Archive for month: August, 2020

Based in Milwaukee (Wisconsin, USA), Mortara Instrument, Inc. recently opened its new manufacturing and distribution facility.

The 64,000-square-foot, air conditioned, high tech facility consolidate and expand Mortara’s manufacturing and distribution operations which were previously split between the company’s headquarters building and its warehousing operation on Sleske Drive in Milwaukee.

‘I am proud of our continued growth and our increasing prominence in the market and in our community,’ said Justin Mortara, the company’s Chief Executive Officer, on the occasion of the ground-breaking ceremony in August 2015. ‘We’re excited to further invest in our community and truly live out our promise that all Mortara products are – Built with Pride in Milwaukee.”

The facility will allow Mortara to continue its growth in Milwaukee, where the company is committed to growing. Since May 2013, Mortara has added approximately 150 jobs, bringing its total global workforce to over 420. The expansion is part of a larger growth plan that will allow for the creation of more than 150 additional jobs over the next five years.

Mortara’s entire portfolio of products is ‘Built with Pride in Milwaukee.’ Mortara is committed to delivering the highest quality products to healthcare providers and their patients. In order to consistently deliver such quality, Mortara remains dedicated to manufacturing its entire portfolio of products in the United States, and more specifically in Milwaukee.

The company is also committed to keep the supply chain as physically close as possible, with 30 per cent of components being produced within 100 miles of its facility. This allows Mortara to ship most orders within 72 hours even if 80 per cent of the orders require custom configurations, whereas many are shipped within 24 hours, if not the same day.

Local sourcing is strategic both to reduce production times, and to invest in the community. As Mayor Tom Barrett said during the ceremony, ‘Mortara’s investment in Milwaukee pays dividends for our entire community. Mortara’s success means more jobs and more economic activity in our city.’

A flourishing community is also beneficial the company’s commitment to innovation. ‘We try to innovate on a timeline of one to three years, whereas the typical rhythm in medical devices is five to seven years,’ Mortara said. The company invests about 8 percent of its revenue into research and development, especially devoted to enhance diagnostic capability and connectivity. This commitment requires recruiting top talent, which can be attracted from the main universities only if the region is thriving.

The new facility was built with aim to reduce the environmental footprint. Among the main features, porous asphalt, LED lighting, heating and cooling powered by a geothermal system, and a blue roof that retains water and releases it slowly, so as to work as a retention pond.

In addition to designing and manufacturing a complete line of diagnostic cardiology and patient monitoring equipment, Mortara Instrument has always been recognized as a leader in the development of algorithms for safe and reliable ECG analysis. Now, Mortara has taken up a new challenge: Alarm Fatigue management.

Due to the increased number of monitored parameters available today and the need to reduce healthcare costs, algorithms must both be more sensitive and prevent more false alarms than in the past. Cardiac Care Units are always so busy that the large number of false alarms generated every day by monitoring systems can become a serious issue for healthcare personnel. This large number of false alarms induces so-called Alarm Fatigue’: in a nutshell, healthcare professionals, tired of wasting time in silencing false alarms, not only lose trust in their monitoring system, but tend to ignore possibly real alarms.

Mortara VERITAS^TM covers a large variety of diagnostic fields: from automatic resting ECG interpretation, to ambulatory Holter monitoring, to real-time algorithms specifically designed for bedside monitors and central stations, largely employed in Coronary Care and Intensive Care Units. Integrated in all Mortara product lines, VERITAS is constantly updated with new features and improved specificity and sensitivity.

Having obtained levels of sensitivity and specificity in line with major manufacturers is not enough to fight Alarm Fatigue. That is why much attention and investment have been devoted to reducing false alarm rates without affecting sensitivity. The updated VERITAS Arrhythmia algorithm defines a new standard in Alarm Fatigue management: up to 60percent less false alarms for lethal arrhythmias when compared to the most common algorithms available on the market, resulting in vast improvement of reliability of the systems on which it is installed.

