already and help visualize it during surgery, the healthy tissue appears the same. In available for cervical cancer, notably HPV thereby supporting the surgeons during this way, the surgeon can see clusters of vaccination combined with well-organized complicated interventions even for the tumours cells that cannot be recognized national programmes for screening and smallest, easy-to-overlook malignant by the naked eye. treatment,” stresses Dr Wild. pieces of tumour. The multispectral fluorescence camera

76 IMIDDLE EAST HEALTH system has been developed by researchers “The visibility of the dye to the camera are recognizable in detail on the monitor. at the Fraunhofer Project Group for depends in large part on the selection of Patients operated under fluorescent light Automation in Medicine and Biotechnology the correct set of fluorescence filters. The have improved chances of survival,” says (PAMB), which belongs to the Fraunhofer filter separates the incident excitation Dr Dimitriadis. Institute for Manufacturing Engineering and wavelengths from the fluorescing In order to be able to employ the Automation (IPA). In the future, this special wavelengths so that the diseased tissue is multispectral fluorescence camera system camera will integrate into various medical also set apart from its surroundings, even as adaptably as possible, it can be converted imaging systems such as, surgical microscopes at very low light intensities,” explained to ‘see’ other combinations of dyes. and endoscopes, etc. Dr Nikolas Dimitriadis, head of the “One preparation that is already Scientists from Mannheim, Germany, Biomedical Optics Group at PAMB. available to make tumours visible exhibited a prototype of the camera at the The researchers require only one camera is 5-amino levulinic acid (5-ALA). Medica trade fair in Düsseldorf in November and one set of filters for their photographs, Physicians employ this especially for last year. A novel aspect of this camera is which can highlight up to four dyes glioblastomas – one of the most frequent that it can display several fluorescent dyes simultaneously. Software developed in- malignant brain tumours in adults,” and the reflectance image simultaneously house analyses and processes the images in explains Dr Dimitriadis. in real time. Systems available until now seconds and presents it continuously on a 5-ALA leads to an accumulation of a have not been able to achieve this. The monitor during surgery. The information red dye in the tumour and can likewise advantage of this is that arteries and delicate from the fluorescent image is superposed be detected with the camera. The nerves that must not be injured during an on the normal colour image. multispectral fluorescence imaging system intervention can likewise be coloured with “The operator receives significantly should passed testing for use with humans dye. They too can then be detected with the more accurate information. Millimetre- this year. The first clinical tests with new camera, since they are set apart from sized tumour remnants or metastases that a patients suffering from glioblastomas are their surroundings. surgeon would otherwise possibly overlook also planned for this year.

MIDDLE EAST HEALTHI77 Oncology

Researchers use nanoparticles to selectively kill tumour cells and spare healthy tissue Hair loss, nausea, vomiting, fatigue, loss of appetite, loss of eye lashes and eye brows, susceptibility to infection – the list of possible side effects from chemotherapy is lengthy. Many cancer patients suffer from © Fraunhofer IAP the intense effects that accompany the treatment. High dosages of cytostatic agents are injected subcutaneously or administered intravenously to halt the growth of tumours and also to destroy resistant cells. The more frequently that cells divide, the more effective the active agent is. This applies especially to malignant tumours. However, healthy mucosal tissue and hair cells divide very rapidly as well. They are therefore attacked as well. Scientists have searched long and hard for a therapy that selectively kills off the tumour cells without damaging healthy tissue. Using a new methodology, Cervical carcinoma cells can be selectively and effectively killed off with encapsulated anti-cancer agents (left). Doxorubicin being prepared – one of the agents frequently researchers from the Fraunhofer Institute utilized in chemotherapy (right). for Applied Polymer Research (IAP) in Potsdam, Germany, hope to break the tests. They each react very differently to experiment, 46.5% of the HCT116 cells vicious circle by utilizing nanoparticles as doxorubicin. HCT116 cells are sensitive to survived a dose of 0.1 µM doxorubicin after vehicles for the anti-cancer agents. Since the substance, in contrast to HeLa cells. We two days, while only 13.3% of the malignant the particles resemble cells on account of ran the experiments with pharmacologically tumour cells failed to be eliminated their structure, they are suited to steering relevant dosages, used by clinicians. The by administering the active agent in pharmaceutical substances to the tumour doxorubicin was added to the cell cultures encapsulated form. selectively, docking there, and efficiently both directly and encapsulated in the nano- “With nanoparticles as carriers, a more eliminating the malignant cells. carriers,” explained Dr Joachim Storsberg. effective and simultaneously lower dosage The researchers used hydrophobic, water- He developed the new therapy jointly is possible. This way, and with a targeted insoluble lipid vesicles as the tiny, 200-250 with Dr Christian Schmidt and Nurdan delivery of the active agent, the healthy nanometer pharmaceutical carriers. They Dogangüzel from IAP in close collaboration cells are likely to be spared and the side are biologically degradable and disintegrate with colleagues from the pharmaceutical effects will be minimized,” said Storsberg. in the body after deployment. Polymers are sciences, Professor Mont Kumpugdee- An additional test result: the used to stabilize the nano-envelope, which Vollrath and Dr J. P. Krause from Beuth encapsulation material is only effective is furnished with molecules highly specific University of Applied Sciences in Berlin. when combined with the active agent. to and recognized by tumour cells. The The unloaded nano-carrier does not attack envelope of the nanoparticle – experts call it Making chemotherapy more tolerable the sensitive HCT116 cells. Using their the vesicles – is constructed similarly that of The results from the laboratory tests: after methodology, Storsberg and his team can a cell. The scientists load these carriers with three days, 43.3% of the HeLa cells survived investigate how effectively an encapsulated doxorubicin, one of the anti-cancer agents a dose of unencapsulated, 1 micromolar pharmaceutical substance acts, as well as frequently used in chemotherapy. Sodium (µM) doxorubicin. When the active agent how ‘toxic’ the actual nanomaterial is. tetradecyl sulfate (STS), a surfactant, helps was introduced via encapsulated vesicles, “That has not been feasible to date,” the active agent to be absorbed better. only 8.3% of the malignant HeLa cells emphasized the chemist. The researchers have already been able survived. The researchers presented their findings to prove the efficacy of their approach in “The pharmaceutical substance in the at Nanotech Dubai, in October, last year. laboratory tests. nano-envelopes was fives times more However, a series of clinical tests with “We utilized both a cervical cancer effective,” said Storsberg. cancer patients will only be set up if these strain (HeLa) and cancer of the large This could also be observed in the tests observations are confirmed in in-vivo intestine (HCT116) for our in-vitro with the intestinal cancer cells: in this experiments.

78 IMIDDLE EAST HEALTH Health Authority-Abu Dhabi addresses lung cancer Lung cancer has emerged as the most Health Authority – Abu Dhabi to cancer-causing substances including deadly form of cancer for males in Abu (HAAD), the regulating body of the asbestos, silica and diesel vapors; air pol- Dhabi and second for both sexes. In healthcare sector of the Emirate of Abu lution; family and medical histories; and 2012, the condition claimed the lives Dhabi, discussed risk factors, preventive suppressed immunity, among others. of 48 people. Lung cancer has a high measures, and general information re- “It is very unfortunate that many mortality, with most cases diagnosed at lated to lung cancer at its Lung Cancer people continue to die of lung cancer the very late stages – typically at stage Awareness Roundtable held in Novem- on a yearly basis despite the fact that 4. By this time, the condition has al- ber last year at the HAAD headquarters. the main cause is known. Our ongoing ready spread to other parts of the body. With the them ‘Breathe Life,’ the forum cancer awareness campaign provides In 2012, 53 cases of lung cancer were marked the second Wave of HAAD’s six- an effective platform for informing the reported, 81% of whom were male with month ‘Live Healthy and Simply Check’ public about the dangers of smoking. 74% being expatriates. cancer awareness campaign which aims to This is coupled with the national ef- Smoking is the leading cause of lung increase knowledge and encourage behav- forts and laws to control tobacco use cancer and is responsible for almost 9 iour that reduces the risk of developing in the UAE. Signs and symptoms can out of 10 cases. Even passive smoking cancer and emphasizes the importance of take years to develop, and late diag- increases the risk of lung cancer by be- regular screenings to decrease the risk of nosis is associated with high mortality. tween 20 and 30% due to the carcino- cancer-related deaths. Smokers can reduce It is thus critical to take the necessary genic content of the over 4,000 chemi- their risk of lung cancer by as much as 30% precautions and measures at the early cal compounds released with tobacco to 50% per cent, 10 years after they quit stages to detect or prevent lung can- smoke. Smoking causes 71% of global the habit. cer,” said Dr. Omniyat Al Hajeri, Di- lung cancer deaths and 22% of global The Authority also discussed other con- rector of Public Health and Research at cancer deaths in general. tributing factors such as workplace exposure HAAD.

MIDDLE EAST HEALTHI79 Thalassaemia

Under diagnosed, under treated, under estimated The campaign to raise awareness of non-transfusion-dependent thalassaemia

The Iron Health Alliance, sponsored by Novartis Oncology, is running a photo documentary campaign to put a human face on the little known condition of non-transfusion-dependent thalassaemia (NTDT). The campaign portrays the inspirational stories of four NTDT patients from India, Italy, Lebanon and Thailand and their life journeys with a chronic disease. Middle East Health shares some of the photos from the campaign and speaks to two specialists in the field: Dr. Androulla Eleftheriou, the Executive Director of the Thalassaemia International Federation; and Professor Ali Taher, Professor of Medicine, Hematology & Oncology at the American University of Beirut. The Iron Health Alliance is a global initiative dedicated to sharing the latest iron-toxicity knowledge with communities worldwide. The mission of the alliance is to increase awareness, provide support, and educate physicians and patients about iron toxicity.

The NTDT Voices campaign www.NTDTVoices.com

The Interviews non-functional molecule, hence a severe anaemia. These genetic conditions are n Middle East Health: What is thal- the commonest of the serious hereditary assaemia and how wide-spread is it? conditions of the human population. It is Dr. Androulla Eleftheriou: Thalassae- estimated that 5-7% of the global popula- mia is a group of hereditary blood disorders tion are healthy carriers of the condition in which a genetic defect does not allow and since transmission is according to re- the adequate production of proteins (glo- cessive Mendelian inheritance, it requires bins) which make up the haemoglobin that both parents should be carriers for an molecule. These globins are four, but the affected child to be born. major conditions arise by non-production The exact carrier rate is not known for all or underproduction of two of them, the population groups, but from estimates it is alpha globin chain and the beta globin expected that around 60,000 new affected chain (usually denoted by the Greek let- cases are born each year (N.B. there are ters α or β). Non-production of a major other inherited abnormalities which affect Dr. Androulla Eleftheriou component of the molecule results in a the haemoglobin molecule which affect the

80 IMIDDLE EAST HEALTH © Thomas Troadec © Thomas Troadec

Above: Michele, 38 years old, Italy, Shop assistant, Beta Thalassemia Intermedia Below: Youssef, 35 years old, Lebanon, Department Head in Retail, Beta Thalassemia Intermedia

MIDDLE EAST HEALTHI81 Thalassaemia

structure rather than the quantity of pro- itoring of this group of patients is necessary This is the reason why the teins, known as variants. These also cause from early childhood to recognize compli- Thalassaemia International anaemia, but have other consequences as cations early. well. These are even more common than Both α or β thalassaemia include a wide Federation has undertaken a the thalassaemias). The exact number of range of syndromes and some of them are special campaign to educate patients is also unknown since the condi- of major clinical significance and, in the and spread awareness not tions are lethal and untreated patients die absence of treatment, result in the early only to patients, parents in childhood and without a diagnosis. Even death and high a rate of morbidity in where they are treated, patient registers are patients. However, a range of thalassae- and health professional not always kept. There will have been sev- mia α or β syndromes were, for many communities around the eral million patients around the globe, had decades, considered as clinically of lesser world, but also to policy treatment been made available. significance and they were marginalised makers and official health- The geographical distribution includes for decades in terms of early diagnosis, ef- the Mediterranean basin, the Middle East, fective monitoring and appropriate treat- related organisations. Our the Indian subcontinent, South East Asia ment. Today this is what we refer to as the aim is to reduce or prevent and Southern China. However, popula- non-transfusion-dependent thalassaemias. the suffering and delayed tion migration has now made these condi- These, are those thalassaemia syndromes diagnosis of thousands tions a global concern. that were not of major clinical significance, Each of these conditions, α or β thal- they did not required life-long transfusion of NTDT patients, who in assaemia, has a spectrum of severity. The therapy for the survival of patients, which number may well exceed more severe forms require regular blood nevertheless ended up with high rates of those with β-thalassaemia transfusions for survival. These transfu- morbidity and poor quality of life at a later major. sion-dependent forms have other conse- point – during adolescence and adulthood. quences, such as iron overload due to the NTDTs are different from the clini- multiple transfusions, which result in vital cally major syndromes, because these organ damage and which needs special- required transfusions only on occasions since 2006. I have witnessed the progress ized management to allow for survival and under special clinical conditions and not made in achieving the vision of this fed- quality of life. Such treatment is available as a life-long therapy. As such, there were eration which is nothing more than the in some countries and has resulted in a no specific guidelines and specific criteria establishment of the ‘right of all patients near normal existence with many patients on when and how to monitor and treat across the world for equal access to quality entering the professions and having fami- these patients. On some occasions, un- health care’. In achieving our vision, our lies of their own. The majority, however, der certain conditions, the thalassaemia mission is the development and establish- do not have access to such care and the syndromes referred to as non-transfusion ment of national control programs or the reason for TIF’s (Thalassaemia Interna- dependent thalassaemias may progress to prevention and quality management of tional Federation) existence is to promote transfusion-dependent syndromes – that haemoglobin disorders in every country such services. is syndromes that require transfusion on where these disorders occur. a life-long basis. The conditions are very Six pillars of activities comprise our work n MEH: What is non-transfusion de- well described with all the most recent at TIF towards our goals: a) the strength- pendent thalassemia? How is it different advances in a text book published in ening of the patients’ and parents’ voice for transfusion dependent thalassaemia 2012 by TIF under the title “Guidelines through the establishment of national pa- and can the disease progress from one for the management of Non Transfusion tient/parent thalassaemia associations; b) form to the next? Dependent Thalassaemia (NTDT)”. It the establishment and continuous upgrad- AE: Some patients can survive initially highlights the criteria for changing from ing of our educational program; c) building without regular transfusions, because of a non-transfusion to a transfusion-depen- collaborations, partnerships and networks genetic factors. The genetic defects that dent thalassaemia syndrome. with different, relevant stakeholders; d) cause thalassaemia are various and can participating or coordinating projects; e) have other genetic factors interacting. n MEH: As the Executive Director of contributing to policy development or In this milder part of the clinical sever- the Thalassaemia International Federa- reforms and; f) establishment of effective ity spectrum, the initial ‘good’ path of tion, what are the key goals you are try- communications with all our partners and the patient, we speak of non-transfusion ing to achieve and what are the key chal- collaborators. dependent thalassaemia (NTDT), which lenges you face? The key challenges, of course, include: may be α or β. AE: I have been with the Thalassaemia a) the under recognition of the contribu- Over time NTDT patients will develop International Federation (TIF) since the tion of haemoglobin disorders to the na- complications, usually in early adult life, 1993 as a volunteer, following and sup- tional, regional and international public which will necessitate recourse to transfu- porting its work through the years, and health and disease burden and; b) the dif- sions and other interventions. Close mon- then officially as the Executive Director ficulties in including these disorders as a

82 IMIDDLE EAST HEALTH © Thomas Troadec © Thomas Troadec

Above: Yoke, 22 years old, Thailand, University student, Hb H Thalassemia Below: Uttam, 41 years old, India, Artisan Jeweler, HbE / beta Thalassemia

MIDDLE EAST HEALTHI83 Thalassaemia

priority in health agendas, in the context of national control, prevention and management plans as a pre-requisite for the effectiveness and sustainability of these programs. It is common that in low-resource countries the focus of the national health authorities is on other health priorities and in overcoming great challenges, such as the management of communicable diseases, the emergence of new agents and the re-emergence of already existing communicable diseases and, of course, the promotion of programs on non-communicable diseases in which haemoglobin disorders occupy a poor place. In addition, weak health infrastructures, low educational health literacy and ‘out-of-pocket’ policies for addressing the cost of treatment for multi-organ diseases, such as thalassaemia and sickle cell disease, indeed constitute important obstacles and challenges in moving forward effectively. In contrast the challenges in high resource countries are different and these focus on increasing the access of patients to treatment and improving already existing services, to address the needs of these diseases, which are often considered as “immigrant diseases” or diseases that were literally introduced into the indigenous population through the migration of populations across geographical and cultural borders. n MEH: What is the federation doing to overcome these challenges? AE: The Federation has officially established communications with international bodies such as the World Health Organisa- tion (WHO) with which we have worked in official relations since 1993, but also with other official health bodies and agencies. like the European Medicinal Agency (EMA), the US Food and Drug Adminis- tration (FDA), the regional collaborating able impact on education and awareness processes in the course of development, offices of WHO, ASEAN and the EU. globally. This programme is comprised of or amendment, of polices that are specific Furthermore, we have established a wide events and publications translated into a or relevant to haemoglobin disorders at a network of medical and health profession- wide range of languages and distributed national, regional and international level. als in more than 60 countries across the across 72 countries as a free-of-charge ser- For example, at a regional level, in Europe world, and created networks of experts of vice to the medical/scientific and patient/ specifically, we had an EU policy report on different disciplines at regional and inter- parent communities. “Haemoglobinopathies on the Move: is national level. The Federation has estab- In addition, we provide a plethora of in- Europe ready?” In Southeast Asia, we have lished an international advisory panel that formation through TIF’s website which is introduced haemoglobinopathies into the supports and develops our educational pro- updated on a regular basis and, of course, agenda, for the first time, of the Associa- gram for which TIF claims a truly measur- through the intervention in consultation tion of South East Asian Nations (ASE-

84 IMIDDLE EAST HEALTH AN). At the international level we have So we have indeed arrived well equipped and integration of the diagnosis, monitor- contributed to the adoption by WHO of in recent years to actually apply some of ing and treatment of the NTDTs into the important resolutions in 2006 and we still the science on NTDTs to elucidate the protocols of national health authorities in continue to be officially integrated in the labyrinth of the unknown around what the same way and to the same level as we WHO programs on non-communicable was for years considered as milder forms have done for the transfusion-dependent diseases, birth defects, blood transfusion on thalassaemia. This is the reason why thalassaemias globally. programs and mother and child health TIF has undertaken a special and specific Furthermore TIF is making an effort to programs. campaign to educate and spread aware- bring together and connect patients and Last, but not least, through our net- ness to patients and parents and health caregivers with a dynamic, online video working and partnerships with other than professional communities around the sharing platform where patients from all thalassaemia disease organisations we world, but also to policy makers and of- over the world can share their challenges promote common policies for addressing ficial health-related organisations. and triumphs in living with thalassaemia. prevention, neonatal screening and man- As a result, patients and caregivers may agement of these disorders in the context n MEH: What do you hope to achieve learn tips and best practices from one an- of other programs, like the rare disease with the NTDT Voices campaign? other, forge bonds where they previously initiatives (EUROPLANproject.eu) at AE: Our aim is to reduce or prevent did not exist, and find comfort and confi- the European level. the suffering and delayed diagnosis of dence in the management of their disease All the aforementioned constitute im- thousands of NTDT patients, who in from one another. portant pillars of our work in addressing number may well exceed those with the numerous challenges we have to face β-thalassaemia major. Early diagnosis on our move forward. and adoption of effective and regular monitoring to allow prompt medical in- n MEH: Why you are running the tervention, are what we wish to achieve NTDT Voices campaign? Why are you through our project in the years to come. focussing specifically on non-transfusion These patients have been in pain and ag- dependent thalassaemia? ony, in uncertainty and out of the regular AE: In the past two decades the focus has follow-up in reference centres. TIF wish- been on the major haemoglobinopathies, es to see this chain stopped here. thalassaemia β homozygous and sickle cell What we hope to achieve with the disease. The dramatic medical and scien- NTDTs Voices campaign is the spread of tific advances that have happened in the awareness, education and the inclusion past three decades have literally converted these fatal childhood diseases into chronic n MEH: What message would you diseases with high expectation rates of sur- like to give doctors and health au- vival and quality of life and have reduced thorities regarding thalassemia? Dr Ali Taher morbidity and mortality related to iron AE: The message we would like to n Middle East Health: How prevalent load, particularly in those countries where give to doctors and health authorities is thalassaemia in the Middle East region appropriate management and monitoring is that the Ariadne’s thread has now – TDT and NTDT? Is it increasing or policies have been adopted and integrated stretched and the patient community decreasing? in national guidelines. has found its way out of the labyrinth Dr Ali Taher: Annually, it is estimat- Furthermore, this progress has allowed of doubt, fear and the unknown, ed that more than 40,000 people world- the medical and research community as thanks to new scientific and medical wide are born affected by β-thalassemia, well as the patient/parent community developments. We feel now that we though it has been suggested that this is globally to understand and realise the are taking the last steps that lead us likely an underestimate. There is a high gaps of treating and monitoring other to the final exit of the labyrinth. We incidence in the Mediterranean basin thalassaemia α or β syndromes that were are now safely advocating that we and Middle East, we estimate that we considered for decades as clinically mild- are able to prevent effectively and to have 3-6% carrier rate. er and not requiring attention or regu- treat and monitor appropriately, all We in the Middle East are proud to be lar follow up. The progress achieved in the range of thalassaemia syndromes, the pioneers in the scientific work done transfusion-dependent thalassaemias has decreasing morbidity and mortality on NTDT in the world. A large bulk of also allowed us to actually concentrate amongst these patients, providing a what we know today about the disease on the gaps in this area and gave us the better quality of life to our global pa- emerged from our centres; we are on the opportunity to utilise the scientific data tient community, integrating them cutting edge of progress in all aspects of and tools that derived from the research appropriately into society and en- the disease. From experience, we esti- and work on transfusion-dependent abling their dreams to come true. mate that one third of thalassaemia cases β-thalassaemia. are NTDT, although accurate incidence

MIDDLE EAST HEALTHI85 Thalassaemia

has not yet been established. ing, counselling, and prenatal diagnosis The Middle East is a very diverse restarted in several at-risk populations in gion; Incidence of thalassaemia is de- the Mediterranean region. At present, creasing in areas where solid awareness several countries in our region have set campaigns exist. However, in areas where up comprehensive national prevention there is lack of education to the general programs, which include public aware- population about the disease, the inci- ness and education, carrier screening, Despite a colossal dence is increasing. and counselling, as well as information effort aimed at on prenatal diagnosis and pre-implanta- reducing the n MEH: To what extent does thalassae- tion diagnosis. In a number of countries, incidence of mia reduce quality of life and life expec- including Lebanon, Iran, Saudi Arabia, tancy? Tunisia, United Arab Emirates, Bahrain, thalassaemia in AT: Since thalassaemia turns from Qatar and Gaza Strip, there is legislation our region, lack of an acute, life-threatening disease into that makes it mandatory to have premar- awareness remains a lifelong chronic condition, assessing ital diagnosis aimed at limiting carrier- the biggest and maintaining quality of life becomes carrier marriage. It is also noteworthy to even more important for patients. A few say that collaboration with religious au- challenge we face. years ago we realized that there was a thorities has increased adherence to such lack of insight about the quality of life premarital programs and is beneficial in that thalassaemia patients have; conse- the long run. quently several studies were done in our centre in Lebanon and in the Middle n MEH: As a doctor in the Middle East region to assess “quality of life” in East, what are the main challenges you thalassaemia patients. Although differ- face with regards to thalassemia? What Last, but not least, pharmacotherapy ent approaches were used they all shared can / or is being done to resolve these is a cornerstone for better health in thal- the same end result; thalassaemia pa- issues? assaemia patients. Many patients in our tients have lower Health Related Quality AT: The Middle East is a vast and ex- region still lack access to adequate treat- of Life (HR-QoL), lower Mental Health tremely diverse region. There is a lot of ment. Since many thalassaemia patients Score and lower Physical Health Score, contrast among countries. Although some come from low socioeconomic status, leg- when compared to the normal popula- countries have excellent awareness and islation should be passed in all countries tion. Contrary to previous beliefs, NTDT treatment programs, some countries still to enable these people to have access to patients report substantially lower Qual- encounter major problems. treatment and have their treatment ex- ity Of Life and mental health problems Despite a colossal effort aimed at re- penses sponsored. when compared to TDT patients. With ducing the incidence of thalassaemia in the advent of new treatment strategies our region, lack of awareness remains n MEH: What message would you like and better understanding of the disease the biggest challenge we face. In order to to give doctors and health authorities in thalassaemia patients’ life expectancy have a good awareness program, multidis- the region regarding thalassemia? has increased massively in the past few ciplinary meetings should be held among AT: The most important message to years. Thalassaemia is now regarded as a physicians, family planning workers, deliver is awareness about thalassemia. chronic disease and patient mortality is nurses and social workers, to discuss the Health authorities and doctors should col- largely related to complications, rather clinical characteristics, the natural histo- laborate to develop a system that aims to than the disease itself. ry, the principles of genetic counselling, prevent new thalassaemia cases. This can and the methodologies for preventing be achieved through awareness campaigns n MEH: As an inherited disease, does the birth of affected children. Population targeted at various levels, a judicial system the high rate of consanguinity in the Arab education makes use of mass media, post- that will to pass strict premarital laws re- world have a role to play in the cause of ers, and informational booklets, which garding thalassaemia and guidance from lo- this disease? What can be done about this? are left at various key sites, such as family cal religious figures. AT: Since thalassaemia is a genetic dis- planning clinics, marriage registries, and We have come a long way, especially in ease and is highly prevalent in the Arab counselling rooms. the past few years in the management of world, the high rate of consanguinity is a Another serious problem we face is of thalassemia. We have had many triumphs major cause of development of this disease. lack serious screening programs in some in this field that has transformed thalassae- Nevertheless the high carrier rate is also countries in the Middle East. A critical mia into a chronic disease. We, in the Mid- major contributor. prerequisite for a screening program is dle East should form a collaborative force In the late 1970s several pilot popu- the organization of adequate facilities to working towards replicating the successes lation programs directed to prevent meet the demand both for screening and in terms of prevention in certain countries β-thalassaemia major by carrier screen- prenatal diagnosis. to the whole region.

86 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI87 International Modern Hospital

How to identify if your headache is dangerous?

experience a migraine. In general practice, threatening emergency. It presents as migraine headaches often go undiagnosed sudden severe headache and may be as- or are misdiagnosed as tension or sinus sociated with vomiting or fainting, it is headaches. As a result, many migraine suf- like bolt from blue, having “never before ferers do not receive effective treatment. headache”. It needs urgent neurosurgical All headache sufferers deserve evaluation and neuroradiological care. by a neurologist. l Cerebral venous thrombosis – women Only 10% of cases of headache are due to on oral contraceptives are prone to throm- secondary causes, like brain tumour, brain bosis of blood vessels (venous sinuses) in haemorrhage, cerebral venous thrombosis the brain – causing headache. Some peo- or infections of brain, etc. ple are prone to blood clotting by birth But one should not delay or miss the may have a history of deep vein throm- diagnosis of secondary headache because bosis. This condition is may be missed on it could be life threatening. Important ex- CT scans. It needs MRI with venogram to By Dr. Prof. Prem Kumar Sinha Consultant Neurologist, International amples of diseases causing secondary head- pick up the disease. It is treated by blood- Modern Hospital, Dubai aches include: thinning drugs, like heparine. l Tumours in the brain, including tu- l Temporal arteritis – inflammation of Headache is defined as pain in the head mours that have spread (metastasized) to the temporal artery which runs beneath that is located above the eyes or the ears, the brain from another organ such as the the skin of the temple. It occurs primarily behind the head (occipital), or in the lung or breast. This needs urgent care for in older people. It presents with headache back of the upper neck. Pain arising from good outcome. and tenderness of the temple and may be sinuses and eyes can also be interpreted l Haemorrhage or hematomas, which associated with fatigue and body aches. If as headache – like glaucoma pain arising are collections of blood underneath the prompt treatment with steroids is delayed, from eyes, which is an emergency, and dura (the covering of the brain) due to it may lead to loss of vision. acute sinusitis. Headache is the present- bleeding from ruptured veins. Subdural l Acute angle Glaucoma with sudden ing symptom in almost one third of cases hematomas typically occur in elderly indi- elevation of pressure inside the eyes, pres- reporting to neurologists. viduals after a fall or other trauma to the ents with painful red eyes. Delay in treat- Headache is a symptom, which may head. Post traumatic bleed with fracture is ment may cause loss of sight. Infections of be secondary to underlying serious dis- due to epidural bleed. This needs urgent the sinuses (Sinusitis), Ear (Otitis), and ease (secondary headache) e.g. tumour or attention. teeth, if not treated promptly may spread may be without any underlying structural l Infections such as meningitis/en- to the brain. serious disease (primary headache), like cephalitis caused by bacteria or viruses migraine or fungus or tuberculosis, presents with What are the tests for headaches? The most common cause of primary headache, vomiting, fever and confused The patient history and physical ex- headache is migraine headaches, or its behaviour. It needs urgent appropriate an- amination provide the best means for variants like tension headaches, and clus- tibiotic treatment – any delay may be life determining the cause of secondary ter headaches, constituting almost 90% of threatening. headaches. Therefore, it is extremely im- cases. In this condition the brain is struc- l Subarachnoid haemorrhages which portant that patients with severe head- turally normal, and headache is triggered are caused by bleeding into the space be- aches undergo examination by a doctor by various environmental factors, like tween the brain and its outer arachnoid experienced in diagnosing and treating sleep deprivation or fasting, etc. It is also lining. The most common source of sub- headaches. A few tests may be useful called primary headache. Migraine affects arachnoid haemorrhage is an aneurysm, in diagnosing the presence and cause children as well as adults. An estimated (a ballooning of the weakened wall of of secondary headaches including blood 6% of men and up to 18% of women will an artery inside the head). This is a life tests, CT scan and MRI scans of the head

88 IMIDDLE EAST HEALTH The role of surgery in diabetes

By Dr. Girish Kumar Juneja, MS, Dip MIS (France) Fellow of ACE Bariatric Center (Emeen, Netherland) Specialist General / Laparoscopic Surgeon Head of Bariatric Dept. International Modern Hospital, Dubai.

