Filenews 1 January 2024 - by Marilena Panayi
New technology medical consumables, advanced medical devices, artificial intelligence, robotic machines and digital applications. They are now valuable tools in the hands of doctors, who can more easily and accurately make safe diagnoses or perform complex and specialized surgeries, without long hospitalization, discomfort or pain to the patient.
Several modern technologies and new methods are also used in Cyprus. Most of them, in fact, are accessible to patients through the General Health System, which, as it is found, has led -through the competition it has created- to the development of more initiatives on the part of doctors and hospitals. Some methods and technologies, however, although offered by medical centers in Cyprus, have not yet been integrated into the GHS. The planning of the Health Insurance Organisation, however, includes their gradual integration, for the benefit of citizens.
Cypriot doctors who apply some of these technologies explain to us the advantages, disadvantages and procedure they follow.
ROBOTIC PROSTATECTOMY
Prodromos Filippou, Urologist – Robotic surgeon
Prostate cancer is the most common malignant disease of men, since about 1 in 6 men will be diagnosed with this disease during his lifetime. "Although it is a malignancy that develops slowly, when symptoms appear the disease is already advanced. By raising public awareness about prostate cancer, but also with the tools available to modern urology, it is possible to diagnose the disease at an early stage, as one of the methods of treating prostate cancer is the surgical removal of the organ, known as Radical Prostatectomy.
Traditionally, this operation was performed with an incision (Open Radical Prostatectomy). Modern technology allows men with prostate cancer to live actively and productively after successfully treating the disease. Recent clinical studies have shown that with Robotic Radical Prostatectomy, the disease is effectively treated, while maintaining normal functions."
"The Da Vinci system allows fine precision movements to be performed through small holes, and this method uses the advantages of three-dimensional vision and the use of microsurgical instruments that reproduce the movements of the human hand. It thus contributes to the execution of complex operations, with minimal surgical trauma and this method uses state-of-the-art medical technology, with the help of which the surgeon gains better and sharper access to vital organs and performs movements of great precision".
The use of this technology – method leads to:
• Shorter hospitalization
• Less pain
• Lower risk for infections
• Less blood loss
• Absence of large and malformed scars
• Faster recovery
• Faster return to normal daily activities
UNIQUE METHODS OF ARRHYTHMIA TREATMENT
Panagiotis Avraamides, Interventional Cardiologist
Pacemaker implantation without electrodes:
"A conventional pacemaker is a device that is surgically placed under the skin of the chest and joined by one or two electrodes, which are guided through the large vessels to the heart. In this way, pulses are regulated when they are too low (bradycardia). It is an effective treatment, but it has complications, such as infection or malfunction of the electrodes. Some patients are very vulnerable to infections or there is no access to large vessels."
For these patients, "there is now a revolutionary new little device, which is implanted directly into the heart, without a surgical incision and without electrodes." This technology/method began to be applied by Dr. Avraamides and his colleagues, from the summer of 2023.
A second innovation "concerns the invasive treatment of atrial fibrillation, the most common cardiac arrhythmia." As Mr. Avraamides explains, "drugs are sometimes not enough and invasive treatment, RF ablation, an effective but time-consuming method, with specific complications, is needed."
"Now a new method has been created, Pulsed Field Ablation (PFA), which delivers high-intensity electrical pulses through a special catheter to the atrial myocardium for a very short period of time. This new technology is extremely effective and presents greater safety than conventional RF ablation ablation. The duration of surgery is also significantly shorter, less than an hour in the majority of patients."
This innovation has recently begun to be implemented in Cyprus.
A NON-INVASIVE METHOD
TO ASSESS LIVER FIBROSIS
Fotis Kosmatopoulos – radiologist
Easy, fast and painless examination, which, under certain conditions, can relieve the examinee from the procedure of the invasive method of biopsy.
