New Normal, New Future - Free Download E book

1
w w w . a s i a n h h m . c o m
Associate Partner
ISSUE 55 2022 www.asianhhm.com
IMPLICATIONS
OF COVID-19 ON
HEART HEALTH
A DIGITAL
REVOLUTION
IN PATHOLOGY
NEW
NORMAL,
NEW
FUTURE
Reshaping the Future
of Health through
MedTech Innovation
Ashley McEvoy
Executive Vice President
and Worldwide Chairman
Medical Devices
Johnson & Johnson

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1
Foreword
MedTech Innovations
Shaping the future of healthcare
extend and expand this adoption to improve the health
outcomes across regions and populations. However,
this increased demand calls for a careful evaluation of
the shift to digital infrastructure and proper regulations
in place to ensure the industry is better prepared for
managing health emergencies.
MedTech companies would do well to innovate and
develop advanced diagnostics & monitoring tools with
a focus on agility, affordability and effective outcomes.
Asia-Pacific will become the second-largest regional
market for MedTech, contributing 35 percent of the
growth over the next two years, according to McKinsey
& Company. Driving MedTech innovation calls for
collaborations and partnerships between MedTech and
healthcare organisations and the region has the potential
to guide the world towards digitisation of MedTech for
enhanced care delivery.
This issue features an interview with Ashley McEvoy,
Executive Vice President and, Worldwide Chairman,
Medical Devices, Johnson & Johnson. Ashley shared her
views on how the pandemic has changed the shape of
healthcare and MedTech in the Asia-Pacific region. She
also talks about how collaborations and partnerships will
drive MedTech innovation in the future.
Hope you find this issue insightful. Please also use
this as an opportunity to share your perspectives for the
upcoming special issue ‘Executives Special’. Write to
me - prasanthi@ochre-media.com.
Prasanthi Sadhu
Editor
Healthcare is shifting from the traditional provider-centric,
in-patient setting to patient-centric, virtual consultations
with increased remote care monitoring. This transition
has prompted the need for MedTech industry to relook
at the products they develop and enhance value in care
delivery.
The COVID-19 pandemic has increased the use of
digital health technologies, and the need to develop
innovative devices or systems that support virtual
health. The last couple of years have seen increased
use of wearables, mobile and app-based technologies
along with data and analytics have been transforming
healthcare delivery.
Advancements in healthcare technologies like
Artificial Intelligence (AI), Virtual Reality and Augmented
Reality 3D-printing, robotics and nanotechnology are
shaping the future of healthcare. This technology boom
is helping address disease and medical conditions
through provision of cheaper, faster and more effective
solutions for diseases.
The pandemic has forced organisations to rethink
their strategic planning understanding the need to
go the digital route and patients have understood the
importance of teleconsultations and the advantages
mobile health applications bring forth.
From increasing productivity to driving operational
efficiency with automation of mundane tasks and gaining
a 360-degree perspective through 3D rendering, the
likes of Robotic Process Automation AI, 3D systems and
the cloud are in focus for the medical devices industry.
The pandemic has created a need for loosening
regulations in offering clearances to address the
medical device demand-supply needs of the sector.
MedTech companies and healthcare organisations have
to collaborate and work in sync for implementation of
digital technologies. There lies a huge opportunity to

CONTENTS
HEALTHCARE
MANAGEMENT
06 Behavioural Health
Gurrit K Sethi, Founder, Miindmymiind
08 Healthcare Technology Entrepreneurship in China
Caiwei Chen, Yongqi Zheng and Pradeep Ray
Centre For Entrepreneurship, University of Michigan-Shanghai Jiao Tong University
Joint Institute
MEDICAL SCIENCES
14 Keep Calm and Reconsider Graft Revision
The impact of coronary stenosis for beating heart
coronary artery bypass grafting
Frank R Halfwerk, Assistant Professor, Cardiac Surgery Innovations Lab, University
of Twente
19 Addressing the Osteoporosis Care Gap in
The Asia-Pacific
M Chandran, Senior Consultant and Director, Osteoporosis and Bone Metabolism
Unit, Singapore General Hospital
M Chadha, Consultant Endocrinologist, P
.D. Hinduja National Hospital and Medical
Research Centre
Q Cheng, Chief Physician and Doctoral Supervisor, Department of Osteoporosis
and Bone Disease, Huadong Hospital
24 Understanding and Predicting Progression to
Hepatorenal Syndrome in Cirrhotic Patients
Roula Sasso, Ahmad Abou Yassine, Department of Gastroenterology
Staten Island University Hospital
38 The Health Impact of Nudges, Influence and Community
Kent Bradley, Chief Health and Nutrition Officer, Herbalife Nutrition
42 Implications of COVID-19 on Heart Health
Audditiya Bandopadhyay and Gyaneshwer Chaubey
Cytogenetics Laboratory, Department of Zoology, Banaras Hindu University
INFORMATION TECHNOLOGY
50 Global Certification for Telehealth Services
K Ganapathy, Member Board of Directors, Apollo Telemedicine Networking Foundation &
Apollo Tele Health Services
56 A Digital Revolution in Pathology
Suresh Vazirani, Founder Chairman, Transasia-Erba International Group of Companies
COVER
STORY
46
NEW
NORMAL,
NEW
FUTURE
Reshaping the Future of Health
through MedTech Innovation
Ashley McEvoy
Executive Vice President and
Worldwide Chairman
Medical Devices
Johnson & Johnson
28 Management of Cerebrovascular Steno-Occlusive
Disease
Contemporary multidisciplinary approach
Benjamin Wai Yue Lo, Neurosurgeon & ICU Specialist
34 Chronic Disease Management
Challenges and opportunities
Prasad Narayanan, Senior Consultant & Director – Medical Oncology
Cytecare Cancer Hospitals

Advisory
Board Beverly A Jensen
President/CEO
Women's Medicine Bowl, LLC
K Ganapathy
Director
Apollo Telemedicine Networking Foundation
& Apollo Tele health Services
Pradeep Kumar Ray
Honorary Professor and Founder
WHO Collaborating Centre on eHealth
UNSW
Nicola Pastorello
Data Analytics Manager
Daisee
Gurrit K Sethi
Founder, Miindmymiind
Pradeep Chowbey
Chairman
Minimal Access, Metabolic and Bariatric
Surgery Centre
Sir Ganga Ram Hospital
David A Shore
Adjunct Professor,
Organisational Development
Business School, University of Monterrey
Gabe Rijpma
Sr. Director Health &
Social Services for Asia
Microsoft
Peter Gross
Chair, Board of Managers
HackensackAlliance ACO
Malcom J Underwood
Chief, Division of Cardiothoracic Surgery,
Department of Surgery,
The Chinese University of Hong Kong,
Prince of Wales Hospital
EDITOR
Prasanthi Sadhu
EDITORIAL TEAM
Grace Jones
Rohith Nuguri
Swetha M
ART DIRECTOR
M Abdul Hannan
PRODUCT MANAGER
Jeff Kenney
SENIOR PRODUCT ASSOCIATES
Ben Johnson
David Nelson
Peter Thomas
Susanne Vincent
PRODUCT ASSOCIATE
John Milton
Veronica Wilson
CIRCULATION TEAM
Sam Smith
SUBSCRIPTIONS IN-CHARGE
Vijay Kumar Gaddam
HEAD-OPERATIONS
S V Nageswara Rao
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6 ASIAN HOSPITAL & HEALTHCARE MANAGEMENT ISSUE - 55, 2022
BEHAVIOURAL
HEALTH
Our behaviours define what we consume and how. The
pandemic has had deep rooted effects on our psyches
and this is bound to impact consumer behaviours. We all
need to closely watch the changes wrought about during
this time and re-strategise what we do and how, as we
reach out to strengthen and expand our businesses.
Gurrit K Sethi, Founder, Miindmymiind
W
e are all defined by our
behaviours, quite literally
so. Our behaviour affects
how we engage with not only the
external world, but also reflects on
how we engage with ourselves. It is
this engagement that drives the world
around us… Yet we hardly ever consider
this fact. Ain’t this true?
I am neither a behavioural health
expert, nor a mental health expert.
However, there are many who practice
without many credentials. In fact, the
rulings and regulations around the
required credentials for counselling
in India is still nascent. But since I
have been a business professional, and
worked through people behaviours
and also suffered business behaviours,
and because I now work in the mental
health and well-being space, I am taking
the liberty of expressing the opinions of
a minion from this field.
As per Wikipedia, the word
‘behaviours’ extends itself to not just
individuals and human beings but also
to all other living beings, systems or
artificial entities in conjunction with
themselves or their environment. How
we react or our mannerisms, as they
play out have been ensconced under
the apparel of behavioural sciences.
This ‘science’ of behavioural sciences is
studied not only with respect to human
beings, but also cultures, systems
etc. So much so that a lot of research
today happens on the behavioural side
of economics as well. Ironically our
behaviour’s are being studied for their
effects on the growth of economy, and
for many business professionals, for how
to use these behaviours for economic
gains for the business.
To understand what created these
behaviours, I researched various
elements of our environment that
surrounds us. And hence I came upon
the need to understand culture and if
it shaped our behaviours. The discovery
that both cultures and behaviours do
get driven and impacted by each other
came upon with some apprehension.
It is so said that human behaviour is
affected by both genetic inheritance
as well as experience. This is quite a
deep-seated aspect. And a very critical
part of our mental frameworks. This
leads to the belief that to support our
behavioural health, it is important to
understand the culture to which one
belongs and, maybe, similar aspects
need to be applied to the behaviours of
other abstracts of our environment –
our work culture especially. The culture
and employee behaviours impact
productivity of the organization.
Many studies ascertain that work life
imbalances and work stress impact
mental health of the employees and
this leads to loss of productivity. The
WHO statistics to this effect are
overwhelming. And these ‘effects and
loss of productivity can definitely be
minimized by the right interventions.
If we look at the world as one large
community and one large economy,
it is invariably driven by basic human
instincts and colored by the effects of
the various cultures. These in turn
are determined by the geography, the
resource availability, the climate and
many other natural factors and how
overcoming challenges arising of these
for survival have evolved over centuries.
As the world got knitted together,
not just by the expanse of the earth,
but more through transportation and
communication channels. As a result,
new patterns of expected behaviours have
evolved. Many of us in the corporate
world undergo trainings on managing
cultural diversity for better work output.
As the global communities have come
together to expand the economic gains, it
is imperative to understand the different
cultures of different geographies, and
HEALTHCARE MANAGEMENT