Diabetes is epidemic, with more than The patient history and 170 million people affected worldwide. It is estimated that the number will ex- physical examination ceed 366 million by 2030. provide the best means In 2000, for the first time in the his- Dr. Girish Kumar Juneja for determining the tory of human evolution the number of Diabetes without morbid cause of secondary adults with excess weight surpassed the obesity but only overweight number of those who were underweight. This category of diabetic patients are not headaches. Excess body weight is now widely recog- obese, but are overweight (BMI 30 – 35). nized as one of leading health threats in Several studies have confirmed improve- most of the countries around the world ment of diabetes in these individuals, but as well as lumbar puncture and electroen- and considered a major risk factor for it still needs more study to confirm that cephalogram (EEG). diabetes mellitus, cardiovascular disease net benefits outweigh harm in this patient and hypertension. population. The good news is that this When must you consult a neurologist? category of patients can also benefit from Many people who suffer from mild head- Surgery newer procedures like: aches medicate themselves with over-the- There are two types of diabetic patients: l Ileal transposition – initial results of counter analgesics, and they usually do not Diabetics with morbid obesity and dia- this procedure are very encouraging seek medical care. Nevertheless, the symp- betics without morbid obesity, but only Patients with diabetes prior to surgery toms of primary headaches and secondary overweight. appear to have greater reductions in car- headaches can overlap. Furthermore, a per- diovascular events than patients without son with a long history of migraine or ten- Diabetes with morbid obesity diabetes. Thus, the benefits appear to out- sion headaches can develop a new second- Recently strong interest has arisen weigh any harm, particularly for obese pa- ary headache. Therefore, a doctor should in weight-loss (bariatric ) surgery as tients with diabetes. be consulted if the headache is: a treatment for diabetes in obese pa- Overall people with shorter duration of l Sudden severe headache (“the worst tients. There is strong evidence that diabetes and less severe of type-2 diabetes ever”) bariatric surgery, beside reducing were linked to higher rates of post surgery l Different than the usual headaches weight, also causes remission of dia- remission. These results lead to the con- l Starts suddenly during exertion betes and the need for anti-diabetic clusion that surgery should be offered ear- l Aggravated by exertion, coughing, medication. lier rather than later in the course of type- bending, or sexual activity With this surgery, remission from 2 type diabetes for those who are eligible. l Associated with persistent nausea and diabetes can vary between 60% to 95% The new endoscopic endobarrier proce- vomiting depending on type of procedure done. dure is showing good results in these dia- l Associated with stiff neck, fever, Procedures which have proven re- betic patients. dizziness, blurred vision, slurred speech, sults are: unsteady gait, weakness or unusual sensa- 1. Gastric bypass Conclusion tions of the arm or leg, excessive drowsi- 2. Gastric sleeve procedure In conclusion we can say that: ness or confusion Both procedures are very effective for 1. Diabetes can be cured or improved by l Associated with seizures diabetes control and remission. surgery, especially in obese people l Associated with recent head trauma Beside weight-loss and improvement 2. Surgery should be offered as a solution or a fall in diabetes status, this surgery helps im- at an early stage for eligible patients l Not responding to treatment and is prove blood pressure. It is known that a 3. Weight-loss surgery not only reduces getting worse 1% reduction in body weight is associ- weight, but also benefits diabetics and reduces l Disabling, and interfering with work ated with a reduction of about 1 mm cardiovascular risk in morbidly obese people and the quality of life in systolic BP and of about 2mmHg in 4. For non-obese, but overweight people, l Requires more than the recommend- diastolic BP whereas 10% reduction of newer procedures like ileal transposition ed dose of over-the-counter analgesics for weight in overweight patients leads to and endoscopic endobarrier procedures are relief 20% reduction in the CVD risk. showing very encouraging results

MIDDLE EAST HEALTHI89 Patient Safety

Interview

Codonics Safe Labelling System improves patient safety, lowers costs King Hamad University Hospital (KHUH) in Bahrain has installed the Codonics Safe Labelling System. Middle East Health speaks to Lt. Colonel (Dr) Khalid Ahmed Al-Sindi about the system. n MEH: Why did KHUH choose to install macy and throughout the facility. Used in macy. This formulary database contains all the Codonics Safe Labelling System (SLS)? pharmacy, CLS enables barcode unit dose of the hospital-approved drugs. Codonics Lt. Col. Dr. Khalid Al Sindhi: King Ha- labelling to improve efficiency and increase worked with KHUH pharmacy staff to en- mad University Hospital (KHUH) in Bah- accuracy. The device creates and prints data sure the formulary was complete and accu- rain is committed to delivering outstanding matrix labels that feature machine-readable rate, and then it was deployed to every SLS healthcare that meets and exceeds interna- barcodes that can be read by SLS or any via the network. The benefit is like having a tional and national standards. The presti- other system with a barcode scanner. pharmacist at every medication preparation gious, technologically advanced hospital is KHUH has recognized the need and location throughout the hospital. leading the region with their commitment safety impact of unit dose vial barcoding. to implement advanced technologies to en- They also understood the value of having n MEH: In which departments / sections sure patients receive unmatched care. a “second set of eyes” for clinicians when of the hospital has it been installed? The operating room (OR) is a hectic medications are prepared, as well as the KAL: SLS is used in the facility’s oper- environment where immediate decisions importance of a “triple check” prior to ad- ating rooms, NICU, PICU, Intermediate must be made, increasing the chance of ministering the drug to the patient. Care Unit, ICU, Labor & Delivery, ER, human error for mistakes such as vial and The Hospital Commander, Major Gen- Day care, Radiology and Pharmacy. ampoule swaps, mislabelling medications, eral (Dr) Salman Bin Ateyatallah Al Khal- Major General Salman Bin Ateyatal- and syringe swaps. Recent estimates re- ifa of the King Hamad University Hospital lah Al Khalifa says the system enables the veal that drug errors occur in one out of says that not only have Codonics systems hospital to quickly, conveniently and ac- every 140 cases* and many more are likely driven down our costs, we have seen an curately label our medications for syringes unreported. In order to ensure medica- improvement in our workflow which has and IVs anywhere immediately upon prep- tion labelling accuracy and compliance enabled our providers to spend time on aration using barcode technology. throughout their hospital, KHUH had a their patients. These user-friendly technol- vision and turned to Codonics Safe Label ogies have helped us provide outstanding n MEH: How does the SLS work? System, an FDA-cleared medical device. healthcare and ensure our patients’ safety. KAL: Safe Label System (SLS) greatly re- A first-of-its-kind technology, Safe Label duces injectable medication errors common System (SLS) helps to significantly reduce n MEH: When was it installed? How in the operating room. SLS simplifies and medication labelling errors and healthcare long did it take to set up? Did it require improves the safety and accuracy of syringe costs through improved patient safety any- specific staff training to use the system? labelling, helping to eliminate vial and am- where medications are prepared. KAL: The Safe Label System and Con- poule swaps, mislabelling, and syringe swaps. KHUH also purchased and installed Co- tainer Labeling System were installed at the SLS sits on your existing anaesthesia drug donics Container Labeling System (CLS) site in December 2012. The systems utilize cart. When a drug is ready to be prepared, to incorporate compliancy into their phar- a formulary which is managed in the phar- the clinician uses SLS to scan the vial or

90 IMIDDLE EAST HEALTH container. The drug is instantly verified dards and has chosen to install the system ing our patients with world-class healthcare, against the pharmacy’s drug database. SLS throughout our hospital not only for com- and we’ve made a choice to do that proac- then speaks and visually displays the drug pliancy, but also for safety. tively through technologies that help avoid name and concentration to confirm the se- To support global medication label- human error in medication preparation and lection, acting as a second pair of eyes. A ling standards, SLS integrates worldwide delivery. The system has become an invalu- full-colour label is printed on demand and best practices and international standards, able tool for our clinicians. We believe that includes the drug name, concentration, including the Joint Commission Interna- the technology should be the standard of preparer’s initials, expiration time and a bar- tional, recommendations of the European care, helping to prevent medication errors code. Once the syringe is prepared and la- Society of Anesthesia (ESA), and ISO stan- anywhere medications are prepared.” belled, it can be ‘triple-checked’. Using SLS dards (a specific colour for each therapeutic * Source: “Syringe Swaps” in OR Still to scan the barcode on the syringe label prior class). With SLS, clinicians will never have Harming Patients; Medication to injection provides the final visual and au- to handwrite labels and every syringe will be Mishap Mitigation Drives 2008 APSF dible confirmation of the drug name as well clearly, safely and compliantly labelled. Workshop, by John H. Eichhorn, MD as the time remaining until it expires. Using the SLS touch screen, dilutions can n MEH: Has there been a noticeable im- Lt. Colonel (Dr) Khalid Ahmed be easily accommodated and include safety provement in patient safety at KHUH Al-Sindi, MBBS, MD, DCP, MIAC, Dip Leadership (RCSI), FRCPath (UK) guardrails to avoid mistakes. When a drug because of this SLS? If so, can you ex- Consultant & Associate Professor Of is diluted, the easy-to-read label is printed plain how and why it has improved? Pathology showing the new dilution and concentration. KAL: Major General Salman Bin Atey- Chief of Pathology, Blood Bank & Labora- From the touch screen, users can also quickly atallah Al Khalifa, says the Codonics sys- tory Medicine print line and catheter labels for both ends. tem not only improves our patient safety, Chief of Diagnostic Departments & Allied Health Services Major General Salman Bin Ateyatallah but it has lowered our healthcare costs and Director, Infection Prevention & Control Al Khalifa says the hospital is keenly aware enabled us to concentrate on what matters King Hamad University Hospital of worldwide medication labelling stan- most – our patients. We believe in provid-

MIDDLE EAST HEALTHI91 Pharmaceuticals

A brief history of insulin Insulin is a peptide hormone, produced by beta cells of the pancreas, and is central to regulating carbohydrate and Sanofi celebrates fat metabolism in the body. Insulin causes cells in the liver, skeletal muscles, and fat tissue to absorb glucose from the blood. In the liver and skeletal muscles, 90 years of insulin glucose is stored as glycogen, and in fat cells it is stored as triglycerides. Insulin stops the use of fat as an energy source by inhibiting the release production of glucagon. With the exception of the metabolic disorder, diabetes mellitus and metabolic syndrome, insulin is Sanofi invited Middle East Health and journalists from several provided within the body in a constant other publications in the region, Russia, and Africa to visit their proportion to remove excess glucose insulin production plant in Frankfurt, Germany in November. The from the blood, which otherwise would trip also included a short stop in Tours, France where, for the first be toxic How was it discovered and how is it time, they showed journalists around their anti-counterfeit drug now produced synthetically? lab. Callan Emery reports. In 1889, the Polish-German physician Oscar Minkowski, in collaboration Sanofi is a global pharmaceutical company they are designed specifically to each re- with Joseph von Mering, removed the with a key focus on diabetes, vaccines and gion. For example, in the Middle East, the pancreas from a healthy dog to test its consumer health. It has a presence in more company launched ‘My Diabetes Story’ to assumed role in digestion. Several days than 100 countries, 112 industrial sites support people with diabetes in the region after the dog’s pancreas was removed, and more than 20 R&D sites. It recently through online peer-to-peer initiatives. Minkowski’s animal keeper noticed a acquired Genzyme which has helped it Since 2007 the campaign has received more swarm of flies feeding on the dog’s urine. expand its footprint in biotechnology and than 5.1 million views and established an On testing the urine, they found there rare diseases. active online community, which has helped was sugar in the dog’s urine, establishing The press trip coincided with World many people in the Arab world overcome for the first time a relationship between Diabetes Day on 14 November as the the taboo about speaking about diabetes. the pancreas and diabetes. It took company celebrated 90 years of involve- In Egypt, Sanofi has been working with another 30 years of various attempts ment with insulin production. In 1923 the the Ministry of Health (MoH) to raise to isolate the secretions from the company’s predecessor Fabwerke Hoechst awareness through TV, print, radio and islets of Langerhans in the pancreas was one of the pioneering companies to online media. before Canadian Frederick Banting, first ‘provide insulin of constant quality on Sanofi has formed similar partnerships in October 1920, concluded that it a large scale’. Today Sanofi manufactures with other MoHs to raise awareness, pro- was the very digestive secretions that Lantus (insulin glargine) – the leading in- mote screening and combat discrimination. Minkowski had originally studied that sulin brand worldwide. In Turkey the company partnered with were breaking down the islet secretions, Beyond the commercial aspect of pro- the MoH and Ministry of Education to thereby making it impossible to extract ducing insulin and related medical devic- promote awareness of diabetes in schools. successfully. es, the company focusses on three initia- The campaign reached 7.5 million stu- The idea was the pancreas’s internal tives: 1. Supporting people with diabetes; dents and more than half a million teach- secretion, which, it was supposed, 2. Working with ministries of health, and; ers in the country. The campaign was so regulates sugar in the bloodstream, 3. Educating healthcare professionals. successful that the company plans to ex- might hold the key to the treatment Although these initiatives are global, tend it to other countries.

92 IMIDDLE EAST HEALTH The Sanofi insulin production plant in Frankfurt, Germany of diabetes. A surgeon by training, for Noble, given that Banting decided results to Macleod on his return to Banting knew certain arteries could be to keep Best for the entire summer, and Toronto in the fall of 1921, but Macleod tied off that would lead to atrophy of eventually shared half his Nobel Prize pointed out flaws with the experimental most of the pancreas, while leaving the money and a large part of the credit for design, and suggested the experiments islets of Langerhans intact. He theorized the discovery of insulin with the winner be repeated with more dogs and better a relatively pure extract could be made of the toss. Banting’s method was to tie equipment. He then supplied Banting from the islets once most of the rest of the a ligature around the pancreatic duct; and Best with a better laboratory, and pancreas was gone. when examined several weeks later, the began paying Banting a salary from his In the spring of 1921, Banting travelled pancreatic digestive cells had died and research grants. Several weeks later, the to Toronto to explain his idea to J.J.R. been absorbed by the immune system, second round of experiments was also Macleod, who was Professor of Physiology leaving thousands of islets. They then a success; and Macleod helped publish at the University of Toronto, and asked isolated an extract from these islets, their results privately in Toronto that Macleod if he could use his lab space to test producing what they called “isletin” November. However, they needed six the idea. Macleod was initially sceptical, (what we now know as insulin), and weeks to extract the isletin, which forced but eventually agreed to let Banting use tested this extract on the dogs starting considerable delays. Banting suggested his lab space while he was on holiday for July 27. Banting and Best were then they try to use foetal calf pancreas, which the summer. He also supplied Banting able to keep a pancreatectomized dog had not yet developed digestive glands; with 10 dogs on which to experiment, named Marjorie alive for the rest of the he was relieved to find this method and two medical students, Charles Best summer by injecting her with the crude worked well. With the supply problem and Clark Noble, to use as lab assistants, extract they had prepared. Removal of solved, the next major effort was to purify before leaving for Scotland. Since Banting the pancreas in test animals in essence the extract. In December 1921, Macleod required only one lab assistant, Best and mimics diabetes, leading to elevated invited the biochemist James Collip to Noble flipped a coin to see which would blood glucose levels. Marjorie was able help with this task, and, within a month, assist Banting for the first half of the to remain alive because the extracts, the team felt ready for a clinical test. summer. Best won the coin toss, and took containing isletin, were able to lower her On January 11, 1922, Leonard Thompson, the first shift as Banting’s assistant. Loss of blood glucose levels. a 14-year-old diabetic who lay dying at the the coin toss may have proved unfortunate Banting and Best presented their Toronto General Hospital, was given the

MIDDLE EAST HEALTHI93 Pharmaceuticals

first injection of insulin. However, the the point where large quantities of insulin method of creating genetically modified extract was so impure, Thompson suffered could be extracted on demand. bacteria to produce insulin. However, due a severe allergic reaction, and further to a lack of clarity with genetic engineering injections were cancelled. Over the next Insulin Hoechst legislation in Germany it was not until 12 days, Collip worked day and night to Meanwhile in Europe, Minkowski had 1998 that the company managed to get improve the ox-pancreas extract, and a founded the German Insulin Committee. a manufacturing plant – using this new second dose was injected on January 23. The Germany company Hoechst, which had process – operational. This was completely successful, not only being doing experiments on pancreas extracts In 1999 the company launched in having no obvious side-effects but also to treat diabetes since 1912, had gained a recombinant human insulin ‘Insuman’, in completely eliminating the glycosuria reputation for producing good quality insulin which finally ended the reliance on sign of diabetes. which was noted by the German Insulin animal sources for insulin production. Children dying from diabetic Committee. Hoechst launched “Insulin The Sanofi Diabetes production plant ketoacidosis were kept in large wards, Hoechst” in Europe in October 1923. we visited is the historic headquarters of often with 50 or more patients in a Building on the discovery that insulin was Hoechst in Frankfurt. ward, mostly comatose. Grieving family much purer and better tolerated when it was In 2001 Sanofi launched ‘Lantus’, members were often in attendance, crystalized, Hoechst progressed to become in a long-acting, 24-hour insulin analog, awaiting the inevitable death. 1936 the first industrial provider to switch which set a new standard in insulin In one of medicine’s more dramatic its entire production to this new crystalline therapy. And in 2005 the company moments, Banting, Best, and Collip form and launched a range of new insulin launched ‘Apidra’, a short-acting insulin went from bed to bed, injecting an entire products in the 1930s and 1940s. analog to help patients achieve glycemic ward with the new purified extract. In 1976 the company’s scientists made control at meal times by enabling them Before they had reached the last dying another major breakthrough by being the to adjust the dose according to the meal. child, the first few were awakening from first to successfully produce a semi-synthetic Sanofi Diabetes in Frankfurt now brings their coma, to the joyous exclamations version of human insulin. However, it took together Research and Development, of their families. a few more years before the company could industrial production of insulin and the Over the spring of 1922, Best produce this new insulin on a large scale. production of medical devices, such as the managed to improve his techniques to In the 1980s the company developed its own insulin pens for injection. Upping the ante in the battle against counterfeit criminals Counterfeit medication is an issue of and corruption in the healthcare system. disorders and infections) whereas before, increasing concern globally. According to Currently the most counterfeit branded counterfeit had more to do with lifestyle the World Health Organisation (WHO) no pharmaceuticals include innovative drugs such as erectile dysfunction. country is free of counterfeit medications. treatments for severe diseases (anticancers, Counterfeit medication is defined by the Most developed countries with effective heart diseases, anticholesterol and WHO as “one which is deliberately and regulatory systems and market control (such antihypertensive drugs, psychologic fraudulently mislabelled with respect to as USA, EU, Australia, Canada, Japan, New Zealand) currently have a low proportion of counterfeit drugs, less than one percent of Fake drugs can kill market value. However, trends point to a l In 1995, 89 people died in Haiti after country considered are limited. shift and there has been an increase in the ingesting cough syrup manufactured with l A survey of seven African countries prevalence of counterfeit medicines even in diethylene glycol (a chemical commonly by WHO found that between 20% and developed countries, says the WHO. The used as anti-freeze). This particular 90% of all anti-malarials failed quality problem is further exacerbated by a number product was made in China and testing. These included chloroquine- of other factors: scarcity and/or erratic transported through a Dutch company based syrup and tablets, whose failure supply of basic medicines, uncontrolled to Germany, before winding up on the rate range from 23% to 38% and distribution chains, large price differentials Haitian market. Counterfeit drugs are sulphadoxine/pyrimethamine tablets, between genuine and counterfeit medicines, even more detrimental to public health up to 90% of which were found to be lack of effective intellectual property right efforts when healthcare resources of the below standard. protection, lack of regard for quality assurance

94 IMIDDLE EAST HEALTH identity and/or source. Counterfeiting can and collaboration, says the WHO. The misappropriations and drug counterfeiting. apply to both branded and generic products different players of the fight against PEI is an organization made up of 27 and counterfeit products may include counterfeiting emphasize the need for an members, based in Washington DC, products with the correct ingredients international regulatory framework. assembling pharmaceutical companies. or with the wrong ingredients, without A number of organisations have been active ingredients, with insufficient active set up to try and prevent the production l ACTA (Anti counterfeit Trade ingredients or with fake packaging. and distribution of counterfeit medicines. Agreement) The WHO points out that counterfeiting These include: In October 2007, the United States, is an underworld activity – inmany cases run l International Medical Products Anti- the European Union, Japan, South Korea, by organised crime syndicates. It is hard to Counterfeiting Taskforce (IMPACT) Mexico and New Zealand announced a detect and investigate. Moreover, countries The WHO launched IMPACT in 2006, in multilateral agreement plan, so as to establish and companies that detect the problem do response to the growing public health crisis stronger measures and reference standards not always report. So, it is hard to know or of counterfeit drugs. IMPACT is a taskforce in order to guarantee the enforcement of even estimate the true extent of the problem. of the WHO, exclusively dedicated to drug protection rules and intellectual property. What is known is that they occur worldwide and medico-surgical material counterfeiting. and are more prevalent in developing IMPACT aims to set up guidelines into Sanofi’s Central Anti-Counterfeit countries. models to help countries in their fight against Laboratory There is no simple or quick solution or drug counterfeiting. In 2007 Sanofi set up a central co- remedy that can be applied to eliminate l PEI (Protect health, Exchange ordinating unit which brings together counterfeit medicines, nor can the problem information, Initiate actions in collaboration internal experts involved in counterfeit be solved by any individual company or with the dedicated authorities) medicines from various departments government. PEI is a non-profitable professional within the company. In 2008 Sanofi The problem has reached a global organization, whose missions consist set up their Central Anti-Counterfeit dimension and needs a global approach in fighting against theft, illegal Laboratory in Tours, France to analyse

MIDDLE EAST HEALTHI95 Pharmaceuticals

Caroline Atlani, the director of Sanofi’s Anti-counterfeiting Co-ordination, speaks to journalists about counterfeit drugs and what Sanofi is doing to combat it.

suspect medicines. The laboratory centralizes all Sanofi products requiring Key actions that countries should take verification about their counterfeit status. l Strengthen legislation ensuring that l Improve collaboration among The largest proportion of products counterfeiting medical products is a crime governmental entities (such as health, received at the lab come from Sanofi’s own and that punishment is commensurate to police, customs, local administrative market surveillance operations through the consequences that it has on personal units, judiciary) that need to work test purchases in high-risk countries and health and on the credibility of national together in order to effectively combat tests on sensitive products on the internet healthcare delivery systems. counterfeiters. and in pharmacies. Other products come l Strengthen regulatory oversight l Develop a communication strategy from customs, the police, health authorities ensuring that all manufacturers, importers, to ensure that health professionals, and health workers. exporters, distributors and retailers the general public and the media are Speaking to journalists, Caroline comply with the appropriate requirements aware of the dangers associated with Atlani, the director of Sanofi’s Anti- that are necessary for a secure distribution counterfeit medicines. counterfeiting Co-ordination, said: “We chain for all medical products. – WHO / IMPACT are seeing a geographical intensification of counterfeiting which is no longer focussed on one or two parts of the 2. Visual check – a microscopic Sanofi has been active for many world, but is now global, largely because examination of the packaging. years in anti-counterfeiting efforts. The of the internet. And it touches every 3. General chemical analysis – chemists group, through its global coordination therapeutic class.” use spectroscopic techniques to give a first network, works with local and In a worrying revelation, she said it is not level analysis of the products chemical international public authorities and clear how vast the counterfeit operations composition and comparing it to reference other stakeholders to protect patients are. “The more we dig, the more we find,” products. from this threat. she noted. 4. Detailed analysis – if it is clear Atlani said the results of their lab She said the WHO estimates that that it is a counterfeit product a detailed analysis are made available to health, around 10% of all medications are fake chemical analysis is carried out to police, customs and judicial authorities and that around 50% of medications sold determine whether the product contains in France and other countries, which on the internet are fake. any active ingredient or possibly toxic provides a foundation for mobilizing The lab undertakes the following 4-step ingredient. local authorities and launching legal procedure to detect fake medicine Atlani pointed out that the real impact action against organised crime networks 1. Traceability – searching for information of fake drugs is on public health. “There is that manufacture and distribute fake in the database to see if the product has been a lack of real treatment. In some cases the drugs. manufactured in a Sanofi site – including drugs may be toxic resulting in death. And checking the batch number, date of fake drugs can also lead to drug resistance IMPACT manufacture and packaging. because of insufficient active ingredient.” www.who.int/impact

96 IMIDDLE EAST HEALTH The controversy over ‘counterfeit’ drugs IRIN reports on one of the biggest hurdles to stemming the global tide of counterfeit medicines – the disagreement over the term itself, which drug companies are accused of hijacking for commercial rather than public health reasons.

There is no dispute over the dangers that falsified/falsely labelled/counterfeit (SFFC) Brazil allege that big drug companies are fake medicines pose. Often containing few medical products will focus not on drafting trying to use WHO to suppress competition or no active ingredients, they are typically a treaty - such an ambition has been from more affordable generics. ineffective - and are sometimes actively abandoned for the time being - but rather on Anna George, of Chatham House’s harmful. Some contain enough of an active developing a “programme of work” to curb Centre for Global Health Security, says ingredient to affect a disease but not enough the sale of such products. This will look at the pharmaceutical industry needs to stop to eliminate it, contributing to the growth best existing practices and can be tailored to insisting on the catch-all term “counterfeit”. of drug-resistance. And they cost almost the situations in different regions. “The industry needs to move away,” nothing to manufacture but bring huge Michael Deats, WHO’s project she told IRIN. “They need to drop that profits to their makers and distributors. manager for quality assurance and safety word that causes so many problems, say The problem is thought to be of medicines, is cautiously optimistic. that their own intellectual property rights widespread in countries with weak “This topic is mired in controversy,” he will be pursued elsewhere, and allow the regulatory oversight; in 2003, Nigerian said, “because of the conflict between debate to focus on health issues.” health officials estimate that 70% of drugs protection of public health and protection in circulation in the country were either of intellectual property. But we are now Shoring up supply chain counterfeit or adulterated. getting to the stage where negotiations are Kamal-Yanni says more lasting solutions But international agreement over how starting to settle down, and we have got a can be found by investing in supply chains to deal with fake medicines has been better chance of moving forward.” in the developing countries worst affected elusive, with discussions getting bogged by the problem. down over exactly what kinds of drugs A focus on trade or health? “As a patient,” she said, “if I have access should be targeted. The problem is that For Oxfam’s senior medical policy adviser, to a trained pharmacist and a good supply the phrase normally used in the debate – Mogha Kamal-Yanni, the concerns of drug chain system, the counterfeiters and “counterfeit medicines” – can refer to far companies are purely a trade issue, with no the people supplying bad-quality drugs more than chalk pills with forged labels. relevance to public health initiatives. will have limited access to the market. The World Health Organization By conflating the two, “you are So investing in the supply chain - and (WHO) defines a counterfeit drug as transferring the duty of checking and in stopping drug shortages in the public “a medicine, which is deliberately and enforcing intellectual property rights sector, which force people to go to private fraudulently mislabelled with respect to from the private owner of those rights to markets with zero regulation - this is the identity and/or source. governments, which have very limited kind of investment that we need before we “Counterfeiting can apply to both resources, and you’re not sorting out the go for an international treaty.” branded and generic products, and problem; the real problem is about bad- At the moment, the issue of a treaty is counterfeit products may include products quality medicines,” Kamel-Yanni told a on hold, says WHO’s Deats. He told IRIN, with the correct ingredients or with meeting at London’s Chatham House. “WHO now has a solid platform and an the wrong ingredients, without active Despite efforts to harmonize copyright agreed mandate, clearly focusing on public ingredients, with insufficient active and intellectual property laws by countries health. We are still at the talking stage ingredients or with fake packaging.” like the US and Japan, which are home to rather than the doing stage, but there is Yet pharmaceutical companies consider many pharmaceutical companies, these now a spirit of cooperation rather than the even safe, efficacious drugs “counterfeit” laws vary greatly around the world. hostility which existed a few years back. when their expensively developed and There have been a number of cases in “The pharmaceutical companies are patented formulas are copied without their which generic drugs manufactured legally major stakeholders in the field, so I don’t permission, or even when their own drugs, in countries like India, on their way to other think you can exclude them, but the licensed and packaged for sale in one countries where those drugs would also be amount of influence they have mustn’t country, are diverted, repackaged and sold regarded as legal, such as Nigeria or Brazil, be disproportionate. The low-income elsewhere at a higher price. have been seized in transit through Europe countries, which are really suffering badly, A meeting at WHO in Geneva in November on the grounds that they violate patents would do better to invest in their supply was due to try to nail down more firmly what recognized under European legislation. chain and systems of oversight, but there’s international control measures should cover The result has been bitter opposition no ‘one size fits all’ solution. Our task now and, just as importantly, what they should not. to attempts to reach an international is to identify priorities and then get to The Meeting of the Member State agreement on combating counterfeit work with a view to minimizing harm to Mechanism on Substandard/spurious/ medicines. Countries like India, China and patients in our member states.”

MIDDLE EAST HEALTHI97 Healthcare Economics

Reducing adverse events in hospitals Effective Interventions

tention might not be devoted to adverse billion and cause 98,000 deaths annually events. However, creating processes to in the United States[4, 5]. Adverse events identify and reduce adverse events is best associated with surgical procedures and done during the early development of medication administration account for the healthcare infrastructure. The cost of not majority of errors[4, 6]. doing so is tremendous, as discussed below, Extensive literature – including the and analyzing adverse events in the Unit- 1999 Institute of Medicine (IOM) report ed States (US) can provide useful lessons. titled “To Err is Human” from the pres- Currently, the US is in the midst of modi- tigious National Academy of Sciences – fying its reimbursement system to incen- documents the serious consequences of tivize providers to prevent adverse events AEs[2, 4, 5, 7, 8]. These AEs cause not only – e.g. the recent Affordable Care Act and substantial financial loss (approximately other rules developed by Centers for Medi- $ 22 billion annually) but also tempo- care and Medicaid Services (CMS) (see rary disability, permanent disability, and By Arby Khan discussion below for details). death[2, 4-6]. For example, medical errors MD, FACS, MBA This article discusses adverse events kill approximately 98,000 people in the in the US and how structuring the reim- US every year[2, 4]. If any individual, re- Introduction bursement system, within the framework gardless of socioeconomic or health in- Adverse events, or medical errors, are of economic theory, can decrease adverse surance status, goes to a hospital today, a significant problem worldwide[1-3]. As events, increase quality of patient care, either for admission or for a day-proce- health systems develop and evolve in the and decrease costs at the same time. As dure, there is a greater than 9% chance Middle East and in other developing na- appropriate to each country in the Middle that he/she will be the victim of a medi- tions, it would be prudent to build into East, all or some of the lessons learnt could cal error[4]. These AEs can happen to any- these systems, early on, ways of tracking be applicable. one – and they do. and addressing such errors[1, 3]. As many In addition to causing loss of money, countries in the Middle East are currently Problem and Magnitude limb, and life, AEs create profound emo- preoccupied with developing the basic Medical errors, also known as adverse tional consequences. Taking your child, foundations of their healthcare infrastruc- events (AEs), are a substantial problem father, or spouse to the hospital for a sim- tures, it is understandable that enough at- in hospitals – they cost approximately $22 ple, routine operation and coming back

98 IMIDDLE EAST HEALTH Figure 1: Conceptual Model for Decreasing Adverse Events: Two of the three antecedent variables are the main drivers for the predictor variables and thus are critical points for intervention (in blue). Double outlined box refers to primary outcome of interest (dependent variable). QUIPs = Quality Improvement Programs, IT = Information Technology home with your loved one in a coffin, individual (or more) better off is to make because the wrong dose of medicine was another individual (or more) worse off”[9, These many deaths administered, is a shattering experience. 10]. However, achieving Pareto efficiency would be equivalent In this day and age, such events occur requires the following stringent, market to those caused by 98,000 times a year. These many deaths conditions: a) that both sellers/buyers 20 Boeing 747 jumbo would be equivalent to those caused by fully understand the goods, b) that both 20 Boeing 747 jumbo jets crashing every are price- takers, and c) that all prices jets crashing every month and killing every passenger on are known to all participants[9]. Clearly, month and killing every board. If 20 Boeing 747 jumbo jets were health care transactions in the United passenger on board. indeed crashing every month, it is certain States (US) and the Middle East, do not that the United States National Trans- meet these conditions – and in such cases portation Safety Board (NTSB) would moving towards Pareto efficiency requires AEs[12] an unnecessary financial burden. immediately ground all Boeing 747s and an external force[9, 10]. Thus the solution In fact, perversely, errors keep patients provide the resources to take immediate to adverse events (AEs) lies in two ap- in hospitals longer and provide more action to fix the problem. The problem of proaches. First, making all key players – revenue under the current fee-for-service AEs is similarly huge and effective action patients, healthcare providers (healthcare model in the US. In the current climate, should be taken to combat this epidemic teams and hospitals), and healthcare pay- implementing QUIPs benefits patients of preventable deaths. The application of ers (private/government insurance) “bet- and healthcare payers but makes health- Economic Efficiency theory, or striving ter off”, and second, creating an external care providers “worse off”. However, now, for Pareto efficiency, could provide the force that encourages critical players to two things are changing: first, reimburse- necessary incentives to prevent AEs in decrease AEs. ment rules are beginning to penalize hos- the United States and the Middle East. AEs increase the cost of health care, but pitals for AEs and second, there is clear hospitals are adept at externalizing these evidence that QUIPs not only decrease Theoretical Application costs[11] and thus consider implementa- AEs, but actually improve profits for Pareto efficient allocation of resources is tion of the necessary quality improve- hospitals[12, 13]. Thus, the solution lies in achieved when “the only way to make one ment programs (QUIPs) that decrease moving towards Pareto efficiency because