The new version of VERITAS will be available on the Mortara monitoring line – Surveyor^TM Central, Surveyor S4 telemetry, Surveyor S12 and S19 bedside monitors – starting November 2016*.

For further information, click  here

Mortara, Surveyor^TM and VERITAS^TM are trademarks or registered trademarks of Mortara Instrument, Inc.

*Not available in the U.S.

Ionizing radiation, from the sun and even the earth, is a daily fact of life. There is little that can be done about this, except to stay away from too much sunlight and protect the skin with sunscreens. On the other hand, people are also sometimes exposed to radiation for medical reasons – such as diagnostic X-Rays or CT scans, or a range of interventional radiology procedures. These procedures offer tremendous benefits for patients and for healthcare providers. The evidence for such benefits has become indisputable in recent years, and covers a wide range of diseases and conditions.

Medical imaging has profound impact on patient management
The American Journal of Roentgenology’ reported in 2011 that abdominal surgeries reduced significantly after CT scans. Physicians planned to admit 75percent of patients to hospital before CT. This level was changed to hospital discharge with follow-up in 24percent of patients after CT. The conclusions of the researchers, from Massachusetts General Hospital, were conclusive: CT ‘changes the leading diagnosis, increases diagnostic certainty, and changes potential patient management decisions.’
Massachusetts General Hospital was indeed one of the first institutions to study the impact of medical imaging. In 1998, a team from the hospital reported that CT was 93-98percent accurate in confirming or ruling out appendicitis. The condition accounted for 1 million patient-days per year in the US, with a similar level eventually found to have other conditions.

From emergency rooms to lung cancer
More recently, the New England Journal of Medicine’ published a study on non-invasive coronary CT imaging in the emergency room. The study found that out of the 8 million visits per year to emergency rooms by patients with chest pain, only 5-15percent were eventually found to be suffering from heart attacks or other serious cardiac diseases. As many as 60percent of patients faced unnecessary admission and testing to exclude acute coronary syndrome.
Meanwhile, it has also been reported that low-dose CT screening reduced lung cancer deaths by at least 20percent in a high risk population of current and former smokers aged 55 to 74. These findings were reported by the National Lung Cancer Trial in the US.

Fight against Alzheimer’s, speeding up clinical trials
In the future, medical imaging holds forth significant promise as a tool in the fight against diseases ranging from osteoporosis to Alzheimer’s, whose incidence is likely to grow sharply as the population ages.
Medical imaging also offers increasing promise as a surrogate endpoint in clinical trials, allowing measurement of the effect of a new drug far earlier than traditional endpoints, such as survival times or clinical benefit.

Concerns about over-use, some alarmist
Nevertheless, there are several concerns about over-use’ – especially for imaging accompanied by radiation such as CT. In the US, according to a June 2012 review in the Journal of the American Medical Association’, CT scans tripled in the period 1996-2010, corresponding to a 7.8percent annual increase. Although this was less than a near four-fold increase in MRI and a 30percent fall in nuclear medicine use, CT has been the target of sometimes emotive campaigns.
One good illustration of this was an Op-Ed in the New York Times’ on January 31, 2014. The article was titled ‘We Are Giving Ourselves Cancer.’ It opened with the observation that we are ‘silently irradiating ourselves to death,’ while its closing sentence urged finding ways to use CTs ‘without killing people in the process.’

The Times’ Op-Ed cited a British study which ‘directly demonstrated’ evidence of the ‘harms’ of CT, and it is here that its authors over-stretched their credibility. The study they referred to was published in Lancet’ in August 2012 and titled Radiation exposure from CT scans in childhood and subsequent risk of leukemia and brain tumours: a retrospective cohort study’. Its authors used data on 175,000 children and young adults and found that the cumulative 10-year risk was higher in relative terms, but translated into one extra case of leukemia and one extra case of brain tumour per 10,000 head CT scans.

