We are all aware that there is a dearth of physicians both in primary healthcare and several hospital specialities in the West, an escalating problem that is particularly acute in the case of anesthesiologists. In some European countries this situation is at least partially the result of poor planning and under-investment in medical education, coupled with aggressive attempts to recruit medical professionals overseas, but there are other factors involved that must be addressed before we can hope to consider approaches that could alleviate the problem.
A major contributing factor is that today’s anesthesiologists are not only active in the operating theatre: their expertise is required during patient evaluation prior to surgery, and in critical care and pain management post-surgery. And not only has medical research augmented the number of surgical procedures that are now possible, but Europe’s increasing numbers of senior citizens, who are the most likely to suffer from non-communicable and chronic diseases, are the main beneficiaries of these innovative approaches. Inevitably this results in the demand for anesthesiologists exceeding the supply.
Another factor is that the generation of predominantly male anesthesiologists who focussed on their careers and were prepared to work in the evenings, at night and during weekends and holidays, severely limiting the time they could spend with their families, are retiring and being replaced by younger specialists who are legally entitled to work fewer hours per week and are also aware that social changes in recent decades, allowing both genders to enjoy satisfactory careers, require them to contribute practically (as well as financially) at home.
There is also a shortage of surgeons in Europe but this problem is not so acute as with anesthesiologists. Sadly this may well be because of the greater prestige enjoyed by practitioners of the former specialization, a situation which should surely be an anachronism. It is to be hoped that the primary goal of all medical professionals is to help their patients but until all specialisms are equally valued and respected for their essential contribution to patient care, some will continue to attract fewer recruits than others. There could even be a long-term solution to the problem if physicians themselves, including anesthesiologists, would value and respect non-medical healthcare professionals as they deserve. Surely the ever evolving technologies available in critical care settings and the relevant training offered could allow specialized anesthesia nurses to be trusted to administer anesthesia for certain procedures and patients, as well as sedation and pain relief, without requiring direct supervision from on high?

While mammography remains the gold standard for detecting breast cancer, research has shown it is not equally effective in all women. In the 40percent of with dense breast tissue, mammography can miss up to one third of breast cancers. This may lead to a delay in diagnosis and a worse prognosis for women with dense breast tissue. Mammography has been shown to miss 30percent of cancer in dense breasts. Using screening ultrasound for women with dense breasts is helping address this challenge. However, the limitations of traditional hand-held ultrasound (HHUS), which include operator dependency, variability and long acquisition times, make it inefficient for broad-scale breast cancer screening. With the introduction of ABUS (automated breast ultrasound), clinicians are able to address these variables and shorten both exam and read times, while increasing sensitivity with a multi-modality approach.

New findings from a Swedish study show a 57percent relative increase in breast cancer detection in women with dense breast tissue when ABUS was used together with mammography.

The system is found to have significantly improved cancer detection in women with dense breast tissue when used together with mammography.

The European Asymptomatic Screening Study (EASY) aimed to evaluate the impact of ABUS in conjunction with full field digital screening mammography (FFDSM) in 1,668 women aged 40-74 with dense breasts. The study showed a 57 percent relative increase in breast cancer detection in dense breast tissue, compared with mammography alone.

‘If ABUS would be a part of national screening programmes in dense breasts, more cancers could be detected at an earlier stage. Many countries are working to try to optimize screening so that each woman can get examinations according to her assessed risk,’ said Dr Brigitte Wilczek, lead researcher on the EASY study.

Dense breast tissue is linked with an increase in the risk of developing cancer. It also makes detecting cancer more difficult. This is because both masses and breast tissue appear white in the mammogram, which makes the search for masses like a search for a snowball in a snowstorm. By contrast, masses appear dark against white tissue with ultrasound technology.

Dense breasts are particularly common in younger women and seems to reduce with age, as on average 74percent of women in their 40s, 57percent of women in their 50s, 44percent of women in their 60s and 36percent of women in their 70s have dense breast tissue.

In the study, published in the European Journal of Radiology, FFDSM was first used in the examination followed by a 3D ABUS exam which took 15 minutes to complete per patient. The inclusion criteria for the women in the study was that they be 40 years or older, asymptomatic, and have heterogeneously dense parenchyma or extremely dense breast on assessment by the radiographer in the screening.