MIDDLE EAST HEALTHI99 Healthcare Economics

now all three players can be made “better adept at externalizing (to third party pay- off” by instituting QUIPS and reducing ers) the extra costs incurred by AEs (e.g. AEs. Still, only 25% of the 6000 hospi- costs due to increased length of stay, ex- tals in the US engage in such QUIPs[13]. tra medications, increased morbidity and It would be critical for Thus, legislation (an external force) mortality, etc.)[11]. Second, keeping pa- countries in the Middle which imposes stricter penalties for AEs tients in the hospital longer because they East to consider, early on, and requires QUIPS in all hospitals will suffer an AE means even more revenue such penalties for excessive provide the last nudge necessary for hos- for the hospital under the fee-for-service pitals to decrease the epidemic of AEs in reimbursement system. In effect, the hos- numbers of adverse events the US. It would be critical for countries pitals are being financially rewarded for and to develop legislation in the Middle East to consider, early on, AEs[11, 13]. Thus, the reimbursement sys- that requires institution such penalties for excessive numbers of tem, a major economic determinant of of quality improvement adverse events and to develop legislation hospitals’ reluctance to reduce AEs, is too that requires institution of QUIPs. If this lax and permissive. It came to be that way programs. If this is done is done early in the development of their because of the strong political lobbies of early in the development of respective healthcare systems it would be the healthcare industry. their respective healthcare immensely beneficial. The political determinants of AEs are systems it would be complicated and healthcare legislation, Determinants of Adverse Events (AEs) some parts of which affect AEs, has his- immensely beneficial. Crafting effective interventions that torically been very contentious in the solve the public health problem of AEs United States[15]. These political debates requires an accurate knowledge of the de- are steered by ideological fervour and pa- terminants of AEs. A Conceptual Model rochial interests of strong political lobbies health insurance that their model is in (Figure 1) which describes antecedent, such as the American Medical Association fact broken, eventually created a political predictor, and mediating variables, pro- (AMA), Health Insurance Association of climate that allowed passage of the Pa- vides a pictorial representation of deter- America (HIAA) or American Health tient Protection and Affordable Care Act minants, causality, and interventions. Insurance Association (AHIA), and the (PPACA) – part of which attempts to The various components of QUIPs (such American Hospital Association (AHA), link reimbursement to patient outcomes as safety culture, use of IT, etc.) are des- to name a few[15]. The cumulative result of and funds studies on quality outcomes[17, ignated as the mediating variables[6, 12] these political forces was legislation which 18]. Thus, political forces, manifested by while the pivotal predictor variable is created a healthcare system that provided legislation and regulations, are now be- the hospitals’ approach to AEs (in this more financial rewards for delivering more ginning to support demands that hospitals case willingness to implement QUIPs). “health care” – regardless of the quality should provide good quality care without In turn, hospitals’ approach to address of health care being delivered. Predict- taking advantage of the reimbursement AEs is determined primarily by the ante- ably, this also led to an exponential rise in system. Countries in the Middle East that cedent variables delineated in Figure 1. healthcare costs and, as a respected histo- are developing their healthcare infrastruc- These antecedent variables are the criti- rian has pointed out, “a better way to ex- tures are, currently, in a position to avoid cal determinants and are mainly econom- ponentially inflate the cost of health care all these costly experiments by creating a ic and political. could not have been devised”[15]. As an reimbursement system that incentivizes The economic determinants have thus example, between 1965 and 1970, federal providers to minimize adverse events, im- far wielded influence on hospitals mainly and state health expenditure increased at prove patient safety, and decrease costs. through the reimbursement system (gov- a staggeringly, unsustainable rate of 20.8% ernment insurance, private insurance). per year[15, 16]. In a nutshell, the medical Interventions This system provides no financial incen- profession and allied stakeholders histori- The linkage of some reimbursements to tives for the hospitals to reduce AEs. The cally lobbied aggressively for legislation quality of care by CMS, only within the Joint Commission (JC) of the United that provided public aid to health care, but past two years, was a good start, but had States realized in 1986 that QUIPs were without public control, without regard to no significant “bite” to it – reflected by necessary to decrease the significant any systematic control on quality of care the fact that only 25% of the 6000 hospi- morbidity and mortality associated with provided, and without reasonable limits tals have thus far implemented QUIPs[13]. AEs[14]. However, in the absence of any on reimbursement[15, 16]. Clearly, these po- The Office of the Inspector General has financial incentives and guiding legisla- litical forces had much to gain from the drawn attention to this lack of interest by tion, the hospitals have had no reason status quo. hospitals[17] and has urged CMS and legis- to address the problem of AEs. In fact, Multiple factors such as the increas- lators to provide more compelling incen- hospitals actually have an economic in- ing US debt, relative decrease in tax rev- tives for hospitals to comply in order to centive not to implement such QUIPs enues, cuts in Medicare and other federal decrease AEs, save lives, and save money. for two reasons. First, hospitals are very programs, and the realization by private If CMS reimbursement rules were strict-

100 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI101 Healthcare Economics

er, hospitals would be unable to externalize References the extra costs of AEs, thus making it at- 1. GE-Healthcare. Top leaders from across tractive to implement QUIPs. As it turns the Middle East come together to dis- out, recent and very good scientific evi- Countries in the Middle cuss potential next steps for patient safety. 2011; Available from: http://www. dence indicates that decreasing AEs not East that are developing healthtechwire.com/ge-healthcare/top- only saves lives but also increases revenues their healthcare leaders-from-across-the-middle-east-come- for the hospital[12, 13]. Thus, hospitals now together-to-discuss-potential-next-steps-for- infrastructures are, patient-safety-2994/. have a financial incentive to address AEs. 2. Medicine, I.o. To err is human: building Now, all three players, patients, hospitals, currently, in a position a safer health care system. 1999; Avail- and payers can benefit from the implemen- to avoid all these costly able from: http://www.iom.edu/~/media/ Files/Report%20Files/1999/To-Err-is- tation of QUIPs. However, a century of experiments by creating Human/To%20Err%20is%20Human%20 resistance to change by the medical profes- a reimbursement 1999%20%20report%20brief.pdf. sion and allied stake holders has created a 3. Wilson, R.M. and et-al, Patient safety in system that incentivizes developing countries: retrospective esti- political and economic inertia that slows mation of scale and nature of harm to pa- down progress in adequately addressing pa- providers to minimize tients in hospital. BMJ, 2012. 344-e832. tient safety (AEs). It would be apparent to adverse events, improve 4. de Vries, E.N., et al., The incidence and the most cursory observer that it is illogi- nature of in-hospital adverse events: a patient safety, and systematic review. Qual Saf Health Care, cal for hospitals to not implement QUIPs 2008. 17: p. 216. if hospitals, and all other players, benefit decrease costs. 5. Pham, J.C., et al., Reducing medical errors and adverse events. Annu. Rev. financially and save lives at the same time. Med., 2012. 63. A stride towards Pareto efficiency is indeed 6. Garrouste-Orgeas, M., et al., Overview of possible. medical errors and adverse events. Ann Thus the following is proposed for coun- Intensive Care, 2012. 2(1): p. 2. 7. Valentin, A., Approaches to decreasing tries in the Middle East: 1) Pass legislation medication and other care errors in the requiring all hospitals to institute QUIPs revenues for hospitals, and saving of pub- ICU. Curr Opin Crit Care, 2013. 19. within a short but reasonable period of lic monies should convince legislators and 8. Hawkins, R.B., et al., Beyond surgical care improvement program compliance: anti- time. This will address inertia and the payers to implement these stricter regula- biotic prophylaxis implementation gaps. political determinants. 2) Change the re- tions, which will represent a turning point The American Journal of Surgery, 2013. imbursement system and stop paying for in the evolution of health care not only 9. Reinhardt, U.E., Can Efficiency in Health Care Be Left to the Market? Journal of patients who suffer AEs and reward the re- in countries in the Middle East, but any Health Politics, 2001. 26(5). duction of AEs. The compelling quadriad other country developing its healthcare 10. Herring, B., Theory - Economics: Efficien- of decreased AEs, saved lives, increased infrastructure. cy and Equity. Health Policy Lecture, 2013. 11. Mello, M.M., et al., Who Pays for Medical Errors? An Analysis of Adverse Event Costs, the Medical Liability System, and Incen- n Arby Khan, MD, FACS, MBA served as the Deputy National Director tives for Patient Safety Improvements. Jour- nal of Empirical Legal Studies, 2007. 4(4). for Surgery for the United States Veterans Health Administration, which 12. James, B.C. and L.A. Savitz. How Inter- oversees 151 hospitals and more than 1000 outpatient clinics. Dr Khan is a mountain Trimmed Health Care Costs regular contributor to Middle East Health. He has written on a range of sub- Through Robust Quality Improvement Efforts. 2011 May [cited 2013; Available jects – such as Human Resources management in hospitals, Change Man- from: http://content.healthaffairs.org/con- agement in GCC hospitals, Brain Death and Hospital Resource Manage- tent/early/2011/05/17/hlthaff.2011.0358. ment and organ transplant-related legislation, among others – with a view abstract. 13. Andel, C., et al., The Economics of Health to improving healthcare in the UAE and the wider region. He is a multi- Care Quality and Medical Errors. Journal organ Transplant Surgeon and Immunologist and has successfully started, of Health Care Finance, 2012. 39(1): p. 1. from the ground up, two multiorgan transplantation programmes – one in 14. Joint-Commission, Joint Commission sets agenda for change. JCAH Perspect., the United States and one in Abu Dhabi. He is the author of many clinical 1986. 6(11-12). and basic immunology papers, and has been educated, trained and employed 15. Starr, P., The Social Transformation of variously at University of California - Berkeley, McGill University, Univer- American Medicine1982: Basic Books. 16. Khan, A., “Value” in healthcare series sity of California - San Francisco, Harvard Medical School, Yale Univer- - Circumstances that shaped early US sity - Graduate School of Immunobiology, University of Pittsburgh - Starzl Healthcare - 1930-2012. Middle East Transplantation Institute, University of Vermont - School of Medicine, and Health, 2013. 17. Levinson, D.R. Adverse Events in Hospi- Columbia University (NY). He also holds an MBA, with Distinction, from tals: National Incidence Among Medicare London Business School. Beneficiaries. 2010; Available from:http:// – The views expressed in this article are those of the author and do not oig.hhs.gov/oei/reports/oei-06-09-00090.pdf. 18. Tate, N.J., ObamaCare Survival necessarily represent the views of the institutions for which Dr Khan has Guide2012, West Palm Beach, FL: Hu- worked or currently works. manix Books

102 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI103 Patient Relations

Roundtable Talks Improving healthcare workforce education and training in the Middle East – challenges and strategies Houston Methodist Global Health Care Services and Middle East Health magazine jointly hosted a roundtable discussion at the Ritz Carlton DIFC, Dubai on 31 October 2013 in association with the American Business Council. The objective of this event was to discuss the evolution of healthcare workforce education and training in the region; highlighting the challenges involved in developing this area as well as potential strategies to improve education and training. Twelve healthcare leaders from different areas of the healthcare industry including regulatory agencies, hospitals, and pharmaceutical and technology related companies participated in the dialogue. Following are some of the highlights of the thought-provoking discussion.

The Discussion as it relates to workforce development and hospitals but demand for quality staff Dr Sarper Tanli, Vice President of Houston sustainability. is high everywhere in the world so it Methodist Global Health Care Services for is challenging. Staff retention is also a the Europe-Middle East-Africa (EMEA) Dr. Sarper Tanli: problem with institutions having to of- region, welcomed the panelists and distin- The first topic relates to the challenges fer incentives such as higher salaries, guished guest Cathy Easter, President and associated with developing the work- accommodation and other privileges to CEO of Houston Methodist Global Health force; as regional health care experts, retain their employees. Care Services in Houston, Texas. what do you feel are the main challenges The roundtable discussion was moder- of developing and retaining a quality Dr. Abdul Karim Saleh: ated by Dr Sarper Tanli who used leading healthcare workforce in the region? Trying to develop a national workforce questions to direct a relatively informal and retain a predominantly expatriate and free flowing discussion among the pan- Dr. Abdulrazzaq Al Madani: workforce is a challenge. In terms of elists. The discussion was opened by Cathy In the UAE, a large proportion of staff developing a national workforce, we’ve Easter who highlighted the importance are recruited from abroad due to the un- come a long way; we’ve experienced a of workforce education and training for derdevelopment of the national work- significant transformation of events re- Houston Methodist, not only domestically force. Hiring staff from abroad is the cently in Abu Dhabi in terms of fast for- but for its global partnerships; particularly only way to attract the best staff for the warding our residency paying initiatives

104 IMIDDLE EAST HEALTH Dr. Sarper Tanli Cathy Easter The Host and Moderator

Attendee Company Name title Dr. Sarper Tanli Houston Methodist Global Vice President, EMEA Health Care Services

The Panelists Dr. Mahmoud Al Dr. Mohamed Yamany AbdulRazaq Nasaif Attendee Company Name title Cathy Easter Houston Methodist Global President and CEO Health Care Services Dr. Mahmoud Al Yamany King Fahad Medical City Chief Executive Officer Dr. Mohamed AbdulRazaq Dubai Health Authority Head Professional Development Center - Nasaif Department of Medical Education Dr. Amer Sharif Dubai Healthcare City Managing Director of Education and Training Dr. Amer Sharif Dr. Abdul Karim Saleh Dr. Abdul Karim Saleh Sheikh Khalifa Medical City Chairman of Education Prof. Sehamuddin Galadari UAE University Professor at UAE University, Board Member for Dubai Healthcare City Authority (DHCA) Prof. Gita Ashok Raj Gulf Medical University Provost Dr. Abdulrazzaq Al Madani Dubai Health Authority Chief Executive Officer, Consultant Physician and Endocrinologist Dubai Hospital Prof. Sehamuddin Prof. Gita Ashok Galadari Raj Dr. Nayzak Raoof American Hospital Chief Medical Officer Dr. Zeydan Abuissa Pfizer Country Manager of Gulf and Levant Lauren Arnold UAE Nursing Council Advisor Peter DeBenedictis GE Healthcare Marketing Director - Middle East & Pakistan to a new standard of graduate medical enced practitioners in the public sector. education. Our hospitals have gained in- We need to create a system that pays by Dr. Abdulrazzaq Dr. Nayzak Raoof stitutional and program level accredita- performance within the public sector and Al Madani tion within a frame of 12-18 months and reduce dependency on the physicians at we now have about 17 programs that are their peak who are the most expensive and accredited by the Accreditation Council most highly targeted by the private sector. for Graduate Medical Education, which is a Chicago-based institution. We’re on Prof. Sehamuddin Galadari: the right track but there are still some ob- It is important to emphasis we are discuss- stacles and challenges to overcome. ing the healthcare workforce in general as there are big challenges to be overcome for Dr. Mahmoud Al Yamany: the non-clinical and support staff as well Dr. Zeydan Abuissa Lauren Arnold In Saudi Arabia in general, there is a lack as the physicians. of flexibility within government-funded or A fundamental problem is the lack of an public hospitals compared to the private academic center within our healthcare fa- sector. The public healthcare system pays cilities. Having educational and academic doctors as salaried physicians, whereas in institutions alongside hospitals is impor- the private sector, doctors are paid per tant; we need to focus on both developing the number of patients they see which is our current workforce but also preparing an incentive to increase productivity. It those in the pipeline. This benefits the is also very difficult to retain the experi- institution by providing better education Peter DeBenedictis

MIDDLE EAST HEALTHI105 Patient Relations

and therefore better clinical service and provides a platform to engage those people coming through the system.

Dr. Sarper Tanli: One concept used in the US is ‘education homes’, combining classroom-based education with practical work experience. Dr Mahmoud Al Yamany speaks at the Roundtable Medical centers take the lead on this, but they are seen as a pool of available resourc- Lauren Arnold: the UAE is always going to be relatively es to be provided by different institutions, Is anyone aware of anything innovative short term. but coordinated under one umbrella. happening around retention aside from I would like to focus now on targeted salary and benefits packages? Lauren Arnold: training pathways and programs and how Does anyone currently measure employee these can help achieve healthcare work- Dr. Mohamed AbdulRazaq Nasaif: satisfaction? Has the staff themselves identi- force efficiency. We are using the concept of the private fied areas, other than salary, that would make sector, which is pay per performance, to them more satisfied and more retainable? Prof. Gita Ashok Raj: increase salaries. This is not necessarily We are starting to focus on the develop- new but the concept of performance-relat- Dr. Amer Sharif: ment of other healthcare professions not ed incentives to top up salaries has been In our experience an employee’s boss and only physicians. We have just finished received well by the employees. the organization’s leadership plays a role. developing programs for technicians, nurses, health information management, Dr. Nayzak Raoof: Dr. Nayzak Raoof: nutritionists and dieticians for example. As a strategy, we are trying to move away In terms of retention, salary is top fol- Healthcare has become much more of a from paying fixed salaries to physicians due lowed by the leadership and their relation- team-based healthcare delivery system. to the high costs to recruit some of the spe- ship with their direct boss. It is now acknowledged that training is cialties. We have developed more of a fee a continuous process. The College of Al- for service model, essentially dividing the Dr. Zeydan Abuissa: lied Health Sciences have developed a set charges between the hospital and the phy- There are three areas we are working on: of courses which they feel are common to sician. This works well in specialties like Pfizer Voice which is a global survey mea- all health professions involving elements primary care and surgery but does not work suring ‘engagement, the inclusive envi- such as critical thinking, problem solving as effectively in supporting specialties such ronment and retention’; a management skills, and communication skills, which as pathology and radiology so here we pay effectiveness survey; and a retention pro- are now being incorporated into the cur- a base salary plus an incentive. I would say gram which we have developed locally. As riculum. These provide a training base that physicians are the least of our prob- you know. in the UAE and Gulf there is before moving on to the more specialized lems; retaining staff such as technicians, no retirement scheme so we have created training, in laboratory sciences for a labo- nurses, and support services is probably a new system where Pfizer allocates an em- ratory technician or imaging sciences for more challenging. ployee a certain amount of money which radiology etc. Ultimately this will result One of the biggest challenges that we is invested, the cost of which is borne by in people working together more col- have is the lack of available, qualified the company. We are also working on an laboratively and eventually improve the workforce in the local market. Recruiting end-of-service indemnity which increases quality of healthcare delivery. from outside the UAE is a very tedious in line with certain performance criteria, and costly process for any institution. and length of service. Dr. Mohamed AbdulRazaq Nasaif: In addition there are no regulations or Education and training is a [non-mone- guidelines that cover the payment model Peter DeBenedictis: tary] area that attracts a lot of valuable for healthcare workers. Leadership is a key driver for retention. At people. For the younger physicians com- GE we have moved from a primarily ser- ing in we have a residency program which Prof. Sehamuddin Galadari: vice-orientated model to more of a partner- is improving every year. There are also Monetary benefits are obviously a major ship with our customers. Over the years we other programs run by the Department of factor but training is also an important have extended our training opportunities to Medical Education within DHA plus the tool to attract and retain staff. Much of our customers particularly in the healthcare DHA facilities themselves which over the healthcare workforce would rather sector. The greatest demand is for leader- the years have developed considerably. work in a place with good training op- ship training since healthcare professionals We are also working on bringing further portunities. However, due to much of receive in depth technical training, but lit- education to nursing, administration and the workforce coming from abroad, and tle focus on leadership skills and developing public health which are all areas we need with many using the UAE as a means to elements such as change management, lean to develop. get to Europe or the US, their time in sigma, process improvement, etc. We’ve

106 IMIDDLE EAST HEALTH seen great results in the region both in terms institutions to adhere to. One of the most unless they are nationals because they of employee retention and improvement in important aspects of this is to establish need two years’ experience before they can patient care as a result of driving these ele- more specialty programs for nurses. be licensed. What are we achieving if we ments within the organization. Nursing and midwifery education in the are training people that cannot practice? UAE and across the GCC has evolved dra- Dr. Sarper Tanli: matically over recent years. Many hospi- Lauren Arnold: Patient safety is a key concern in most tals use standards whether it’s magnet or There are some regulatory hurdles to be over- healthcare institutions. How do you another body to reshape how the practice come to build a strong workforce. We have think the use of training and education environments are organized, but it’s just just conducted a policy analysis looking at all can be optimized to improve patient safe- beginning. The schools are starting to of the policy decisions across the UAE that ty and quality in your organization? teach more leadership content and more prevent the expansion of a nursing workforce practice content that focuses on team and we hope to use this to have a productive Lauren Arnold: work rather than professional isolation dialogue with the regulators. The UAE Nursing and Midwifery Coun- and that’s really important. This country imports most of its nursing cil was developed three years ago through workforce and most would agree that these a decree to set standards for education, Prof. Sehamuddin Galadari: nurses should be experienced. However, practice and regulation. There are a One problem that we have had is that in we are now graduating a number of Emi- number of guidelines and frameworks terms of building the national workforce, rati and non-Emirati nurses locally who that we’re looking at to set standards na- there is still some stigma associated with peo- can’t possibly have any experience as fresh tionally for a positive practice environ- ple joining the field. So there has to be posi- graduates. We are asking the regulators to ment, such as the Magnet program in tive education and clear career guidelines. recognize that we must grant them the op- the US and similar programs around the portunity to have a job so they can gain world. We’ve just issued the UAE Nurs- Dr. Nayzak Raoof: that experience and we are starting to see ing and Midwifery strategic plan for edu- I believe there is a requirement that gradu- progress here. There are a lot of barriers we cation and also standards for educational ates are not allowed to practice in Dubai can solve through productive dialogue.

MIDDLE EAST HEALTHI107 Patient Relations

Dr. Amer Sharif: Speaking specifically about the two years’ experience regulation we tackled this by allowing local graduates to go through a period of on-the-job training which paid less than the average salary for the role. It satisfies the legality of employing somebody without experience and helps the individuals gain the experience they need. school was established. place concerning CME and you cannot We have also established the simulation practice unless you fulfill this requirement. Cathy Easter: center and the Al Maktoum Medical Library However, we need more activities to be From the US perspective we have a similar electronic resources. We are now looking at available locally. concept. We are able to hire new graduates, the core educational components, support- so that’s not a regulatory hurdle. However, ing the authorities, academic institutions Dr. Abdul Karim Saleh: the fact is our graduates are not really qual- and government bodies and looking at how It is the same in Abu Dhabi; physicians are ified to provide direct patient care so what we can add value to the workforce, in Dubai, required to meet a minimum of 50 CME we’ve done is firstly, we will only hire new the UAE and regionally. hours per year. In terms of safety, obviously people that have a four-year degree from safety is the backbone of education every- the medicine perspective, which has been Dr. Sarper Tanli: where and the prime focus for all accredi- an enormous success factor for us by rais- There is a lack of positions dealing with tation surveys. However, most of these ac- ing the standards of care. We have also put new diseases or diseases that we encoun- creditation services focus on process rather a very robust graduate nurse curriculum in ter a lot here, such as diabetes. Diabe- than outcomes. Regulations should be place so that from a leadership perspec- tes is very prevalent yet we do not have more outcome-oriented and that may add tive, people know what’s expected of the enough qualified diabetes educators in value in terms of patient safety. new graduates versus the existing nurses. It this country. also helps them gain that experience and Dr. Mohamed AbdulRazaq Nasaif: expertise, similar probably to your on-the- Dr. Abdulrazzaq Al Madani: There is a lot of scope for expansion but job training so that they are of incredible Through the Emirates Diabetes Society we the number of applications we receive for value to us organizationally. have tried to build up the area of diabetes CME accreditations in the UAE is increas- education. We graduated more than 130 ing year on year. Many are internal events, Dr. Sarper Tanli: diabetes educators through programs in con- but there are an increasing number held by Dr. Amer you are running an amazing train- junction with the International Diabetes groups such as the Emirates Medical Asso- ing and education center in DHCC and col- Federation and the University of UAE in Al ciation and different conference organizers laborating with a lot of institutions conduct- Ain and the University of Leicester from the that are open to the public. This is definite- ing training and education programs, what UK, all of whom were certified. However, ly an area of growth in Dubai. do you see happening in this area? there is no such career as a diabetes educator in many institutes, which is something I’ve Dr. Sarper Tanli: Dr. Amer Sharif: been fighting for in DHA [Dubai Health In terms of CME hours most gulf coun- The governments and authorities should Authority] and in Abu Dhabi. tries set a minimum number of hours of invest significantly in career advancement CME training per year; however, there is opportunities right from the beginning. Prof. Sehamuddin Galadari: no connectivity to privileging. How can We need to develop institutions that pro- There are multiple aspects to this since we link our CME to privileging and en- vide on-the-job training, internships, ca- there may not be regulations in place to hance the skill sets of the workforce to reer advancement opportunities, residen- license the educator. positively affect outcomes? cies, fellowships and so on. Without this We can then move on to our next topic our healthcare services will not improve. Dr. Sarper Tanli: which centers on the expanding role of At the Mohammed Bin Rashid Al Can we now focus a little on continu- simulation in the healthcare training en- Maktoum Academic Medical Center, ous professional education (CME)? How vironment. I would be interested to hear we are looking at the gaps in the system. can we put regulations around it, how how the integration of simulation impacts For example, one of the first programs es- can we use the new technique of simula- the development of medical staff in your tablished was the postgraduate dentistry tion training effectively and how can we organization? program. This country develops a lot of maintain patient safety and training stan- undergraduate dentists through Ajman dards as new technology comes through? Dr. Nayzak Raoof: College and Sharjah University, but There is a level of discrimination in terms there are few career advancement op- Dr. Nayzak Raoof: of physician qualifications depending on portunities, hence the graduate dentistry The DHA has already put legislations in the country of certification. For example,

108 IMIDDLE EAST HEALTH the US Board of Certified Physicians is ical City and in practice a board certified Al Maktoum Academic Medical Center more scrutinized than others and has a physician would not be asked to recertify and I think simulation is key for a lot recertification process in place that is not provided that they maintain their seat and of clinical specialties. Regarding CME I required in Europe. The American gradu- CME hours. Every program has a defined set agree that we need to focus on outcomes; ates feel that the system is unfair as they of privileges associated with it and anything we need to look at the gaps in the skills of are being put under more pressure due to outside this requires a minimum level of ad- our workforce and focus on these. Mov- the tighter US guidelines. ditional training. In addition, privileging is ing away from CME, we can learn a lot reviewed every three years and any proce- from the strong education and postgradu- Cathy Easter: dure that the physician did not practice; or ate structure that has strengthened the Could you link this back to medical staff disease entity they did not work on in that Saudi system. The Saudi Commission for privileging, meaning regardless of country of time drops out of their privileges. However, Specialties has been instrumental there; origin you have to be recertified periodically? there are a lot of procedures that physicians Oman has also taken on board the ex- don’t get to see on a regular basis. Simula- perience of Saudi; Bahrain is setting up Dr. Nayzak Raoof: tion could bridge this gap, which is what a similar program; and we’ve signed an The challenge comes due to the processes in- drove us to build the ‘virtual hospital’ which MOU with the Saudi Commission. I also volved. A US board qualified physician would is basically an entire building being designed think it is very important for us to estab- need to travel to the US and sit a recertifica- to carry out simulations, so that healthcare lish a robust education system that links tion exam. In Germany there is no recertifica- providers can be trained on procedures or the public and private sectors. tion system so how are we going to recertify continue to practice them in order to re- this physician here in Dubai at the hospital? ceive or maintain their privileges. Dr. Sarper Tanli: It sounds like we would like to create a Dr. Mahmoud Al Yamany: Dr. Amer Sharif: system to integrate education and train- Until last year I chaired the Accreditation We have established a similar ‘virtual ing and put it together for any healthcare Privileging Committee for King Fahad Med- hospital’ in the Mohammed Bin Rashid professional to utilize, connected to cre-

MIDDLE EAST HEALTHI109 Patient Relations

dentials and privileging. We also need to November. Our faculty is also encouraged sion versus training within healthcare. We look at the benefits of simulation training to attend external conferences. spend anywhere between 5% - 7% of our versus traditional lectures and training total budget on training but that includes programs. How can healthcare institu- Dr. Sarper Tanli: education as part of the scholarships, etc. tions help address the problem of profi- It is important to emphasize that we are The point is, I as a CEO cannot retain ciency training and make use of simula- beginning to see more focus on simula- certain categories of employees and one tion technology? tion training, although in its infancy example is nursing. They tend to move compared to the technology available, through the tertiary care hospitals in Saudi Dr. Abdulrazzaq Al Madani: and in the future I feel that online train- Arabia to the Far East and to the Far West Conferences are a good way to refresh ing will also be utilized more. where they get citizenship. They’re not go- knowledge and receive training; there I would now like to discuss financing. ing to stay in Saudi Arabia no matter what are usually workshops run alongside the There are obviously dollars being spent I do. Yet this is not their fault as the system conference program designed to im- so the question is what proportion of does not allow them to stay. prove the skills of the participants. In healthcare spending should be spent on Dubai we have many such conferences education and training; is it enough, how Dr. Abdulrazzaq Al Madani: and workshops. Gaining CME hours for do we use it, who should be the one fi- If we could work on the retirement system, these conferences is an incentive for nancing it, and who coordinates it? and on social security, we would stand a the medical staff to attend and improve better chance. their skills. Prof. Sehamuddin Galadari: Healthcare is big business, and you have Dr. Mahmoud Al Yamany: Peter DeBenedictis: to think long term. The shortsighted view I couldn’t agree more. But the problem One thing we’re introducing to the re- would be why waste money on training, is, if you give me the option of retiring in gion is online learning. We have a library I should hire another doctor to get more Saudi without citizenship, or retiring in of 350 courses, which are certified in the patients. However, retention is key and Ireland as an Irish citizen, then the answer US, but the main challenges we have en- there is nothing more valuable than loy- is obvious. I think we need to capitalize countered are getting the students to reg- alty. Thinking long term I would invest on focused training opportunities that en- ister for such courses, and ensuring that at least a third of my budget on education courage employees not to look for other what they’ve learnt is actually being put and training, because I know there will be opportunities so we can keep them within into practice. a return on my investment. our institution for as long as we can. We need to make the individual feel that the Dr. Sarper Tanli: Dr. Zeydan Abuissa: institution is giving something back. Another tool we’ve been using for the I worked in Pfizer France for 12 years where last few years is interactive video web it is law that 2% of revenues should be allo- Peter DeBenedictis: conferences. Unfortunately, most of cated by any organization for training and de- Middle Eastern countries are facing glob- those conferences are accredited in the velopment which is a huge amount. I feel the al scarcity issues and that’s not going to US. We need to create an easier way UAE has done a great job in building interchange. Training is not going to stop them to accredit these conferences locally to national and global benchmarks in many in- leaving in the long run. GPs are probably provide the best opportunities to our dustries such as hospitality but not in health- one of the scarcest groups globally and it’s physicians. care and I think we have to ask ourselves only getting worse as time goes by; it’s a big why healthcare is not viewed as an industry challenge to retain them because they are Prof. Gita Ashok Raj: that attracts capital. We need to change this a skill that is needed globally. At Gulf Medical University our Health mindset. The UAE GDP is in the range of Communication Division hosts all the $350 billion, the second largest GDP in the Dr. Mahmoud Al Yamany: conferences and seminars and work- Arab world after Saudi Arabia, yet only 3.7% I think training has its place, but once you shops, which are organized by the col- or 3.3% is invested in healthcare whereas in reach retirement age it’s a different story. leges. All the colleges are encouraged to the US they invest well over 10% When we think of retirement in KSA, it’s organize at least one annual conference for Saudi nationals only. A private pension or two workshops. Dr. Mahmoud Al Yamany: scheme offered to non-nationals might be We also have our own internal monthly It’s actually 19% of the GDP in the States, an incentive to keep staff. events which include: a journal club re- not 10%... lated to clinical care or healthcare, a jour- Dr. Amer Sharif: nal club for medical education, a clinical Cathy Easter It would not be so bad if we lost these society meeting and research presenta- …and it’s an unsustainable amount. valuable staff to the local market rather tions. These events are accredited either than abroad as is often the case. The by HAAD, MOH in Dubai or DHA. We Dr. Mahmoud Al Yamany: market here is small and to be able to also have an annual scientific meeting in That is a different issue; healthcare provi- hire from within the Emirates instead of

110 IMIDDLE EAST HEALTH bringing somebody from abroad would be highly beneficial. It becomes very expensive to continually hire from outside.

Dr. Abdulrazzaq Al Madani: If you want to improve the service you are giving to your customer, you have to improve the standard of your employee. Even if their length of service is short by training them we will improve the standard of care we can provide in that time. Even if they go, I ben- efited from the years that they stayed. So in the healthcare system, I believe continuous education is a must. If you don’t do regular training you are outdated and cannot treat your patients properly.