ALARA and the principle of necessity and justification
In other words, while few would argue that there is no risk from radiation, it is clear that such risks are small and that even these small potential risks could be controlled further by reducing exposure to radiation.
Both industry and healthcare professionals are endeavouring to ensure that such a goal is achieved.
Manufacturers of CT and other radiation imaging equipment seek to keep exposure to radiation for both patients and medical staff to a minimum – and below their regulatory limits – by using the ALARA (As Low As Reasonably Achievable) principle to design their products. Key methods include use of the most dose-efficient technologies available and seeking to ensure that optimum scan parameters are used for a patient and examination type.
Meanwhile, in the clinical setting, doctors seek to ensure that radiation imaging examination is ordered only when absolutely necessary and justified, while radiographers optimize the radiation dose used during each procedure.

Safety, information and awareness
Since the mid-2000s, radiologists and medical physicists have taken steps to increase controls on radiation risks to patients. These have essentially focused on promoting the safe use of medical imaging devices, supporting informed clinical decision making and increasing patient awareness.
One of these initiatives is known as Image Gently, a collaborative initiative by radiology professional organizations and other concerned groups. Its target is to specifically lower radiation dose during the imaging of children.
A related initiative, led by the American College of Radiology (ACR) and the Radiology Society of North America (RSNA), is Image Wisely. This is essentially an awareness campaign whose goals are to eliminate unnecessary’ procedures and lower doses to minimal levels required for clinical effectiveness when necessary. One aspect of Image Wisely is collaboration between medical radiologists and manufacturers to improve performance of radiology equipment and allow physicians to make real-time assessments of whether radiation levels are acceptable.

Initiatives by professional societies
Such initiatives are closely supported by professional radiology societies. The ACR has developed Appropriateness Criteria (corresponding to the federal requirements on appropriate use) to assist referring physicians and radiologists in prescribing the best imaging examination for patients – based on symptoms and circumstances. One tool consists of the display of imaging options and associated radiation levels for a specific procedure. The aim is to reduce imaging examinations by assuring that the most suitable exam is done first.
In Europe, the European Society of Radiology’s flagship EuroSafe Imaging’ has the same objective, to maximize radiation protection and quality/safety in medical imaging. The initiative was launched at the European Congress of Radiology in 2014 and has so far attracted over 50,000 individual supporters (known as Friends of EuroSafe Imaging’). Over 200 institutions (industry and healthcare providers) have also endorsed the initiative.

Accreditation programmes
Accreditation programmes are also being targeted by the ACR and ECR, in order to assess facilities based on imaging competence, adherence to latest dose guidelines, and personnel training. Given the pace of technology development in imaging, certified radiology and nuclear medicine professionals are increasingly recommended or (in some cases) required to earn continuing education credits on radiation safety.
In Europe, the ECR has joined forces with the European Federation of Organizations for Medical Physics (EFOMP), the European Federation of Radiographer Societies (EFRS), the European Society for Therapeutic Radiology and Oncology (ESTRO), the European Association of Nuclear Medicine (EANM), as well as the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) on an EU-promoted radiation education project called MEDRAPET. The findings, published in 2014, revise the previous Radiation Protection 116 Guidelines on Education and Training.

The Bonn Call for Action sets roadmap for the future
Many of these initiatives have been inspired by a conference held in Bonn, Germany, at the end of 2012, which was sponsored jointly by two United Nations bodies – the International Atomic Energy Agency (IAEA) and the World Health Organization (WHO). The outcome of the conference, which was attended by participants from 77 countries, is known as the Bonn Call for Action, and aims to strengthen medical radiation practices into the 2020s.