‘The study shows that it is feasible to implement 3D ABUS into a high volume mammography center and increase the cancer detection rate while maintaining an acceptable low recall rate,’ said Dr Wilczek.

The recall rate for ABUS and FFDSM combined was only +0.9percent compared to FFDSM alone. This is an acceptable low recall rate well within the recommendations of the European guidelines for quality assurance in breast cancer screening.

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Mortara Instrument’s new family of Surveyor WiFi telemetry solutions is designed to offer diagnostic-quality ECG acquisition and to work on the existing WiFi network, with no need for a dedicated network infrastructure. Its outstanding features have been the key decision factors for Policlinico San Donato (Milan, Italy), one of the top-ranking centers for the study and treatment of cardiovascular diseases, to select Mortara telemetry system.

Mortara designed the Surveyor S4 solution based on three main criteria: cost saving, coverage and clinical excellence.

Cost is a major priority of today’s healthcare professionals and also one of Mortara’s top concerns. The Surveyor S4, thanks to its advanced design, can operate on existing WiFi infrastructure to broadcast physiological signals. It eliminates the cost of a proprietary antenna network, which is required by traditional telemetry systems. Removable, rechargeable batteries allow a lower ecological footprint than disposable batteries, while also reducing running costs.

Coverage (i.e. the areas where the patients can be monitored) is also revolutionized with the Surveyor S4; the use of WiFi technology allows patients to be monitored virtually wherever the WiFi signal is available throughout the facility. This means more freedom for the patient, but also extends patient monitoring to more departments; the ability to clinically monitor and evaluate patients is enhanced without additional beds being added to the traditional telemetry area.

Mortara takes pride in delivering clinical excellence. VERITAS^TM is the suite of algorithms created by Mortara to analyze ECG signals. The Surveyor S4 family includes the latest algorithms that provide clinicians with absolute reliable data. From basic to lethal arrhythmias, VERITAS is the ideal companion for clinicians. In addition, all Surveyor S4 mobile monitors offer diagnostic quality acquisition; combined with the true 12-lead ECG amplifier, they offer best-in-class 12-lead ST segment analysis. True 12-lead ECG monitoring allows physicians to detect early ST segment changes and obtain a complete evaluation of the cardiac profile of the patient, without additional tests.

Founded in 1969, IRCCS Policlinico San Donato is part of an 18-hospital network that provides over 5,000 beds, and is also host to the Medicine School of the University of Milan. The clinical arrhythmology and electrophysiology ward, run by Professor Carlo Pappone, is one of the international excellence centers for the treatment of all types of cardiac arrhythmias.

Atrial fibrillation, Brugada syndrome, Wolff-Parkinson-White (WPW) syndrome, and cardiac electro-stimulation are among the main research fields. In particular, the research on, and treatment of, supraventricular arrhythmias is a primary focus and area of expertise for this group of clinicians, as testified by the number of publications on international top-ranking journals, and directly witnessed by the large population of patients who have already successfully undergone trans-catheter ablation procedures.

Given the outstanding reputation of his center, Professor Pappone has chosen Mortara as the best-in-class partner in order to deliver excellent diagnosis and treatment.

Policlinico San Donato is one of the many centers where the Mortara monitoring solutions have been adopted and that every day helps to improve healthcare throughout the world.

In April 2011, the World Health Organization (WHO) warned that indiscriminate use of antibiotics was giving rise to resistant ‘superbugs’ which could render the drugs useless. Three years later, it warned about the arrival of a ‘post-antibiotic era.’ In autumn 2014, US officials termed antibiotic resistance a threat to national security.
However, awareness of this challenge has been present for decades. In the early 1990s, ‘Newsweek’ dramatically highlighted the threat in a cover story titled ‘End of the Miracle Drugs.’ A few months later, ‘Time’ magazine followed up with a feature on the ‘Revenge of the Killer Microbes.’