Conclusion The session was concluded by Cathy Easter who summarized her thoughts on the discussions by saying: “I think this brought a lot of thoughts together and I think one of the things I took from this is around incentivizing; I think you do have obvious workforce challenges and so you might want to start thinking around the incentives for your non-physician caregivers as well. From experience, when we strongly wanted to improve our patient satisfaction scores one of the things we ended up doing was providing a quarterly incentive that was non-executive, non-physician, to everyone else in the organization – people who sweep the floors, change the linens, provide the direct care from the nursing perspective, the therapy side, and by sharing those successes financially, on a quarterly basis, we were able to really unite people. “Most people don’t go into healthcare because it is a strong industry, but because they want to take care of people. At any rate, I do think often it’s creating a set of incentives that can create better retention. I think training and education are great incentives, so perhaps utilize those more strategically, because it sounds as if you have a lot of them, but some of them may not be of the same value add proposition. “Another positive thing that I heard is you have a lot of opportunities to create this system. You don’t have a system that you have to now go back and re-tool, and you have a lot of the people, whether on this table or clearly around other tables that you can really spend some energy, effort and get some things going in the right direction and in very measurable ways. I do think the metrics piece is key, healthcare is in some ways, whether we like it or not, a business, but to use a term from the States – ‘No money, no mission’. You can’t stay in business, you can’t take care of people if you really don’t have the bottom line to be able to do that. So you have to continue to keep that in focus and strategically overlay some of these other things and, since it is a business and hopefully one that is successful, sharing back that wealth with people that will create incentives and rewards around the things you are trying to meet. “I thank you all for giving me the opportunity to participate in this really exciting conversation”. Dr Sarper Tanli thanked all attendees for a valuable discussion and for sharing their views on such a wide range of topics from workforce incentives and retention strategies, the importance of allied health and nurse development through to continuing medical education and privileging.

MIDDLE EAST HEALTHI111 Children’s Mercy Center

Minimal incisions, maximum outcomes day. In addition, less common diseases presented at the 2013 American Pediat- such as achalasia, inflammatory bowel ric Surgical Association (APSA) meeting disease, Hirschsprung Disease, esophageal indicating an improved cosmetic benefit atresia and fistula, congenital diaphrag- for the single site approach shortly after a matic hernia, and pulmonary parenchymal SSULS appendectomy when compared to masses are also approached using the mini- the traditional three-port appendectomy, mally invasive surgical (MIS) technique. but this cosmetic advantage is no longer Our center was one of the early pioneers present at two years following the opera- in the use of the laparoscopic approach for tion (Accepted, J. Pediatr Surg). fundoplication and the thoracoscopic ap- These studies are conducted through our proach for esophageal atresia. Center for Prospective Clinical Trials un- Center for Prospective Clinical Trials der the direction of Shawn St. Peter, MD. As one of the largest pediatric mini- More information on our trials is available mally invasive surgery programs in the on our website at cmhclinicaltrials.com. By George W. Holcomb III, MD, MBA United States, we’re also leading the de- Surgeon-in-Chief; Director, Center for velopment of best practices that have the Center for Pectus Excavatum Minimally Invasive Surgery; The Katharine potential to influence the care of children and Pectus Carinatum B. Richardson Endowed Chair in Pediatric Surgery; Professor of Surgery, University of around the world. In addition to the emphasis on laparoscopy Missouri-Kansas City School of Medicine In 2003, our surgeons began prospective and thoracoscopy as operative approaches randomized clinical trials in order to better for a number of surgical conditions, the sur- counsel our families regarding the advan- geons at Children’s Mercy also have a large At the Children’s Mercy Center for Mini- tages and disadvantages of either the MIS experience with the minimally invasive re- mally Invasive Surgery, children, including approach or the open operation. Our first pair (Nuss procedure) for pectus excavatum. the tiniest of patients, receive the latest study compared 200 infants (100 in each More than 500 patients have undergone and most effective procedures in mini- arm) undergoing either a laparoscopic or this operation at our Center for Pectus Ex- mally invasive surgery. Our state-of-the- open operation for pyloric stenosis (Ann cavatum and Carinatum (cmhpectus.com) art surgical facility is especially equipped Surg 2006;244:363-370). with extremely good results, and over 15 to perform pediatric laparoscopic, thoraco- A number of other randomized clinical manuscripts have been published regarding scopic and other minimally invasive tech- trials have followed completion of that our experience with the Nuss operation. niques, which result in less postoperative initial study, including trials investigating Also, for the past two years, the surgeons discomfort and minimal scarring. the operative and postoperative manage- within this pectus center have begun to The Center for Minimally Invasive Sur- ment for appendicitis, one study compar- employ dynamic bracing for managing chil- gery (cmhmis.com) was established in 1999 at ing fibrinolysis vs. thoracoscopic decorti- dren with pectus carinatum, and more than Children’s Mercy Hospital, located in Kansas cation for empyema, and several studies 300 patients have been seen and evaluated City, Missouri (USA), to highlight our em- looking at whether or not the esophagus to date. There has not been the need to phasis on the laparoscopic and thoracoscopic should be mobilized significantly during a perform a single pectus carinatum operation approaches for common as well as unusual laparoscopic fundoplication. since dynamic bracing was initiated. surgical problems in infants and children. Finally, two of these prospective trials Over the past 14 years, more than have investigated the use of single site um- Contact Us 10,000 minimally invasive operations bilical laparoscopic surgery (SSULS), and To learn more about how we can partner have been performed. A number of com- compared the single site approach to the with you to improve the lives of your mon operations such as laparoscopic ap- traditional three- or four-port laparoscopic patients, contact International Services pendectomy, fundoplication, gastrostomy, operation for appendectomy and chole- at +1-816-701-4524 or send an email to and cholecystectomy are performed each cystectomy. A quality of life survey was [email protected]

112 IMIDDLE EAST HEALTH St. Luke’s Medical Center

St. Luke’s Medical Center performs first successful adult fecal microbial transplant

St. Luke’s Medical Center, in conjunction tibiotics usually are not helpful. Because working together to develop an FMT pro- with The University of Texas School of the diversity of their microbiome – the gram to treat patients with refractory & Public Health in Houston, has successfully good bacteria in the intestines – is re- recurrent CDAD. treated its first patient with a fecal micro- duced, a repletion of this good bacteria l People with chronic diarrhea from bial transplantation (FMT). The proce- (or bacterial flora) is required for a cure. CDAD can contact St. Luke’s Interna- dure was led by a team, including Herbert Currently, the only effective way to re- tional Service at 832-355-3350 L. DuPont, MD, MACP, lead clinical in- establish bacterial flora is the fecal micro- or email us at stlukeinternational@ vestigator; F. Lyone Hochman, MD as the bial transplantation (FMT). In FMT, bac- stlukeshealth.org to learn about patient’s gastroenterologist; and Zhi Dong teria is isolated from the stool of a healthy the program and to see if they Jiang, MD, DrPH, laboratory investigator, patient and put into the lower intestine qualify. who prepared the FMT. of the person with recurrent CDAD, The FMT procedure was performed in one single treatment. The success in September 2013 and follow-up treat- rate is more than 70 percent with ments have helped relieve the symptoms recoveries that persist, and there of CDAD (Clostridium Difficile Associ- are no known complications of ated Diarrhea or C diff) in 47-year-old FMT, although treated patients Patricia Melancon of Liberty, Texas. and donors are followed to en- “The procedure was not difficult,” said sure safety of the treatment. Melancon. “Five days after the procedure, it “It’s our hope that our FMT was the best I’ve felt in the last year.” program being developed here at CDAD or C diff is increasing dramati- St. Luke’s will lead to new treat- cally in hospitals and nursing homes ments for this life-threatening throughout the United States, Canada, condition,” said Dr. DuPont. and Europe. The intestinal infection St. Luke’s Medical Center causes severe diarrhea and can lead to and The University of Texas kidney failure and/or death. Studies have School of Public Health are shown that C diff-associated deaths in Texas have tripled over the past decade. “Estimates suggest that we have 300- 400 patients in Houston, and more than 1,700 patients in Texas, with this chronic intermittent disease. It leads to a miser- able existence and requires recurrent hospitalization,” said Dr. DuPont. “A Fecal Microbial Transplant is the only effective way to give these patients back their everyday, normal lives.” When a patient is first diagnosed with CDAD, antibiotics are used for treatment. After two or more recurrences, an-

MIDDLE EAST HEALTHI113 Antibiotics

Researchers explore strategies to develop new technologies for fighting antibacterial resistance

“Antibiotic resistance threatens a return There are many attempts to tackle to the pre-antibiotic era”. The World bacteria resistance. One team focuses on Health Organisation uses this strong ex- developing antibacterial textiles, for expression when referring to a phenomenon ample. Bulgarian born chemist Tzanko that is rapidly spreading: the increasing Tzanov, also from the Polytechnical Nowadays, if you resistance of microorganisms to antimi- University of Catalunia, has developed a acquire an infection crobial medicines, such as antibiotics. technology to make sanitary fabric asep- in a hospital, it is WHO estimates indicate that the excess tic. This strategy is based on the use of extremely rare for the mortality due to resistant bacterial hospi- a combination of zinc nanoparticles, en- tal infections exceeds 25,000 every year, zymes and ultrasounds. The research is infecting bacterium in Europe. part of EU-funded SONO Project, aimed to not be resistant to “Nowadays, if you acquire an infection at the development of a sonochemical multiple antibiotics. in a hospital, it is extremely rare for the process for the production of medical an- infecting bacterium to not be resistant tibacterial textiles. to multiple antibiotics,” says Australian Like silver, zinc has a strong antiseptic microbiologist Harold Stokes, research effect. While the fabric is immersed in the teria. Horizontal gene transfer, by which director at the ithree institute, University water, ultrasounds cause bubbles contain- bacteria are able to transfer genetic mate- of Technology, Sydney (UTS). ing zinc oxyde nanoparticle to explode rial to an entire population, favours the The trouble is that antibacterial re- and the particles to be embedded in the spread of resistant genes to many patho- sistance is not fully understood. Recent textile. genic bacteria. My concern is that the research has shed some light into the re- “We use enzymes that improve the ad- wholesale spreading of this technology for sistance mechanism. Jordi Garcia-Ojalvo herence of the particles, and biopolymers use for non-medical purposes might foster and Pau Rué, researchers previously based that improve the antibacterial effect,” resistance. Antibiotics and antimicrobials at the Polytechnical University of Cata- explains Tzanov. “The combination of should only be used in a hospital context. lunia, in Barcelona, Spain, where they biopolymers, nanoparticles and enzymes The same applies to this technology.” were members of a team that developed results in an extraordinary adherence – Other experts have further reserva- a 2-D model of the biofilms formed by which resists 70 high temperature laun- tions, despite the quality of the results. Bacillus subtilis, a soil bacterium which dry cycles – and in a better antimicrobial “The antimicrobial results of this tech- forms spores to tolerate extreme environ- effect.” The idea is to produce hospital nology are good,” says Annalisa Pantosti, mental conditions. gowns or linen to help prevent the spread- an expert of microbial resistance from the “When the colony of bacteria is under ing of resistant bacteria. Italian National Health Institute ISS, in stress,” says Rué, “wrinkle structures in Some experts believe this approach Rome. “Yet, I have doubts on its actual ef- the biofilm conveying resistance to the could have some use, as long as it is lim- ficacy for the nosocomial infections,” she colony are formed.” ited to hospitals. “This technology needs says. “In a hospital, the transfer of bac- The formation of these structures is initi- to be evidence-based studied to see how teria may occur because of the hands of ated by massive spatially self-organised cell effective it really is, but it may help to the staff, for not properly sterilized medi- death, they observed. “With our simulation, reduce the microbial load in a hospital,” cal devices, or for infection of chirurgical we demonstrated that these patterns result says Harold Stokes. sites during the operations.” She believes from interaction between extracellular ma- According to the Australian microbiol- current protocols provide for disposable trix production and cell death,”Rué says, ogist, the risk of using these antimicrobial gowns and masks, and therefore such tex- adding: “without a matrix, cells die all to- agents outside a nosocomial environment tiles cannot help much. She concludes: gether, no wrinkles are formed and no resis- is high. “Consider that the WHO emphasises tance occurs.” This finding could therefore “There are several examples where the that the single intervention that can sig- help understand how bacteria develop resis- broad use of antibiotics has favoured a nificantly lower nosocomial infections is tance to external agents. large increase in resistant genes in bac- very simple: washing hands.” – youris.com

114 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI115 Autism Earliest marker for autism found in infants Study finds attention to others’ eyes declines in 2 to 6-month-old infants later diagnosed with autism

Eye contact during early infancy may be a key to early identification of autism, according to a study funded by the US Na- tional Institute of Mental Health (NIMH), part of the National Institutes of Health. Published 6 November 2013 in the journal Nature, the study reveals the earliest sign of developing autism ever observed-a steady decline in attention to others’ eyes within the first two to six months of life. “Autism isn’t usually diagnosed until after age 2, when delays in a child’s social behaviour and language skills become apparent. This study shows that children exhibit clear signs of autism at a much younger age,” said Thomas R. Insel, M.D., director of NIMH. “The sooner we are able to identify early markers for autism, the more effective our A 5-month-old infant participates in eye-tracking research. A decline in eye fixation reveals signs of autism present already within the first 6 months of life treatment interventions can be.” Typically developing children begin to well as the non-human spaces in the im- are intact shortly after birth in children with focus on human faces within the first few ages. Children were tested at 10 different autism. If clinicians can identify this sort hours of life, and they learn to pick up so- times between 2 and 24 months of age. of marker for autism in a young infant, in- cial cues by paying special attention to other By age 3, some of the children – nearly terventions may be better able to keep the people’s eyes. Children with autism, how- all from the high risk group – had received child’s social development on track. ever, do not exhibit this sort of interest in a clinical diagnosis of an autism spectrum “This insight, the preservation of some eye-looking. In fact, a lack of eye contact is disorder. The researchers then reviewed early eye-looking, is important,” explained one of the diagnostic features of the disorder. the eye-tracking data to determine what Jones. “In the future, if we were able to use To find out how this deficit in eye-look- factors differed between those children similar technologies to identify early signs of ing emerges in children with autism, War- who received an autism diagnosis and social disability, we could then consider in- ren Jones, Ph.D., and Ami Klin, Ph.D., those who did not. terventions to build on that early eye-look- of the Marcus Autism Center, Children’s “In infants later diagnosed with autism, ing and help reduce some of the associated Healthcare of Atlanta, and Emory Univer- we see a steady decline in how much they disabilities that often accompany autism.” sity School of Medicine followed infants look at mom’s eyes,” said Jones. This drop The next step for Jones and Klin is to from birth to age 3. The infants were di- in eye-looking began between two and six translate this finding into a viable tool vided into two groups, based on their risk months and continued throughout the for use in the clinic. With support from for developing an autism spectrum disor- course of the study. By 24 months, the chil- the NIH Autism Centers of Excellence der. Those in the high risk group had an dren later diagnosed with autism focused on program, the research team has already older sibling already diagnosed with au- the caregiver’s eyes only about half as long as started to extend this research by enrolling tism; those in the low risk group did not. did their typically developing counterparts. many more babies and their families into Jones and Klin used eye-tracking equip- This decline in attention to others’ eyes related long-term studies. They also plan ment to measure each child’s eye move- was somewhat surprising to the researchers. to examine additional markers for autism ments as they watched video scenes of a In opposition to a long – standing theory in in infancy in order to give clinicians more caregiver. The researchers calculated the the field-that social behaviours are entirely tools for the early identification and treat- percentage of time each child fixated on absent in children with autism – these re- ment of autism. the caregiver’s eyes, mouth, and body, as sults suggest that social engagement skills l doi:10.1038/nature12715

116 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI117 The Nebraska Medical Center

The Nebraska Medical Center offers advanced treatment options using ocular imaging technology for diagnosis and management of Primary Intraocular Lymphoma Serious Medicine. Extraordinary Care.

That has always been the motto for the University of Nebraska Medical Center/ The Nebraska Medical Center (“TNMC”). And certainly the specialists and researchers at TNMC are doing everything to maintain such reputation in the area of uveitis and intraocular lymphoma. In 1929, Percival Bailey first coined the term primary central nervous system lymphoma (PCNSL). Since the entry of PCNSL into the world of medical literature, countless medical advances regarding its pathogenesis, diagnosis, and prognosis have resulted. Yet, during the past eight decades , PCNSL is still bound to a harrowing prognosis, as relapsing CNS lymphoma has one-year overall survival of 25-40%. PCNSL is the second most common intracranial mass lesion. It is highly prevalent in the human immunodeficiency virus (HIV)-infected population – a population Longitudinal wide-angle color fundus photographs (P200 Tx, Optos, Inc.) on the left and which continues to expand in the Middle spectral domain optical coherence tomography (OCT, Spectralis, Heidelberg Engineering, Inc.) Eastern and North African regions. on the right of a patient with primary intraocular lymphoma. (A) First day of presentation: However, advances in the diagnosis of fluid in the retina is circled on the OCT. Arrowheads indicate hyper-reflective signals on the retina (photoreceptor layer, PRL, and retinal pigment epithelium, RPE, layer). OCT scan was one subset of PCNSL – primary intraocu- performed before the diagnostic vitrectomy. Color fundus image is from Day 14 following lar lymphoma (PIOL) – are proving to be vitrectomy. (B) Day 19: the arrows indicate intraretinal fluids on the OCT. Lesions on the pivotal to the early detection of eyes with PRL and RPE are pointed. (C) Day 77: hyper-reflective signals on the RPE pointed by the arrowheads on the OCT have arguably thickened. Hyper-reflective signals are also seen in the PIOL and allowing the physician to pre- inner retina. An arrowhead points to an example in the inner nuclear layer of the retina. serve sight in such eyes by initiating early therapy. PIOL is a rare non-Hodgkin’s MD, MSc, McGaw Memorial Endowed challenge,” Dr. Nguyen expands further. lymphoma, which consists of large B-cells. Chair in Ophthalmology, Inaugural Direc- However, several advanced imaging While PIOL may represent a mere 1% of tor of the Truhlsen Eye Institute (TEI). techniques are now being utilized to help the non-Hodgkin’s lymphomas, 1% of “Chief patient complaints typically consist diagnose and follow patients with PIOL. intracranial tumors, and less than 1% of of blurred vision and floaters without pain- “We are employing most if not all of them, intraocular tumors, 60-80% of PIOL cases ful or red eyes; however, clinical manifes- even those techniques in development” eventually develop CNS involvement. tation varies among patients. PIOL also says Yasir J. Sepah, MBBS, Director at “The diagnosis of PIOL itself was con- masquerades as infectious, non-infectious, TNMC. There are several techniques that sidered to be very difficult for a long time or idiopathic inflammation of the eye and have been used to evaluate patients with due to its masquerading features and low often even responds to corticosteroid ther- suspected PIOL. Fluorescein angiogra- incidence,” explains Quan Dong Nguyen, apy, thus contributing to the diagnostic phy is useful for monitoring the changes

118 IMIDDLE EAST HEALTH in the size of hypofluorescent lesions. In- saved the patient’s sight and also life. the outcome, early diagnosis and appropri- docyanine green angiography also reveals We have conducted extensive research ate treatments with careful monitoring are hypofluorescent lesions, although it is not on this subject and have published vari- necessary,” emphasizes Diana V. Do, MD, as sensitive as fluorescein angiography. ous seminal scientific papers in this area. Vice Chair for Education and Director at “Now, spectral-domain optical coher- And, we apply what we have learned from TNMC “The masquerading features and ence tomography (SD-OCT) may be em- the OIRRC to the patients who are being low incidence of PIOL make the diagnosis ployed to assess the degree of lymphoma examined at TEI, providing those who quite challenging,” Dr. Do reiterates. infiltration. SD-OCT findings of distorted are suspected to have PIOL or those with Nizar Mamdani, executive director of retinal layers and hyper-reflective signals atypical uveitis with the most compre- the TNMC’s International Healthcare in the forms of bands and nodules have hensive evaluation,” states Dr. Sepah. says, “Our researchers and specialists are recently been reported by our team and Although treatment is individualized for great examples of the caliber of specialists may further help in early identification of each case of PIOL, systemic methotrexate and researchers working tirelessly to help eyes with PIOL, especially in cases where and rituximab are currently considered to provide better lymphoma treatment op- there is no CNS involvement. The Fig- be first-line therapy. The affected eyes may tions. Through strategic collaborations in ure illustrates the course of a patient with be radiated in addition to systemic and 44 countries, we provide innovative treat- PIOL managed by Dr. Nguyen. The diag- intravitreal chemotherapy. Improvement ment options for cancercare and trans- nosis was missed by two comprehensive with local and intrathecal chemotherapy plantation to patients around the world”, ophthalmologists and two retina special- has also been reported. In some patients, says Mamdani. TNMC also provides cus- ists before Dr. Nguyen established the autologous stem cell transplant following tomized training and educational programs critical findings which led the patient not high-dose chemotherapy has been shown for specialists, nurses and allied healthcare only able to learn of the diagnosis of PIOL to be effective. professionals. but also subsequently of CNS lymphoma. PIOL is a highly malignant neoplastic l Contact: [email protected] Such proper diagnoses have certainly disease with poor prognosis. “To improve www.unmc.edu/international

MIDDLE EAST HEALTHI119 The Rehabilitation Institute of Chicago

The Only #1 Hospital for 23 Years Straight The Rehabilitation Institute of Chicago 350 clinical studies underway dedicated to (RIC) has once again been named the #1 improving treatments and creating better rehabilitation hospital by U.S. News & outcomes for patients. Highlights of a few World Report – a recognition unmatched include: by any hospital of any kind anywhere in l Bionics – New England Journal of the United States. Medicine recently published a paper on the RIC provides fundamentally different world’s first thought- controlled bionic leg. The Ability Institute of RIC – care than any other hospital, serving the Developed by an integrated research team Opening 2017 largest number of the most complex pa- at RIC, this leg learns and performs activi- This year marked a historic milestone in tients and treating a wide range of condi- ties unprecedented for any leg prosthetic. the history of the Institute as they broke tions from stroke, traumatic brain injury l Robotics Lab – RIC uses assistive de- ground on their new research hospital. and spinal cord injury to cerebral palsy, vices to facilitate finger extension, grasp Scheduled to open in early 2017, many cancer related conditions and other neu- and hand recovery. Used with clinical believe that this is more than just a new rological disorders. Each year they treat therapists in a virtual reality environment, hospital – it’s a whole new way of looking over 50,000 patients from more than 70 researchers are advancing new treatments at medicine. It will establish a new para- countries throughout the world. for stroke patients affected by hand weak- digm of translational research and clinical ness and paralysis. care and an extraordinary unification of The world’s best research directly l Non-Invasive Brain Stimulation - researchers, clinicians, patients and tech- impacts recovery This technique tests whether brain stimula- nology. Five new Innovation Centers will The future of medicine is the integration tion reduces inappropriate nerve impulses be established within the hospital that will of researchers, scientists and clinicians to the injured side of the brain, ultimately each apply new and promising treatments working together in the same space. RIC improving hand and arm movements. to help improve and eliminate the effects is leading this future with the develop- l Motion Analysis Center – Monitor- of impairments in the human brain, spinal ment and implementation of their new ing and analyzing gait and upper extrem- cord, nervous system and limbs in adults ‘AbilityLabTM’. This innovative model of ity function during daily activities enables and children. These innovation centers care allows the staff to share findings with researchers to assist patients with cerebral will focus on the dominant organ-system patients and their care team in real time palsy, spina bifida, spinal cord injury, and and its molecular and cellular basis of enabling them to solve problems faster and many other conditions. function and recovery. By focusing on how achieve greater outcomes. cells and organs respond to interventions RIC holds an unparalleled research dis- designed to promote movement, function tinction with a record eight, multi-year, and medical recovery, they will advance multi-million dollar federal research desig- knowledge, create new standards and dis- nations. Currently there are also more than seminate these findings across the world. AbilityLabsTM will also be created to fur- All medical centers say that ther infuse 21st biomedical science into they marry research and the clinical environment and align therapies with core functionalities: Think & patient care, but very few Speak, Arms & Hands, Legs & Walking, are willing to make the Coordination & Endurance and Pediat- enormous investments and rics. To learn more about the new hospital changes – including physical or how you can be a part of bringing this vision to life, visit their website at: www. design changes – to make that advancehumanability.org. happen. The design of the new l RIC’s Global Patient Services department hospital removes the barriers is available to help answer your questions and that prevent sharing across support your patient referrals. For more information, visit www.ric.org or to speak with one large complex organizations. – of our GPS representatives about making a W. Zev Rymer, MD, PhD, Vice patient referral call +1.312.238.1188 or email: President of Research at RIC [email protected]

120 IMIDDLE EAST HEALTH University of Chicago Medicine

Ali’s journey back to health

When 13-year-old Ali Al-Mammari arrived at the University of Chicago Medi- cine last summer, he could barely walk due to his severe sickle cell anemia. He ambled down the hallway with a cane, his hips and shoulders locked, with a look of excruci- ating pain on his young face, despite the medication he was taking. “At home, he would lie on his bed cry- ing in pain,” said his father, Mohammad Al-Mammari. “He was sad he couldn’t do things, and we were in the emergency department constantly trying to get him some relief.” Three months after receiving a bone marrow transplant at the University of Chicago Medicine Ali returned home to the United Arab Emirates no longer experiencing debilitating pain, but rather was running, riding a bicycle and playing soccer. pain, widespread tissue damage, stroke and in the hospital, Ali needed to regain his “He was so much more mobile when death. Ali had the most severe form of the strength and coordination. He received he left than when he arrived,” said Kelly disease; it had taken over his life. that help at the Rehabilitation Institute Kramer, advanced practice nurse for the In collaboration with his physicians of Chicago (RIC), where his treatment pediatric bone marrow transplant program in Abu Dhabi, plans began to bring Ali included daily exercises, therapy sessions at the University of Chicago Medicine to Chicago for treatment that would im- and age-appropriate function goals, such Comer Children’s Hospital. “And he no prove his quality of life. When the family as dribbling a ball so he could play soc- longer had any pain. Although he spoke arrived, Cunningham’s team determined cer again. very little English, I could tell he was pro- that Ali was indeed a good candidate for “Although it is rare for patients with gressing just by looking at his face.” a bone marrow transplant. And there was sickle cell disease to need a transplant, our Today, the cheerful 14-year-old is back even more good news: “He was lucky that team has performed more than 40,” said to being a young teen, ready to enter Omar, his 12-year-old brother, was an ideal Cunningham. “Few programs worldwide seventh grade, loves math and dreams of donor,” said Cunningham. have as much experience. Besides sickle being a fighter pilot. “He is doing all the “Omar was very cooperative and wanted cell disease, we care for children and young things his friends can do,” said his physi- to help his brother,” said Al-Mammari. adults with high-risk leukemia, lymphoma cian John M. Cunningham, MD, director “Having a match with his own brother and other genetic diseases. We have a of hematopoietic stem cell transplanta- made it special. We were very happy.” highly experienced and sophisticated team tion and chief of pediatric hematology/ The Center for International Patients to handle these tough cases.” oncology. “I visited him in January and assisted the family with all their needs, The Al-Mammari family has high praise Ali is doing well.” arranging translation services, transpor- for the University of Chicago Medicine’s Ali’s sickle cell anemia was challeng- tation and accommodations while in staff and especially their physician, Dr. ing in that he had two problems: constant Chicago. “The Center’s staff also gave us Cunningham. “He is one-of-a-kind and and severe pain, and blocked hips, said moral support and helped build trust and very much like part of our family,” said Al- Cunningham. This uncommon, inherited understanding with the medical staff,” said Mammari. “Not only is he a great doctor, disorder can cause problems ranging from Al-Mammari. but he’s a wonderful human being and re- moderate discomfort to profound, lasting After the transplant and two months ally like another father to my son Ali.”

MIDDLE EAST HEALTHI121 Medical Waste

Regulated medical waste management for the 21st century

manner whenever feasible; pollution that This steam or ozone cannot be prevented or recycled should be treated in an environmentally safe manner technology provides whenever feasible; and disposal or other the most cost effective release into the environment should be and environmentally employed only as a last resort and should friendly solution for be conducted in an environmentally safe manner.” (Pollution Prevention Act of dealing with medical 1990. Public Law 101-508, 1990). waste, blood products, As a microbiologist that participated in sharps containers and the scientific validation of the first field de- other biohazardous waste ployment of the Red Bag Solutions medical waste processing technology at Johns products. It diverts up Hopkins University, I am confident that to 100% of regulated By Richard W. Gilpin, , Ph.D., RBP, this technology will continue to set the CBSP, SM(NRCM)-Emeritus medical waste from benchmark in the 21st Century. President, R. Gilpin, Limited landfills and repurposes This steam or ozone technology provides the most cost effective and environmental- the waste into secondary Biomedical laboratories, hospitals, non- ly friendly solution for dealing with medi- fuel sources and recycling hospital healthcare sites and manufactur- cal waste, blood products, sharps contain- programs including waste ing sites generate medical waste that may ers and other biohazardous waste products. to fuel. contain biohazardous microorganisms or It diverts up to 100% of regulated medical materials perceived by the public as poten- waste from landfills and repurposes the tially infectious. waste into secondary fuel sources and re- cal facilities can greatly reduce their cradle Organizations have a duty to minimize cycling programs including waste to fuel. to grave liability for biohazardous material the impacts of medical waste disposal in Red Bag Solutions is the only treatment since only municipal trash leaves the facil- the 21st Century. technology that simultaneously grinds and ity, and all paper or electronic confidential Onsite disposal of medical waste satisfies sterilizes medical waste with no hazardous patient information is rendered totally un- these goals: chemicals, negative air emissions or odors. readable during the process. l Disposal cost avoidance Volume is reduced up to 90% and weight l Liability avoidance by up to 30%, enhancing an organization’s References l Reduction of institutional health and sustainability initiatives. The processed 1. Minimization and Management of safety hazards waste is ground into a confetti-like mate- Wastes from Biomedical Research l Environmental protection rial that is guaranteed sterile and unrecog- Edward H. Rau, Robert J. Alaimo, Pe- l Regulatory compliance nizable. The sterilized waste can be placed ter C. Ashbrook, Sean M. Austin, Noah l Community relations directly into the facilities compactor as Borenstein, Michelle R. Evans, Helen Onsite disposal of medical waste is a na- ordinary municipal trash. There are also M. French, Richard W. Gilpin, Joseph tional goal. “The Congress hereby declares several recycling options that can result in Hughes Jr., Sherilynn J. Hummel, Al- it to be the national policy of the United additional savings, while further reducing ice P. Jacobsohn, Charlyn Y. Lee, Scott States that pollution should be prevented the amount of material sent to a landfill. Merkle, Tad Radzinski, Richard Sloane, or reduced at the source whenever feasible; The RBS approach is safer for patients, Kathryn D. Wagner, and Larry E. Wean- pollution that cannot be prevented should employees, and the community. With on- er. Environ. Health Perspect. 108(suppl be recycled in an environmentally safe site destruction of infectious waste, medi- 6):953–977 (2000)

122 IMIDDLE EAST HEALTH The use of ColActive Plus and ColActive Plus Ag in the management of acute and chronic wounds maintaining optimal moisture balance and gen dressings do not have the binding sites inhibits microbial growth. exposed and so therefore the MMP prote- I use this collagen product because it has ases are unable to bind to the dressing. the following properties; ease of applica- RCDR’s mission and vision is to im- tion, does not stick to the skin, fast acting, prove the quality of life for diabetes pa- By Louise Jackson pain free and is an effective antimicrobial tients in the UAE by combining compas- dressing which can target a wide range of sionate, modern diabetes care, ColActive Rashid Centre for Diabetes and Research microorganisms. ColActive Plus Ag con- Plus is aligned to this mandate as it is a (RCDR), a United Arab Emirates Ministry tains ionic silver for broad spectrum anti- leading, modern collagen dressing con- of Health Organisation (MOH), managed microbial activity which lasts for up to 6 taining both CMC and alginate which and operated by Swedish Global Health days, therefore helping to reduce biobur- none of the other leading collagen dress- Partner (GHP) is a specialised tertiary Dia- den through the patented bioactive matrix ings contain together. betes Centre in Ajman. The foot clinic at and promote wound closure. The dressing RCDR treats UAE National’s with acute contains carboxymethylcellulose (CMC) l Louise Jackson is a Podiatrist and and chronic diabetic foot ulcers. The clinic and alginate. The alginate provides ab- Head of The Foot Clinic at RCDR. She has been using ColActive Plus and ColAc- sorption allowing the dressings to remove is a founding member of the Emirates tive Plus Ag in the management of acute and excess exudates from the wound bed whilst Foot and Ankle Club. chronic wounds which may have arrested in maintaining the optimal moisture bal- Prior to moving to the UAE Louise the cellular phase of closure. The attributes ance for wound healing. The open binding worked at leading London hospitals and of the collagen matrix product that make it sites exposed to MMP’s readily bind to the clinics in the public and private sector; so effective for wound healing are; it keeps wound dressing and digest the dressing as Chelsea and Westminster and St Mary’s granulation tissue moist, it has Dual-MMP opposed to the healthy tissue unlike other Hospital, Chelsea Consulting Rooms and inhibition capability, fast acting, capable of protease modifying dressings. Other colla- Portobello Clinic Notting Hill.