The Bonn Call consists of ten major actions. These are described below:

• To enhance implementation of the principle of justification. There is explicit emphasis on the use of clinical decision support (CDS) technology towards such a goal.
• To enhance implementation of the principle of optimization of protection and safety. There is a specific call to ensure the establishment, use and regular updating of diagnostic reference levels for radiological procedures, including interventional procedures, and to develop and apply technological solutions for patient exposure records, harmonize dose data formats provided by imaging equipment and increase utilization of electronic health records.
• Strengthen manufacturers’ role in contributing to the overall safety regime. This seeks to enhance radiation protection features in the design of both physical equipment and software, and to make these available as default features rather than optional extras.
• Strengthen radiation protection education and training of health professionals.
• Increase availability of improved global information on medical exposures and occupational exposures in medicine, with specific attention to developing countries.
• Improve prevention of medical radiation incidents and accidents. One interesting facet here is a call to work towards including all modalities of medical ionizing radiation as part of a voluntary safety reporting process, with specific emphasis on brachytherapy, interventional radiology, and therapeutic nuclear medicine, in addition to external beam radiotherapy.
• Strengthen radiation safety culture in healthcare.
• Foster an improved radiation benefit-risk-dialogue.
• Strengthen the implementation of safety requirements globally.
• Develop practical guidance to provide for the implementation of the International Basic Safety Standards in healthcare globally.

Although some of the Bonn Call points are repetitive, the document is noteworthy in terms of setting a minimal set of common rules for a very wide range of stakeholders – manufacturers, health professionals and professional societies.

Point 6 seeks new work on effective’ dose
Point 6 of the Bonn Call is both ambitious and timely. Although the concept of effective dose’ (or effective dose equivalent) was introduced in the mid-1970s to provide a common framework for evaluating the impact of exposure to ionizing radiation via any means, technology’s uneven leaps have not made it easy to follow through. Data for doses by different radiographic imaging modalities used in radiation therapy are scattered widely through literature, making it difficult to estimate the total dose that a patient receives during a particular treatment scenario. In addition, interventional systems are often configured differently from diagnostic set-ups and imaging systems do not distribute radiation in similar ways. For example, planar kV imaging attenuates rapidly along the line of sight, while CT dose is uniformly distributed through a patient. This makes it difficult to sum dose in a radiobiologically consistent manner.

Point-of-care testing (POCT) refers to diagnostic tests which are performed physically close to a patient, with the results obtained on site. They are conducted at primary care centres and at hospital bed sides (increasingly, in emergency departments and intensive care units, too).
POCTs are also used in the field in settings such as natural or man-made disasters, and accompanied by telemedicine, in patients’ homes.

Saving time and space
While traditional diagnostic tests involve taking patient specimens, transporting them to a laboratory for analysis and then returning the results to a physician, POCTs cut out both the transport and laboratory. As a result, they provide quicker turnaround time (TAT), sometimes near-instantaneously.
In the past, the traditional laboratory-centric process was unavoidable due to the sheer size of equipment required for diagnostic tests. In recent years, technology developments – especially in terms of miniaturization – have made it possible to perform a growing number of tests outside of the laboratory. One recent book on biomedical engineering (D. Issadore and R.M. Westervelt (eds.), Point-of-Care Diagnostics on a Chip, Biological and Medical Physics, Biomedical Engineering’, Springer-Verlag, Berlin 2013) notes the array of sophisticated, low-power and small ‘microfilters, microchannels, microarrays, micropumps, microvalves and microelectronics …. integrated onto chips to analyse and control biological objects at the microscale’, that have made decentralized diagnostics possible.

Impact on efficiency, outcomes – and costs
Such time savings can have a dramatic impact on downstream clinical efficiency and patient outcomes. In many cases (although not universally or under all circumstances), they also save costs.
For example, POCT can reduce revenue losses due to workflow delays of test-dependent medical procedures – such as disruptions in magnetic resonance imaging (MRI) or computer tomography (CT) queue. This is not a rare occurrence, and delays in radiology testing have been shown to extend total length of stay in the emergency department (ED).