Bug resistance too knows no frontiers
The Centers for Disease Control and Prevention (CDC) has estimated that resistant bacteria lead to 23,000 deaths in the US every year. In Europe, the ‘British Medical Journal’ has urged authorities to harmonize antibiotic prescribing practices in order to tackle resistance. In spite of little effect on patients’ recovery times, an EU-funded study called GRACE identified wide variations in antibiotic use. For coughs, for example, antibiotic prescribing by physicians ranged from 20% in some countries to 90% in others.
Nevertheless, according to a report in the ‘The New York Times’ at the end of 2014, efforts to crack down on “inappropriate antibiotic use in the United States and much of Europe have been successful,” with prescriptions dropping from 2000 to 2010. Such a drop has, however, been “more than offset” by growing use in the developing world, according to ‘The Times’.
Indeed, like bugs themselves, drug-resistant bugs seem to know no frontiers.

Large emerging markets drive global drug sales
The ‘Times’ reports that sales of antibiotics for human consumption worldwide rose by 36% in the 2000-2010 period, with more than three-fourths of this increase accounted by the BRICS group of major emerging markets (Brazil, Russia, India, China and South Africa).
Such findings have been endorsed by an authoritative study, published in September 2015 by the Center for Disease Dynamics, Economics and Policy (CDDEP). The CDDEP report,  which has drawn up a global Resistance Map for antibiotics, found sharp growth in resistant bacteria in developing countries, notwithstanding much lower per capita use of antibiotics.

India: highest risk case
The respected journal ‘New Scientist’ has recently also covered the CDDEP report, singling out culprits as countries with growing wealth – “especially India,”… “where more people are demanding antibiotics for minor infections.”
Indeed, the CDDEP highlights the case of E. coli in contaminated water or food, where India shows the world’s highest rates of resistance to nearly every available drug. Other problems in India include MRSA, where isolates have shown prevalence rising sharply, from 29% in 2009 to 47% in 2014 and Klebsiella pneumoniae, which can cause fatal lung infections. In 2014, 57 per cent of Klebsiella pneumoniae samples tested in India were resistant to carbapenems, an antibiotic used as a last resort. By comparison, the figure six years ago was virtually zero.

Resistant bacteria and infants
Antibiotic resistance has an especially dramatic impact on Indian infants. According to the ‘New York Times’ article in December 2014, bacterial infections resistant to most known antibiotics led to the death of more than 58,000 newborns in India compared to the previous year. The head of Sir Ganga Ram Hospital, one of India’s top medical facilities, stated that such infections were unheard of just five years previously. “Now, close to 100 percent of the babies referred to us have multi-drug resistant infections,” he lamented.
Ironically, due to high rates of infant mortality, the Indian government has been encouraging women, sometimes with financial incentives, to deliver babies in hospitals. The programme seems to have worked. Within a decade, the share of babies born in hospitals has more than doubled to over 80%.
However, the government has spent little to increase hospital capacity. As a result, maternity wards are overcrowded, sometimes with two or three women per bed. Apart from overcrowding, many hospitals are unhygienic. A UNICEF survey of 94 district hospitals and health centres in the Indian state of Rajasthan found 78% lacked soap at hand-washing sinks, while 67% of toilets were unsanitary.

The impact of bacterial resistance is, however, not just confined to newborns. Resistant bacteria cost the life of Uppalapu Shrinivas, one of India’s most famous musicians, at the age of 45.
Indeed, according to Dr. Timothy R. Walsh, a professor of microbiology at Cardiff University, India is creating a “tsunami of antibiotic resistance that is reaching just about every country in the world.”

NDM1: New Delhi’s global export
Researchers have already tracked superbugs with the so-called NDM1 (New Delhi metallo-beta lactamase 1) genetic code, first identified in India. NDM1 makes bacteria resistant to almost all antibiotics, including carbapenems – the drug of last resort.
The first report about NDM1 was published in ‘Lancet Infectious Diseases’ in April 2011, and made headlines due to the fact that this was the same time when the World Health Organization warned about superbugs.
The ‘Lancet’ study was sponsored by the EU and reported that NDM1 was found in about one fourth of water samples in New Delhi, the Indian capital. The authors speculated that, since many Americans and Europeans travelled to India and Pakistan for elective medical procedures, it was likely the superbug gene could eventually spread worldwide.