MIDDLE EAST HEALTHI123 Non-Communicable Diseases

Analysts say there is urgent need for action to reverse impact non-communicable diseases are having on GCC economies Failure to act could result in economic burden of $68 billion by 2022

Rapid economic advances in the Gulf Cooperation Council (GCC) countries have led to the population adopting a sedentary lifestyle. The result is a rising incidence of non-communicable diseases (NCDs), such as cardiovascular illnesses, cancer and respiratory diseases. NCDs have become the leading cause of death in the GCC. And, their prevalence – which is at epidemic levels – is undermining the societal gains stemming from economic development. In fact, with current prevalence rates, the total direct and indirect cost of the most common NCDs for the GCC will be close to US$36 billion in 2013 – one and a half times official healthcare spending. Given the magnitude of the problem, GCC governments must act rapidly. Analysts at Booz & Company suggests they must develop national and GCC-wide NCD agendas that will enact short-term and long- term pro¬grams before the epidemic imposes a heavy toll on their societies.

The economic development of the GCC negatively affects individuals’ quality of life, less to economic activity. Chronic illness countries has brought with it a signifi- diminishes their ability to contribute eco- and shorter life spans deplete the quality cant cost – a rising incidence of NCDs. nomically and drains healthcare resources. and quantity of the work force.” In effect, in little over a generation, GCC Booz & Company’s perspective focuses on Moreover, labour productivity is dimin- countries have improved their standards of five of the most common NCDs in the GCC, ished because workers are less effective. Sim- living from developing country levels to which were taken from the 14 NCDs listed by ilarly, NCDs lead to increased absenteeism, those of advanced economies. the WHO’s Global Burden of Diseases study. because of work missed due to sick days. Non-communicable diseases have been Although diverse in symptoms, the five Booz & Company used Harvard–WEF’s linked to developed economy lifestyles, NCDs highlighted share common lifestyle-re- Cost of Illness approach to measure the namely bad eating habits, high-sugar and lated or behavioural risk factors such as tobacco direct and indirect costs of NCDs in the fat-heavy diets, and a lack of physical ex- use, a fat-heavy diet, and physical inactivity: GCC. The Cost of Illness method is com- ercise. Increasing wealth has, of course, had l Cardiovascular diseases are responsi- prehensive and relies on tangible data. positive public health effects, such as fund- ble for 29% of deaths from NCDs globally. Booz & Company also collected data from ing large-scale public health awareness and l Malignant neoplasms cause 13% of local ministries, centres of statistics, and vaccinations campaigns to tame the threat global NCD deaths. regional reports linked to the selected of communicable diseases, such as polio, l Chronic respiratory diseases contrib- NCDs from all six GCC member states. measles, rubella, and others. However, in ute to 7% of global NCD deaths. By developing an econometric model using the GCC, as elsewhere, these gains to pub- l Neuropsychiatric conditions are re- the Cost of Illness model and the latest avail- lic health and individual well-being are now sponsible for 2% of NCD deaths worldwide. able and reliable statistics, Booz & Company being offset by the increasing prevalence of l Diabetes mellitus cause 2% of NCD was able to generate estimates for the direct NCDs and associated mortality rates. deaths around the world. and indirect costs of NCDs in 2013, and fore- “The result is that NCDs have become casts for the expected burden in 2022. the leading causes of death and dis¬ability, Economic burden “We calculated that the total direct and thus making the GCC one of the region’s The economic burden of NCDs comes in indirect cost for the five selected NCDs worst affected by the global increase in two cost forms, direct and indirect. in 2013 will be around $36 billion for the chronic diseases,” said Gabriel Chahine, a “Direct costs are typically those associ- GCC, rising to around $68 billion by 2022,” Partner with Booz & Company. “This trend ated with the treatment of patients, such stated Chahine. “The burden is greater, and is projected to result in NCDs causing over as consultations, medications, and clinical clearly less sustainable, when the total cost three-quarters of all deaths globally by 2030, operations,” added Jad Bitar, a Partner with of NCDs is compared to healthcare spend- up from 63% in 2008, with significant cost Booz & Company. “More significant is the ing. In 2013, the five top NCDs in the GCC implications for healthcare systems.” indirect economic penalty that NCDs im- will impose an economic penalty equivalent pose. From a national perspective, NCDs to close to one and a half times all six of the A chronic problem reduce life expectancy, which means less governments’ healthcare budgets.” NCDs, also known as chronic diseases, im- output. In addition to the immense burden The economic burden per capita for pose a tremendous human and economic on the patients, NCDs also affect the pa- the different GCC countries in 2013 will cost; their generally gradual development tients’ families, causing them to contribute range from $516 in Saudi Arabia, or 3.6%

124 IMIDDLE EAST HEALTH Pierre Assouad Gaby Chahine Jad Bitar of non-oil GDP per capita, to $2,001 in should aim for a better quality of life for Long-term programs Qatar, equivalent to 4.1% of non-oil GDP residents, a reduction in unnecessary med- Stakeholders should design and launch per capita. By 2022, the total cost per ical costs and improved productivity.” long-term programs in parallel to ensure capita will reach $758 in Saudi Arabia 1. Coordinate and educate: Coordination continuity of effort and sustainability of and $2,778 in Qatar. The lowest economic is important because the nature and magni- results. Long-term programs typically fo- burden will be in Oman, which, in 2022, tude of the required interventions demand a cus on behavioral change at the individual will have a NCD per capita cost of $603. centrally-led, collaborative effort involving level and at the healthcare system level, In comparison, in 2011 OECD economies key public and private stakeholders. Educa- and may have an effect on regulations and spent $3,327 per capita on healthcare. tion is also vital to convince all stakeholders funding. There are three types of long-term to accept the imperative of slowing the pro- programs: youth, adult and professional. Tackling the issue gression of NCDs; and education is the most – Youth: The aim of these programs is to edu- To tackle the crippling financial and hu- effective tool for empowering patients and cate teachers and others (e.g., sports coaches) man costs of NCDs, GCC govern¬ments encouraging them to change their lifestyles. who care for young people and can educate and other stakeholders need to identify 2. Prevent and cure: In practical terms, them on NCD risks and healthy lifestyles. These and understand the underlying risk factors any national strategy should tackle NCDs at programs can shape the behavior of the young associated with these illnesses. two different levels – direct curative care or within schools and their communities. “There are two kinds of primary NCD early disease management and prevention. – Adult: Programs aimed at adults will fo- risk factors that are root causes of these ill- 3. Encourage structural and behavioural cus on select audiences to improve their knowl- nesses: non-modifiable and modifiable, said changes: Preventative action to lower the edge and ability to manage their conditions and Pierre Assouad, Senior Associate with Booz prevalence of modifiable risk factors requires to reduce the impact of primary risk factors. & Company. “In terms of policy responses, the development and implementation of a – Professional: The aim of professional pro- modifiable risk factors are the most amena- combination of short-term and long-term grams is to sensitize health providers about NCDs ble to change and have the highest impact collaborative programs targeting structural and direct them toward resources they can use to on individuals. Non-modifiable risk factors changes as well as behavioural changes. prevent, detect, and treat such diseases. lie outside the control of the individual and GCC countries must urgently take ac- are linked to age, hereditary/genetic condi- Short-term programs tion to push back the rising tide of NCDs. tions and other socioeconomic, cultural, Short-term programs should be rapidly de- Without comprehensive programs that and environmental determinants.” signed and implemented by GCC govern- enable better allocation of healthcare re- Governments, through appropriate reg- ments. These efforts aim to alter or strength- sources to treat the root causes of NCDs, ulations and policies, can improve some en current structures to limit the impact of as well as their symptoms, the human, non-modifiable risk factors, such as envi- modifiable and non-modifiable primary risk the societal, and the economic burdens ronmental influences, including toxicity factors. There are three main areas in which associated with these diseases will reach levels of products and air quality. Modifi- governments can make immediate changes: crippling levels. Governments will need able risk factors are behavioural in nature financial, regulatory and clinical. to involve a wide array of public and and include tobacco use, physical inactiv- – Financial: These measures financially re- private stakeholders in such programs to ity and an unhealthy diet. ward, or penalize, individuals to reduce the im- help create the optimal enabling environ- pact of primary risk factors. This includes taxes ment for lifestyle changes. They should An effective strategy on unhealthy products, such as fast food, soft also implement screening programs for all “With risk factors growing and healthcare drinks, and cigarettes, and subsidies for healthy NCDs and utilize the wealth of informa- budgets already under strain, GCC govern- ones, for example, healthy food at schools. tion collected to design more effective ments need to sound the alarm within their – Regulatory: These measures involve and targeted interventions. Programs societies and embark upon national programs adopting and enforcing rules and regulations to lower risk factors and better manage to stem the NCD epidemic,” said Bitar. “The that limit the availability and promotion of un- NCDs necessarily involve a degree of goal of national programs that combat NCDs healthy products and ensure the availability of innovation and experimentation. With should be to disseminate positive behavioural healthy alternatives in different settings, such proper monitoring and measurement, messages that educate the population about as schools and government buildings. successful schemes can be institutional- imminent health risks, rather than to simply – Clinical: The aim of clinical measures is ized, and lower-impact programs can be defensively focus on restraining the growing to leverage existing health services and infra- curtailed. Over time, investment of re- incidence of chronic diseases.” structure to limit the impact of primary risk fac- sources in effective programs dealing with Assouad added: “GCC countries there- tors. Clinical programs include comprehensive NCDs should restrain the growth of GCC fore need to urgently factor NCDs into national screening programs to identify at-risk healthcare spending and improve the re- their long-term health planning and they groups and to ensure early detection of NCDs. gion’s health landscape.

MIDDLE EAST HEALTHI125 Neurology

Establishing the basis of humour

The act of laughing at a joke is the result of a two-stage process in the brain, first detecting an incongruity before then resolv- ing it with an expression of mirth. The brain actions involved in understanding humour differ between young boys and girls. These are the conclusions reached by a US-based scientist supported by the Swiss National Science Foundation. Since science has demonstrated that animals are also capable of planning into the future, the once deep cleft between the brain capacities of humans and animals is rapidly disappearing. Fortunately, we can still claim humour as our unique selling point. This makes it even more astonishing that researchers have considered this attribute but fleetingly (and have spent much more time on negative emotions such as fear), write the Swiss neuroscientist Pascal Vrticka and his US colleagues at Stanford University, in the journal Nature Reviews Neuroscience.

Strangely cheerful feelings In their recently published article (*), the researchers demonstrate that, while laughter at a joke requires activity in many different areas of the brain, just two separate elements can be identified among the complex patterns of activity. In the first part, the brain detects a logical home video – or entertaining – such as orders such as autism or depression often incongruity, which, in the second part, it clips of children break-dancing. On aver- have a modified humour processing activ- proceeds to resolve. The ensuing feeling age, the girls’ brains responded more to ity and respond less markedly to humour of cheerfulness arises from a brain activ- the funny scenes, while the boys showed than people who do not have these dis- ity that can be clearly differentiated from greater reaction to the entertaining clips. orders. Vrticka believes that an improved that of other positive emotions. understanding of the processes that take Moreover, in the study of 22 children Benefits of improved understanding place in our brain when we enjoy the ef- aged between six and thirteen, the re- Vrticka speculates that these sex-based fects of an amusing joke could be of great search team led by Vrticka showed that differences could play a role in helping benefit in the development of treatments. sex-specific differences in the processing women to select a suitable (and humorous) (*) Pascal Vrticka, Jessica M. Black of humour are formed early on in life. The mate. Aside from this, humour also plays and Allan L. Reiss (2013). The Neural researchers recorded the children’s brain a key role in psychological health. This is Basis of Humor Processing. Nature Re- activity while they were enjoying film demonstrated, among other things, in the views Neuroscience, online. clips that were either funny – slapstick fact that adults with psychological dis- doi:10.1038/nrn3566

126 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI127 Boston Children’s Hospital

Expanding the boundaries of pediatric hand reconstruction and transplant surgery

cal well-being of patients as well. there will always be children who cannot Combining training in adult and pediatric be helped by traditional therapies. To ad- orthopedics, hand surgery, plastic surgery and dress the needs of these patients, members microsurgery allows our clinicians to provide of Boston Children’s Hand and Recon- a comprehensive level of care unmatched in structive Microsurgery Program and Pe- most other hospital settings. In addition, our diatric Transplant Center have recently patients have access to social workers, psy- launched the world’s only pediatric hand chologists, psychiatrists, hand therapists and transplant program. The first adult hand child life specialists, all trained to support the transplant in the United States was per- unique needs of children. formed in 1999, and since then more than While we strive to provide the best 50 have been done on adults worldwide. treatments available to our patients, we However, thus far, there have been no also are deeply involved in the research of transplants from a donor to a genetically congenital hand deformities in hopes that different pediatric patient. But in recent By Amir Taghinia, MD Plastic surgeon at Boston Children’s our work will one day lead to universal years, medical knowledge, expertise and Hospital’s Hand and Reconstructive improvements in the care of these condi- technology have evolved to a place where Microsurgery Program tions, benefiting patients across the globe. we are now able to offer this as an option Currently, Brian Labow, MD, a researcher to patients on a research basis. Our hands are a vital part of how we in- and hand surgeon in our program, is spear- The program is being performed under teract with the world around us. From heading research efforts to elucidate the ge- a research protocol, which will evaluate feeding ourselves to putting on our own netic mechanisms that cause the congenital the safety and efficacy of bilateral hand clothing, hands are instrumental in many enlargement of digits of the hand or feet, or transplantation in children. Data will be of our daily activities. But the hand is other limb overgrowth syndromes. collected on patients to measure the out- about so much more than just function- Through microarray analysis of four comes of the procedure and the patients’ ality. Whether you’re expressing emotion patients with macrodactyly, he and col- progress for periods of 10 years or longer. through hand gestures or touching a loved leagues discovered that the growth factor Boston Children’s transplant team has one, our hands are often deeply involved pleiotrophin is an important modifier of extensive experience with solid organ in our social interactions, many of which this disorder (Lau et al 2012 PLOS One). transplants and immunosuppression. This help define us as people. Recently, collaboration between Labow strength, combined with our renowned And unlike many of the organs and body and the laboratories of Matthew Har- hand surgery and rehabilitation team, ex- parts treated in medicine, a patient’s hands ris, PhD, and Matthew Warman, MD, in tensive research capabilities and pediatric are often out in the open for everyone to Boston Children’s Department of Ortho- background gives us a unique opportunity see. As hand surgeons, we must always be pedics, was established to further this re- to offer this experimental procedure to conscious of this to ensure we are not only search. Using human genetic material and children who may benefit from it. doing all we can to preserve or improve our model systems of overgrowth in zebrafish We value your input and look forward to patients’ hand functionality, but doing so and mice, they hope to uncover more clues partnering with you until every child is well. in a way that makes the hand as symmetri- behind the causes of macrodactyly and Please feel free to contact our Hand and Re- cal as possible with the unaffected hand. other overgrowth disorders to help inform constructive Microsurgery Program or our At Boston Children’s Hospital’s Hand patients and their families, and physicians Pediatric Hand Transplant Program at any and Reconstructive Microsurgery Pro- treating the condition. time with comments, questions or ideas. gram, we recognize that pediatric hand l Taghinia may be reached though Boston reconstruction goes beyond surgery and Pediatric hand transplant program Children’s International Health Services: management of congenital or acquired But no matter how far research refines [email protected] hand deformities: complete care must sup- and expands the treatment of congeni- bostonchildrens.org/internationalreferral port the social, emotional and psychologi- tal and trauma-related hand differences, +1-617-355-5209

128 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI129 Cincinnati Children’s Hospital Medical Center

Combination therapy shows early promise against stubborn leukemia

In early-stage studies, combining mTOR vived about 175 days. inhibitors with chemotherapy was far more Although laboratory results involving effective against T-cell acute lymphoblas- cell lines and mice do not necessarily trans- tic leukemia (T-ALL) than stand-alone late to human treatment, the researchers treatment, according to new research post- say their findings suggest a new treatment ed online by the Nature journal Leukemia. strategy for T-ALL. Inhibition the FA Current treatments for T-ALL achieve pathway coupled with chemotherapy may The disease comes about a 90 percent initial remission rate. also be useful against other types of cancer. back because of But scientists are searching for improved Guo and his collaborators are continu- drug resistance that therapy because relapses often occur, re- ing their studies by developing “human- sulting in an overall survival rate between ized” mice, which have been transplanted leads to relapse. 60 and 70 percent. with patient cells of relapsed and refrac- Our study uncovers “The disease comes back because of drug tory disease, to further test mTOR inhibi- a way to enhance resistance that leads to relapse. Our study tors in combination with AraG, another the effectiveness of uncovers a way to enhance the effective- chemotherapy agent used clinically to ness of chemotherapy,” said Fukun Guo, treat T-ALL. chemotherapy. PhD, study first author and a researcher in the Division of Experimental Hematology Blocking a key protein may help and Cancer Biology at Cincinnati Chil- treat aggressive form of leukemia dren’s Hospital Medical Center. Targeting the RUNX1 protein – a tran- The new study involved laboratory cell scription factor that helps regulate blood lines of human leukemia and mouse mod- cell development – may provide a new ap- therapy, radiation or bone marrow trans- els of the disease. A key breakthrough proach to treating acute myeloid leukemia plant. These treatments can be risky or came when the research team discovered (AML), according to a study led by re- only partially effective depending on the that a molecular mechanism in the Fan- searchers at Cincinnati Children’s. patient as well as the variation and pro- coni anemia DNA repair pathway also The findings, posted in theJournal of gression of disease. Mulloy and colleagues appears to make T-ALL resistant to che- Clinical Investigation, found that RUNX- are searching for targeted molecular ap- motherapy. This same pathway has been 1plays an unexpected role in supporting proaches that could be more effective and linked to drug resistance in other types of the growth of AML when the condition is carry fewer side effects. cancer, Guo says. fueled by fusion proteins. The research team developed a mouse To block the FA repair pathway in leuke- “RUNX1 is generally considered a tu- model of AML that is driven by fusion pro- mic cells, researchers tested three mTOR mor suppressor in myeloid neoplasms, but teins and a mixed-lineage leukemic gene inhibitors currently under development – our study found that inhibiting its activ- called MLL-AF9. When researchers genet- pp242, AZD8055 and INK128 – in combi- ity rather than enhancing it could be a ically inhibited RUNX1 and an associated nation with three chemotherapies – AraC, promising therapeutic strategy for AMLs protein called core-binding factor subunit Etoposide and Cisplatin. driven by fusion proteins,” said James beta (Cbfb) in these mice, it stopped the In one example highlighted by the re- Mulloy PhD, a researcher in the Division development of leukemia cells. searchers, mice treated only with pp242 of Experimental Hematology and Cancer While findings based on mouse models or AraC died from their leukemia within Biology at Cincinnati Children’s and lead do not always translate to human disease, 80 days. However, 75 percent of mice re- investigator. the findings demonstrate that RUNX1 ceiving combination treatment survived AML develops and progresses rapidly, merits further research as a potential thermore than 100 days and 50 percent sur- requiring prompt treatment with chemo- apeutic target for AML.

130 IMIDDLE EAST HEALTH NewYork-Presbyterian/Morgan Stanley Children’s Hospital

First-reported emergency pediatric surgery of its kind: 5-year-old girl has massive tumor removed from abdomen and heart

Last year, a 5-year-old New York girl un- Dr Emile Bacha is the Chief derwent an emergency operation involv- of the Division of Cardiac, Dr. Tomoaki Kato, surgi- ing the removal and partial-re-implan- Thoracic & Vascular Surgery cal director of liver and at NewYork-Presbyterian/ intestinal transplantation tation of her liver and her right kidney Columbia University Medical at NewYork-Presbyterian along with open heart surgery to resect an Center and Director, Congenital Hospital/Columbia Uni- otherwise inoperable tumor. The 10-hour and Pediatric Cardiac Surgery at versity Medical Center NewYork-Presbyterian/Morgan and chief of Abdominal operation, the first reported emergency Stanley Children’s Hospital. Dr. Organ Transplantation pediatric surgery of its kind, was led by Bacha also serves as the Calvin and professor of surgery Dr. Tomoaki Kato and Dr. Emile Bacha F. Barber Professor of Surgery at at Columbia University the Columbia University College College of Physicians and at NewYork-Presbyterian/Morgan Stan- of Physicians and Surgeons. Surgeons. ley Children’s Hospital. The procedure to remove an extensive cancerous pediatric patient’s body to cool, the abdominal team patient’s prognosis will depend on how she tumor included several medical teams spe- isolated the tumor. When the patient’s body responds to a rigorous treatment regimen cializing in abdominal, cardiothoracic, pe- reached the optimum temperature, Dr. Ba- involving chemotherapy, a bone marrow diatric surgery and anesthesia. The tumor, cha’s team opened the heart and pulled the transplant, radiation, and finally, immuno- a neuroblastoma, was shaped like an un- top of the tumor from the right atrium. Si- therapy. “At this point, we are guardedly op- even set of barbells connected by a thick multaneously, the liver and the remainder of timistic about her long-term prospects,” says shaft. Tethered to the top of the right kid- the tumor were taken out of the abdomen. Dr. Darrell Yamashiro, pediatric oncologist ney, the tumor had worked its way into the The liver was repaired and re-implanted at NewYork-Presbyterian/Morgan Stanley liver and ballooned into much of the right while the patient remained on bypass. The Children’s Hospital and associate professor atrium of the heart by muscling through a patient was then re-warmed and blood cir- of pediatrics, pathology and cell biology at large connecting vein (the largest vein in culation was restarted. After blood flow to the Columbia University College of Physi- the body), the inferior vena cava (IVC). the liver was re-established, the patient was cians and Surgeons. “At the time of surgery, the IVC extending taken off bypass. l For more information, visit: www.nyp.org from the liver to the heart was completely Although the patient’s initial symptoms blocked, creating a backup of blood from appeared to be relatively mild, seemingly In the Region the legs and abdominal organs below the overnight they had gotten much worse. Recently, New York-Presbyterian Hos- diaphragm. The tumor was also inside the By the time she was rushed to NewYork- pital/Columbia University Medical heart, pressing against another major vein Presbyterian/Morgan Stanley Children’s Center (NYP/CU) signed an agree- and partially blocking blood flow from the Hospital, all of her symptoms pointed to a ment with American Fetal & Children’s lungs and the upper body,” says Dr. Kato, complete blockage of blood flow from the Heart Center in Dubai Healthcare City surgical director of liver and intestinal liver, notes Dr. Kato. “Without immediate in the UAE to collaborate and improve transplantation at NewYork-Presbyterian intervention, it’s unlikely she would have access to cardiac services for children Hospital/Columbia University Medical lived another 24 to 48 hours.” in UAE, educate and train physicians, Center and chief of Abdominal Organ The cardiothoracic team’s window to re- and jointly conduct research. Transplantation and professor of surgery sect the tumor and repair the IVC was just In addition, NewYork-Presbyterian at Columbia University College of Physi- 30 minutes, to guard against irreparable dam- Global Services (NYP) and Al Mur- cians and Surgeons. age during the cooling process. What’s more, jan Medical Company Limited have As a first step, Dr. Kato and his team both teams had to work in lockstep, timing signed a cooperation agreement to opened the abdominal cavity to mobilize their actions seamlessly. “Like a delicately enable NYP to establish a presence the kidney and parts of the tumor and pre- choreographed dance, we had to work in in the Kingdom of Saudi Arabia. The pare abdominal blood flow to the bypass synchrony, sometimes together, sometimes agreement will facilitate access to the machine. Next, Dr. Bacha’s team opened apart,” says Dr. Bacha, chief of the division of expertise of NYP and its two primary the chest and put the patient on cardio- Cardiothoracic Surgery, director of Congeni- medical school affiliates, Columbia pulmonary bypass. This set the stage for tal and Pediatric Cardiac Surgery at NewY- University College of Physicians & another procedure, deep hypothermic cir- ork-Presbyterian/Morgan Stanley Children’s Surgeons and Weill Cornell Medical culatory arrest (DHPA), which cools the Hospital and the Calvin F. Barber professor College, to support the advancement body to 18 degrees centigrade to safely stop of surgery at Columbia University College of of health care in Saudi Arabia. The the patient’s blood flow. Physicians and Surgeons. office will open in early 2014. As the cardiothoracic team waited for the While no longer in immediate danger, the

MIDDLE EAST HEALTHI131 Healthcare Education

Philips Healthcare Education – meaningful learning for enhanced patient care Unlock your potential

With over 1,000 learning activities delivered by professionals with relevant, up-to- can also deliver its educational courses at ered across clinical areas such as oncology, date, experience. The course methodology your hospital. cardiology, radiology, critical care, wom- helps enhance your problem-solving skills en’s health and more, Philips can design a via real-world case studies and in addition, Everyone’s talking about Philips education tailored training program to optimize your gives you the chance to network, and share 97% of attendees rated our courses as and your team’s skillset. From individual ideas with professionals across the Middle good or excellent, with 100% stating courses to long term learning pathways, East and beyond. they would recommend the class to their Philips Healthcare Education has some- colleagues. thing for everyone. Your long term partner in the Middle East As part of its ongoing commitment to l For more information on Philips educa- Interactive, practical, courses delivered by healthcare education Philips has estab- tional services please contact: knowledgeable and professional people lished training centers - in Dubai, Beirut, [email protected] Taking a Philips course helps you become and Riyadh. All centers are designed for or visit the website proficient in clinical applications, get the hands on, and interactive learning. Philips www.healthcare.philips.com/me_en most out of your technology, and gain a deeper insight into different ways of working. All our courses are designed and deliv- Dubai Healthcare City and Philips Healthcare work together to enhance professional healthcare education Arab Health Customer Royal Philips and Dubai Healthcare The first 4 courses have already education village – a must City (DHCC) signed a memorandum been delivered at the Mohammed Bin visit for all attendees of understanding (MoU) in May 2013 Rashid Academic Medical Center in During Arab Health 2014 Philips will to conduct comprehensive medical DHCC – digital breast imaging, OR be hosting a variety of mini-seminars education courses and continuous pro- and Cathlab related L3D TEE ultra- at its customer education village. The fessional development programs in the sound technique, MR Cardiac as well program will cover topics of interest to UAE. The partnership will further en- as 3D cardiovascular ultrasound. radiologists, cardiologists, critical care hance the capabilities of the healthcare Attendees commented that “speak- staff, administration, and all specialties workforce in line with the UAE’s strat- ers were very knowledgeable, courses relating to women’s health and more. egy for 2011-2013 to provide world- are very informative, and it’s a com- Come visit us, take part in one of the class healthcare and shows the con- fortable environment within which presentations and discuss with us how tinued commitment of Philips to the to ask questions and share experi- we can design a program just for you. country, its citizens and residents. ences”

132 IMIDDLE EAST HEALTH Royal Brompton Hospital Respiratory weaning from mechanical ventilation: Leading the way for independent breathing Professor Michael Polkey, Consultant Physician at Royal Brompton Hospital, discusses the pitfalls of mechanical ventilation and why a respiratory weaning service may be needed. Mechanical ventilation is the process of con- In the event that removal of the en- tor, suitable for use on the general ward or necting a patient to a machine that is able to dotracheal tube is unsuccessful, then the even at home. Once we are happy that the do the patient’s breathing for them. Since the patient will require ‘weaning’ from me- patient can breathe easily with this device, tube is inserted through the upper airway, the chanical ventilation if they are to resume the tracheostomy is withdrawn. patient has to be sedated with drugs. Once the a normal life – or indeed to leave the ICU. Royal Brompton Hospital is the UK na- patient is past the acute crisis, or their surgery At Royal Brompton Hospital, we pro- tional centre for heart and lung disease and is over, the doctors will try to get the patient vide a consultant-led multidisciplinary ap- therefore receives referrals from surround- to breathe for themselves. proach to ensure that the patient has the ing intensive care units that find their pa- In most cases this process works without best chance of weaning from mechanical tients difficult to wean. We also welcome problems, but with a few patients it is impos- ventilation. A key technique with which referrals from overseas and already have sible to remove the endotracheal tube at the we have a lot of experience is the use of established links with intensive care units first attempt. The reason for this is usually non-invasive ventilation to allow the pa- across the Middle East. due to underlying medical conditions such tient to ‘bridge’ from tracheostomy ven- l Should you have any questions about as lung disease, heart disease, muscle weak- tilation. With this approach the support the respiratory weaning service at Royal ness or retention of sputum in the airway, all of the ventilator is given by a tightly fit- Brompton Hospital, or to refer a patient, of which impede independent breathing. ting face mask from a ‘low-tech’ ventila- please email: [email protected]

MIDDLE EAST HEALTHI133 PharmaceuticalsConferences & Expos

Arab Health Exhibition & Congress 27-30 January 2014 Dubai, UAE Urgent need for effective surveillance and control of emerging infectious diseases in UAE

The GCC countries receive around two Standards of healthcare are generally migrant construction workers, include million working expatriates annually and high in the Emirate of Dubai, reflecting poor living conditions in many migrant 25% of these expatriates suffer from health high levels of public health over the last worker camps as well as lack of awareness issues, specifically infectious diseases. The decades. However, communicable diseas- among employers and employees of the most prevalent infectious diseases among es still stand as a concern to the Emirate health impact of these diseases.” expatriate workers are influenza, chicken and plans are still on-going to control and The GCC countries have been success- pox, hepatitis, TB, malaria, sexually trans- eradicate such diseases. fully implementing labour expatriate med- mitted diseases, food borne disease, fecal- “The increase in prevalence of many ical testing programmes in worker’s home oral transmission diseases, and others. Com- infectious diseases together with the on- countries in the hope that the spread of municable diseases still remain a concern to going evolution of viral and microbial these critical infectious diseases could the UAE authorities, despite the fact that variants, and selection for drug resistance, be minimized. These expat workers get the incidence of many communicable dis- suggests that infections will continue to tested again once they enter the country eases has declined sharply in recent years, emerge, and probably increase,” says Dr and screened again for the working visa emphasising the urgent need for effective Salama. “This emphasises the urgent need renewal. surveillance and control in the region. for effective surveillance and control in “Despite the extensive screening efforts Dr Wasif Muhammad Alam, Director, the region. Early warning of emerging and to tackle the problem of infectious disease Public Health & Safety, Dubai Health re-emerging infections depends on our transmission among expatriate employees, Authority (DHA), and Dr Rasha Salama, ability to identify unusual patterns and oc- a key factor remains health awareness and Senior Specialist, Public Health, Dubai currences as early as possible. Information health promotion which plays a vital role Health Authority (DHA) will be discuss- exchange and collaboration with GCC in educating employers and employees ing the current climate of infectious dis- countries is, therefore, essential.” about the risks of contracting and spread- eases in the UAE and GCC at the new According to Dr Alam: “The spread of ing these diseases, especially for the dis- Emerging Diseases of Public Health: Strat- communicable disease among expatriate eases that are not currently screened in egies and Interventions Conference at the workers can be fatal and the consequenc- the region, such as chicken pox, hand to Arab Health Exhibition & Congress from es are wide ranging. Factors that contrib- mouth diseases, food and water borne dis- 27-28 January 2014 at the Dubai Interna- ute to the spread of infectious diseases eases that immigrant workers may carry,” tional Convention & Exhibition Centre. among expatriate workers, specifically adds Dr Alam.