"Hepatic elastography (fibroscan) is a non-invasive method in assessing liver fibrosis and is an extremely useful tool for hepatologists worldwide." It is used for "the quantitative assessment of liver elasticity (stiffness), which is associated with the degree of liver fibrosis, without it being necessary for the patient to follow the invasive method of biopsy. It is mainly recommended for the initial assessment of fibrosis in untreated patients."
This examination is performed with the Fibroscan device, which "is a specialized computer, which has an electronic system for ultrasound transmission and reception, vibration commands and signal analysis. The ultrasound transducer is used for ultrasound emission and reception. Moderate amplitude and low frequency vibrations are transferred from the vibration system to the tissues through the transducer creating an elastic wave which propagates through the tissues. At the same time, sound follows the sequence of the wave and determines its speed, which is directly related to the elasticity of liver tissue. The harder the tissue, the greater its speed. The results shall be expressed in kilopascals (kPa)'.
It is "a simple examination that does not require any preparation by the examinee. The doctor covers the tip of the transducer with gel and places it on the patient's skin, between the ribs, aiming at the right lobe, in the middle of the parenchyma. The tip of the transducer is placed in a part of the liver that is at least 6 cm thick and free from large vascular structures. The measurements are made at a depth of 25-65 millimeters from the surface of the skin."
The advantages of the method "apart from the fact that it is an easy, painless and fast examination, include the extremely short time of each measurement (one second), the extraction of immediate results and the excellent reproducibility. Of great importance is also the fact that the sample taken is 100 times larger than the biopsy, 10 successful measurements can be achieved at the same point, while unreliable measurements are rejected by the machine."
Contraindications: "On the other hand, hepatic elastography is not suitable for all patients. There are technical limitations, such as the presence of ascites (accumulation of abnormal amount of fluid inside the abdomen), obesity and narrow intercostal spaces. Hepatic elastography has no place in the diagnosis of cirrhosis/fibrosis in patients with acute liver injury, but can be used to monitor the progression of the lesion. It is also contraindicated for pregnant women and people with a pacemaker.
Patients suffering from chronic liver disease, such as chronic hepatitis of any etiology (B, C, autoimmune), alcoholic hepatitis, steatohepatitis due to diabetes mellitus and other causes, pharmaceutical hepatitis, hemochromatosis, etc., it is very important to be checked, after consultation by their treating physician, for the possibility of developing fibrosis before liver cirrhosis develops, so that appropriate therapeutic measures can be taken immediately and preventively".
THE COMPLETE RESTORATION OF A LOST HUMAN SENSE
Andreas Anagiotos – Otolaryngologist
"The restoration of an important sense, hearing, even in cases of complete loss (deafness) is no longer a product of science fiction. This possibility is offered through cochlear implantation in cases of severe hearing loss – deafness, in which classic hearing aids do not offer satisfactory recovery".
A cochlear implant is a small electronic device "which is placed in the ear with a delicate operation. A few days later, the outer part of the implant, i.e. the speech processor, is placed and immediately the system is activated. The sound received by the processor's microphone is converted into an electrical signal, which is transferred directly to the auditory nerve and from there to the brain. The previously hard of hearing or deaf person now hears everyday sounds, perceives speech and enjoys music. To reach this wonderful result requires, for some time after implantation, practice or speech therapy, so that the neuronal system of the brain adapts to the new type of stimulus offered to it (brain plasticity)".
Cochlear implantation "is preceded by a process of evaluation and counselling by a team of specialists, which consists of: otolaryngologist, audiologist , speech therapist, psychologist and if it is a child teacher of the deaf. The personalized medicine approach ensures that the right implant is selected for each patient."
"So we have in our hands a method that achieves something unique: the complete restoration of a lost sensation in a person. Biotechnology is rampant and developments in the field in the coming years are expected to be even more exciting."
MAGNETIC RESONANCE IMAGING – IMAGING OF JOINTS
Andreas Panagiotou – Radiologist
"MRI arthrography is one of the internationally recognized methods for assessing joint pathology. It is an imaging test that uses contrast dye to better assess the joint (e.g. shoulder, knee or hip), which cannot be achieved through standard MRI imaging alone."