7
to keep the sensitivities in mind as we
connect across different countries. Each
place has its own unique way of living
and environment driven by resources
and other elements of this environment.
One thing is for sure, communication
is key, and, if one looks deeper, the key
aspects and strains of human behaviour
do remain the same, albeit with some
differences
But one thing remains sacrosanct
through all of this: behaviours are the
defining factors for humans, systems
andcultures–foroutput,endresult,and
the final product. It is well understood
that the environment affects, rather
shapes these behaviours and vice versa.
And, thus it becomes important to
understand the environment to be able
toshapethebehaviours.Especiallywhen
we all exist in such a volatile, uncertain,
complex, ambiguous (VUCA) world!
This is true not just for our day
to day living, as behaviours add to
the quality of it, but also true for our
business environments, our political
environments as well as the social
fabric which is an essential core of our
survival. The ongoing pandemic has
made our already VUCA world more
so. The effects of these on people’s
health, homes, and other behaviours are
telling.
There is an increased focus on
behavioural and mental health today.
This heightened focus has been driven
by the widened need supply gap hugely
as a key after effect of the pandemic.
There are an enormous number of
mental health start-ups that have
sprung up across varied geographies
– some serious players, some fly by
night operators. The need of the hour
today is not just better regulations and
governance by the respective authorities
but by our own selves as well to
recognize our issues well in advance and
nip the evil in the bud.
Awareness about mental health and
mental well-being needs to be given due
importance by educators, employers,
and by each one of us. While we all
look out for developmental anomalies
and mental disease evidences, the focus
needs to also shift to creating strong
mental frameworks in the first place.
With strong mental frameworks
driven right through our developmental
years, we will all be better equipped to
handle our emotional ups and downs
largely motivated by our VUCA world.
Perhaps a focus on creating a mentally
strong human force actually leads to a
less toxic and a less VUCA world.
While we work around the above
challenges through research-based
methodologies, let us all focus on
looking after our behavioural health
today and give it the requisite attention
– recognize and understand our own
pain points, address those pain points
by seeking professional help, in time.
Ironically enough, the same can be said
for systems, businesses etc.
Let me conclude by saying that
if health is wealth, our behaviours are
the cornerstones or the tombstones of
everything around us, be these of our
lives, our health, our work or the overall
economy.
Gurrit K Sethi, Founder, MIINDMYMIIND, contributes to healthcare
by bringing to life new concepts which enhance accessibility, helps
providers re-engineer businesses, works with Global Challenges
Forum (a Swiss Foundation) on sustainable health initiatives. An
avid traveller and voracious reader, these attributes provide her with
incisive insights about people and systems and what drives them.
AUTHOR
BIO

Healthcare Technology
Entrepreneurship in
China
Entrepreneurship in healthcare is growing rapidly all
over the world. Thanks to the explosion in the Internet
and mobile technologies and the cooperation among
technologists and medical professionals, China is seeing
some great progress in this field. This article discusses
some cutting edge technology entrepreneurship in China,
using the technique called Business Model Canvas.
Caiwei Chen, Yongqi Zheng and Pradeep Ray
Centre For Entrepreneurship, University of Michigan-Shanghai Jiao Tong University Joint Institute
E
ntrepreneurship in healthcare
technology is one of the fastest
growing investments in the
startups in the world today as seen
from the reports from the venture
capital industry. China is a country of
entrepreneurs with nearly 25 per cent
of the Chinese technology professionals
becoming entrepreneurs. Therefore, it
is not surprising that entrepreneurship

9
in healthcare technology is growing
rapidly in China. The Centre For
Entrepreneurship (CFE) at the
University of Michigan-Shanghai
Jiao Tong University Joint Institute
(UM-SJTU JI) is a premier institution
in Asia training engineering students
for entrepreneurship through courses
and practicum projects in collaboration
with local startups and the corporate
businesses. Since the Business Model
Canvas (BMC) is the de-facto standard
method of presenting and validating
entrepreneurship ideas, this article
uses BMC to analyse healthcare
entrepreneurship in China through case
studies in projects that CFE has been
involved in.
Thearticlestartswithanintroduction
of BMC followed by two case studies;
one involving the Haiyang Group,
the largest private sector aged care
provider in China (that started with the
entrepreneurial vision of the founder and
CEO Mr. Max Xu) and a new startup
called MiDIVI (led by Chen Liang) that
is involved in the deployment of cutting-
edge Mixed Reality (MR) application
in surgery in China. The case studies
discuss the business model of each of
these sectors using BMC, followed by
brief comments from the leader of each
company.
Business Model Canvas1
Business model canvas (BMC) is a
systematic way to present the developing
plan of a company’s product with
nine building blocks. BMC helps the
company in keeping the major decisions
consistent with the product positioning.
At the initiation stage of an idea, it is
done with guesses, which enables the
company to clarify the whole developing
strategy. Then later during validation
1 A. Ostenwalder and Y. Pigneur, Business Model Genera-
tion. USA: Wiley, 2010. ISBN: 9780470876411.
phase, the company can evaluate and
improve its plan based on BMC.
Value propositions are the core values
of a product, namely how it provides
a solution to the problems from each
specific Customer Segment.
• The Customer Segments describe the
target customer groups, to whom the
Value Propositions are designed for.
Channels indicate through which media
the product will reach the Customer
Segments, and how each of them is
integrated.
• Customer Relationships refer to
the strategies to get, keep and grow
customersbased ondesignated Customer
Segments.
• Revenue Streams are strategies the
company adopts to gain profit from
each Customer Segment. These include
the major revenue sources and pricing
model.
• Key Resources include the most
important things to keep the BMC

suppliers and Haiyang is the only single
company in China which covers three
pension models which is institutional
pension, community pension and home
pension. The main customer segment is
the elderly who need to be taken care of
but lack all-day-long face-to-face care.
These “new Chinese seniors” are more
open to digital technologies and are
also concerned about their own health.
Channels for Haiyang can be divided
into two parts: healthcare applications or
programmes which can be downloaded
directly online, and specialised wearable
electronic devices which can be bought
from both online and physical stores.
In order to strengthen customer
relationship, Haiyang provides multiple
high-quality products and makes good
connection between customers and
caregivers. The revenue streams can
be formed in two parts: direct earning
from multiple telehealth products and
funds from investment cooperation.
models in pension industry. Their main
product is Continuing Care Home-
based Community (CCHC), which is
a smart pension model supported by
multiple digital technologies. Haiyang
group is now the largest private sector
aged care provider in China and it has
been a partner of UM-SJTU JI CFE led
by Pradeep Ray in the recently concluded
project (2019-2021)“Digital Health for
the Elderly” that led to the publication
of the book “Digital Methods and Tools
for Healthy Ageing”, (2021) eds Pradeep
Ray, Siaw Teng Liaw and Artur Serrano,
published by IET (UK).
1 Analysis based on BMC
The value proposition for Haiyang is
to provide a comprehensive pension
chain service integrated with digital
technologies, which enables the elderly
to have a better life and relaxes their
children. Most of the competitors in the
industry are system or software service
work, mainly from financial, physical,
intellectual and human perspectives.
• Key Partners can be strategic alliances
to jointly provide a complete product or
service, suppliers of Key Resources, and
so on.
• Key Activities usually consist of
development, maintenance and
promotion of the product. Cost
Structure is the plan for expenditure on
each Key Resources and Key Activities.
Case Study of Haiyang Group2
Shanghai Haiyang Internet Elderly
Services Co., LTD. (hereinafter referred
to as ‘Haiyang’) is a leading company
which provides comprehensive pension
service in China. Haiyang focuses on
developing an integration of digital
technology, new business forms and new
2 Z. Hao, M. Xu, L. Li and P. Ray, “Role of Technology
in Aged Care in China,” in Digital Methods and Tools for
Healthy Ageing. U.K.: IET, 2021, ch. 11. ISBN: 978-1-
83953-462-1.