134 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI135 PharmaceuticalsConferences & Expos

The Brain Forum introduces three new technologies in the Middle East The Kingdom of Saudi Arabia hosted the progress of brain “The Brain Forum”, a first-of-its-kind sym- research to the latest posium in the Middle East. Some of the advances, challenges world’s top neurologists and pioneers in and opportunities in the field of ‘brain research’ and personal- neuroscience and per- ized healthcare came spoke at the two-day sonalized medicine. conference on December 3 and 4, 2013. Building upon these “The Brain Forum” organized by W initiatives, The Brain Science in collaboration with King Ab- Forum not only con- dulaziz University, (KAU), King Abdul- nected leaders, but lah University of Science and Technol- invited other entre- ogy (KAUST) in Saudi Arabia, the Saudi preneurial leaders to learn from one an- storage, analysis, visualization and com- Society of Neurology and NeuroPro AG other and more importantly, inspire one munication via a cloud-based Saas model. Switzerland, focused on “Challenging another to achieve much more. By leveraging the latest developments the Future.” Renowned scientists from Among them were three exciting new in cloud computing technology VMLpro- around the world presented their latest innovations of great interest. An EEG am- EEG is able to cut the time of traditional discoveries and open discussions were bulatory headset, the NeuroTrail was pre- data analysis from hours to minutes at a held on the future of brain research and sented. NeuroTrail is a flexible, ergonom- fraction of the traditional computing costs. related healthcare challenges. New tools, ically-designed, wireless headset for use in NeuroPro is revolutionizing the speed and technologies as well as other personal- the real-time capture of EEG and ECG effectiveness with which neural data is ized healthcare innovations to improve signals as well as other biometric data. De- processed and the usability of brain signal diagnoses, management and treatment of signed to adapt to individual head shapes, analysis to facilitate neurology research, brain disorders were shown. the NeuroTrail headset is comfortable and disease monitoring and physician-patient The W Science initiative was launched intended for every day, long-term use. interactions. When it comes to epilepsy by Dr. Walid Juffali to support outstanding The NeuroTrail headset, undergoing prediction, another exciting development scientific projects and facilitate collabora- clinical validation, features 1 to 8 chan- was showcased – a user-friendly, ambula- tions among leading scientists working at nels of EEG captured with state of the art tory, wireless integrated solution for the the interfaces of different scientific disci- non-invasive electrodes. Recorded EEG / capture and analysis of EEG and other plines to address unmet medical needs and ECG / other data is transmitted wirelessly biological data in a clinically-validated improve the quality of personalized care. in real-time using Bluetooth or Bluetooth- system for the prediction of epileptic sei- Commenting on the event, Dr. Walid Juf- LE and can be used for a wide range of zures. A modular solution including the fali stated: “This event convenes some of clinical (e.g. epilepsy prediction) and non- following components: Ambulatory wire- neuroscience’s greatest minds under one clinical (e.g. gaming) applications. In ad- less headset for the measurement of EEG roof. It creates the opportunity for intel- dition, an EEG Virtual Mobile Laboratory and other signals e.g. ECG Clinically vali- lectual dialogue and insights that can made its debut at The Brain Forum this dated and patented algorithm for the real- invigorate efforts to combat some of the year. VML pro EEG, an EEG Virtual Mo- time analysis and prediction of epileptic world’s most pressing health-related issues bile Laboratory Virtual Mobile EEG data seizures. Easy-to-use software application referring to neurological illnesses. management and analysis laboratory rep- for the analysis and prediction of epilep- With over one billion people affected resents a convenient, one-stop solution for tic seizures, providing seizure probability by some type of neurological disorder neural signal storage and analysis on the alerts to a mobile device. worldwide, The Brain Forum was a highly go. This solution will provide researchers anticipated event; the two-day forum and health professionals with the ability to The Brain Forum on YouTube saw discussion on topics ranging from easily upload captured brain signal data for www.youtube.com/user/thebrainforum

136 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI137 PharmaceuticalsConferences & Expos

MEDICA – good international business contacts Good international business contacts ated by medical technology in Germany. Medicine (DGIM) will serve as a partner are becoming increasingly important for “Not only is the export quota high. For- for organising professional aspects of the manufacturers of medical technology and eign trade is almost the only factor driv- MEDICA Education Conference. With medical products. Only those that are ing growth. more than 22,000 members, the DGIM is well-positioned at the international level “On the other hand, competition in the one of the largest professional medical as- are able to balance weaknesses in indi- German market is tough, not least because sociations in Europe. vidual markets and profit in the long run of the many international players,” Tobias Other offerings at this year’s event, from a market that, seen globally, is grow- Weiler, managing director of SPECTAR- aimed at an international audience, were ing. That is the key message conveyed af- IS, explained. the International Conference on Disaster ter four days of events (20-23 November The German Medical Technology As- and Military Medicine – DiMiMED, and 2013) at MEDICA 2013, the world’s larg- sociation (BVMed) sees purchasing pools the MEDICA Medicine + Sports Confer- est medical trade fair, and COMPAMED as the reason for increasing pressure on ence, addressing special concerns of sports 2013 (20–22 November 2013), the leading prices in Germany. Such concentration of medicine. As premiers at this year’s event, trade fair for the supplier market for medi- purchasing power is a further market trend both conferences were extremely well at- cal technology manufacturing. reflected at MEDICA. tended and succeeded in closely knitting More than half of the some 132,000 “The number of entities maintaining a transfer of medical knowledge on the trade visitors came from abroad, arriving hospitals is decreasing. Demand is thus one hand with presentations, by MEDICA from more than 120 countries. From the becoming concentrated in increasingly exhibitors, of related product innovations 4,641 exhibitors representing 66 countries, larger medical care networks and hospital on the other. Such products include wear- visitors obtained information on the entire groups. Consequently, especially high-level able applications for recording vital body spectrum of new products for high-quality, decision-makers are attending MEDICA,” data, “anti-gravity” treadmills that support efficient medical care – ranging from medi- noted Horst Giesen, director of MEDICA + gentle rehab training and, of particular in- cal technology and electromedicine, labo- COMPAMED with Messe Düsseldorf. terest for disaster and military medicine, ratory technology, physiotherapy products mobile medical imaging systems as well as and orthopaedic technology to health IT. Revised programme emergency equipment for on-site first aid. “We have observed a growing num- To accommodate, through both trade fair ber of visitors in recent years particu- and conference events, the continually COMPAMED larly from those emerging countries that growing number of international visitors COMPAMED, the international trade are especially promising for the medical seen in recent years, the previous confer- fair for the supplier market for medi- technology industry, namely from among ence programme was completely revised cal technology manufacturing, was held Asian countries, from India, Russia as for MEDICA 2013. The newly planned parallel to MEDICA. With 681 exhibi- well as South America and China,” said MEDICA Education Conference was well tors from 37 countries, a new historical Joachim Schäfer, managing director of attended on every day of the event. The record was set for the event. The exhibi- the Messe Düsseldorf. This assessment conference included courses providing ad- tors presented to the some 17,000 visitors is shared by Germany’s leading industry vanced training on topics for general prac- an abundance of technology and service associations: SPECTARIS, ZVEI and titioners and practical training on devices, solutions for use in the “MedTech” in- BVMed draw attention to the signifi- which afforded national and European dustry – everything from new materials, cance of exports in their current market CME certification, as well as high-level components, preliminary products, pack- forecasts on MEDICA 2013. According scientific workshops on focus topics, pre- aging and services to complex micro sys- to these reports, international business sented by highly prominent speakers. tem and nanotechnology. accounts for 68% of the almost 23 billion As has been planned for some time, from l The next MEDICA Düsseldorf will take euros in current annual revenues gener- 2014 on, the German Society for Internal place from 12-15 November 2014.

138 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI139 PharmaceuticalsConferences & Expos

A new platform for IVD dialogue Most medical professionals would agree Hartmann said that that there is an increasingly linear cor- IVD’s role in determin- relation between IVD results and patient ing treatment choices is treatment decisions. Innovations in IVD growing. He stated that (in vitro diagnostics) have a direct and the key missions of Roche often life-changing impact on patients Days revolved around and their healthcare outcomes. Inaugu- improving the quality of rated this year, ‘Roche Days Middle East’ is IVD results, helping the the latest contribution to increasing both industry mature and de- the knowledge and professionalism of the livering results that are Middle East’s diagnostics field. “trusted, produced here Held from November 11-13, 2013, in and not always referred Dubai, Roche Days provided a platform out [of the region].” for local and regional opinion leaders and experts from both public and private insti- A much needed platform tutions to share their experiences in IVD. The relaxed and active at- Moritz Hartmann, General Manager of mosphere at Roche Days Moritz Hartmann, General Manager of Roche Diagnostics Middle East Roche Diagnostics Middle East (RDME) provided many of the re- welcomed some of the regions key industry gion’s key experts with a positive environ- ity is already there, credibility is there so I leaders and opinion formers at the opening ment for an easy exchange of experiences. don’t have to wait for it.” ceremony on November 11. For Dr. Fayad Dandashi, Founding Similarly, Dr. Laila Abdel Wareth, Commenting on the delegates present, Manager of Futurelab in Saudi Arabia, Chair of Pathology & Laboratory Medi- Hartmann said: “It’s a unique gathering of Roche Days was a great way to bring cli- cine Department, Sheikh Khalifa Medical industry experts that have come together ents closer together. He said: “I believe in City said: “The best thing we found with to exchange their latest experiences and having a close rapport with clients. Edu- Roche is the support. The diagnostics, challenges in an industry that is not just cation and knowledge is really what the technological, and logistics support were blooming but exploding.” end consumer is missing and this is the all there for us.” gap now being filled by Roche Days.” Building trust The platform for discussion offered by Learning to work with new technologies The healthcare sector in the Middle East Roche Days is what Dr. Baher Badwi, ap- RDME’s Head of Marketing, Giannis Bat- is growing exponentially both in terms of preciated about the event. The lab direc- akis, sees the aim of Roche Days as bring- new facilities, new technologies and pa- tor at Erfan Hospital said: “I think from ing the region’s customers together, with tient numbers. With such a rapidly evolv- what we’ve seen today [Roche Days] is the “ultimate goal that it becomes part of ing industry, sharing information can add very helpful. It’s very much needed that RDME’s service culture to its customers”. enormous value – particularly in IVD, customers talk to each other. It brings Roche Days also provides an open op- where IVD results are the basis for 60% of to the surface the questions that people portunity to receive feedback directly ac- spending on healthcare systems. Trust is, of want to ask. They get the experience of cording to the needs of the industry in the course, a major factor. other people.” region, which allows RDME to become an Hartmann stressed the necessity of devel- Dr. Amid Abdelnour, Chief Executive even better partner. oping trust in the region’s diagnostics and in Office at Biolab, was also impressed with “If there is a demand for us as the IVD recognizing the region’s experts. IVD’s role Roche’s continuous development. He said: partner, then we know it’s going to be an in day-to-day patient care and treatment “I expect a lot of advancement and a lot of important and challenging year for us to choices cannot be underestimated. automation from Roche. I know reliabil- deliver on it as well,” Hartmann said.

140 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI141 PharmaceuticalsConferences & Expos

Professor Ismail Matalka, President of the Congress and Chairman of the Department of Pathology and Laboratories at the Jordan University of Science and Technology, speaks to delegates.

400 regional and international pathologists attend the 25th Congress of the Arab Division of the International Academy of Pathology in Amman Jordan bids to host the 32nd Congress of the International Academy of Pathology

Jordan hosted the 25th Congress of the In- delegates attended the event. standards in addition to recent updates by ternational Academy of Pathology - Arab The congress included a rich scientific leading experts on all specialities of labora- Division, and the 5th Conference of the program consisting of timely topics in pa- tory medicine (clinical pathology) clini- Jordanian Society of Pathologists, which thology and laboratory medicine. There was cal microbiology and infection control, was inaugurated by the Mayor of Amman, a special session on breast and uterine cervix immunology and serology, coagulation and Akel Baltaji, in a ceremony held at the tumours and diseases – and the use of indi- haematology, stem cells and blood bank- Royal Hotel, Amman. cators in their early detection and the pre- ing, and clinical chemistry. Professor Ismail Matalka, President of diction of their progress, as well as the latest Professor Matalka added: “This confer- the Congress and Chairman of the Depart- uses of immunostaining that assist in early ence is a platform that allowed various ment of Pathology and Laboratories at the warning of tumours, and their treatment. participants to showcase the latest updates Jordan University of Science and Technol- “Pathology and laboratory medicine are in this medical field, such as oncology and ogy, stated: “The congress was a great op- the cornerstone of medical work in gen- more. Roche was a strong contributor to portunity to review the latest findings on eral, because they contribute to a large the conference as Roche’s latest technolo- tumour and disease diagnoses. It will also degree in reaching an accurate diagnosis gies and methods were shown to reach the lead to establishing channels for close and and accordingly to the most appropriate most accurate diagnostic results.” permanent cooperation between patholo- treatment. This Congress follows the steps As the 25th Congress of the Interna- gists in the Arab world and their Arab of previous meetings in its commitment tional Academy of Pathology - Arab Divi- counterparts abroad, in addition to other to continuous education in pathology and sion was held in Jordan for the sixth time. platforms of cooperation between Arab promoting the discipline to junior train- Prof Matalka noted that it is a clear indi- pathologists and their global counterparts ees and exposing them to the new trends cator of the scientific status that the king- in the areas of pathology and laboratory of the field and the experts in them,” dom enjoys in all specialisations. It also medicine diagnosis and research.” stated Professor Ghazi Zaatari, Professor demonstrates Jordan’s capabilities in pro- The congress was held with the par- & Chairman of Department of Pathology viding excellent therapeutic services, not ticipation of eminent scientists from the & Laboratory Medicine at the American only on the local level but also the region. United States, United Kingdom, France, University of Beirut Medical Centre and He indicated that Jordan – on behalf Spain and Germany, and a number of Arab the Secretary of the Arab Division. of the Arab Division – submitted a bid scientists abroad, in addition to scientists Other topics covered by the internation- to host the 32nd Congress of the Inter- and experts from Jordan, Morocco, Alge- al speakers included tumours of the liver, national Academy of Pathology for 2018. ria, Tunisia, Libya, Iraq, Syria, Lebanon, lung, blood, and lymph nodes. There were Approximately 5,000 experts from around Yemen, Egypt, Kuwait, Bahrain, United reviews of the latest classification schemes the world are expected to attend the Arab Emirates and Oman. Four hundred as per most recently adopted international event.

142 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI143 PharmaceuticalsConferences & Expos

53,000 attend RSNA to learn about latest developments in radiology

By Jay Franco Middle East Health Correspondent

The 99th Scientific Assembly and Annual 1080p LCD monitor which ensures image panoramic volume organ scan enabling Meeting of the Radiological Society of quality, and has a more compact design to clinicians to easily capture, visualise and North America (RSNA) was held from 1-6 improve comfort, ergonomics and access. quantify a full organ (e.g. liver or pan- December 2013 in Chicago, USA. More n Toshiba: Aplio 500, by Toshiba, creas), a full uterus or a full fetus in a 3D than 53,000 people came to the event to combines advanced visualization capa- panoramic volume. attend some 5,000 scientific research pre- bilities, workflow automation tools and n Sonosite: X-Porte, by Fujifilm So- sentations and education exhibits. RSNA ergonomics for more accurate diagnoses nosite, demonstrated its high resolution offers the latest developments in radiology and improved departmental efficiency. It ultrasound kiosk which was intended to in- and related imaging technologies dealing has two advanced features: a) Fly Thru crease access to ultrasound visualization for with diagnosis, intervention and therapy. (4D ultrasound that allows clinicians to patients. It was designed to cure side-lobe Alongside the conferences, the exhibi- ‘fly through’ interiors of fluid-filled ducts imaging artifacts, through a brand new type tion had a lot of new products and tech- and vessels), and b) Smart Fusion (syn- of technology used in an ultrasound system: nologies to offer. We have covered the best chronizing CT or MR with live ultrasound SonoSite’s Extreme Definition Imaging of the best modality wise as follows: to located hard-to-find lesions and aid in (XDI). XDI is a new beam forming algo- ultrasound-guided biopsies. rithm that significantly reduces the visual Ultrasound n Philips: EPIQ – the newest ultra- clutter from side-lobes that affect all ultra- n Siemens: HELX Evolution was intro- sound system showcased by Philips for the sound products regardless of system size. The duced by Siemens as part of the Acuson first time, delivers excellent image resolu- resulting ultrasound image appears cleaner S family. It offers a 21.5 inch LED backlit tion and details. It offers the world’s first with optimal tissue differentiation.

144 IMIDDLE EAST HEALTH n Zonare: A high frequency ultrasound correct location during surgery, and the includes a high-field superconducting mag- transducer, L20-5 was showcased by Zona- 32-slice configuration is designed to pro- net with a co-designed patient incubator. re. This transducer has a 32 mm aperture vide more detailed imaging for bone frac- It is capable of monitoring and supporting and up to 5 cm penetration. It provides tures, inner ear examinations, and vascular critical neonatal patients during their MR excellent imaging for pediatric, musculo- applications. Both configurations of the imaging examinations followed by obser- skeletal, breast, testicle, interventional, Somatom Perspective feature the SAFIRE vations. vascular, contrast enhanced ultrasound (Sinogram Affirmed Iterative Reconstruc- n Hologic: Hologic’s MultiView MR (CEUS), advanced research and other ap- tion) algorithm, which enables the user to software offers advanced options to pro- plications. It is based on ZONE Sonogra- reduce radiation dose by as much as 60% vide real-time 4D (3D + time) imaging phy Technology (ZST), which is an inno- or improve image quality correspondingly. processing, speed, flexibility and dedicated vate approach to echo data acquisition and MRI algorithms for both breast and pros- image formation. Using a small number Magnetic Resonance (MR) tate diagnostic viewing. MultiView is a of large “zones”, ZST acquires ultrasound n Philips: Philips’ Ingenia 1.5T and state-of-the-art imaging platform for MRI data up to 10 times faster than conven- 3.0T set a new standard in image quality, visualization and interventional guidance. tional ultrasound and extracts more infor- clarity, scanning efficiency and scalability. mation on each transmit receive cycle. The key benefits are to drive clinical per- X-Ray formance (with digital clarity and speed n Toshiba: Toshiba’s automated Computed Tomography (CT) to ensure more diagnostic info in shorter RADREX-i digital radiographic system n Toshiba: Toshiba featured their most timeslots), to enhance patient experience can reduce overall procedure time, allow- advanced CT system, Aquilion ONE VI- and to ensure economic value. ing radiologists to enhance workflow and SION, which offers low-dose exams with n Siemens: Magnetom Skyra 3T and increase patient throughput. The robust the largest bore, widest coverage and thin- Magnetom Area 1.5T offered by Siemens system is available with a wireless detector nest slices, and can accommodate more are designed to enable fast body MRI for and includes features necessary for imaging patients including bariatric and patients all patients. Alongside these systems was a variety of patients, from pediatric to bar- with high heart rates. It is equipped with their new StarVIBE MR pulse sequence to iatric. The system features RexProtect dose AIDR 3D, fast acquisition speeds and ad- enable free breathing, contrast-enhanced savings technology; RexSpeed technology vance dose reduction technology which liver imaging for patients who are unable to automate workflow and; RexView with make CT imaging safer by reducing radia- to easily manage breath-holding. Also new image preview to enhance patient care by tion dose. was their TWIST-VIBE MR sequence de- allowing technologists to make point-of- n Medic Vision: SafeCT Iterative signed to enable correct contrast imaging care decisions. Image Reconstruction by Medic Vision in dynamic liver MRI for all patients and n Agfa: A new small-format, wireless flat provides a cloud-based low-dose CT lung lesions, allowing fast, robust liver imaging DR panel detector, DX-D 35C was show- screening service which allows any radiol- with full 4D coverage. The sequences Star- cased by Agfa HealthCare. With its small ogy department to perform low-dose CT VIBE and TWIST-VIBE will be available 30x38 cm size, it is ideal for orthopaedic and lung screening without purchasing and as the FREEZEit package. other radiography imaging. It provides high implementing iterative reconstruction n Toshiba: Toshiba’s Vantage Titan 3T signal-to-noise ratio for higher contrast and technology. Lung images are forwarded to came equipped with advanced multi-phase high diagnostic confidence, plus twice the a remote cloud-based SafeCT system for RF transmission technology that reduces dose quantum efficiency (DQE) of gadolini- processing. troublesome dielectric shading artifacts. um-based solutions. n Philips: The world’s first spectral The system is able to produce whole-body n Fujifilm: Fujifilm Medical Systems detector-based CT by Philips - IQon images and is suitable for hospitals that announced their 510(k) clearance from Spectral CT allows clinicians to use co- require advanced MRI capabilities and the FDA of its gadolinium and cesium lour within CT images to identify the abdominal imaging. It comes with a 71 digital x-ray detectors for pediatric use. composition of what they see. They can cm aperture for bariatric patients, reduces The smallest format 24x30 cm cesium add spectral resolution to image quality claustrophobia, and ensures patient com- iodide detector is specifically designed to and can get the anatomical information fort with their patented Pianissimo tech- offer high DQE performance for low dose they are used to with CT. nology that significantly reduces acoustic x-ray exams such as for small patients and n Siemens: Siemens’ Somatom Per- noise during scanning. The system also anatomy such as extremities, shoulders, c- spective family of CT scanners demon- features an enhanced M-Power interface, spines and more. strated the capability of a new 16- and which simplifies MR scans by automati- n Nuance: Nuance announced their 32-slice configurations, with the option cally guiding clinicians to more accurate faster and more accurate speech recogni- of upgrading to the established 64- and and efficient exams. tion PowerScribe 360 platform that en- 128-slice configurations. The 16-slice n Time Medical Systems: The indus- ables a quality, data-driven approach to Somatom Perspective ensures that pain- try’s first neonatal Neona MRI system was radiology reporting for radiology groups, relieving analgesics are delivered to the launched by Time Medical Systems, which hospitals and healthcare systems. This

MIDDLE EAST HEALTHI145 PharmaceuticalsConferences & Expos

platform allows radiologists to more easily navigate changing reimbursement models by driving efficiencies in the creation of actionable, structured reports that directly improve patient care. It is aimed at empowering the delivery of high-quality care, driving faster and more accurate report generation, simplifing communication of patients’ critical test results and enhancing quality and performance with analytics. n PROTEC: Proslide 32 DR –Touch, developed by PROTEC, is a fully digital and mobile x-ray, ideal for emergency rooms, ICU departments as well as orthopaedic and part-radiologic clinics for x-ray exposures of immobile patients. It comes with a 22” multi touch wide screen monitor, which provides high performances, easy to use workflow and allows high quality images with optimized dose.

PACS n Carestream: Carestream demonstrated their works-in-progress (WIP) new generation of its VuePACS platform which is designed to create productivity- enhancing capabiities for radiologists 2D/3D SUV, triangulation, size measure- event locations worldwide. The footage and referring physicians, including em- ment, alpha bending, window/level, gam- demonstrates how the clarity, resolution bedding access to key image data using ma, etc for molecular imaging. Both these and detail of 4K images hold great poten- links within the report which merges solutions are based on Windows Server tial for increased visualization. In addition images into the reporting workflow. It 2008 R2 64-bit platform and provide real- to producing beautiful images, the display’s also includes an innovative teleradiol- time performance matches or even surpass- Multi-View feature lets medical profession- ogy module that gives remote radiologists es that of local applications with local data. als see a “quad-split” view of four full HD access to prior exams and automatically They support all common client platforms signals on one display, helping them view sends radiology reports to the requesting such as Windows (32-bit and 64-bit) – XP, different angles simultaneously of the same facility. Vista, 7 & 8; Apple MacOS, iOS; Android procedure. n Paxeramed: Paxeramed displayed 2.0 and newer, and can support multiple n Ampronix: Hybridpixx, a stand- their third generation of PaxeraUltima monitors on client computers. alone unit newly introduced by Ampro- 3.0 – a versatile browser based multi- nix, replaces 6 separate monitors, creates modality medical viewer that delivers a Displays a 56” medical display that enables one to consolidated work list, zero-footprint and n Sony: New developments in 4K and orient six video sources simultaneously vendor-neutral access (VNA) to stud- 3D imaging technologies were highlighted into the 50”x25” video grid based on ies throughout the enterprise with a full by Sony Electronics. The LMD-2451MT viewing preferences and for multiple us- spectrum of diagnostics and reporting 24-inch display was part of their 3D medi- ers. It is important to note that the unit tools – all from a single login. It is capa- cal display line, joined by a 32-inch model. contains all of the hardware needed to ble of sharing large data sets to multiple The 24-inch version is featured for its use perform the feat, and is designed to be a locations, and features a patient history as a secondary monitor for 3D review of quick installation. Once it is mounted to timeline enabling access to a patient’s interventional procedures by GE Health- the boom and cables are connected, it is entire clinical history. care, taking signals from a GE Vivid E9 totally operational. It comes with 5 pre- n Thinking Systems: Thinking Sys- cardiac ultrasound scanner. Also show- sets and 5 customizable video configura- tems offered their cloud-based solution in cased was a new 65-inch Pro BRAVIA 4K tions with a 10.4” touch screen controller PACS for Radiology and Molecular Imag- professional display to show 4K footage re- and intuitive software. ing. It supports all radiology modalities, cently captured at the Anatomy Lab of the l The next meeting will mark the cente- including CT, MR, CR/DR, ultrasound, flu- Duke School of Medicine. The Sony cam- nary year of the RSNA, and will take place oro, etc; and includes comprehensive PET- era used was the F55, the same 4K camera from 30 November – 5 December 2014. For CT/SPECT-CT fusion functions including model now in use on movie, TV and live more information, visit www.rsna.org

146 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI147 PharmaceuticalsConferences & Expos

Second Annual Emirates Oncology Conference gives boost to cancer care in the GCC

The second edition of the industry-leading The Second Emirates Oncology Confer- simply phenomenal. The fact that we Emirates Oncology Conference was held ence: ‘Setting New Standards in Cancer have been able to bring 1,000 health- was held at Emirates Palace, Abu Dhabi in Care’ was hosted by the regional cancer re- care professionals together to share their November last year and received a record ferral centre, Tawam Hospital, in affiliation own experiences of treating cancer and number of delegates from the healthcare with Johns Hopkins Medicine, and the Abu working with cancer patients and their profession across the Middle East. Dhabi Health Services Co. (SEHA). Ses- families, to learn from leaders in their The delegates attended more than 100 sions included paediatric oncology, clinical respective fields of oncology, to see and sessions over the course of three days, led by trials and cancer registry, and gynaecologi- hear the latest findings across so counties almost 90 expert speakers from 13 countries cal oncology, as well as breast cancer; pal- and so many different forms of cancer – around the world – including the Middle liative care; gastrointestinal, urology and which impact so many families across the East, Europe, North America, Asia and pulmonary oncology; and haematology. Emirate and across the region – is an in- Australasia. The speakers were hand-picked Closing the conference, Dr Moham- credible achievement. I’m proud that the as leaders in their respective fields of cancer med Jaloudi, Chair, Emirates Oncology Tawam Hospital team has been part of it, treatment and care, each able to give global Conference, said: “The feedback we have and I’m grateful to SEHA for their sup- and regional perspectives on industry-shap- had from delegates and visitors over the port, and to all of our speakers who made ing insights and innovations. course of these last three days has been this event such a resounding success.”

International EECP Society officially launched at the Third International EECP Symposium On Saturday, October 12, 2013, at the therapy in its endeavor to improve the encouraged by the enthusiastic endorse- 3rdInternational EECP Symposium held quality of life for all. ment we have received right at the launch during the 24th Great Wall International Dr. William E. Lawson, Professor of of the Society, and look forward to work- Congress of Cardiology and Asian Pacific Medicine and Chief of the Division of ing with colleagues all over the world to- Heart Congress 2013 in Beijing, China Cardiology at Stony Brook University, wards of our common goal of benefiting the International EECP Society (IEECPS) New York, USA was selected as the So- more people with EECP therapy.” was officially established. ciety’s first president. Dr. Guifu Wu, Presi- The 3rd International EECP Sympo- IEECPS is an independent not- dent and Director of the Fourth People’s sium was organized by a group of cardio- for-profit association of physicians, Hospital of Shenzhen, China was elected vascular experts including Dr. Hu Dayi, researchers and other professionals as Vice President of the Society. Many President of the Great Wall International involved in the study, research, applica- leading international experts in cardiology Congress of Cardiology, Dr. C. Richard tion and provision of Enhanced Exter- as well as in EECP therapy participated in Conti, President Emeritus of the Ameri- nal Counterpulsation (EECP) Therapy. the Society’s preparation meeting during can College of Cardiology, Dr. William E. The objective of the Society is to raise the Symposium and joined the Society, Lawson, Dr. GuiFu Wu and Dr. John CK awareness about EECP therapy as an signaling great support for EECP therapy. Hui, an internationally recognized EECP effective treatment modality for heart “With the recent development of scien- expert. The Symposium was sponsored by disease and to explore applications of tific evidence supporting EECP therapy as Vasomedical Inc., Westbury, New York, EECP in other ischemic diseases. an effective treatment for ischemic heart USA, the world leader in Enhanced Ex- Through publishing newsletters and ex- disease, we realized the need to bring to- ternal Counterpulsation technology, and pert consensus and organizing events such gether expertise in the field to discuss Chongqing PSK-Health SciTech Devel- as conferences and symposiums, the Soci- best practices, promote research, increase opment Co. Ltd., Chongqing, China, the ety will be actively engaged in disseminat- acceptance and drive utilization of the leading manufacturer in external counter- ing the latest research results, educating therapy globally. The International EECP pulsation systems in China. clinicians and other healthcare profes- Society provides just such a platform that sionals, and promoting patient awareness will effectively execute these challenging International EECP Society to increase global acceptance of EECP tasks,” stated Dr. Lawson. “I am extremely www.ieecps.org

148 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI149 Durbin

The challenge of transporting medicines

utor for the quality of the product that from the US Pharmacopeia and the Paren- reaches the patient. The most significant teral Drug Association have urged pharma- of these is a requirement for all ‘ambient’ ceutical companies to demand more quality products (those that require storage from assurance measures from their logistics pro- 15°C – 25°C) to be packaged in tempera- viders. I am certain that the new EU GDP ture-controlled boxes. guidelines will also have a similar influence. I am left wondering at the impact of Some countries in the region have already such a move. Although distributors such as taken steps to boost their cold chain security. ourselves will always meet regulations and Saudi Arabia, for example, has introduced guidelines set by the authorities, how will an entry requirement making it mandatory this work in the common workplace? Will for individual shipments of pharmaceuticals our customers be prepared to pay for expen- requiring temperature controlled storage to sive temperature-regulated packaging? be documented on arrival. It’s not unusual for Durbin to source a Training of staff in high risk areas also By Leslie Morgan, OBE product in England (where temperatures needs to be intensified. Ground handling Managing Director Durbin PLC. are variable depending on the season) and at airports and customs/authorities inspec- Leslie Morgan is a member of the Royal Pharmaceutical Society of transport it to the Middle East where tem- tions – anyone that comes into contact Great Britain peratures regularly soar above 40°C. with the shipment needs to be trained on The transportation and distribution of how to handle the product and to ensure pharmaceuticals requires special consider- that it does not fall out of the remit of its It’s always been a challenge to transport ation in warm climates such as the Middle storage conditions. medicines from one part of the world to East. It is of paramount importance that the The increasing formalisation of quali- another. They are sometimes heavy and/or perfect temperature of the shipment is main- fications, contracts and processes that fragile and in most cases, time is of the es- tained and managed throughout transit. the new EU GDP guidelines outline is sence. The challenge becomes even great- I have seen the reliance on technology compelling. They demand a much higher er when the product needs to be stored in the pharmaceutical supply chain grad- level of quality in terms of service and within a specified temperature range. ually rise in the last decade. In the last supply, and set a basic benchmark that The responsibility is huge – a single few years, sensor-based systems have be- will encourage all providers to maintain loose link in the supply of temperature- come increasingly commonplace to alert high levels of service and further help to controlled products could mean that cost- at the slightest change of temperature, or ensure our pharmaceuticals are as safe ly and essential pharmaceuticals are left even lighting fluctuations. Temperature and effective as possible. in an unusable or even potentially dan- data monitors – electronic devices which gerous state. Cortisone cream, for exam- can be set to take readings at regular in- Durbin PLC is a British company ple, can separate and become ineffective tervals throughout transit – can also be based in South Harrow, London. once it is exposed to temperatures above placed in the box. Established in 1963, the company 30°C. Other drugs such as insulin might In the past, these devices were primar- specialises in supplying quality lose its effectiveness once it is exposed to ily used for fridge line products and not for assured pharmaceuticals, medical freezing temperatures. those requiring storage from 15°C – 25°C. equipment and consumable supplies In March this year, the EU Good Dis- However, with the new EU GDP guide- to healthcare professionals and tribution Practices were published. The lines in place, customers will now have to aid agencies in over 180 countries. guidelines have been updated to reflect the specify whether they want thermally regu- As well as reacting rapidly to more complex logistic supply chains of cur- lated packaging or temperature monitors emergency situations, Durbin PLC rent times, and to ensure that control over in with their ‘ambient’ pharmaceuticals. responds to healthcare supply the quality and integrity of the distribution Regulations surrounding the transporta- needs from local project level to chain is maintained all the way from manu- tion of medicines in the Middle East have national scale programmes. facturer to patient. become tighter in the last few years and Web address: www.durbin.co.uk The new GDP guidelines enforce a they are only likely to become more rigor- Email: [email protected] much larger responsibility on the distrib- ous in the future. The updated guidance

150 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI151 Anaesthesia

Study expands concerns about anaesthesia’s impact on the brain As paediatric specialists become increas- Fudan University, Shanghai, China. ingly aware that surgical anaesthesia may Researchers exposed newborn, juvenile have lasting effects on the developing and young adult mice to a widely used brains of young children, new research aesthetic called isoflurane in doses ap- suggests the threat may also apply to adult proximating those used in surgical prac- brains. tice. Newborn mice exhibited widespread Researchers from Cincinnati Chil- neuronal loss in forebrain structures – dren’s Hospital Medical Center report in confirming previous research – with no the Annals of Neurology (June 5, 2013) significant impact on the dentate gyrus. that testing in laboratory mice shows an- However, the effect in juvenile mice was aesthesia’s neurotoxic effects depend on reversed, with minimal neuronal impact the age of brain neurons – not the age in the forebrain regions and significant of the animal undergoing anaesthesia, as cell death in the dentate gyrus. Physicians should once thought. The team then performed extensive carefully discuss with Although more research is needed to studies to discover that age and matura- patients, parents and confirm the study’s relevance to humans, tional stage of the affected neurons were the study suggests possible health impli- the defining characteristics for vulner- caretakers the risks and cations for millions of children and adults ability to anaesthesia-induced neuronal benefits of procedures who undergo surgical anaesthesia annu- cell death. The researchers observed simi- requiring anaesthetics, as ally, according to Andreas Loepke, MD, lar results in young adult mice as well. well as the known risks PhD, a physician and researcher in the Research over the past 10 years has Department of Anesthesiology. made it increasingly clear that com- of not treating certain “We demonstrate that anaesthesia- monly used anaesthetics increase brain conditions. induced cell death in neurons is not cell death in developing animals, raising limited to the immature brain, as previ- concerns from the Food and Drug Ad- ously believed,” said Loepke. “Instead, ministration, clinicians, neuroscientists vulnerability seems to target neurons of a and the public. As well, several follow-up certain age and maturational stage. This studies in children and adults who have finding brings us a step closer to under- undergone surgical anaesthesia show a standing the phenomenon’s underlying link to learning and memory impairment. mechanism” Cautioning against immediate applica- New neurons are generated abundantly tion of the current study’s findings to chil- in most regions of the very young brain, dren and adults undergoing anaesthesia, explaining why previous research has Loepke said his research team is trying to carefully discuss with patients, parents focused on that developmental stage. In learn enough about anaesthesia’s impact and caretakers the risks and benefits of a mature brain, neuron formation slows on brain chemistry to develop protec- procedures requiring anaesthetics, as well considerably, but extends into later life in tive therapeutic strategies, in case they as the known risks of not treating certain dentate gyrus and olfactory bulb. are needed. To this end, their next step conditions.” The dentate gyrus, which helps con- is to identify specific molecular processes Loepke is also collaborating with re- trol learning and memory, is the region triggered by anaesthesia that lead to brain searchers from the Pediatric Neuroimaging Loepke and his research colleagues paid cell death. Research Consortium at Cincinnati Chil- particular attention to in their study. “Surgery is often vital to save lives or dren’s Hospital Medical Center to examine Also collaborating were researchers from maintain quality of life and usually can- anaesthesia’s impact on children’s brain us- the University of Cincinnati College of not be performed without general anaes- ing non-invasive magnetic resonance imag- Medicine and the Children’s Hospital of thesia,” Loepke said. “Physicians should ing (MRI) technology.