From lab downscaling to targeted solutions
Early POCTs were based on the simple transfer of traditional methods from a central laboratory, accompanied by their downscaling to smaller platforms. At a later stage, unique, innovative assays were designed specifically for POCT (such as the rapid streptococcal antigen test). This was accompanied by the development of wide arrays of POCT-specific analytic methods, ranging from the simple (such as pH paper for assessing amniotic fluid) to the ultra-sophisticated (for example, thromboelastogram for intra-operative coagulation assessment).
Today, the typical POCT test arsenal includes cardiac biomarkers, hemoglobin concentrations, differential complete blood count (CBC), blood glucose concentrations, coagulation testing, platelet function, pregnancy testing as well as tests for streptococcus, HIV, malaria etc.

Beside and near-bedside POCT
POCT devices are used in a wide range of healthcare settings. They can be divided into two broad groups, depending on size and portability – bedside and near-bedside.
Bedside POCT devices are smaller, usually hand-held, and offer the greatest mobility. Due to their compact nature they are often more specialized and limited in overall functionally. Many are enclosed in test cassettes (such as easy-to-use membrane-based strips) and based on portable, sometimes handheld, instruments. This family of POCT requires only a single drop of whole blood, urine or saliva, and the tests can be performed and interpreted by a general physician in minutes. Nevertheless, some of them can be quite sophisticated.
New POCTs for early detection of rheumatoid arthritis, for example, require only a single drop of whole blood, urine or saliva, and can be performed and interpreted by any general physician within minutes. Two of the earliest efforts in this area were made in Europe. The first, from Sweden’s Euro-Diagnostica detects antibodies to CCP, while Rheuma-Chec from Orgentec in Germany combines two biomarkers – rheumatoid factor and antibodies to MCV. These tests are targeted at primary care.

Near-bedside (or neighbourhood) devices are larger and typically located in a designated testing area. They provide higher calibration sensitivity and quality control and are used for more complex diagnostic tests than their smaller bedside counterparts.
They are themselves also far more complex, with high degrees of automation in comparison to their bedside POCT counterparts. This automation contributes to the increased speed and ease-of-use of the devices. However, it also leads to challenges in training users.

The imperatives of turnaround time
As mentioned, the principal interest in POCT is to reduce turnaround time (TAT) – the duration between a test and the obtaining of results which aid in making clinical decisions. The impact of this has been profound in the emergency department.
Already in 1998, a randomized, controlled trial in the A&E department of a British teaching hospital assessed the impact of POCT on health management decisions. The results, published in British Medical Journal’ in 1998, found that physicians using POCT reached patient management decisions an average of 1 hour and 14 minutes faster than patients evaluated through traditional means.

Use in emergency departments
Though the bulk of POCT is conducted by primary care physicians, one of its fastest growing users has been hospital EDs, which the British Medical Journal’ study hinted at almost 20 years ago.
POCT’s relevance for emergency departments is multi-faceted.
In the ED, prolonged wait times and overcrowding directly correlate to reduced patient satisfaction and adverse clinical outcomes. Several European countries have regulations on length-of-stay time targets in EDs, requiring that patients must transit through four to 8 hours. Though there are several factors at play here, no one would argue that reducing the delay between sample collection and test results can enable healthcare professionals to arrive at quicker decisions and increase patient throughput. POCTs make this possible.
One study in Switzerland evaluated adding POCT to B-type natriuretic peptide levels for ED patients presenting acute dyspnea as their primary symptom. POCT was not only associated with significant decreases in time to treatment initiation, but was also associated with a shorter length of stay and a 26percent reduction in total treatment costs.
Another study on D-dimer POCT in the ED found a 79percent reduction in TAT compared to central laboratory testing and resulted in shorter ED lengths of stay and reduced hospital admissions, while a randomized study in coagulopathic cardiac surgery patients found that POCT-guided hemostatic therapy led to reduction in transfusion and complication rates, and improved survival.