11
Raw material of the products and
software providers are the key resources
for Haiyang. Chinese government
and medical centers are Haiyang’s key
partners. The former offers supporting
funds and policies and the later provide
the best user experience, share the data
and do rapid assessment. Key activities
of Haiyang include effective production,
training for the elderly to use the
products and high-quality maintenance.
The cost mainly goes to three areas:
raw materials, software support, and
community workers’ salary.
2 Interview excerpts
UM-SJTU JI CFE team interviewed the
CEO of Haiyang Group, Max Xu (Chao
Xu) in 2021 as he has been an award-
winning entrepreneur and the founder
of the Haiyang group. In his view the
nine building blocks of BMC is ranked
in the following order (from important
to less important): value proposition,
revenue streams, customer relationship,
key partners, customer segments,
channels, key activities, cost and key
resources. Apart from the elements in
BMC, he believes that people in the core
entrepreneurial team are also important
for a start-up. The whole team should
have a clear division of work, avoid
homogeneity, and be brave to face
failure.
Case Study of MiDIVI
MiDIVI is a digital health technology
startup in Shanghai, China and MiDIVI
has been a partner of the UM-SJTU JI
Centre For Entrepreneurship (CFE) in
offering practicum courses like VX423
for which Caiwei Chen was an intern
in this company in 2021. One main
product of MiDIVI, Jinshu, is a surgery
navigation system integrating medical
image processing and Mixed Reality
(MR) technique based on MR goggle
— Microsoft HoloLens. It is supposed
to assist Healthcare Practitioners (HCPs)
before, during and after operations,
currently supporting percutaneous
puncture biopsy (PPB) for cardiothoracic
surgery and neurosurgery department,
to name a few. Jinshu consists of three
parts, the MiDIVI smart holographic
cloud platform (MSHCP) on personal
computer, the J-MRview on HoloLens,
and J-control on an iPad.
1 Analysis Based on BMC
The value propositions of Jinshu vary
with customer segments.
For HCPs, Jinshu provides assistance
throughout the whole surgery process.
Before surgery, MSHCP builds a 3D
hologram model of operative field from
2D images (such as CT images), then
generate the preoperative plan (such
as to determine the precise position of
puncture) with deep learning algorithm.
During surgery, J-MRview superimposes
the hologram model on real-time view
according to predefined feature points on
the patient’s body. Following the model
HCPs can precisely position the surgical
tools without further measurement.
HCPs can also ask remote experts for
help using the meeting module. After
surgery, HCPs can review the recorded
operation video filmed by HoloLens.
For patients, Jinshu clearly illustrates
their conditions and the expected
operation procedure with the 3D
holograms. Besides, more accurate
surgery lead to better therapeutic effect.
For hospitals, Jinshu helps to lower
surgical error rate and thus prevent
potential medical disputes. Besides, the
remote guiding module promotes fair
treatment through the society, equalising
accessibility to high level medical
resources for people from all segments of
society.
For traditional medical device
enterprises, Jinshu as a representative of
information technology advancement
facilitates the growth of their
competitiveness in the market.
Thefirststeptobuildstrongcustomer
relationships is to get customers, which
closely relies on the chosen channels. In
general, customers are obtained through
direct contact with targeted customers.
Since the products apply promising
technology advancement, collaboration
cases with medical departments are
reported by local satellite television
channel, while collaborative projects are
propagated on partners’ websites. Besides
MiDIVI actively attends conferences
and exhibitions to present its ideas.
To keep and grow customers,
products are continuously upgraded
in response to clients’ feedback. Since
MiDIVI is a relatively small enterprise,
it is possible to tailor project for specific
needs, providing better customer
experience. Beyond the cutting-edge
products, free trials of supplementary
services (such as a remote meeting
module) are also offered to current
customers.
Key activities include software
development, marketing and after-sales
service, each corresponds to several Key
resources.
MiDIVI focuses on developing
medical image processing algorithm
and operational navigation application.
Jinshu also incorporates surgery
aid devices based on HoloLens
and the optical measurement and
electromagnetic (OME) tracking device
from NDI.
For research and development
(R&D), MR and deep learning
technicians are major human resources.
To protect intellectual property and to
distinguish from competitors, patents
are also of key importance.
The particularity of medical devices
segment leads to a special financial
resource structure. Sale and application
of medical devices is strictly controlled
by government because they are closely
related to human life and health. For
the same reason, the productisation
commonly takes more than one year, and
licensing takes even longer. Therefore,
financing, instead of profiting from
common trade, is the vital R&D funds.
MiDIVI being one of the small
and medium-sized enterprises (SMEs),
marketing is a crucial part to obtain
customers and expand market share.
Consistent with Channels, MiDIVI

provides demonstrations to investors
and employ online media to promote
products like Jinshu.
Key partners are mainly of three
types. First, companies such as Microsoft
and NDI are key suppliers that provide
MiDIVI with necessary hardware.
Second, strategic alliance is set up with
Jingteng Tech, to name a few, with
whom projects are co-launched to make
the most of each company’s strength.
Third, several medical experts provide
both professional surgical aids and
practical suggestions as users.
The revenue streams include direct
sale and investment. There are two
possible ways for Jinshu’s sale. Hospitals
usually purchase the whole set of device
and service, while some medical device
companies may pay for cloud service on
use basis. Yet as described, there are strict
restraints on the transactions. Currently
the expenditure is mainly covered by
investor funding.
AsanITproduct,thecoststructureof
Jinshu consists of software development
and maintenance. To take the remote
meeting module as an example, R&D
expenses include purchase of resources
such as software development kit.
Hardware production also takes a
considerable portion. Apart from
HoloLens and OME tracking device,
surgical tools and human anatomical
models are needed for simulation and
tests. In addition, there are expenses of
administration, including rent, business
trip and consumables.
2 Interview excerpts
UM-SJTU JI CFE team interviewed the
CTO of MiDIVI, Chen Liang in 2021
as he has been an entrepreneur and the
founder of the MiDIVI. Chen Liang
believes that the value proposition is
the most important element among the
nine building blocks. He regards it as
the origin which makes an entrepreneur
clear about his goal and decides the eight
rest elements. From the perspective of
MiDIVI, the value proposition should
include both the innovation of product
and business. The former needs to solve
the pain of doctors and patients and the
latter means to put ideas into practice.
Besides, Chen Liang thinks that it is
hard to conclude any element in BMC
as a less important one. He would rather
describe it as a dynamic process and
judgement should be made on how to
allocate people and one’s energy during
different periods.
Conclusion and future
Entrepreneurship in healthcare
technology is now booming all over
the world. This article has provided a
brief overview of healthcare technology
entrepreneurship in China through two
case studies; one large group (Haiyang)
and one new startup (MiDIVI), using a
Caiwei Chen is a member of the
University of Michigan (UM)-Shanghai
Jiao Tong University (SJTU) Joint Institute
(JI) Center For Entrepreneurship (CFE)
and chairs the IEEE Technology and
Engineering Management Society (TEMS)
student branch in JI. She is interested in
interdisciplinary development in business
field, with major interest in entrepreneur-
ship and business analytics.
Yongqi Zheng is the current treasurer of
the IEEE-Technology and Engineering
Management Society (TEMS) Student
Branch at the University of Michigan-
Shanghai JiaoTong University Joint
Institute. He is a member of the UM-SJTU
JI CFE and particularly particularly inter-
ested in industrial engineering, product
innovation and entrepreneurship.
Pradeep Kumar Ray is the
Founder Director of the Centre For
Entrepreneurship (CFE) at the University
of Michigan-Shanghai Jiao Tong University
Joint Institute and is currently lead-
ing an international research initiative
called Technology Entrepreneurship for
Sustainable Development (TESD) involv-
ing more than twenty partners from all
over the world. He is the founder of the
WHO Collaborating Centre on eHealth
in the University of New South Wales
(UNSW)-Australia (2013).
AUTHOR
BIO
conceptual model called Business Model
Canvas (BMC), now extensively used for
modelling and validating startups. BMC
is also used to teach entrepreneurship
to students all over the world and these
case studies would help summarise
startup ideas. However, students of
entrepreneurship also learn (while
doing projects) that much more details
need to be added to the BMC for a real
startup business and that is the subject
of courses like VX420 (Entrepreneurship
Basics) taught in the UM-SJTU JI.
More research is needed to fill the gaps
in BMC as discussed in the forthcoming
book “Technology Entrepreneurship for
Sustainable Development” by Springer
in 2022 with Pradeep Ray and Rajib
Shaw as co-editors.

13
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KEEP
CALM AND
RECONSIDER
GRAFT
REVISION
Preoperative angiography in combination with
intraoperative graft flow measurements may improve
durability of coronary artery bypass grafts. However,
native coronary flow might impair bypass graft flow
based on stenoses’ severity, leading to inferior long-term
outcomes. Intraoperative routine snaring of a coronary
artery detects significant competitive flow, possibly
intercepting unnecessary perioperative graft revisions.
Frank R Halfwerk, Assistant Professor, Cardiac Surgery Innovations Lab
University of Twente
The impact of coronary stenosis
for beating heart coronary artery
bypass grafting
be overestimated and impacts short and
long-term outcomes of CABG.
A heart lung machine takes over
the heart’s pumping function and
gas transfer of the lungs during heart
surgery. Major drawbacks, however, are
a systemic inflammatory response, acute
kidney injury or brain infarctions. For
coronary artery bypass graft (CABG)
improves symptoms, quality of life and
survival in these patients. A stenosis
with a diameter reduction < 50 per
cent is considered a mild stenosis, 50
– 70 per cent as moderate, and > 70
per cent as severe. Unfortunately, the
degree of coronary stenosis can easily
The heart, inadequate blood supply,
and revascularisation
The coronary arteries supply the heart
itself with oxygen and nutrients. Severe
narrowing of these coronaries (stenosis)
might lead to chest pain or a heart attack.
Myocardial revascularisation by either
percutaneous coronary intervention or
MEDICAL SCIENCES