152 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI153 Clinical Guidelines

New hypertension guidelines offer practical, clinical information for doctors and patients

High blood pressure affects approximately one in three adults in the Americas, Eu- rope, some Asian countries and Australia, and one billion people worldwide. Because of this epidemic, The American Society of Hypertension, Inc. (ASH) and the Inter- national Society of Hypertension (ISH) are pleased to announce the creation of first- of-their-kind guidelines for the diagnosis and treatment of Hypertension: “Clinical Practice Guidelines for the Management of Hypertension in the Community.” These are the first guidelines to be usable for medical practitioners in any socioeconomic environment around the globe, from those countries with state-of-the-art equipment to those that lack basic resources. And, most importantly, they are designed with guidance that is easy to implement for doctors and healthcare professionals in even the most impoverished areas. The guidelines were first published on December 17 by the Journal of Clinical Hypertension in the U.S. and the Journal Hypertension we wanted to create Guide- tion of treatment guidelines that are de- of Hypertension in Europe. They will also lines for management of hypertension for signed to educate medical practitioners, appear in medical journals across Latin practitioners, which would provide easy doctors in training and other health care America and have been endorsed by the to follow recommendations that were providers, ASH is furthering its commit- Asian Pacific Society of Hypertension. evidence-based and could be carried out ment to our mission through initiatives that The guidelines have already been trans- in countries that have healthcare systems aim to improve the clinical management of lated to French, Spanish and Creole, and with either limited or with abundant re- hypertension and its complications,” says there are plans to continue translations for sources, and above all, that were simple Dr. William B. White, professor of medi- populations across the globe. and user-friendly, contributing thus to the cine and current President of ASH. “These guidelines have been written control of this highly prevalent condition. The guidelines’ 25 authors include top to provide a straightforward approach to Indeed, hypertension is the number one hypertension specialists and pharmacists managing hypertension in the commu- cause of burden of disease worldwide,” says from around the world, including past and nity. We are so proud to have created a Dr. Ernesto L. Schiffrin, President of ISH. present officers of the American Society of set of guidelines that can help not only Hypertension is the most common Hypertension and the International Soci- doctors but also patients understand their chronic condition dealt with by primary ety of Hypertension. disease and the care they receive,” says care physicians and other healthcare Dr. Michael A. Weber, Editor-in-Chief practitioners. There is also a close rela- Clinical Practice Guidelines for of the Journal of Clinical Hypertension, tionship between blood pressure levels the Management of Hypertension in the former ASH President and current ISH and the risk of cardiovascular events, Community Council member. strokes and kidney disease. www.ash-us.org/documents/ASH_ “Within the International Society of “With the development and dissemina- ISH-Guidelines_2013.pdf

154 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI155 Public Health

Atrial fibrillation is a serious global health problem – WHO

Atrial fibrillation, long considered the every sense of the word,” Chugh said. “It most common condition leading to an ir- can lead to stroke, hospitalization, as well regular heartbeat, is a growing and serious as lost productivity. Our findings indi- global health problem, according to the cate that atrial fibrillation is on the rise first study ever to estimate the condition’s around the world and it’s a huge public worldwide prevalence, death rates and so- health burden.” cietal costs. During the analysis, Chugh and a team The World Health Organization data of researchers systematically analyzed analysis, led by Sumeet Chugh, MD, as- data from selected population-based re- Atrial fibrillation has a sociate director of the Cedars-Sinai Heart search studies, from among 1,784 pub- huge cost in every sense Institute, shows that 33.5 million people lished medical research studies on atrial of the word. It can lead to worldwide – or .5% of the world’s popula- fibrillation, to estimate global and region- tion – have the condition. Funded partly al prevalence, incidence and mortality stroke, hospitalization, as by the Bill & Melinda Gates Foundation related to this condition. well as lost productivity. and the Cedars-Sinai Heart Institute, “Finding out the scope of the problem Our findings indicate that the analysis was conducted with the as- is step No. 1,” Chugh said. “Our hope is atrial fibrillation is on the sistance of the University of Washing- that we can develop a sustainable global ton’s highly respected Institute for Health plan to manage atrial fibrillation and find rise around the world and Metrics and Evaluation, which seeks to new and effective ways of preventing this it’s a huge public health identify the world’s major health prob- condition.” burden. lems so society can best allocate medical Among the study’s findings: resources and funding. l In 1990, an estimated 570 of 100,000 Atrial fibrillation occurs when electri- men had atrial fibrillation. In 2010, cal impulses in the upper chambers of the the prevalence rate for men was 596 of heart, called the atria, become chaotic and 100,000. cause an irregular heartbeat. The irregular l For females, an estimated 360 of more women with atrial fibrillation are dy- heartbeat can result in heart palpitations 100,000 women had atrial fibrillation in ing in developing countries. In the U.S., along with a variety of symptoms such as 1990. In 2010, that rose to 373 of 100,000. deaths linked to atrial fibrillation now are fatigue. When the heart isn’t pumping l In 1990, the number of new cases of comparable between the sexes. blood effectively, blood can stagnate and atrial fibrillation in men was estimated at “A lot more research is needed to fully clot. If the clots break apart and travel to 61 per 100,000 population. In 2010, the understand this continuing worldwide the brain, they can cause a stroke. number of men with new cases of atrial fi- increase,” Chugh said. “Although the The study, believed to be the first to brillation rose to 78 per 100,000. chance of developing atrial fibrillation determine the number of people globally l The number of new cases of atrial does increase with age, these findings are with atrial fibrillation, is published online fibrillation in women was 43 per 100,000 not entirely explained by the aging world in the peer reviewed medical journal Cir- population in 1990. In 2010, the number population. Several other factors have culation and is scheduled to be published of new cases in women was 60 per 100,000. been suggested and need to be better eval- in the Feb. 25 print edition of the journal. l Although deaths linked to atrial fi- uated, from obesity and hypertension to air “Atrial fibrillation has a huge cost in brillation are rising around the world, pollution.”

156 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI157 The Digital Hospital

New iPad-based ‘early warning’ system used for hospital patient monitoring

Handwritten medical observation charts cally and displayed instantly. The nurse could become a thing of the past in hos- will use this score to help decide whether pitals with the development of a pioneer- medical intervention is needed. The new system will ing patient monitoring system developed Researchers in the University of Ox- in Oxford hospitals. An iPad-based early- ford’s Institute of Biomedical Engineering help nurses, who work warning system developed with EPSRC (IBME) and clinical staff from the OUH in busy, high-pressure funding is one of the projects funded by Trust, in particular Intensive Care Medi- environments, care for the ‘Safer Hospitals, Safer Wards’ £260 cine specialists Drs Peter Watkinson and patients more efficiently million (about US$424 million) Brit- Tim Bonnici, have worked in close col- ish NHS Technology Fund to improve laboration to develop the system. The EP- and effectively. patient safety. The £1.1 million funding SRC-funded Centre for Doctoral Training will allow the team of biomedical engi- at the IBME is also enabling the study of neers and clinicians from the University the clinical impact of the new system at of Oxford and the Oxford University first hand across a variety of wards. In the future, it is planned to take ad- Hospitals (OUH) NHS Trust to roll out “The new system will help nurses, who vantage of next-generation scores tailored the system across all adult wards in the work in busy, high-pressure environ- to different patient groups, for example Trust’s acute hospitals. ments, care for patients more efficiently those recovering from surgery. The new approach uses the latest com- and effectively,” says Professor Lionel At present, six vital signs are measured puter tablet technology both to record Tarassenko, Professor of Electrical Engi- to calculate the Early Warning Score: and to evaluate patients’ vital signs. It neering, who leads the project. heart rate, respiratory rate, blood pres- will help alert medical staff to patient de- “The traditional chart-based method sure, arterial oxygen saturation (‘the terioration on the wards more reliably. of recording vital-sign data is susceptible sats’), temperature and level of conscious- The Research Councils UK Digital to errors in both recording and analysis ness. Details of oxygen therapy and clini- Economy Programme, which is led by of vital signs. This has been shown in cal concerns can also be recorded on the the Engineering and Physical Sciences multiple studies, including one funded iPad at the same time. The system has Research Council (EPSRC), funded the by the Oxford BRC. Furthermore it lim- been designed with the future in mind so research underpinning this unique ‘track- its the availability of the data to the bed- that it can easily be extended to include and-trigger’ system; its translation onto side, making its sharing across the hospi- other data, such as blood sugar levels or the ward was supported by the Oxford tal difficult. neurological observations. Biomedical Research Centre (BRC), “The new electronic system auto- “We see the new system as a major step which brings together university academ- matically calculates the hospital’s Early towards the ‘digital hospital’ in which all ics with clinicians at the Oxford Univer- Warning Score, a scoring system which sources of patient information are inter- sity Hospitals (OUH) NHS Trust. we have developed from extensive statis- linked and all healthcare staff are inter- Just as now, nurses will regularly take tical studies of patient data. This high- connected. This can only have a positive readings of a patient’s vital signs such as lights combinations of vital-sign read- impact on patient safety,” says Professor heart rate and blood pressure. But instead ings which give cause for concern. The Tarassenko. of writing the information on an observa- system also enables all vital-sign data tion chart, they will input it into an iPad and scores to be accessed instantly by Audio slideshow of the research or computer tablet. An Early Warning all relevant healthcare staff, wherever in https://www.youtube.com/ Score will then be calculated automati- the hospital they may be.” watch?v=V8R4xVeOK9Y

158 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI159 Hospital Design

Luminous ceiling developed to comfort patients

Royal Philips has developed a media en- the German Federal Ministry of Economy In the new intensive care rooms at the abled luminous ceiling that can simulate and Technology (AiF). Charité Clinic the medical apparatus has energizing daylight to comfort critically ill Philips has played a significant role been hidden from view and the level of patients. The LED based ceiling has been in designing this innovative concept, noise has been reduced. The innovative introduced into clinical use by the Charité thanks to its expertise in lighting design LED luminous ceiling from Philips adapts Campus Virchow Clinic in Berlin as part and technology. to suit the patient’s specific wishes: the of a unique stress-reducing concept called “We find that particularly in such criti- doctor in charge of the patient’s care ‘Parametric Spatial Design’. Hospital staff cal areas as the intensive care department, enters a number of parameters relat- can enter the desired parameters and the lighting design is becoming increasingly ing to the patient’s wellbeing on a tab- large, sky like area creates visuals and light important in the patient environment,” let PC. A program specially designed by moods customized to the situation of indi- explains Roger Karner, Managing Direc- ART+COM controls the screen in such vidual patients, enabled by software from tor of Philips Lighting DACH. Together a way that the light is tailored to suit the ART+COM. The Clinic has implemented with our partners we can provide health- patient’s needs and an appropriate mood the concept in two of its intensive care pa- care establishments like the Charité is created in the patient room. Amongst tient rooms to enhance the healing envi- Clinic with turnkey lighting solutions other things, live weather updates from ronment for patients who are severely ill. that are tailored precisely to the specific the German meteorological office are Research shows that most people will at needs of their patients,” adds Karner. used to support this process. least once in their life be treated in an Inten- sive Care Unit. In many cases the patients’ LED lighting in the luminous ceiling Light and its role in enhancing lives are at risk as they await an operation The luminous ceiling concept from the healing environment or start to recover after surgery. In this criti- Philips combines the natural, dynamic For many years Philips has been re- cal phase they often find their surroundings rhythm of daylight and the effects of searching and developing special light- irritating and hostile. Clinical research has gentle colourful light and visual content. ing systems for hospitals. The advent of shown that factors like loud noise, inappro- It incorporates 15,400 LEDs and extends digital lighting technology of LED al- priate lighting conditions and social isola- from the ceiling onto the wall in front of lows an unprecedented level of control tion can increase the risk of patients in in- the patient’s bed, and therefore fills their of colour temperature and light inten- tensive care slipping into a shock-like state. field of view completely. sity that has made this new concept pos- Until now there has been very little In addition to the RGB (colour) LEDs, sible. Philips has very recently installed data available about the health-related high-performance LEDs with a warm-white its HealWell lighting system in the effects of hospital rooms with a controlla- and cold-white colour temperature have German Heart Center in Berlin and in ble atmosphere. For this reason, intensive also been integrated into the ceiling. They other hospitals in Germany, the UK, the care physicians, psychologists and sleep are able to produce light output that is com- Netherlands, Central Europe, Middle researchers at the Charité Clinic in Ber- parable with the light from a clear sky in East and South East Asia. This system lin will continue to work together with summer. It is this high level of light output simulates the natural, dynamic rhythm its partners GRAFT architects and the that brings the biological effect of light into of daylight. A pilot study carried out in ART+COM design studio to use the in- the intensive care room. It supports the pa- conjunction with the University Clinic tegrated spatial concept for research over tient’s natural day/night rhythm and helps in Maastricht has researched the effects the coming twelve months. The Paramet- to promote healthy sleep patterns. of this system: HealWell led to improve- ric Spatial Design concept was developed ments in the quality of sleep of patients, by GRAFT architects, the ART+COM How the luminous ceiling enhanced mood and a rise in satisfaction design agency and the Charité Clinic in adapts to patient needs levels among patients and healthcare Berlin in a joint venture and funded by The first prototype is now in clinical use. workers.

160 IMIDDLE EAST HEALTH MIDDLE EAST HEALTHI161 Carestream’s newest image acquisition/mini-PACS software adds support for DR imaging systems

Carestream’s newest version of Image systems using the DRX-1 and new small Software supports enhanced Suite Software offers a flexible image ac- format DRX 2530C (25 x 30 cm) detec- image sharing capabilities quisition, processing and storage platform tors, as well as Carestream’s tethered Image Suite also features new CAR- that now supports CARESTREAM wire- TDR 3543 detector and TDR 3543C ESTREAM OmniLink Software that can less DR as well as CR imaging systems, detector that are available in select mar- provide secure Web-based transmission of and an optional mini-PACS. Image Suite kets. This is in addition to the current imaging studies and deliver many of the offers Web-based patient scheduling, im- support of the DIRECTVIEW Classic capabilities of a virtual private network at age review and reporting, and flexible ar- CR and the DIRECTVIEW Vita family a fraction of the cost. OmniLink Software chiving solutions. of CR systems. enhances the sharing of images by offering Unveiled the same week as The Interna- Carestream’s optional mini-PACS de- rapid transmission speeds, high-level secu- tional Day of Radiology, this versatile of- livers advanced reading and reporting rity features, and the ability to compress fering is ideal for urgent care centers, imag- tools – and the newest software also de- and encrypt files for transmission. This soft- ing clinics and a broad range of physicians livers the ability to view imaging studies ware notifies the sender and receiver when and specialists, including orthopaedists, on mobile tablets such as iPads in select an imaging study is received and alerts the podiatrists and chiropractors. The new countries outside of the U.S. The system sender if the file is not received. It also sup- software is available worldwide. also supports a wide variety of specialty ports transmitting image to a PACS using “We offer a flexible platform for custom- measurement tools including Lippman- cell phones or mobile devices for health- ers who want to move from CR to DR or Cobb angle, goniometry and coxometry. care facilities outside of the U.S. from film to digital imaging. Our software Other new Image Suite software up- Image Suite systems provide DICOM stor- offers the same user interface and workflow grades include: age for MR, CT and ultrasound exams and for both modalities, which reduces train- l Vendor-neutral exposure index value reporting software allows users to create, edit ing time and makes the transition easier,” for each image so technologists can see if and view reports attached to studies. Users can said Heidi McIntosh, Carestream’s Global they are within the exposure range. output imaging exams to CD/DVDs, DICOM Marketing Manager for X-ray Solutions. l Hardware and software that can au- printers and other PACS systems. Imaging ser- “Existing Image Suite users can upgrade tomatically acquire DAP and technique vices providers of all sizes can minimize capital to DR technology with a minimal invest- information from multiple vendors’ gen- investment and achieve obsolescence protec- ment because they keep the same console erators and DAPs. This eliminates the tion by purchasing PACS, image sharing and and software platforms and just add a DR need for manual data entry; and vendor-neutral archiving on a pay-per-use ba- detector and license.” l Supports transfer of images to Or- sis with Vue for Cloud-Based Services. The software now supports images thoView software for pre-operative ortho- l For more information, captured by Carestream’s wireless DR paedic planning and templating. visit: www.carestream.com.

162 IMIDDLE EAST HEALTH Welch Allyn solutions designed for use in settings requiring portability, flexibility, efficiency and patient safety

Welch Allyn, a leading global provider of medical diagnostic devices, recently introduced several new solutions designed to help improve patient outcomes including a new connected electrocardio- graph (ECG), integrated light-emitting diode (LED) lamp technology and a disposable single-patient-use blood pressure cuff. The user-friendly Welch Allyn CP 150 was designed to help improve practice workflow. The seven-inch, color touch-screen display with an integrated user interface eliminates the need to track between the display and keyboard and allows for fast and easy entry of patient data helping to save time and reduce errors. A lead quality display is also incorporated into the touch screen, which helps easily and efficiently identify lead connection problems. An instant-on feature pow- ers up the device quickly to take an ECG at a moment’s notice and the advanced filters provide optimal ECG trace quality to ensure accurate readings. The CP 150 can be transported easily with the battery-pow- ered operation and up to 100 test results can be stored on the device. ECG results can also be transferred directly to a USB memory stick for additional storage or uploaded to the practice’s data management system through the Welch Allyn CardioPerfect Workstation. Now available to customers outside the United States and Canada, optional LED lamps will be offered in the company’s four most popular core diagnostic device platforms—traditional otoscopes, MacroView otoscopes, traditional ophthalmoscopes, and PanOptic ophthalmoscopes. The efficiency of LED lamps also results in lower temperature output which may increase comfort for both the patient and the caregiver. Welch Allyn LED lamps feature patented SureColor technology, which provides consistent color output while light intensity is lowered to improve the view or increase patient comfort. It allows the color of the light to remain the same even as the light intensity is dimmed. Welch Allyn FlexiPort EcoCuffs are designed to remain with one patient for the duration of the hospital stay and then be disposed of upon release. As part of the FlexiPort line of disposable blood pressure cuffs, EcoCuff utilizes the FlexiPort single-point connection standardization system, allowing the EcoCuff to follow the patient into virtually every room and connect to nearly every device in the hospital. The lightweight EcoCuff is made of 100 percent polypropylene and does not contain BPA, DEHP, Latex, PVC or other materials that can leach into the environment in a landfill or release harmful chemicals when incinerated. EcoCuff is capable of being recycled in areas where polypropylene recycling is available. l For more information, visit: www.welchallyn.com

MIDDLE EAST HEALTHI163 Walmark is a leading producer of food supplements

Walmark is a leading producer of food supplements in Central and Eastern Europe. The company has one of the most modern pharmaceutical plants in the Czech Repub- lic complying with GMP standards. It has a strong market position in the domestic Czech market as well as in another 7 Euro- pean markets through its subsidiary companies (Slovakia, Poland, Hungary, Romania, Bulgaria, Lithuania and Latvia). Besides the domestic market and subsidiary markets, there are systematically developed business activities in more than 30 countries in Eu- rope, Middle East, Asia and Africa. One of the significant novelties in order to maintain physical and mental Walmark has a comprehensive prod- Walmark’s product portofio is Spektrum vitality. Spektrum Gummies is available uct portfolio. The product portfolio is Gummies – a complex of vitamins in bal- in two delicious fruit flavours with no ar- constantly modified according to global anced proportions for adults in gummy tificial colours. trends on one side and to particular needs form which is so easy to use. Every day l For more information, of customers on the other side. you can get the key essential vitamins in visit: www.walmark.eu Fanem to exhibit their neonatology products Fanem, a leading manufacturer of neonatology products, will once again participate in the Arab Health Fair 2014, in the Brazilian Pavilion, exhibiting its advanced products that increase the efficiency of health services and the efficacy of health treatments. The software update of the Fanem Vision Advanced 2286 Incubator will be a highlight during the event, equipped with fourth generation (G4) technology that permits a higher data processing speed, better screen response time and visualization of the parameters, which enhances the user’s operation. The alarm management system, incorporated into the update, brought to the Vision Advanced 2286 Incubator an evolution of pulse oximetry monitoring, enabling less alarm triggers related to saturation (SpO2) measurements, thus reducing undue triggering. It also counts on an alarm sound volume adjustment and a distinction between low, medium and high-priority alarm settings. l For more information, visit: www.fanem. com.br 164 IMIDDLE EAST HEALTH Timesco at forefront of laryngoscopes design, manufacture Timesco Healthcare, England, has been at the forefront of laryngoscopes design, manufacture and innovative developments in intubation for over four decades. Timesco manufactures the world’s number one single use disposable fibre optic laryngoscopes system “Callisto”, which is complemented with Callisto single use and Optima reusable LED handles. Complete ranges of single use, “Callisto”, “Europa” and reusable “Optima”, “Sirius” laryngoscopes systems covering from neonate to adult intubation, as well as specialist, Robert Shaw, Seward, and difficult intubation “Eclipse” tilting tip blades are available. The Timesco Laryngoscope programme is also available with a new Rechargeable system. Timesco has also added innovative, award winning, energy savings systems for extended battery life, EES and ION. The Timesco Laryngoscope programme is part of Timesco product ranges which cover all disciplines of surgery. Timesco surgical and medical ranges cover premium O.R. quality Surgical Instru- ments, Dental, Electro surgery, Diagnostic, EMS etc Timesco has been established since 1964 and is one of the largest privately owned quality surgical and medical companies in UK. We are approved suppliers to many MOH’s throughout the world including the NHS in UK. We have regional distribution in the Middle East and have an office in Dubai. Contact the manager, Misbah Jabbar, email: misbah.jabbar@ timesco.com, phone: 00971 508 451019. Timesco is an ISO, FDA, CE and SFDA registered company. l Arab health: Z1G30 l For more information please visit: www.timesco.com

MIDDLE EAST HEALTHI165 Richard Wolf introduces integrated operating room management system

Richard Wolf will present, during the Arab Health in Dubai, the first fully network- based integrated OR core nova as well as the compact media management platform core.media and core.expert – a comprehensive operating room management system. Richard Wolf is setting new benchmarks in 3D endoscopy with its ENDO- CAM Epic 3D HD a high-resolution 2x3- chip system. Furthermore, Wolf will also launch two new flexible sensor ureterorenoscopes – BOA VISION and COBRA VISION. Richard Wolf is a mid-sized company manufacturing medical instruments. It em- The core nova from Richard Wolf ploys a workforce of more than 1,400 and maintains a global network of 14 subsidiar- kets a large range of products for minimally wave lithotripsy and technical endoscopy. ies and 130 foreign representatives. The invasive surgery and endoscopy in human l For more information, company develops, manufactures and mar- medicine, and for extracorporeal shock visit: www.richard-wolf.com Obtain Nature-standard editing on your research manuscripts and grants

Balancing a clinical workload with obtaining funds and writing research papers can be challenging, but Nature Publishing Group (NPG) and its exclusive partner Macmillan Science Communication (MSC) can help. NPG Language Editing (languageediting.nature.com) uses native English-speaking editors familiar with the language convention in your field, with graduate-level training at top US universities. Thanks to a stringent quality check, the edit improves the clarity and sense of the writing, to help reduce the risk of misunderstandings or rejection due to poor Eng- lish. MSC Scientific Editing (msc.macmillan.com/en/editing) goes even further, by allowing you to benefit from highly detailed, Nature-standard editing and advice. MSC’s editors understand what it takes to get published – almost all have both professional experience of editing at a high-impact journal and a PhD. NPG journal decisions are independent of MSC (and NPG Language Editing), so you can get extensive pre-submission input from experts who think like journal editors, without harming your chances of publication.

166 IMIDDLE EAST HEALTH CTK Biotech obtains worldwide exclusive license from CDC for use of patented, chimeric virus in dengue diagnostic tests

CTK Biotech, Inc. and the United States Centers for Disease Control and Prevention (CDC) have reached a license agreement that grants CTK the worldwide-exclusive, diagnostic commercial rights to a patented dengue virus developed by a CDC laboratory. Utilizing this advanced technology, CTK has recently launched an improved line of its OnSite Rapid Tests for the detection of anti- dengue IgG and IgM in serum, plasma and whole blood specimens. Previous generations of dengue diagnostic tests were limited in their ability to detect IgM which is particularly important during the early stage of dengue infection when it is the predominant disease marker. “The chimeric virus developed by the CDC has the potential to dramatically improve the diagnosis of dengue virus infection,” said Ta-Hsiang Chao, PhD, Director of Research and Development at CTK Biotech. “It preserves all antibody binding sites on the viral surface, a critical factor for detecting both IgG and IgM produced in response to the native virus. The improved capacity to detect, diagnose and treat dengue is particularly significant as the global spread of dengue continues. An estimated 400 million dengue virus infections occur annually; 40% of the world’s population lives in areas with dengue virus transmission.” While Southeast Asia typically bears much of the global burden, dengue virus transmission is common in 100 tropical and sub-tropical countries around the world, including Asia, the Pa- cific, the Americas, Africa and the Caribbean. In 2013, Europe experienced its first sustained transmission of dengue fever since the 1920’s. Until a safe and effective dengue vaccine is available, further spread of the virus is inevitable. Joel Heidecker, Vice President of Marketing and Sales at CTK Biotech, reinforces the importance of virus detection when trying to control the spread of a disease, stating: “Early identification and distinguishing between primary and secondary infections can lead to early treatment aimed to limit the severity of the disease, an important step in reducing mortality rates. Our top priority at CTK is to develop high quality, cutting-edge point of care diagnostic products that effectively respond to the needs of the population. Our recent partnership with the CDC positions us at the forefront of the IVD market with the advantage of using the most advanced dengue technology for our research.” CTK Biotech, Inc. is a privately-owned biotech company located in San Diego, California that develops and manufactures innovative immunodiagnostic tools and point of care in vitro diagnostic test kits for distribution in more than 60 countries. CTK’s product lines include OnSite Rapid Tests, ELISA Test Kits and Positivia External Controls specialized in blood borne, tropical/ parasitic, hepatitis, respiratory, gastrointestinal, sexually transmitted and hormone/neonatal diseases. CTK facilities are ISO 13485 certified and in compliance with Food and Drug Administration Quality System Regulations. l For more information, visit: www.ctkbiotech.com

MIDDLE EAST HEALTHI167 HI-CARE, the TLV Healthcare ultimate OT media bridge This suspended media bridge optimizes sides, rail(s) and tube(s) on internal and/ since all additional shielding is designed the quality of surgical interventions by or external faces of the unit, cover(s) and/ by aeraulics specialists. providing surgeons, anaesthetists and op- or tube(s) on the housing using the whole erating room staffs an easy access to power length of the beam. Cleaning and decontamination supplies, communication technologies The smooth shapes and surfaces allow and data transfers, medical gas that can Easy access to functionalities easy cleaning and decontamination be- be easily positioned hand reach according The recommended under-beam height tween two operations. to each procedure, thanks to the amazing (2000 mm) allows easy access to the fea- flexibility offered by its eight internal and tures, which are within hands reach of all Maintenance external sides thanks to its innovative ro- staff members while keeping the distribu- The technical equipment fixed at the tating corners system. tion unit compact. The HI-CARE thus back of the unit with direct access The HI-CARE can be adapted to suit contributes to the quick availability of through dedicated clipped covers pro- any multi-disciplinary operating theatre the room for the next intervention in the cures quick maintenance, optimizing the as each one is individually tailor-manu- multidisciplinary operating theatres. availability of the operating rooms. facture to perfectly fit dimensions and organisation of this high risk area. Operating room turnover RGB (Red Green Blue) Lighting In one single unit, HI-CARE combines The rotating corners with indexation Indirect integrated lighting on the up- energy distribution, equipment carriage enable rapid modification of equipment per part of the HI-CARE beam provides and peripheral lighting of the area... positioning and therapy devices between comfortable vision for the different two operations, ensuring the benefit of members of the operating staff whilst en- Perfectly adapted equipment an optimised workspace for anaesthetists, abling peripheral tasks to be safely car- To comply with all international norms surgeons and their staffs. ried out. The comfort provided by the and standards, the HI-CARE suspended different dimmable colours of the LED distribution beam is specifically designed Hygiene lighting system offers infinite possibili- and manufactured to meet the specifica- Compatible with all ceiling laminar air ties for the patients emotional manage- tions of each customer: extra low voltage/ flow systems thanks to its tailor-made ment (red light relaxes, blue stimulates) low voltage electric currents, medical gas design, the HI-CARE contributes to the as well as improved vision (green for en- alarm monitoring, any brands and stan- fight against nosocomial infection by doscopy, x-rays). dards on internal and/or external beam protecting the air flow from turbulence l For more information, visit: www.tlv.fr