In MRI arthrography, "a thin needle is used to inject contrast medium into the joint, followed by MRI to obtain better and more accurate images of the joint under examination. While MRI is most commonly used to examine the shoulder and hip joints, it can also be used to examine other joints, such as the knee, wrist, ankle or elbow."
The test can be performed on a joint "either when there is persistent and unexplained pain, discomfort, loss of movement and/or changes in the way the joint functions, or when the problem is not detected on standard MRI imaging."
The more specific reasons include:
• The evaluation of problems (e.g. ruptures) in the soft tissues of the joint, such as labrums, ligaments, tendons, cartilage and articular capsules.
• Check for damage from repeated dislocations of the joint.
"MRI arthrography involves an invasive medical procedure, so it requires a high degree of expertise from the medical radiologist. In direct arthrography, which offers the best possible imaging result, the joint is catheterized with a fine needle, under the guidance of ultrasound (US) or computed tomography (CT), in order to inject the contrast agent directly into the joint cavity.
After injecting the contrast medium into the joint, an MRI follows. Although this examination is specialized, no preparation is required from the examinee before the examination. During and shortly after the infusion there may be some discomfort in the joint, however, it is temporary and the examinee can usually return to normal activities immediately after the procedure."
CHALLENGE TEST – FOR PEOPLE WHO HAVE TROUBLE EXERCISING
Andreas Epiphaniou – Clinical Ergophysiologist
"The challenge test is a diagnostic procedure used to evaluate and diagnose exercise-induced bronchoconstriction or exercise-induced bronchospasm. This test is especially important for people who experience respiratory symptoms, such as wheezing, coughing, chest tightness or shortness of breath, during or after physical activity."
The challenge test includes:
- Basic assessment: in which, prior to the test, the person's basal lung function is measured using spirometry. Spirometry evaluates the volume and flow of air during inhalation and exhalation.
- Exercise protocol: the person is then asked to participate in a standard exercise protocol that often includes aerobic activities such as running on a treadmill or using a stationary bike. The intensity of exercise gradually increases to elevate the heart rate.
- Post-exercise assessment: After the completion of exercise, the person repeats spirometry to measure lung function immediately after exercise and at specific intervals after (eg 5, 10 and 15 minutes after exercise)
"The test results are compared with the basic measurements. A significant drop in lung function (typically a 10% greater reduction in forced expiratory volume in one second FEV1) after exercise indicates exercise-induced bronchoconstriction."
Diagnosis and recommendations: Based on the results of the tests, healthcare professionals can proceed to the diagnosis and determine the severity of the condition.
"It is important to note that the exercise challenge test should be conducted under the supervision of trained medical personnel, especially in cases where there may be a risk of severe bronchoconstriction."
The test "helps health care providers understand how exercise affects a person's airway function and helps develop a tailored treatment plan for those experiencing exercise-induced respiratory symptoms."
LUNGCANCER AND SCREENING PROGRAMMES
Stelios Demetriou – Medical Radiologist
"Lung cancer is the most common cause of cancer death worldwide. Through a series of studies, evidence of mortality reduction is found through the implementation of screening programs with annual low-dose chest CT in selected individuals at high risk of disease. According to U.S. guidelines, low-dose CT screening for lung cancer should be performed on individuals:
– with a history of smoking for at least 20 pack-years, eg. 1 pack of cigarettes a day for 20 years or 2 packs a day for 10 years (active smoker or smoking cessation within the last 15 years).
– aged 50-80 years.
Screening tests should not be considered mandatory for high-risk patients, but should be given a choice, after discussing in detail the advantages and disadvantages."
The main advantages of the low-dose CT screening program are:
– The diagnosis of lung cancers at an early stage, contributing to a better prognosis of the disease and potentially reducing mortality. Indicatively, a 5-year survival rate of 52% is reported in patients diagnosed with stage I cancer compared to 5% in patients with stage IV cancer.