15
CABG, the heart lung machine can be
abandoned by performing off-pump
coronary artery bypass grafting where
the heart keeps beating during surgery.
Intraoperative choices and
challenges lead to postoperative
complications
Patients’ own arteries from the chest or
lower arm can be used to create these
coronary bypasses. These arterial grafts
have excellent long-term functionality,
and low redo revascularisation rates.
Arterial grafts require proper handling to
avoid early technical failure. Competitive
flow from native coronaries that are
not narrowed enough impacts long
term success of the coronary bypass.
Detection of competitive flow for arterial
grafts as early as possible after making
the anastomosis might predict the long-
term patency.
Intraoperative assessment of graft
flow can be measured with transit
time flow measurements (TTFM).
European guidelines on myocardial
revascularisation suggest routine use
of intraoperative bypass graft flow
assessment. Unfortunately, this quality
control technique is not always used, nor
handled upon adequately during surgery.
The first signs of a failed graft are heart
rhythm changes, postoperative new onset
of chest pain and a potential myocardial
infarction might occur. Often, the
patient already left the operating theatre,
and bypass graft revision is not possible,
or should be considered for another
surgical procedure.
Cut-off values for TTFM to
indicate graft failure are still debated,
and are not uniform between clinical
studies. In a recent study conducted
at Thoraxcentrum Twente of Medisch
Spectrum Twente (Netherlands),
preoperative angiography findings were
combined with intraoperative TTFM in
50 CABG patients without the use of a
heart lung machine (off-pump CABG).
All patients had significant coronary
artery disease as established by heart
team discussion between a cardiologist
and heart surgeon.
Temporary closing of a severely
narrowed coronary artery
During off-pump CABG, a bypass graft
was made with the left internal thoracic
artery (LIMA) on the largest coronary
artery on the front side of the heart (left
anterior descending artery, LAD). This
coronary artery was then temporarily
closed and the bypass graft flow was
measured with TTFM. Hereafter, a
new measurement was performed with
the coronary artery reopened. After the
MEDICAL SCIENCES

This increase might indicate an open,
and functional anastomosis affected
by competitive flow from the native
coronary artery. Here, surgical graft
revision will not likely improve baseline
TTFM values such as mean graft flow
or graft patency, resulting in a useless or
even harmful procedure.
Is snaring safe?
Snaring the LAD is a widespread method
to obtain a bloodless operative field, and
is well tolerated by patients. Indeed, this
technique is comparable to intracoronary
shunting regarding postoperative heart
enzyme rise. Atherosclerotic plaques or
calcified coronary arteries make shunting
technically more tough. Prolonged
snaring might induce blood vessel injury,
and arrhythmias, but are reversible up to
20-30 minutes of snaring.
Patient-specific decision making
before and during surgery
Patient-specific decision making
is performed daily in heart team
discussion between cardiac surgeons and
cardiologists according to international
guidelines. Here patient characteristics
determine decision making for a surgical,
percutaneous or conservative treatment.
Combining patient characteristics with
procedural characteristics could further
tailor treatment and thus improve
outcomes for patients.
Professional information for
decision making is scattered. Direct
comparison between competing
treatments or diagnosis modalities is
often lacking. For assessing coronary
artery stenosis, visual eyeballing by a
cardiologist is most common, although
high intra-and inter-observer variability
exists for many years with low
concordance around clinical relevant
cut-off points. Some centres use
quantitative coronary analysis (QCA)
with 2D or 3D reconstruction using
cardiac angiography to analyse degree
of stenosis for research purposes, but are
rarely used for heart team discussions.
To predict graft patency, it is no match
initial bypass graft, arterial grafts were
placed to other parts of the heart.
As expected, higher values of
bypass graft flow were observed with
the coronary artery snared, effectively
preventing any competitive flow.
More interestingly, the mean graft
flow increased from 20 mL/min with
open LAD to 30 mL/min with snared
LAD and differed between severity of
coronary stenosis groups (Figure 1). In
more than half of the patients (52 per
cent) the mean graft flow was lower than
clinical relevant TTFM cut-off values
with the LAD open. Graft flow increased
in 16 patients after snaring the LAD,
and shifted to acceptable TTFM values.
Adequate intraoperative
quality control improves
patients postoperative
quality of life, reduces
life-events such as
myocardial infarctions or
unnecessary graft revisions,
and therefore reduces
hospital costs of prolonged
treatments.
Figure 1: Mean LIMA graft flow (mL/min) increased with LAD snared compared to open LAD strati-
fied to degree of stenosis. A third of all patients shifted from a low mean graft flow ≤ 20 mL/min
with LAD open, to higher flows with LAD snared. Whiskers show the 25th and 75th percentile ±
1.5 times interquartile range in the Tukey box‐and‐Whiskers plot. LAD, left anterior descending
coronary artery; LIMA, left internal mammary artery.
MEDICAL SCIENCES

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compared to functional assessment
using the more invasive fractional flow
reserve (FFR). Here, clinical cut-off
values are also debated and might even
differ between percutaneous coronary
intervention or CABG. Future studies
Frank R Halfwerk is Assistant Professor and leads the Cardiac Surgery
Innovations Lab at the University of Twente and is Technical Physician in
cardiothoracic surgery at Thoraxcentrum Twente, Medisch Spectrum in
Enschede, the Netherlands. His focus is on personalized treatments for
patients with predictable surgical outcomes. Underlying study: Halfwerk FR
et al. Intraoperative transit time flow measurements during off-pump coronary
artery bypass surgery: The impact of coronary stenosis on competitive flow.
Journal of Cardiac Surgery, 2021. https://doi.org/10.1111/jocs.16103.
AUTHOR
BIO
should investigate the cut-off values of
FFR or QCA for PCI and CABG to
optimise outcome for patients.
Implications for daily practice
Heart time discussions should carefully,
and objectively evaluate the functional
degree of coronary stenosis to determine
revascularisation strategies. Because
preoperative visual estimation proves
to be difficult, intraoperative evaluation
of a stenosis is pivotal. Routine snaring
of the LAD during off-pump CABG
demonstrated an increase in mean graft
flow among all coronary stenosis groups.
A third of clinical cut-off TTFM values
for graft failure shifted to acceptable
values. Therefore, regular use of TTFM
and careful analysis of competitive flow
according to the method described
in the underlying study can be useful
to identify competitive flow in case
of intraoperative borderline TTFM
parameters. Adequate intraoperative
quality control improves patients
postoperative quality of life, reduces life-
events such as myocardial infarctions
or unnecessary graft revisions, and
therefore reduces hospital costs of
prolonged treatments.
Clinical studies should establish
definitive evidence regarding routine
snaring of the LAD during off-pump
CABG. These studies should focus
on the prevention of unnecessary
intraoperative graft revisions and
postoperative heart attacks.
References are available at
www.asianhhm.com
Figure 2: The degree of left anterior descending (LAD) coronary artery stenosis is quantified with
quantitative coronary analysis. A left internal thoracic/mammary artery (LIMA) bypass graft was
made on the LAD with beating heart coronary artery bypass graft surgery. Intraoperative graft flow
measurements were performed with the LAD open, and snared. Regardless of preoperative coronary
stenosis, the LIMA graft flow increased with LAD snared, but was more substantial in mild to moder-
ate stenoses.
MEDICAL SCIENCES

19
Addressing the
Osteoporosis Care Gap
in The Asia-Pacific
In the Asia-Pacific there are significant inconsistencies
in clinical practice guidelines for the management and
prevention of osteoporosis and fragility fractures. These
guidelines vary in scope and recommendations. To address
this, in early 2021, APCO launched The APCO Framework
– the first pan-Asia-Pacific clinical practice standards for the
screening, diagnosis, and management of osteoporosis.
M Chandran, Senior Consultant and Director, Osteoporosis and Bone Metabolism Unit,
Singapore General Hospital
M Chadha, Consultant Endocrinologist, P
.D. Hinduja National Hospital and
Medical Research Centre
Q Cheng, Chief Physician and Doctoral Supervisor, Department of
Osteoporosis and Bone Disease, Huadong Hospital
A significant challenge to overcome
The survival of those who sustain
an osteoporotic fragility fracture is
significantly compromised for up to
six years, with patients facing twice
the risk of death within the first year.
Furthermore, a prior fracture at any site
doubles a person’s risk of refracture.
In the Asia-Pacific alone, an
overwhelming 319 million people aged
50 years and over are projected to be at
risk of osteoporotic fracture over the next
three decades. More than 50 per cent of
the world’s hip fractures are expected to
occur in the region by the year 2050.
TheAsia-Pacificishometo4.5billion
people, a rapidly ageing population,
and vastly different healthcare systems.
Given the anticipated, exponential
growth in fragility fractures due to
MEDICAL SCIENCES

20
the region’s ageing population, mass
urbanisation and increasingly sedentary
lifestyles, recognition of the monumental
human and socio-economic burden of
osteoporosis, and the severe impact of
fractures on a patient’s independence and
quality of life, is critical. Osteoporosis
must become an urgent priority on
regional and global health agendas.
Despite alarming osteoporosis and
fragility fracture statistics worldwide
and the extensive availability of safe
and effective osteoporosis therapies,
more than 80 per cent of fragility
fracture patients are neither assessed, nor
treated, thereby placing a substantial,
but importantly, preventable burden on
already strained healthcare systems.
Osteoporosis is vastly under-
diagnosed and under-treated.
Disturbingly, millions of people
worldwide at high risk of fracture remain
unaware of this underlying, silent
disease. Sadly, people often only discover
they have osteoporosis after sustaining a
first fracture. A fragility fracture, which
occurs every three seconds worldwide,
compromises quality of life and loss of
independence. Worryingly, one-in-four
patients who sustain a hip fracture die
within a year, and less than half of those
who survive, regain their previous level
of function.
Osteoporosis can compromise a
person’s quality of life through loss of
independence and productivity, chronic
pain, disability, emotional distress,
reduced social interaction, and self-
limitation caused by a fear of falling.
Less than a third of hip fracture patients
regain their pre-fracture level of mobility,
while more than 80 per cent are restricted
with their daily activities, such as driving
or grocery shopping. Importantly,
osteoporosis not only affects those living
with the disease, but also their family,
and the community at large.
Among all osteoporotic fractures,
hip fractures incur the greatest
morbidity, mortality, and social and
financial costs. An analysis of nine Asian
countries and regions from the Asian
Federation of Osteoporosis Societies
(AFOS) revealed the number of hip
fractures will more than double from
1.13 million in 2018, to 2.54 million
in 2050.5 In 2018, the estimated cost
of hip fractures obtained from nine
Asian countries or regions was USD 7.5
billion. By 2050, projections suggest
this will rise to approximately USD 13
billion.5 Overwhelmingly, the costs for
treating a single hip fracture represents
approximately 19 per cent of APAC’s
regional per-head annual gross domestic
product (GDP).
China and India contribute to the
highest absolute number increase in
hip fractures in the region. In fact, the
two countries constitute approximately
37 per cent of the world’s population,
and therefore, largely account for the
anticipated hip fracture epidemic
expected in the Asia-Pacific.
Between 2025 and 2050, the
population of India is projected to
grow from 1.4 billion, to 1.88 billion,
with those aged over 50 who are more
susceptible to osteoporosis, expected to
constitute 33 per cent of the population
by the middle of the century.
In India alone, the direct medical
costs of hip fractures was an estimated
USD 256 million in 2018, the costs for
which are projected to increase to USD
612 million by 2050.
In 2013, 50 million people in India
were either osteoporotic, or considered
to be living with low bone mass. The
2018 AFOS study predicted the number
of hip fractures in India would more than
double, from approximately 332,000 in
2018, to 792, 000 in 2050.
Importantly, compared to Western
populations, hip fractures occur a decade
earlier in the Indian population.
Similarly in China, the projected
direct cost of hip fractures is expected to
rise from USD 1,690 million in 2018, to
USD 4063 million by 2050, while the
number of hip fractures is projected to
increase from almost 485,000, to more
than 1.17 million between the same
period.
Projections suggest the total number
of osteoporosis-related fractures in China
will increase from 2.33 million in 2010,
to 5.99 million in 2050.
In recent years, several paramount
themes that profoundly impact strategies
employed for osteoporosis management
have emerged.
These emerging concepts in
osteoporosis care should be astutely
considered and incorporated into new
and revised guidelines, following careful
deliberation of their applicability to local
health care practices.
MEDICAL SCIENCES