168 IMIDDLE EAST HEALTH Clinicians welcome high quality single-use cervical biopsy punch

Showcasing at this year’s Arab Health, DTR positive feedback including: wound that heals quickly. Alternatives Medical’s Rotating Cervical Biopsy Punch “The rotating punch biopsy is slick, easy commonly lack a precise cutting jaw, is a timely development in light of the in- to use and sharp” creating poor biopsies with continued creasing need for cervical cancer screenings “The reusable forceps [biopsy punches] wound trauma which leads to longer pa- and human papilloma virus (HPV) testing. consistently produce inadequate samples tient recovery time. This cost effective solution not only - cross-cut, crushed or torn - this causes This addition to an extensive range of ensures clinics can run smoothly through confusion and further unnecessary follow- Single-use gynaecology instruments is a improved instrument availability, but up. I want to use these disposable forceps truly ‘fit-for-purpose’ instrument that can guarantees a good quality biopsy every [Single-use biopsy punch]” enhance existing procedures. time. It is clear to see why it has been re- The rotating jaw provides first time l For more information, ceived so well in the market, with notable sharpness and a precise cut with a cleaner visit: www.dtrmedical.com

MIDDLE EAST HEALTHI169 Mediflex to show open and laparoscopic surgery products at Arab Health

Mediflex is a pioneer in the surgical re- handle. They are avail- traction field having worked with Dr. able in several different Mel Greenberg in the 1960s and Dr. John configurations includ- Bookwalter in the 1970s to design and ing right angle, trian- manufacture neuro and general surgery regular and angled trian- tractor systems. Mediflex is committed to gular. global and regional improvement of the quality and safety of healthcare. Mediflex Suture Grasper has a presence in over 50 countries, and Closure Device and has participated in Arab Health annually Suture Passer Guide since 2010. The Suture Grasper Closure Device is dis- Nathanson StrongArm Liver posable and used for Retraction System laparoscopic fascia, The system includes a Single Arm Strong- tacking hernia mesh Arm Holder and Positioner along with 3 in position prior to final placement, per- Nathanson Hooks and 2 Instrument Tips. cutaneous suturing and ligating abdomi- The hooks and tips feature the Mediflex nal wall bleeders. hexagonal fitting and can be easily at- The Suture Passer Guide used in con- tached to and removed from any Medi- junction with the Suture Grasper Closure flex surgical holder and positioner with Device enables surgeons to close each the quick disconnect feature. The system trocar site safely and efficiently. This re- attaches to operating table rails. It offers usable guide is made of stainless steel and height adjustability and the ability to po- allows for a cost effective and sition the Nathanson Hook at different reliable solution for trocar lengths and angles. A single central lock- site closure. ing knob secures the system in a matter of seconds. The height adjustability also Airway-Assist allows the vertical post to be lowered so it The Airway-Assist provides a hands free no longer obstructs the surgeon or assis- method to maintain a patent airway and tant. This system is especially suited for holds consistent neck extension and jaw bariatric procedures. thrust during Mask General and MAC anesthesia. It also provides an additional Lapro-Flex Articulating Retractors “hand” during laryngoscopy and allows anesthesia induction. These retractors can be introduced precise external manipulation of the glot- l Arab Health: 1B56 through a 5mm cannula and articulated tis for better visualization. It also applies l For more information, to their shape by rotating a knob in the cricoid pressure during rapid sequence visit: www.mediflex.com

Find in-depth features, expert commentaries at Nature Middle East The Arab world has a rich history of features, expert commentaries and scientific breakthroughs. Ensure you’re research highlights to regional jobs, part of the scientific and medical com- event listings and alerts direct to your munity gaining access to the latest re- inbox – Nature Middle East is your speaking Middle East. search in the region. free comprehensive portal keeping you l Sign up to the free alert: From the latest news, in-depth at the centre of science in the Arabic www.nature.com/nmiddleeast

170 IMIDDLE EAST HEALTH ALLIBERT MEDICAL offers innovative French design for modular hospital furniture ALLIBERT MEDICAL, with over 20 rails designed by Allibert Medical allow for a full decontamination process. Last years’ experience, designs and manufac- users to choose their own configuration innovation, the top tray is completely re- tures in France a smart range of hospital whatever their scope of interventions movable for cleaning. furniture with a low ecological footprint. (emergencies, anaesthesia, exams, ban- Universal Design: Daily tasks are made To provide an efficient organisation, lo- daging). The special right-Left sliding easier thanks to many features as light-weight gistics and storage solution in all hospitals shelf provides to end-users more comfort aluminium frame and ergonomic design . A areas (OR, ICU, ER, wards and in-patient during treatment process. wide range of attractive color options bestows pharmacies), ALLIBERT MEDICAL Durability concept : All materials were a modern atmosphere inside hospitals. emphasized in its conceptions the im- chose for their long value durability; body Keyless Concept: Improving safety and portance of cutting-edges technologies, frame in aluminium, top tray in ABS, draw- reducing medication error is part of our modularity, hygiene and safer. ers in anti-microbial polypropylene. Easy achievements. The intelligent electronic Those unique features and innovative maintenance is provided through a concept lock, which allows track user activity, concept set ALLIBERT MEDICAL apart of sliding and removable drawers without remains a guarantee for a safe and con- from the competition: mechanical ball-bearing rails system. trolled storage of medicines. “P20”: an upgrading modular concept: EasyClean: To reduce nosocomial in- On the strength of its experience, AL- A modular system with total interchange- fection, ALLIBERT MEDICAL develops LIBERT MEDICAL offer its know-how able components permits to upgrade your a unique concept allowing a quick dis- to serve your equipment projects. Con- trolley in time. The new EasyClip side mantling of the products without tools tact us at [email protected]

MIDDLE EAST HEALTHI171 The Infinium Omni III patient monitor

Designed for a fast paced work environment, the Infinium Omni III patient monitor offers an extremely simple and adaptable user interface. Patient information along with vital sign settings can be quickly modified to meet the needs of a patients changing condition. The Omni III offers a standard high resolution 15 inch touch screen to optimize the speed of patient care. The user can therefore make quick screen adjustments, set default settings, alarm limits, and manage up to 72 low the user to customize the monitor’s offer 2 levels of networking and connec- hours of detailed patient data. acuity level while the patient’s condition tivity. The Omni III is HL7 compliant. changes. If desired, the user can move The HL7 network protocol will allow Upgradable from a basic vital signs monitor, to a con- for all patient information and vital sign From the general floor to high acuity sur- tinuous bed side monitor, to an operating trends to be transferred and stored on a geries, the Infinium Omni series patient room monitor while keeping the patient hospital information system. For non- monitors are designed to fit-in and move on a single monitor at all times. HL7 medical facilities, there is the In- amongst many patient care areas. The finium Omniview central station which Omni III offers standard measurements Connective allows the real time remote monitoring of: non-invasive blood pressure, ECG The Omni III offers several connective and network of up to 64 Omni patient with arrhythmia detection, motion toler- solutions to network multiple monitors monitors. The Omniview archives full ant SpO2, Temperature, and Respiration and/or manage patient data on an elec- disclosure of all patient vital sign trends. rate. End-tidal Co2, Anesthetic Agent tronic medical records platform or a HL7 The patient data from the Omniview measurement, 12 lead ECG, Cardiac Out- based hospital information system. The can be very simply saved, stored, printed, put and Invasive blood pressure can added Omni III patient monitor offers Ethernet and, transferred. on-site by simply attaching our plug in and RS-232 connections with an open l For more information, modules. This field upgradability can al- source communication protocol. Infinium visit: www.infiniummedical.com

DM Systems introduces Heelift AFO DM Systems introduces the redesigned “Instead of creating ‘just another AFO’, flexion contracture Heelift AFO, a unique ankle foot or- we wanted to create a product that solves l Treatment of plantar fasciitis thosis designed to offload the heel multiple problems,” said DM Systems’’ l Treatment/prevention of foot while also providing superior foot drop founder Denis B. Drennan, MD. drop deformity support. Having introduced the first A non-slip sole allows patients to walk l Treatment of Achilles tendonitis heel offloading boot of its kind, Hee- short distances (preferably with assis- Founded in 1979, DM Systems is lift Suspension Boot, DM Systems has tance), meaning the boot does not have committed to quality outcomes across established a reputation as a global to be removed and reapplied each time the continuum of care with innova- leader in the prevention and treatment the patient is transferred from the bed or tive products developed by orthopedic of heel pressure ulcers. DM has applied wheelchair. surgeons to reduce wound prevalence that expertise to the traditional AFO, Along with its offloading capabilities, while saving time and money. Other producing a softer, gentler solution. A Heelift AFO is indicated for: products include the Heelift Glide, smooth fabric cover and forefoot strap l Dorsiflexion ankle support for para- Heelift Suspension Boot, and Heel- help to keep the boot in place by al- lyzed legs Safe DVT Hose. lowing the boot to move with the pa- l Use as a comfortable night splint l For more information, tient while the patient is in bed. l Treatment/prevention of plantar visit: www.heelift.com

172 IMIDDLE EAST HEALTH Simply Plug n Play – with RTI’s Black Piranha The new RTI Black Piranha brings a quickness and power to your X-ray QA work flow. The Black Piranha includes what you would expect in a multifunction meter. Connection to various accessories, tablet and PC is automatic – just plug n play. The Quick Check feature identifies So when the work is done, if you want a the probes you insert and selects the op- complete report of your work – just press timum Piranha settings for your measure- print! ments. You can even easily program your Use your tablet/laptop as both an inter- own default start-up screen. The Black Pi- active display during the measurements mode. This Ocean 2014 feature provides ranha can measure on Rad, Fluoro, Dent, and as a powerful analysis tool when you a quick and easy way to start your mea- Mammo, and CT. are back at the office. No unnecessary, surements. Simple and accurate measure- The Black Piranha is complimented by time-consuming data-transfer at the end ments along with data and waveforms are the Ocean 2014 software which makes of the day. instantly displayed. Templates are provid- your workflow more intuitive and work Measurements and data are stored – al- ed. Just power-up and go. will move quickly. Ocean 2014 can per- lowing for analysis, trending and printed Whether you use a Windows tablet form instant real-time analysis during reports – even months after you have (Windows 8 Pro tablet) or laptop, this your measurements. Ocean also prepares completed your measurements. will be an indispensable QA tool. a report in the background as you go. Ocean 2014 also features Quick Check l For more information, visit: www.rti.se

MIDDLE EAST HEALTHI173 The Intersurgical i-gelO2 Resus Pack contains all you need

In emergency medicine, you need equip- able time is not wasted deflating and inflat- ment that’s easy and rapid to use. The i- ing a cuff. This allows a patent airway to be gel O2 Resus Pack contains everything you established in the quickest possible time. need to prepare, insert and secure the i-gel In many cases, insertion can be achieved O2 quickly and efficiently: an i-gel O2 su- in less than five seconds5. praglottic airway, a sachet of lubricant, air- With our new i-gel O2 Resus Pack, you way support strap and a suction tube. have all the advantages of a standard i-gel The i-gel O2 has been specially designed in the new i-gel O2, along with everything Resuscitation. 2007 Apr;73(1):161-2. to facilitate ventilation as part of standard you need to prepare, insert and secure the 3. Soar J: The i-gel supraglottic air- resuscitation protocols, such as those des- device in one pack, allowing you to stay way and resuscitation - some initial ignated by the European Resuscitation focused on what really matters during re- thoughts: Council (ERC). However, the i-gel O2 also suscitation – the patient. Resuscitation. 2007 Jul;74(1):197. incorporates a supplementary oxygen port 4. UK Resuscitation Council Advanced for the delivery of passive oxygenation, or References: Life Support Guide (5th Edition). Re- Passive Airway Management (PAM), as 1. Gatward JJ, Thomas MJC, Nolan JP, vised June 2008. part of an appropriate Cardio Cerebral Re- Cook TM: Effect of chest compres- 5. Bamgbade OA, Macnab WR, Khalaf suscitation (CCR) protocol. sions on the time WM: Evaluation of the i-gel airway in A number of case reports and clinical taken to insert airway devices in 300 patients. studies have highlighted the potential ad- a manikin: Br J Anaesth. 2008 Eur J Anaesthesiol. 2008 vantages our standard i-gel device offers in Mar;100(3):351-6 Oct;25(10):865-6. the resuscitation scenario1,2,3,4, where 2. Gabbott DA, Beringer R: The i-gel su- l For more information, visit: seconds can make all the difference. With praglottic airway: A potential role for www.intersurgical.com its unique, soft, non-inflatable cuff, valu- resuscitation?: www.i-gel.com HARD Manufacturing launches new critical care crib HARD Manufacturing is introducing its newly designed Do- ernbecher II Critical Care Crib. The Doernbecher II Criti- cal Care Crib is specifically designed for the PICU when a Safety Top is necessary for the patient who may become more active. When the Safety Top is not needed, the Do- ernbecher Critical Care Crib is available for the PICU. HARD Manufacturing manufacturers and sells cribs as small as 61cmx91cm Cribette for the NICU to as large as a 91cmx211cm Youth Bed for the Pediatric patient population. Every Electric Crib we manufacture has the availability of the optional built in Weigh Scale. The Weigh Scale has the accuracy rate of +/- 0.1kg. All Pediatric Cribs and Youth Beds are standard with an Anti-Microbial Epoxy Coating. Since 1876 the HARD commitment to quality, performance, and value has never changed. Through continuing improvements and developing new technologies, the HARD goal is to maintain its earned position of leadership. Only in this way, can HARD Manufacturing continue to serve the Healthcare marketplace with products that meet its ever-demanding needs. HARD Manufacturing is the world’s #1 manufacturer of Hospital Cribs and Youth Beds. l Arab Health: US Pavilion # 1A42 l For more information, visit: www.hardmfg.com

174 IMIDDLE EAST HEALTH Analox are launching the Medical ACG, a revolutionary medical gas monitoring system

The Medical ACG can be used for continuous or spot check testing of O2, CO2, VOC’s, CO, H2O, SO2, NO and NO2 all in one system. This enables users to check gases such as: Medical Air, Medical Grade Oxygen and Nitrous Oxide and to verify manual recording or external testing. wards and Neonatal units. compliance with industry standards such as It is the perfect solution to ensure com- Analox also offer a wide range of labora- the European Pharmacopeia, NFPA99 and pliance with mandatory legislation and tory gas safety products including Oxygen HTM 02-01. duty of care. The system can be used in depletion monitors, portable and fixed The Medical ACG is easy to install and numerous applications such as: COPD CO2 detectors, flammable gas sensors and maintain and offers peace of mind and better (Chronic Obstructive Pulmonary Diseas- OEM sensor technology. safety for patients. Its Datalogging feature also es) Treatment, ARDS (Acute Respiratory l For more information, offers full traceability and negates the need for Distress Syndrome), Cardiac & Trauma visit: www.analox.net

MIDDLE EAST HEALTHI175 Combating hypothermia and pressure related tissue trauma through warming and true pressure relief

Whether it’s the development of post- result is a significant reduction in pressure- surgical teams maintain safe core temper- operative pressure ulcers or complications related sores and ulcers, as well as anaes- atures during procedures, especially with from perioperative hypothermia, patients thesia-induced hypothermia. today’s ORs being kept extremely cold face a wide range of risks from prolonged TABLEGARD’s innovative design is to prevent cell death. BERCHTOLD’s surgical procedures. based on the body’s own physiology, mim- integrated system produces a surface That’s where TABLEGARD comes in. icking the peristaltic motion of muscles temperature range of 28-43 degrees C, This revolutionary patient care system to generate even, gentle movement in helping reduce the risk of perioperative from BERCHTOLD is the only OR table 15-minute cycles throughout an extended hypothermia. mattress that provides both pressure man- procedure. l For more information, agement and warmth during surgery. The TABLEGARD is also changing the way visit: www.berchtold.biz

Are you still using BVMs? In the pre-hospital environment bag So why are BVMs still the standard of fied Automated Ventilator (SAVe II) is valve devices have been the standard care? They are the standard of care be- a hybrid between a bag valve device and of care for the past 50 years. However, cause transport ventilators are either too an expensive transport ventilators. Like because a bag valve device requires con- expensive or too complicated to be widely many transport ventilators, it is compres- stant and steady manual pumping by the used. A ventilation device that mitigates sor-driven and has an array of sensing operator, it does not guarantee consistent the potential for injury, reduces operator capabilities and safety alarms. However, air delivery. The operator is literally set- error, complies with guidelines, and im- it requires minimal training and uses a ting the tidal volume and respiratory rate proves a medical responder’s ability to per- height chart to dial in an appropriate ini- with every squeeze of the bag. Unsurpris- form other critical tasks is needed. tial tidal volume for the patient. It only ingly, BVMs have been linked to a high Just as AEDs made their way from the weights 1.1 kg and can deliver air for up incidence of hyperventilation and gastric hospital, to ambulances and eventually to to 10 hours. It’s simple and reliable ven- insufflation. In addition to the safety public places, ventilators need to evolve tilation for the pre-hospital environment. concerns of bag valve devices, bagging to become smaller, easier to use and more The SAVe II is produced by completely incapacitates a responder affordable. Simplified Automated Ventila- AutoMedx and distributed in partner- from addressing other injuries, perform- tors, originally designed to triage critically ship with JD Honigberg. ing compressions, attending other pa- injured soldiers on the battlefield, may be l For more information, tients, or transporting the patient. the answer. The second generation Simpli- visit: www.automedx.biz

176 IMIDDLE EAST HEALTH Carrier arms from CIM med to connect anesthesia machines now TÜV- tested

CIM med has announced successful TÜV testing of its carrier arm for the Philips IntelliSave AX700 anesthesia machine. These results support CIM med’s ambition to produce the safest clinical mounting systems on the market. CIM med will be exhibiting its new carrier arm solutions at the Arab Health in Dubai, January 27-30, 2014. TÜV Süd, the German safety monitoring agency, examined the CIM med carrier arm for two core criteria. The ground cable connections were tested for impedance and current load capacity (testing specifi- arm features a special bracket to limit the Philips IntelliSave AX700 with a CIM cations IEC 60601-1:2005). Component pivoting arc of the first articulation to 90 med carrier arm at any time. TÜV-certi- grounding inside the carrier arms provides degrees. This ensures tilt safety even when fied carrier solutions by CIM med are also the required safety. TÜV Süd also tested carrying 22 kilograms. available for anesthesia machines by other the system for stability at a 10-degree The carrier arm is available with con- manufacturers. tilt when fully euipped (DIN EN 60601- nections for PDMS and patient monitors l Arab Health: Z3D19 1:2007). The extra-length, triply articulat- with modules. An authorized service tech- l For more information, ed and height-adjustable, 700-millimeter nician can help health facilities retrofit the visit: www.cim-med.com

MIDDLE EAST HEALTHI177 Hill Rom’s Progressa Bed System has groundbreaking technology

Progressa Bed System is more than just a in different ICU disciplines bed. With the help of the Progressa Bed through upgradability and System’s integrated functionality and lift configurability. system, caregivers can maintain optimal The Progressa Bed System therapeutic positioning, deliver evidence- can be configured and upgraded based therapies and help restore mobility to meet a wide range of require- to minimize the risk of cardiovascular, re- ments within a hospital, while spiratory, metabolic and muscular disor- providing a consistently supe- ders, as well as delirium. rior user experience. You can StayInPlace is a ground-breaking tech- decrease total-cost-of-ownership by using n Significantly contributes to shorten- nology that is only available with the Pro- ONE supplier to reduce maintenance, spare ing ICU length of stay gressa Bed System, and prevents patient parts and training costs. n Enables Progressive Mobility while migration, minimizing the need for patient Clinical efficiency provided by the Pro- reducing the risk of adverse events such as repositioning. gressa Bed System: line displacement The Progressa Bed System is the only l Eases the individual steps of Progres- n Shortens time to first out of bed. ICU bed platform on the market that sive Mobility at every level of patient acu- l For more information, meets the needs of Critical Care patients ity and tolerance email: [email protected]

178 IMIDDLE EAST HEALTH Static Systems launch wireless nurse call system Static Systems’ Fusion-IP range of nurse call systems now includes a radio based solution to be shown at Arab Health for the first time. ‘Fusion-IP Aspire’ is fully compatible with other equipment in the IP range and establishes Fusion-IP as one of the most comprehensive and technically advanced healthcare communication solutions available. In addition to the company’s RNIB endorsed, waterproof patient hand unit, other features that set Aspire apart include a ‘two-way’ health-check for unrivalled system integrity, and exceptionally low power consumption ensuring extended battery life. Furthermore, in common with other Fusion-IP solutions, Aspire can operate easy to set up using an ‘out of the box and standalone, work alongside a wired system, ready to go’ approach that did not neces- and, being IP based, can connect with a sarily require specialist support. site’s LAN. Commenting on Fusion-IP Aspire, Static In the design brief for Aspire Static Sys- Systems’ Marketing Manager, Jennie Hor- tems were insistent that the look and feel rocks said: “We see Aspire as most suited of the devices should conform to that of to low acuity environments such as health existing SSG equipment already widely centres, or as a temporary system for use used in healthcare environments. The aim during ward upgrades. However before rec- was that patients and staff alike would be ommending a solution we look at client re- familiar with the equipment whether it quirements, and based on ‘best advice’ rec- was wired or wireless. ommend either a wired or wireless system.” Other design considerations were that l For more information, Aspire should be cost-competitive and visit: www.staticsystems.co.uk Career resource for scientists Naturejobs is the global career resource and Meet employers in person jobs board for scientists. At naturejobs.com, Attend the Naturejobs Career Expo for ca- search thousands of science jobs worldwide, reer advice and to meet recruiters. www. across a range of disciplines, from student- naturejobs.com/careerexpo ships to CEO level. View science careers advice Keep up Naturejobs can help you throughout your with the latest careers articles and more at job search and your career: www.naturejobs.com/news or subscribe to our newsletter www.naturejobs.com/newsletter Find a job Search jobs, set up alerts and research em- Ask us questions ployers at www.naturejobs.com or use our mo- If you have a science career question get in bile app. www.nature.com/mobile/naturejobs contact with us and where possible we’ll do our best to answer. Search for “Naturejobs” Help employers to find you on your preferred social media platform. Upload your CV and make your profile Take advantage of naturejobs.com and searchable. www.naturejobs.com/cvupload grow your career with us.

MIDDLE EAST HEALTHI179 Siemens launches Artis one angiography system for universal use Siemens recently introduced a new an- treatment or pacemaker implantations are giography system optimized for a broad also established routine procedures. clinical utilization. Artis one is designed Siemens Healthcare developed Artis for routine interventions, which represent one to support all of these interventions. most angiographic procedures. Energy consumption with the new system is up to 20% Flexible with low space requirement lower than with Artis zee floor. Despite being floor-mounted, the new an- Thousands of angiographic procedures giography system is similar in positioning are performed each day worldwide. On flexibility to ceiling-mounted systems and the one hand, these include treatment of requires substantially less space: Artis one highly complex cases requiring a high de- occupies only 25 square meters, compared gree of tailoring of the angiography lab’s to the usual 45 square meters required by configuration. On the other hand, there ceiling-mounted systems. The system fea- are many routine interventions, which tures several axes which can be moved represent the clear majority of cases. These independently of each other. This allows include, for example, revascularizations of physicians and hospital staff to easily posi- peripheral arterial or venous occlusions, tion the system where needed – regardless functional tests of dialysis shunts (surgical of where the physician is standing. vascular connections between arteries and The system covers body heights of up veins) in patients with kidney failure or of to 2.1 meters without the need to reposi- implanted ports in tumour patients. tion the patient, even for the imaging of Diagnostic angiographies of narrowed cor- peripheral vessels. When necessary, the onary arteries (coronary stenosis) and their system allows free access to the patient’s

180 IMIDDLE EAST HEALTH head in order to provide optimal care during the procedure. Buttons on the table side console are tactile so that they can be easily operated even under the sterile covering. The on-screen menu allows the physician to navigate directly using the heads-up display. All information about the procedure is thus kept right in front of the operator’s eyes. The comfortable 30 inch display size delivers images up to 90% larger than conventional 19 inch monitors.

Premium applications, powerful x-ray tube With Clearstent Live, Artis one offers a feature which until now was only available with the premium family Artis Q and Artis Q.zen. This application for interventional Fresenius Kabi presents the new cardiology allows the physician to mask out the movement of the beating heart in order to place the stent in precisely the right MRI Guard to the Agilia family position. Furthermore, the new system is As a new addition to the Agilia fam- the patient, at all times during the pro- equipped with the proven “Megalix” x-ray ily, Fresenius Kabi brings the use of the cedure, with visual and audible signals. tube of the Artis zee system family featur- Agilia infusion and syringe pumps into Infusion data is stored in the infusion ing flat emitter technology. Using a tube the magnet resonance units where infu- pumps during the MRI procedure. current of up to 250 milliampere (mA), the sion therapy patients can benefit from New accessories and consumables system generates images with outstanding uninterrupted treatment during an will be introduced during 2014 such quality and high contrast resolution. MR procedure. The MRI Guard Agilia as “Ambulance holder”, new oncology In order to keep radiation exposure for prevents interference generated by the sets, etc. completing our offer for the the physician and patient as low as pos- Agilia Infusion pumps from affecting Agilia range. sible, Artis one offers the most extensive MR image quality, and the guard shields l For more information, feature set for dose reduction of any angi- the infusion pumps against electromag- visit: www.fresenius-kabi.com ography system on the market. netic disturbances from the MRI system. or contact Fresenius Kabi Representa- By using 20% less energy than Artis zee An indicator tells you where to positive Office Middle East & Gulf: floor, Artis one also helps reducing option the MRI Guard Agilia safely near +971 4 346 75 30 erational costs. This is mainly achieved

MIDDLE EAST HEALTHI181 The Back Page

World’s smallest pacemaker implanted in patient for first time

In December, Medtronic announced the cal trial. The Micra TPS is an investiga- Micra TPS can be introduced directly first-in-human implant of the world’s tional device worldwide. into the heart via a minimally invasive smallest pacemaker: the Micra Transcath- At one-tenth the size of a conventional procedure, without the need for leads,” eter Pacing System (TPS). The device was pacemaker, and comparable in size to a said Clemens Steinwender, M.D., head of implanted in a patient in Linz, Austria as large vitamin, the Micra TPS is delivered cardiology at the Linz General Hospital in part of the Medtronic global pivotal clini- directly into the heart through a catheter Linz, Austria. “The combination of this inserted in the femoral vein. Once posi- novel technology with a transcatheter pro- tioned, the pacemaker is securely attached cedure can benefit patients by potentially to the heart wall and can be repositioned reducing pocket or lead complications and if needed. The miniature device does not recovery times observed with traditional require the use of wires, known as “leads”, surgical pacemaker implants.” to connect to the heart. Attached In contrast to current pacemaker im- to the heart via small tines (or plant procedures, the Micra TPS implant prongs), the pacemaker deliv- does not require a surgical incision in the ers electrical impulses that chest and the creation of a “pocket” un- pace the heart through der the skin. This eliminates a potential an electrode at the source of device-related complications, end of the device. and any visible sign of the device. “Because of “Micra TPS is an example of the sig- its small size nificant investment we have made in and unique disruptive technology, specifically the design, the miniaturization of implantable cardiac devices,” said Pat Mackin, president of the Cardiac Rhythm Disease Manage- ment business and senior vice president at Medtronic. “Less invasive, miniature device technologies show strong promise in improving patient outcomes and implant procedure efficiency. Through our global Micra TPS clinical trial, we intend to generate robust evidence of these benefits to patients and clinicians throughout the world.”

Micra TPS study design The study is a single-arm, multi- centre global clinical trial that will enrol up to 780 patients at approximately 50 centres. Initial results from the first 60 patients, followed up to three months, are expected in the second half of 2014.

182 IMIDDLE EAST HEALTH Agenda Selected schedule of regional medical meetings, conferences and exhibitions

Event Date / City Contact

n JANUARY 2014

1st Non-Communicable Chronic 9 – 11 Jan, 2014 www.ncdcongressuae.com/index.php Diseases Congress in the UAE Dubai, UAE

5th European Society of 10 – 11 Jan, 2014 www.ese-hormones.org/education/ Endocrinology Clinical Update Abu Dhabi, UAE clinicalupdate.aspx

Pan Arab Rheumatology 2014 14 – 17 Jan, 2014 www.panarabrheumatology2014 Dubai, UAE dubai.com/

Arab Health 2014 27 – 30 Jan, 2014 www.arabhealthonline.com Dubai, UAE

MedLab Dubai 27 – 30 Jan, 2014 www.arabhealthonline.com/ Dubai, UAE Medlab

World Heart Failure 28 – 30 Jan, 2014 http://www.worldheartfailure.org Society Congress Abu Dhabi, UAE

n FEBRUARY 2014

UAE International Dental Confer- 4 – 6 February, 2014 www.aeedc.com ence & Arab Dental Exhibition Dubai, UAE

3rd Biotechnology 10 – 12 February, 2014 www.biotechworldcongress.com World Congress Dubai, UAE

6th International Conference 10 – 12 February, 2014 www.icddt.com on Drug Discovery & Therapy Dubai, UAE

3rd Annual American Society for 19 – 21 February, 2014 http://asnme.org/index.html Nutrition Middle East Congress Dubai, UAE

International Conference on 19 – 21 February, 2014 http://www.icce-2014.com/ Cardiac Emergencies Tehran, Iran

11th Gulf Heart Association & 4th 26 – 28 February, 2014 http://gha-bha2014.com/ Bahrain Heart Association Congress Manama, Bahrain

9th International Breast 26 – 28 February, 2014 http://en.crc.sbmu.ac.ir/ Cancer Congress Tehran, Iran

n MARCH 2014

Middle East Wounds 1 – 3 March, 2014 www.woundsandscarmeeting.com and Scar Meeting Dubai, UAE

Int’l Spinal Cord Injury Conference 4 – 5 March, 2014 [email protected] Riyadh, KSA www.spineconfksa.com

International Medical Travel 5 – 6 March, 2014 www.medicaltravelexhibitions.com Exhibition and Conference Dubai, UAE

MIDDLE EAST HEALTHI183 Special features* AgendaThe Back Page in the next issue of Selected schedule of regional medical Middle East Health: meetings, conferences and exhibitions n Arab Health Review Event Date / City Contact n Anaesthesia n Imaging - Ultrasound Int’l Advanced Orthopaedics 6 – 8 March, 2014 http://www.aocongress.com/ Congress Dubai, UAE

Dubai Pharmaceutical & 10 – 12 March, 2014 www.duphat.ae Plus Technologies Exhibition Dubai, UAE n Middle East Monitor 2014 GulfThoracic Congress 13 – 15 March, 2014 http://www.gulfthoracic.com/ Dubai, UAE n Worldwide Monitor

Patient Safety & Quality 16 – 19 March, 2014 www.patientsafetymiddle n The Gene Pool Congress Middle East 2014 Abu Dhabi, UAE east.com n The Laboratory

ArabLab, The Expo 17 – 20 March, 2014 www.arablab.com n Product news Dubai, UAE

Abilities-ME 24 – 26 March, 2014 www.abilitiesme.com Abu Dhabi, UAE

Int’l Emergency & Catastrophe 25 – 27 March, 2014 www.emergency.ae Advertising Management Conference & Dubai, UAE For advertising queries, Exhibition (IECM 2014) please contact the sales and marketing department in Dubai: OBS-GYNE Exhibition 30 March - 01 April 2014 www.obs-gyne.com Tel: +9714 391 4775 & Congress Dubai, UAE Email: [email protected] n APRIL 2014 Occupational Safety and 1 – 3 April 2014 andrew.macgregor@ For international contacts, please see Health Middle East Abu Dhabi, UAE reedexpo.ae masthead at front of magazine.

Dubai Derma 2014 8 – 10 April 2014 www.dubaiderma.com Dubai, UAE Subscriptions IMTEC OMAN – 2014 15 – 17 April, 2014 www.imtecoman.com Subscribe online at: Muscat, Oman [email protected] www.MiddleEastHealthMag.com or call: +971 4 391 4775 15th Dubai Spine Conference & 19 – 22 April, 2014 www.dubaispine 10th Pan Arab Spine Conference Dubai, UAE conference.com/

11th Annual Middle East 20 – 22 April, 2014 http://www.me-oto.com/ Editorial Otolaryngology Conference & Dubai, UAE For editorial queries, submission of articles, Exhibition: Head & Neck Surgery product news or press releases, please contact the editorial department in Dubai: ICJR Middle East 2014 April 30 – May 2, 2014 www.icjr-me.com Tel: +971 4 334 6609 Dubai, UAE Email: [email protected]

Middle East Health is the region’s only independent English-language medical trade magazine. It is the oldest and most well-established medical trade magazine in the region having served the healthcare industry for more than 35 years.

* Features may be subject to change.

List your conference: Website If you have upcoming conference/exhibition details which you would like to list in the www.MiddleEastHealthMag.com agenda, please email the details to the editor: [email protected]

184 IMIDDLE EAST HEALTH