Since then, NDM1 has been found in Europe, the Middle East, Japan and the United States. 
Meanwhile, back in India, what worries public health experts is “that the NDM 1 gene appears to have spread to germs that cause cholera and dysentery, two common and dangerous ailments in India.” In other words, it may be no exaggeration to say that the drug resistance problem is about to explode.

From toilet deficits to untreated sewage
The roots of the problem are complex. Bacteria spread relatively easily in India, since an estimated half of Indians defecate outdoors. Meanwhile, much of the sewage generated by the other half, who use toilets, is also left untreated. The result is expected: Indians have some of the world’s highest rates of bacterial infections – and resistance.
Cardiff University microbiologist Dr. Walsh says up to “95% of adults in India and Pakistan” carry bacteria that are resistant to ‘last-resort’ antibiotics such as carbapenems. By comparison, only 10% of adults in the Queens area of New York carry such bacteria.

The answer to no sanitation: use antibiotics, preventively
Ironically again, rather than building better infrastructure for sanitation, the response in India to growing bacterial infections has been to resort indiscriminately to antibiotics, which are often sold without a prescription. According to the December 2014 report in ‘The New York Times’, Indians collectively take more antibiotics than any other group of people.
Together, the lack of sanitation and overcrowding in hospitals may well have catalysed the superbugs. Doctors across India too have lent the crucial helping hand by responding to the hospital sanitation crisis through doling out antibiotics. In the Indian State of Haryana, for example, almost every baby born in hospitals in recent years has been injected with antibiotics – “whether they showed signs of illness or not,” Dr. Suresh Dalpat, deputy director of child health told ‘The New York Times’.
Completing the circle is the fact that the resistant bacteria, created by indiscriminate use of antibiotics, find their way into hospital sewage. As mentioned, much of this is untreated and dumped into canals and pits in nearby communities, leading to the infection of pregnant women, the delivery of ill infants – and more antibiotics.

A perfect storm
Though some Indian health experts believe drug-resistant bacteria to be largely confined to hospitals, some of India’s top neonatologists suspect the bacteria have begun “thriving in communities and even pregnant women’s bodies.”
“India has a perfect storm,” says Dr. Ramanan Laxminarayan, author of the CDDEP report. “You put all the things together and it’s this gigantic petri dish of experimentation that is resulting in highly pathogenic strains.”

Nevertheless, rushing to blame India alone (or India and other developing nations) for the growing drug resistance may not be helpful, or entirely accurate. Carbapenemases like NDM-1 have also been discovered elsewhere. For example, Klebsiella pneumoniae carbapenemase (KPC), currently the most common carbapenemase, was detected in the US in 1996 and has since spread worldwide. In addition, enterobacteriaceae which produce KPC have recently been reported as becoming common in the US.

Drug industry in India adds to the problem
In India, nevertheless, yet another growing area of concern seems to be loose compliance with regulations by Indian manufacturers of antibiotics. In early 2011, ‘Scientific American’ reported high levels of antibiotic resistance in bacteria downstream from a waste-water treatment plant in the southern Indian State of Andhra Pradesh.
Citing findings by a Swedish-led research team, the article noted that drugs in the effluent water from the plant were “sometimes equivalent to the high doses that are given therapeutically.” The antibiotic-rich water originated from the plants of 90 bulk drug manufacturers in the region.

The next wave: animal antibiotics in India
The other area for attention does not concern human use of antibiotics. Their overuse in chicken, pig and cattle farms in the US has also provoked the growth of resistant strains. Research has not only shown that “as much as half of antibiotic prescriptions in the United States are unnecessary,” but also that an estimated 80 percent of antibiotic sales remain directed at animals. 
In Europe, unlike the US, antibiotics for animal growth have been banned since 2006. However, their use in medicated feeds continues. This, in turn, fuels resistance to antibiotics, and not just through animals. One study in Poland discovered high levels of resistant bacteria in gardens, orchards and forest soils, largely due to manure from antibiotic-fed animals.

Unfortunately, India does not seem to be heeding such lessons. Its booming economy has led to rapid growth of industrialized animal husbandry, where antibiotic use is widespread. A science group in New Delhi found antibiotic residues in 40 percent of chicken samples.