21
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vertebral fractures – and organisational
characteristics.
Another important emerging theme
is the urgent need to employ health
economics to inform intervention
thresholds and indications for specific
classes of osteoporosis therapies.
For example, a significant body
of evidence obtained through analysis
of nine active interventions across
14 countries, has demonstrated anti-
osteoporosis therapies are cost-effective
in women at high risk of fracture.When
compared with no treatment, active
osteoporotic drugs were generally cost
effective in postmenopausal women
aged over 60-65 years with low
bone mass, especially those who had
sustained prior vertebral fractures.
While vast heterogeneity
exists in epidemiologic and
economic characteristics of
One of the emerging osteoporosis
themes is the importance of Asia-
Pacific-wide systemic integration of case
identification and management at all
levels of health systems, including acute
care services, when patients present with
fractures through Post Fracture Care
Coordination Programs, such as Fracture
Liaison Services (FLS).
These coordinated systems of care
aim to identify, treat and monitor
patients presenting with a fragility
fracture. Intervention can halve the
incidence of fragility fractures, deliver
significant financial savings, and most
importantly, save lives.
Furthermore, FLSs compared with
usual care, have been shown to increase
bone mineral density (BMD) testing,
improve initiation of osteoporosis care,
and adherence to treatment, and reduce
mortality rates.
Fracture Liaison Services
(FLS) compared with
usual care, have been
shown to increase bone
mineral density (BMD)
testing, improve initiation
of osteoporosis care, and
adherence to treatment, and
reduce mortality rates
In the Asia-Pacific, there are currently
111 FLS centres, 19 of which have been
awarded a gold star rating, based on
evaluation of achievement against the
International Osteoporosis Foundation’s
(IOF)BestPracticeFrameworkstandards
for four key fragility fracture patient
groups – hip fractures, other in-patient
fractures, outpatient fractures and
MEDICAL SCIENCES

23
countries undoubtedly influencing
recommendations included in
national and regional clinical practice
guidelines, health economic analysis
is playing an increasingly important
role in informing the relative value of
osteoporosis therapies, and helping
determine how to best allocate finite
health care resources and determine
the cost effectiveness of interventions.
A much-needed solution
The Asia-Pacific Consortium on
Osteoporosis (APCO)1
was launched
in May 2019. The overarching goal
of APCO is to stem the tsunami of
osteoporotic fractures in the Asia-
Pacific, and to promote quality care in
osteoporosis.
There are significant inconsistencies
in clinical practice guidelines in the
Asia-Pacific for the management
and prevention of osteoporosis and
fragility fractures. These guidelines
vary extensively in scope and
recommendations. There is also a lack
of information available on adherence
to national guidelines in daily clinical
practice.
Minimum clinical standards for
the assessment and management of
osteoporosis are therefore urgently
required in the Asia-Pacific, to inform
clinical practice guidelines, and
improve osteoporosis care.
After employing a comprehensive
5IQ analysis and the well-established
Delphi Consensus process to analyse
the 18 clinical practice guidelines
existing in the Asia-Pacific region,
in early 2021, APCO launched
The APCO Framework2
– the first
pan-Asia-Pacific clinical practice
standards for the screening, diagnosis,
and management of osteoporosis,
targeting a broad range of high-risk
groups.
Implementation a set of minimum
1 https://apcobonehealth.org/
2 https://apcobonehealth.org/apco-framework/
clinical standards care for the screening,
diagnosis, and management of
osteoporosis is expected to significantly
reduce the burden of osteoporosis not
only in the Asia-Pacific region, but also
worldwide.
To further support the HCP
community in the Asia-Pacific in the
implementation of minimum clinical
standards, APCO recently developed
the APCO HCP Peer to Peer
Educational Modules 3
– a 17-module
educational series designed to arm
osteoporosis champions in the Asia-
Pacific, with information, supporting
data, topical literature summaries, and
best practice examples that support
and emphasise each of The APCO
Framework’s 16 minimum clinical
standards and address emerging
themes in osteoporosis care.
3 https://apcobonehealth.org/apco-education-modules/
The development and launch of
peer to peer educational resources
for the HCP community designed to
encourage wide scale implementation
of minimum clinical standards,
demonstrates APCO’s ongoing
commitment to achieving greater
consistency in national and regional
clinical practice guidelines for the
screening, diagnosis, and management
of osteoporosis in the Asia-Pacific,
wide scale implementation of FLS and
calling for due consideration of health
economics by guideline developers and
policy makers in the Asia-Pacific.
Manju Chandran, who is the International
Osteoporosis Foundation 2021 IOF Olof
Johnell Science Awardee, is an interna-
tionally renowned Endocrinologist. She
is a Senior Consultant and Director of the
Osteoporosis and Bone Metabolism Unit
at Singapore General Hospital, and the
inaugural Chairperson of the Asia-Pacific
Consortium on Osteoporosis (APCO).
Manoj Chadha is Consultant
Endocrinologist at P
.D. Hinduja National
Hospital and Medical Research Centre,
Mumbai, India. He is Immediate Past
President of the Indian Society of Bone
Mineral Research (ISBMR), Past President
of the Endocrine Society of India, Regional
Representative at the International
Osteoporosis Foundation (IOF), and
APCO member.
Qun Cheng is Chief Physician and
Doctoral Supervisor, Department of
Osteoporosis and Bone Disease, at
Huadong Hospital affiliated with Fudan
University, Shanghai, China. She is
Director of the Shanghai Medical
Association of Osteoporosis, Deputy
Leader of the Chinese Medical Association
- Geriatric Society of Bone Metabolism,
and APCO member.
AUTHOR
BIO
MEDICAL SCIENCES
For more information visit
www.apcobonehealth.org.
www.asianhhm.com

Understanding and
Predicting Progression to
Hepatorenal Syndrome
in Cirrhotic Patients
Hepatorenal syndrome is a severe complication in cirrhotic patients
associated with high mortality. Diagnosis of difficult and often delayed
due to diagnostic criteria. Understanding the pathophysiology,
predictors, and precipitators of hepatorenal syndrome can aid
clinicians in making the diagnosis and early initiation of therapy..
Roula Sasso, Ahmad Abou Yassine
Department of Gastroenterology, Staten Island University Hospital
P
atients with liver cirrhosis often
present with acute kidney
injury (AKI) which is a cause
of high morbidity and mortality.
Cirrhotic patients are at an increased
risk of intravascular volume depletion
secondary to certain medications (such
as diuretics or lactulose, which are
commonly used in this population),
gastrointestinal bleeding and decreased
effective arterial blood volume secondary
to splanchnic vasodilation, all of which
result in decreased renal perfusion and
renal injury.
Hepatorenal syndrome (HRS)
is a form of AKI in decompensated
cirrhotic patients and is mainly caused
by a hyperdynamic circulatory system
resulting in renal vasoconstriction and
systemic inflammation. HRS is the
only form of AKI in cirrhotic patients
MEDICAL SCIENCES