From ACS to pregnancy tests, and overcrowding
Favourable perspectives on POCT in the ED have strengthened over time. One recent study in Critical Care’ found POCT increased the number of patients discharged in a timely manner, expedited triage of urgent but non-emergency patients, and decreased delays to treatment initiation. The study quantitatively assessed several conditions such as acute coronary syndrome (ACS), venous thromboembolic disease, severe sepsis and stroke, and concluded that POCT, when used effectively, ‘may alleviate the negative impacts of overcrowding on the safety, effectiveness, and person-centeredness of care in the ED.’
A great deal of attention has been given to the use of POCT in emergency settings for screening patients who presented with symptoms of acute coronary syndromes (ACS). The rapid identification and treatment of ACS patients is critical.
Due to the time-sensitive nature of ACS, reduced TATs can offer a clear advantage. POCT has been shown to increase the speed at which positive cases of ACS are accurately identified, allowing physicians the ability to admit and initiate treatment at a faster rate than previously possible. Decreased TATs also can result in the earlier identification of negative cases of ACS, thereby increasing the number of successful discharges, and allowing for more efficient use of hospital resources .

The ICU and POCT
Unlike the ED, the use of POCT in intensive care units is still in its infancy. In 2013, researchers at Germany’s Klinikum rechts der Isar in Munich sought to retrospectively investigate whether POCT predicted hospital mortality in over 1,500 ICU admissions. The results were mixed. Lactate and glucose seemed to independently predict mortality. So did some forms of metabolic acidosis, especially lactic acidosis. However, anion gap (AG)-acidosis failed to show any use as a biomarker.
One of the most important areas for POCT focus in the ICU consists of sepsis – which is directly correlated to poor outcomes. ICU patients often have other ongoing disease processes whose biomarkers are shared with sepsis, such as raised white blood cell count and fever. More crucially, many ICU patients are already on antibiotics at admission, making microbiological cultures redundant.

POCT as part of health management strategy
Overall, POCTs have an impact and make most sense when utilized as part of an overall health management strategy which enhances the efficiency if clinical decision-making. Indeed, the rapid TAT provided by POCT allows for accelerated identification and classification of patients into high-risk and low-risk groups, improving quality of care and increasing clinical throughput.
POCT results are often available in minutes. However, decreased TATs on their own mean nothing, until they provide clinical pathways means to impact on workflow. The latter varies widely across healthcare settings.

Differences in practice
Such a scenario is by no means straightforward. In Europe, for example, POCT use is highly irregular and differs greatly between institutions and countries. Though differences in operating procedures are natural by-products of institutional cultures, there are some oversight and quality control issues which healthcare leaders must address to take maximum advantage of POCT.
Answers to the above are not a question of if’ but when’.

Regulation – the future ?
The future of POCT may well be shaped by regulators, and their response to the kind of pressures mentioned above.
In Europe, POCT devices are regulated under the 1998 European Directive 98/79/EC on in vitro diagnostic medical devices, which became operational in 2001. POCT devices are not specifically mentioned or referred to in this directive, and at the European level, coverage of POCT is referred by international standard ISO 22870:2006, used in conjunction with ISO 15189 which covers competence and quality in medical laboratories.
In the US, CLIA88 (Clinical Laboratory Improvement Amendments of 1988) provided a major impetus for growth in POCT. The rules, published in 1992, expanded the definition of laboratory’ to include any site where a clinical laboratory test occurred (including a patient’s bedside or clinic) and specified quality standards for personnel, patient test management and quality.
One of CLIA88’s biggest contributions to POCT growth was to define tests by complexity (waived, moderate complexity and high complexity control), with minimal quality assurance for the waived category.
CLIA88 has been followed by US federal and state regulations, along with accreditation standards developed by the College of American Pathologists and The Joint Commission. These have established POCT performance guidelines and provided strong incentives to ensure the quality of testing.