– Accidental findings, not related to lung cancer (mainly chronic respiratory lung disease and cardiovascular disease, such as atherosclerotic disease of the coronary vessels and thoracic aortic aneurysm). Early diagnosis and appropriate follow-up of these findings could lead to reduced morbidity and mortality in patients.
The main disadvantages of the sorting program are:
The high rate of false positive, accidental findings, unrelated to lung cancer, which may lead to further unnecessary tests and treatments, significantly increasing costs
– possible "overdiagnosis" – i.e. the diagnosis and treatment of lung cancers that would not be discovered without the implementation of a screening program
– the inadvertent, non-diagnosis of cancer in screening tests (missed lung cancer), which rarely happens.
Remarkably, patient participation in lung cancer screening programs has both a positive and negative effect on smoking cessation."
Nevertheless, Mr. Demetriou said, "through screening programs, the benefits to the population seem to be greater than the harmful effects, a goal that so far seems to be achieved by implementing the annual low-dose CT screening in selected groups of smokers. It is noted that so far there are no official and state-organized screening programs for lung cancer in Cyprus."
As in the examinations of other organs, "e.g. breast and prostate, where a calibrated system for the evaluation of suspicious lesions for malignancy (BI-RADS & PI-RADS respectively) has been established, so in the case of lung examination with CT, a calibrated lung nodule evaluation system (Lung-RADS) has been proposed, aiming at standardizing, based on algorithms, the re-examination and management of patients".
"Automation in detection, measurement and characterization of pulmonary nodules using computers and artificial intelligence is a constantly evolving practice in clinical practice, aiming to increase the validity and effectiveness of screening programs."
ARTIFICIAL INTELLIGENCE IN MEDICINE
Dimos Michaelides – Medical Radiologist
"Imaging medicine nowadays holds a dominant position, both in the diagnosis and in the post-treatment monitoring of diseases. For this reason, reliable and accurate imaging is of utmost importance in order to make the appropriate clinical decisions for the treatment of the patient. Modern imaging machines aim to achieve the best possible imaging, which in turn contributes to achieving the best possible diagnosis.
Using MRI as an example, the time of the examination, which is directly related to the patient's cooperation, can be significantly reduced in MRI scanners that have a high magnetic field of 3T, maintaining high imaging clarity. A larger diameter of the magnet hole offers a feeling of comfort to claustrophobic and more burly patients, while the artificial intelligence that has been incorporated into the most modern machines helps the technologist to perform the examination sooner, but also to minimize alterations in imaging due to patient movement or due to the presence of metal, air, etc."
Artificial intelligence, "which in its infancy had raised concerns among the radiodiagnostic population about their possible replacement by artificial computers, has emerged as their ally and assistant, providing them with the tools for more reliable diagnoses and increasing their effectiveness. A modern MRI scanner with a stronger magnetic field of 3T (Tesla) is clearly superior to a lower magnetic field of 1.5T scanners and open type MRI scanners of 0.3T".
"In small anatomical areas, such as the pelvis, prostate, uterus, rectum, joints, musculoskeletal system and brain, but also in paediatric patients, a 3T MRI scanner achieves higher spatial resolution and contrast resolution."
With high-resolution images in front of him, "the experienced physician-radiologist can draw up his conclusion with more precision and certainty, providing a clinically oriented diagnosis without the need for further tests to clarify any inconclusive findings. Sharper images also "oblige" the doctor to process and highlight pathologies that may not be visible with lower power MRI scanners.
Modern imaging machines of this range also have all the relevant software (some with Artificial Intelligence-AI) and techniques required for a holistic imaging, without the need for the patient to visit different diagnostic centers. The imaging achieved is equivalent to specialized centers abroad and is fully accepted by them in case a patient wishes to send his examinations before going for treatment or post-treatment".
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