25
that results from liver dysfunction, yet
it is often difficult to differentiate from
other causes of AKI in cirrhotic patients.
As such, this often leads to a delay in
diagnosis, management, and worse
patient outcomes.
Based on the current International
Club of Ascites (ICA), the previously
known HRS- type 1 has been renamed
HRS-AKI and diagnosis requires AKI
based on the current KDIGO guidelines
in the presence of cirrhosis and ascites,
48 hours or appropriate resuscitation,
diuretic withdrawal, and exclusion of
other causes of AKI.
Establishing predictors for
development of HRS in cirrhotic
patients with AKI could aid clinicians
in establishing a diagnosis of HRS
sooner rather than later and allow them
to initiate goal-directed management.
Some studies have attempted to describe
predictors of HRS in this population of
patients, however many of these studies
have been limited by small sample sizes
and poor generalizability. Additionally,
the definition and diagnostic criteria
of HRS has evolved over the years,
necessitating the reevaluation of older
studies in the field.
The evidence
A recent retrospective case-control study
conducted by Sasso et al. evaluated 529
cirrhotic patients admitted with AKI
acrossmultipleNorthwell-healthhospital
sites in New York City. The primary
outcome was development of HRS-AKI
during hospital stay. Patient variables
including demographics, past medical
history, laboratory data, medication
history and hospital complications were
evaluated to determine predictors of the
development of HRS-AKI in this cohort
of patients.
This study compared outcomes
of patients who developed HRS-AKI
to those who did not and found that
those who did develop HRS-AKI were
more likely to have a history of alcoholic
cirrhosis, evidence of portal hypertension
and large volume ascites, a diagnosis of
spontaneous bacterial peritonitis, lower
sodium levels and platelet count as
well as higher bilirubin, creatinine and
INR levels. Mortality was also higher
in patients who developed HRS-AKI
compared to those who did not.
This study found that a history of
ascites, baseline serum creatinine >2.5
mg/dL, albumin < 2g/dL, bilirubin
>2 mg/dL and spontaneous bacterial
peritonitis to be independent predictors
or progression to HRS-AKI (Figure 1).
Treatment of HRS-AKI
Treatment of HRS-AKI is challenging
and restoration of baseline kidney
and liver function is rare. Treatment
is usually directed towards avoiding
irreversible renal injury by increasing
effective intravascular volume and renal
perfusion.
Albumin infusions for volume
expansion is often used to prevent
worsening of kidney dysfunction at
the earlier stages of AKI in attempt
to prevent progression to HRS-AKI.
Albumin might also provide some anti-
inflammatory benefits. Pentoxifylline
has also been evaluated as a possible
MEDICAL SCIENCES

of AKI. In the study by Sasso et al.,
mortality was 40 per cent among those
with HRS-AKI.
Understanding the pathophysiology
and precipitating factors for
development of HRS-AKI is critical.
In the setting of high portal pressures
(often seen in decompensated cirrhotic
patients), the renal vasculature eventually
becomes vasoconstricted in response to
splanchnic vasodilation and activation
of the renin-angiotensin-aldosterone
system. This results in a reduction of
glomerular filtration and retention of
sodium and water. Additionally, systemic
inflammation as a result of bacterial
infections has been suggested to play
a role in the progression of HRS-AKI
(figure 2).
Furthermore, several clinical
conditions have been linked to
the development of HRS-AKI.
Worsening ascites can cause elevated
intra-abdominal pressures leading to
compression of the renal vasculature and
worsening kidney dysfunction. Some
studies have demonstrated that large
volume paracentesis may be associated
to liver transplant or for patients with
no evidence of improvement in renal
function who are not eligible for liver
transplantation. TIPS results is shunting
of blood from the portal vein to the
hepatic vein, essential decreasing portal
pressures which can lead to improvement
in renal function. While some studies
suggest that TIPS might be an effective
method of improving renal function, is
it often not feasible in patients with high
MELD scores (as is the case for many
patients with HRS-AKI) given the high
risk of hepatic encephalopathy.
Liver transplant is the only definitive
and most effective treatment option for
HRS-AKI, resulting in restoration of
kidney function in up to 80 per cent
of patients. However, at the time of
diagnosis of HRS-AKI, patients are
often poor candidates for transplantation
based on MELD scores.
Discussion
Prognosis of patients with HRS-AKI is
poor, with several studies demonstrating
higher mortality in patients with
HRS-AKI compared to other forms
agent in the prevention of progression to
HRS-AKI, however further studies are
needed to determine efficiency.
Vasoconstrictor therapy increases
renal perfusion and is the main approach
to treatment in HRS-AKI. Terlipressin,
a synthetic vasopressin analogue is
available in Europe, Australia, New
Zealand and parts of Asia and is the first-
line treatment option for patients with
HRS-AKI. Clinical trials have shown
improved kidney function and patient
survival with the use of Terlipressin
and even better outcomes with the
combined use of Terlipressin and
albumin. Other vasopressor therapies
such as Norepinephrine have been used
for treatment of HRS-AKI with some
studies showing equal efficacy
In countries where Terlipressin is not
available, the combination of midodrine
and octreotide is often used, however,
convincing data on the efficiency of this
combination is lacking.
Other treatment options include
hemodialysis and transjugular
intrahepatic portosystemic shunt (TIPS).
Hemodialysis is often used as a bridge
MEDICAL SCIENCES

27
with HRS-AKI secondary to intravascular
fluid shifts and potentiation of the
renin-angiotensin-aldosterone system.
Spontaneous bacterial peritonitis results
in a hyperinflammatory state that has
been suggested to precipitate HRS-AKI
and cardiogenic shock results in decreased
effective intravascular volume, contributing
to renal dysfunction. Additionally, certain
medications such as diuretics, non-steroidal
anti-inflammatory drugs and lactulose may
contribute to HRS-AKI (figure 2).
By understanding the pathophysiology
of HRS-AKI and integrating the clinical
conditions associated with HRS-AKI and
the established evidence-based predictors
of progression to HRS-AKI, clinicians can
stratify cirrhotic patients into high risk or
low risk for HRS-AKI allowing for earlier
diagnosis and management of this high
mortality condition.
www.asianhhm.com
Sasso is a medical resident at
Northwell health. After completing
medical school, she pursued two
years of post-doctoral fellowship at
the department of Hepatology at the
Medical University of South Carolina.
Her research interest focus on compli-
cations of portal hypertension. Sasso is
going to start her gastroenterology and
hepatology fellowship at the University
of New Mexico
Abou Yassine is a medical resident at
Northwell health. His research interest
focus on critical illness in cirrhotic
patients including severe infections
and sepsis. Abou Yassine will complete
chief-resident training at Northwell
health before pursing a fellowship in
critical care.
AUTHOR
BIO
MEDICAL SCIENCES

Management of
Cerebrovascular
Steno-Occlusive Disease
Patients with steno-occlusive cerebrovascular disease
are at risk of ischemic symptoms from haemodynamic
insufficiency in the presence of reversible hypoperfusion,
exhausted autoregulation and impaired vasodilatory
reserve. Multidisciplinary management approach
includes blood pressure management, antithrombotic
therapy, treatment of underlying brain-body interactions
targeted at optimising cerebral blood flow and oxygen
delivery, and revascularisation procedures.
Benjamin Wai Yue Lo, Neurosurgeon & ICU Specialist
P
atients with symptomatic steno-
occlusive disease have a risk of
recurrent stroke of at least 10-15
per cent within 5 years. Progressive
atherosclerosis of internal carotid artery
(ICA) or middle cerebral artery (MCA)
is the most common cause of impaired
distal cerebral perfusion with cerebral
misery hypoperfusion (Figure 1, Table
1).
Cerebral Hypoperfusion & Collateral
Circulation
In the setting of cerebral hypoperfusion,
recurrent ischaemic events occur
depending on the following factors: (1)
amount of collateral cerebral circulation;
(2)extentofhaemodynamicimpairment;
(3) age; (4) cardiac status; (5) presence
of metabolic syndrome of hypertension,
hyperlipidemia and insulin resistance;
(6) factors affecting coagulation, blood
Contemporary multidisciplinary approach
oxygen carrying capacity and delivery
(such as anaemia and other haematology
disorders, systemic infections and sepsis,
renal and hepatic disorders).
In addition to the traditional cerebral
ischaemic symptomatology pertaining to
the affected vascular territory (Table 2),
orthostatic symptoms, syncope, transient
global amnesia, episodic limb shaking
and watershed infarction are possible.
In states of misery perfusion,
compensatory cerebral vasodilation
is not possible as the cerebral
autoregulatory capacity is exhausted and,
as a result, cerebral blood flow decreases
proportionally with cerebral perfusion
pressure (Figure 1). Possible cerebral
collateral circulation routes include:
(1) contralateral internal carotid artery
(ICA) through anterior communicating
artery; (2) posterior circulation via
posterior communicating artery; (3)
MEDICAL SCIENCES

29
leptomeningeal or pial collaterals; (4)
collateral circulation from external
carotid artery (ECA) with retrograde
flow and connections with ophthalmic
artery, extracranial connections between
ECA or vertebral artery (VA) branches
and distal ICA; (5) collaterals through
dural meningeal arteries to cortical
arteries; (6) anterior cerebral artery
(ACA)-posterior cerebral artery (PCA)
connections via the limbic loop; and (7)
anterior spinal artery collaterals with the
vertebrobasilar circulation.
Medical management principles
Medical management strategies are
essential to treatment of cerebral
ischaemic events and prevention of
recurrent strokes in face of cerebral
hypoperfusion. These include: (1)
cautious individualised blood pressure
management (usually systolic blood
pressure targets of 130-160 mmHg
for those with severe bilateral carotid
stenoses); (2) maintenance of fluid status
to maintain appropriate plasma oncotic
pressures for adequate cerebral perfusion;
(3) anti-platelet and anticoagulant
therapies (single anti-platelet agent
and anticoagulant for those with
embolic strokes or in the setting of
cardiac arrthymias; dual anti-platelet
therapy, with laboratory evidence of
responsiveness to these agents, for those
with atherosclerotic disease or perforator
events), (4) statin, and (5) glycaemic
control.
Treatment of underlying brain-
body interactions are also essential,
including attention to haemodynamic
stability, cardiac status, optimising
cerebral oxygen delivery with avoidance
of anaemia, goal-directed therapy for
sepsis, optimisation of renal perfusion
and avoidance of coagulopathy and
encephalopathy due to underlying
multi-systemic involvement, particularly
renal or hepatic impairment.
Identification of surgical candidate
For patients with symptomatic severe
(> 70 per cent) carotid stenosis,
carotid endarterectomy or angioplasty/
stenting is considered. Thrombectomy
is considered for patients with embolic
strokes to large size cerebral vessels.
For patients who have been medically
optimised but are still at risk of
ischaemic symptoms of haemodynamic
insufficiency due to ICA/MCA stenosis/
occlusion in the setting of hypotension or
orthostasis, one can identify candidates
with reversible hypoperfusion, exhausted
autoregulationandimpairedvasodilatory
reserve. Consideration of extracranial-
intracranial bypass procedure can be
reliably made to identify patients who
have reasonable chances of augmentable
flow-induced long-term cerebral blood
flow re-organisation (collateral shift)
while preventing future hypoperfusion
events. Identification of these
candidates is made after blood pressure
management, antithrombotic therapy
and treatment of underlying brain-
body interactions targeted at optimising
cerebral blood flow and oxygen delivery.
Investigational adjuncts
In addition to clinical findings on
presentation and with monitoring
(Table 2), other adjunctive investigations
are useful in identifying such surgical
candidates. CT perfusion scans
demonstrate ischaemic penumbra
of increased time-to-peak (TTP,
time between first arrival of CT
contrast intracranially and its peak
concentration), increased mean transit
time (MTT, average time for blood
to travel through a volume of brain),
with relatively preserved cerebral blood
volume (CBV) due to vasodilation
and recruitment of collateral flow, and
decreased cerebral blood flow (CBF).
As reference, an infarcted core shows
increasedTTP,increasedMTT,decreased
CBV and decreased CBF. SPECT
(single photon emission computerised
tomography) scan with acetazolamide
(DiamoxTM) is used to identify patients
with haemodynamic insufficiency who
exhibit reversible hypoperfusion and
decreased cerebrovascular reactivity
when challenged with acetazolamide
(Figure 3a-c). In those who are in the
misery perfusion stage of haemodynamic
insufficiency, they are already maximally
MEDICAL SCIENCES

vasodilated and dysautoregulated. In this
regard, they cannot further vasodilate
in response to increased carbon dioxide
tension from diuretic acetazolamide, a
carbonic anhydrase inhibitor.
Quantitative MR angiography
(q-MRA)’s non-invasive optimal vessel
analysis (NOVA) is also essential to
quantify and measure blood flow
through large vessels of the Circle of
Willis (Figure 3b). Together with formal
cerebral angiography, it can be used to
estimate pial and collateral flow. It gives
reasonable estimates of augmentable
flow to ensure appropriate blood
velocity ranges after bypass, and also in
anticipation of longer term collateral
shift, cerebral blood flow re-organisation.
Surgical procedure
Direct superficial temporal artery
(STA) [donor] and middle cerebral
artery (MCA) M4 cortical branch
[recipient] bypass is generally
preferred. Meticulous attention to
blood pressure control, maintenance
of intravascular volume and depth
of anaesthesia are essential to avoid
cerebral hypoperfusion during these
cases with underlying steno-occlusive
disease. Intraoperative end-to-side
anastomoses are performed using 10-0
nylon sutures with indocyanine green
(ICG) and intra-operative angiographic
confirmation of anastomotic patency.
Individualised blood pressure goals
with gradual liberalisation of these
parameters are done post-operatively
with continuation of antithrombotic
agents to maintain anastomotic patency
and to avoid reperfusion-related injury.
Conclusion
For patients who have been medically
optimised but still at risk of ischemic
symptoms of haemodynamic
insufficiency due to steno-occlusive
cerebrovascular disease, one can identify
candidateswithreversiblehypoperfusion,
exhausted autoregulation and impaired
vasodilatory reserve. Consideration
of extracranial-intracranial bypass
Artery Normal Mean Flow Velocity [MFV]
(cm/s)
ICA Siphon < 70
MCA M1-M2 < 80
ACA A1 < 80
BA < 50
VA < 60
PCA < 50
Arterial Stenosis (50 per cent) Mean Flow Velocity [MFV] (cm/s)
ICA Siphon, ACA (A1) < 90
MCA M1-M2 < 100
BA-VA-PCA < 70
Figure 1. Stages of Cerebral Hypoperfusion.
Table 1. Cerebrovascular mean flow velocities.
ICA = internal carotid artery, MCA = middle cerebral artery, ACA = anterior
cerebral artery, BA = basilar artery, VA = vertebral artery, PCA = posterior
cerebral artery.
procedure can be reliably made to
identify patients who have reasonable
chances of augmentable flow-induced
long-term cerebral flow re-organisation
while preventing future hypoperfusion
events. Identification of these candidates
are made after medical optimisation,
including blood pressure management,
antithrombotic therapy and treatment
of underlying brain-body interactions
targeted at optimising cerebral blood
flow and oxygen delivery.
MEDICAL SCIENCES

31
Table 2. Stroke Syndromes
Carotid
asymptomatic bruit
TIAs (transient ischemic attacks): transient monocular blindness,
weakness, numbness, speech/language disturbance
sudden deficit in MCA and/or ACA territory
progressive or stepwise hemispheric deficits (watershed
infarction)
MIDDLE CEREBRAL ARTERY (MCA) STROKE SYNDROMES
MCA - entire territory
contralateral gaze palsy, hemiplegia, hemisensory loss, spatial
neglect, hemianopsia
(left) global aphasia
MCA – deep
contralateral hemiplegia, hemisensory loss
(left) transcortical motor (non-fluent aphasia, intact repetition)
and/or sensory (receptive) aphasia
lacunar syndromes - pure motor hemiparesis, sensorimotor
stroke
MCA – parasylvian
contralateral weakness and sensory loss of face and hand
(left) conduction aphasia, apraxia, Gerstmann's syndrome (dys-/
a-graphia, dys-/a-calculia, finger agnosia, left-right disorientation)
(right) constructional dyspraxia
MCA - superior division
contralateral hemiplegia, hemisensory loss, gaze palsy, spatial
neglect
(left) Broca's aphasia
MCA - inferior division
contralateral hemianopsia or upper quadrantanopsia
(left) Wernicke's aphasia
(right) constructional dyspraxia
ANTERIOR CEREBRAL ARTERY (ACA) STROKE
SYNDROMES
ACA - entire territory
contralateral hemiplegia
abulia
incontinence
transcortical motor aphasia or motor and sensory aphasia
limb dyspraxia
ACA – distal
contralateral weakness of leg, hip, foot, shoulder
sensory loss in foot
transcortical motor aphasia or motor and sensory aphasia
limb dyspraxia
ACA – deep
lacunar syndromes - pure motor hemiparesis, sensorimotor
stroke
ACA - anterior choroidal
hemiparesis, hemisensory abnormalities, hemianopia
MIDBRAIN STROKE SYNDROMES
Midbrain basis (Weber's syndrome)
PCA (posterior cerebral artery) branches, top of basilar
CN (cranial nerve) 3 fascicles - ipsilateral 3rd palsy (ptosis, no
eye adduction, no up/downgaze +/- dilated pupil)
Midbrain tegmentum (Claude's syndrome)
CN 3 fascicles - ipsilateral 3rd palsy
red nucleus, superior cerebellar peduncle fibers - contralateral
ataxia
Midbrain basis and tegmentum (Benedikt's syndrome)
CN 3 fascicles - ipsilateral 3rd palsy
cerebral peduncle - contralateral hemiparesis
red nucleus, substantia nigra, superior cerebellar peduncle fibers
- contralateral ataxia, tremor, involuntary movements
PONS STROKE SYNDROMES
Medial pontine basis (dysarthria hemiparesis - pure
motor hemiparesis)
basilar artery (paramedian branches), ventral territory
corticospinal/bulbar tracts - contralateral face/arm/leg
weakness, dysarthria
Medial pontine basis (ataxic hemiparesis)
basilar artery (paramedian branches), ventral territory
corticospinal/bulbar tracts - contralateral face/arm/leg
pontine nuclei/pontocerebellar fibers - contralateral ataxia
(occasional ipsilateral ataxia)
Medial pontine basis and tegmentum (Foville's
syndrome)
basilar artery (paramedian branches), ventral and dorsal
territories
corticospinal and corticobulbar tracts - contralateral face/arm/
leg weakness, dysarthria
facial colliculus - ipsilateral face weakness, ipsilateral horizontal
gaze palsy
Medial pontine basis and tegmentum (Pontine wrong-
way eyes syndrome)
territories
corticospinal and corticobular tracts - contralateral face/arm/leg
abducens nucleus/paramedian pontine reticular formation -
ipsilateral horizontal gaze palsy
MEDICAL SCIENCES

Medial pontine basis and tegmentum (Millard-Gubler
syndrome)
territories
corticospinal and corticobulbar tracts - contralateral face/arm/leg
CN7 fascicles - ipsilateral face weakness
Medial pontine basis and tegmentum (Other regions)
territories
medial lemniscus - contralateral decreased position and vibration
sense
medial longitudinal fasciculus - internuclear ophthalmoplegia
(affected eye impaired adduction)
Lateral caudal pons (anterior inferior cerebellar artery -
AICA)
middle cerebellar peduncle - ipsilateral ataxia
vestibular nuclei - vertigo, nystagmus
trigeminal nucleus and tract - ipsilateral facial decreased pain and
temperature sense
spinothalamic tract - contralateral body decreased pain and
temperature sense
descending sympathetic fibers - ipsilateral Horner's syndrome
Lateral caudal pons (Other regions)
labyrinthine artery - inner ear - ipsilateral hearing loss
Dorsolateral rostral pons (superior cerebellar artery -
SCA)
superior cerebellar peduncle and cerebellum - ipsilateral ataxia
other lateral tegmental structures (variable) - variable features of
AICA syndrome (lateral tegmental involvement)
MEDULLA STROKE SYNDROMES
Medial Medulla
paramedian vertebral artery (VA), anterior spinal artery (ASA)
pyramidal tract - contralateral arm/leg weakness
medial lemniscus - contralateral decreased position/vibration
CN12 nucleus/fascicles - ipsilateral tongue weakness
Lateral Medulla (Wallenberg's syndrome)
posterior inferior cerebellar artery (PICA), vertebral artery (VA)
inferior cerebellar peduncle, vestibular nuclei - ipsilateral ataxia,
vertigo, nystagmus, nausea
trigeminal nucleus, tract - ipsilateral facial decreased pain and
temperature sense
spinothalamic tract - contralateral body decreased pain and
temperature sense
descending sympathetic fibers - ipsilateral Horner's syndrome
nucleus ambiguus - hoarseness, dysphagia
nucleus solitarius - ipsilateral decreased taste
VERTEBRAL ARTERY (VA) STROKE SYNDROMES
Subclavian Steal
asymptomatic
sometimes vertebrobasilar (VB) TIAs (dizziness, slurred speech,
faintness, imbalance)
Extracranial Vertebral Artery (VA)
asymptomatic
sometimes VB TIAs
Intracranial Vertebral Artery (VA)
lateral medullary syndrome (Wallenberg's syndrome)
medial medullary syndrome (tongue paralysis, contralateral
hemiplegia)
hemi-medullary infarction
PICA infarction (dorsolateral medulla and lower half of
cerebellum)
BASILAR ARTERY STROKE SYNDROMES
Basilar occlusion
often preceding TIAs
at onset headaches, dizziness, paresthesia, confusion followed
by CN palsies
neuro-ophthalmologic abnormalities (such as vertical skew,
oscillopsia, downbeat nystagmus), ataxia, quadriparesis/plegia,
locked-in syndrome, coma
Lacunes
pure motor hemiparesis, dysarthria-clumsy hand, pure sensory
stroke, sensorimotor stroke
Paramedian and short circumferential arteries
crossed syndromes with ipsilateral CN palsy
contralateral motor, sensory or sensorimotor deficits
neuro-ophthalmologic abnormalities, dysarthria, ataxia
Superior Cerebellar Artery (SCA)
limb ataxia, dysarthria, CN4 palsy (diplopia worse in downgaze),
Horner’s syndrome, contralateral thermoanalgesia
Anterior Inferior Cerebellar Artery (AICA)
limb and trunk ataxia, CN7 & 8 palsies, Horner’s syndrome,
contralateral hemiplegia and hemisensory loss
Posterior Inferior Cerebellar Artery (PICA)
pseudovestibular syndrome, nystagmus, trunk and limb ataxia,
lateral medullary syndrome
Top of Basilar Occlusion
abnormal pupils, convergence, vertical eye movements,
CN3 palsy, hemiplegia/quadriplegia, sensory loss, ataxia,
hypersomnolence, inattention, abnormal behaviour, confusion,
hallucinations, memory loss, visual defects, abnormal
movements
Thalamic Infarcts
abulia, memory loss, dysphasia, dyspraxia (anterolateral
infarction)
MEDICAL SCIENCES

33
hypersomnolence, coma, abnormal vertical eye movements and
convergence, disorientation, amnesia, dysphasia (anteromedial
infarction)
pure sensory stroke, sensorimotor stroke, Dejerine-Roussy
syndrome (lateral infarction)
visual field defects (dorsal and lateral geniculate body infarction)
POSTERIOR CEREBRAL ARTERY (PCA) STROKE
SYNDROMES
PCA - deep and superficial territory
part of syndrome of top of basilar
PCA - deep territory
thalamopeduncular infarcts
PCA – superficial
cortical blindness
visual field defects (homonymous hemianopia, altitudinal
hemianopia, quadrantanopia)
abnormal color vision, pallinopsia, micropsia
visual agnosia, pure alexia, hemidyslexia, prosopagnosia,
memory deficits, topographic disorientation, amnesic aphasia
Figure 3a. MR Angiogram showing left ICA
functional occlusion.
Figure 3b. Quantitative MRA showing
decreased left MCA flow.
Figure 3c. SPECT showing slight reversible
hypoperfusion after acetazolamide challenge (right).
Acknowledgement: Acknowledgement is made to Dr. David J. Langer for his expertise in this clinical area.
Benjamin W Y Lo is a neurosurgeon and ICU specialist. His clinical
focus is cerebrovascular disorders. His research focus characterises
brain-body interactions in neurocritical care patients with cerebro-
vascular disorders. Dr. Lo’s qualifications include FRCSC certification
in neurosurgery (2009), FRCSC certification in critical care medicine
(2011), MSc and PhD degrees in clinical epidemiology and biosta-
tistics from McMaster University. His clinical experience includes
working as neurosurgeon and ICU specialist at St. Michael’s Hospital,
University of Toronto; Montreal Neurological Institute & Hospital, McGill
University; and Northwell Health Lenox Hill Hospital, New York.
AUTHOR
BIO
MEDICAL SCIENCES

In this article Dr Prasad shares his views on
chronic disease management based on four
key principles organ focus, standardised global
care guidelines, multidisciplinary approach and
tumour board and patient centric cancer care.
Prasad Narayanan, Senior Consultant & Director – Medical Oncology
Cytecare Cancer Hospitals
CHRONIC
DISEASE
MANAGEMENT
Challenges and opportunities
W
hen a disease persists for a long time, it presents different challenges.
Whether it is diabetes, asthma or hypertension, chronic disease
management is the key. This essentially entails helping the patient
live a ‘normal’ life, despite there being no cure for the ailment.
As an oncologist, I see cancer patients today live longer than ever before.
We have newer and smarter treatment modalities for cancer getting approved
on a regular basis. According to National Cancer Institute, USA, 67 per cent of
people diagnosed with cancer have survival rates of at least five years. That’s a
remarkable increase of over 20 per cent in the last four decades.
The Indian Council of Medical Research (ICMR) registry also reports a
similar trend in cancer survival, despite almost 60 per cent of cancer cases in
India being diagnosed at an advanced stage. In other words, even when there’s
no cure per se available, medical science can help patients lead a good quality
of life.
MEDICAL SCIENCES

35
Treating cancer
Cancer is counted among the top 10 chronic diseases
globally. However, the term ‘cancer’ refers not just to one
disease, but a collection of more than 100 diseases – from
breast cancer and colon cancer to blood cancer and skin
cancer – with wide-ranging characteristics that usually
call for varied treatments.
Cancer management depends on multiple factors,
such as type of cancer, disease response, remission or
relapse, tolerance to treatment, age and overall health
of the patient, to name some. Studies show that lifestyle
changes, early detection and timely treatment can help
prevent and cure many cancers, including breast cancer,
cervical cancer, oral cancer, prostate cancer and skin
cancer. Also, treating an early stage cancer is nearly 80
per cent more cost-effective and the survival rates are five
times higher than at later stages.
Current cancer treatments include chemotherapy,
immunotherapy, radiation therapy, and surgery.
However, modalities are changing rapidly. For instance,
most cancers needed chemotherapy or other IV drug
treatments in the past. But today an increasing number
of patients – almost 30 per cent in case of lung cancer
patients – are treated with targeted therapy, mostly by
way of oral medications!
With targeted therapies, researchers are looking at
targeting the cancer-causing genetic changes in tumours
– no matter where the cancer develops in the body – to
combat the disease. Similarly, precision medicine can help
predict targetable mutations and figure out how the body
would process certain drugs even before one takes them.
Precision medicine holds immense promise in
cancer care.
We can no longer look at cancer treatment as a one-size-
fits-all; it has to be tailored to each individual, such that
the therapies work with the body’s makeup to help fight
cancer in the most effective manner.
Immunotherapy, also called biotherapy, is another
cancer treatment, powered by one’s own immune system.
There are two common types of immunotherapy. First,
monoclonal antibodies, which are designed to recognise
and attack cancer cells, and have an overall good response
with limited side effects. Second, checkpoint inhibitors
that work by blocking checkpoint proteins from binding
with their partner proteins. This prevents the “off” signal
from being sent, allowing the T cells to kill cancer cells.
Vaccines are also a type of immunotherapy that work
to boost the body’s immune system to fight cancer. There
are vaccines, such as the Human Papilloma Virus (HPV)
vaccine that help prevent cancers caused by a virus, and
vaccines that are used to treat certain cancers, such as
prostate cancer and cervical cancer, by
activating the immune cells. Researchers
are in the process of testing vaccines for
several types of cancer.
Organ site approach
Traditionally, we have approached
cancer unlike most other diseases with
potential for turning chronic; not
associating it with the organ that it
impacts. Of course, this is no longer
true for the medical fraternity. Today,
we have colleagues who have spent years
understanding how the disease not only
impacts a specific organ but certain
different parts of an organ.
For instance, head and neck cancers
comprise over 17 sites, including oral
cavity, nasal cavity, and ear, to name
some. We need to look at cancer from
an organ site approach, whereby there
are dedicated teams for each type of
cancer.
However, the awareness among
patients with regards to organ site focus
and how it impacts the course of their
treatment, chances of recurrence, and
post-treatment life is still quite low. For
many of them, especially semi-rural and
rural patients, all types, and stages of
cancer are associated with life-limiting
illness.
Hence, a major area of growth as
we look to effective chronic disease
management would also be to educate
patients and people at large about how
every cancer isn’t the same in terms of
its symptoms, risk, survival, and life
post treatment. Disseminating a lot
more knowledge about organ site-focus
can go a long way in reducing anxieties
around the disease.
Cytecare is one of the first private
hospitals in India to offer organ site-
focus-based oncology care. Our practice
is based on four prominent pillars
— organ site focussed and specialist
oncologists, standardised global
guidelines and tumour board, patient-
centric culture and clinical research.
The multidisciplinary team of clinicians
is strongly guided by national as well as
MEDICAL SCIENCES

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