\r\n\tIn this book, the different factors of liquefaction, the field methods and laboratory tests to identify a potentially liquefiable soil aim to be reviewed; in addition with history cases (ground behavior during the occurrence of an earthquake, state of stress, deformation, shear strength, flow, etc.).
\r\n\tA very important aspect of this topic is the presentation of the different constructive techniques used to ground improvement (vibrocompaction, dynamic compaction, jet grouting, chemical injection, replacement, etc.), placing special emphasis on those constructive methods used to solve problems on structures already located in areas of low relative density with liquefaction potential, where the installation of monitoring and control equipment is also required (tiltmeters, piezometers, topographic points, seismographs, pressure cells, etc.).
Skin cancer represents one-third of all cancers that are diagnosed every year worldwide. From all types of skin cancer, cutaneous melanoma is the least frequent among this group of malignant tumors, it is however, the most highly invasive and metastatic tumor. It has also shown an important growth of around 150% in its appearance since 1971, having an estimation of 76,250 new cases diagnosed in the USA in 2012. In 1971 there was only 1 case in 600 white people. In the period of 1992 to 2004, its annual growth was of 3.1%. This led to an estimated incidence of 1 in every 90 white people by 2000. By 2010 it was 1 in every 50, for people above 50 years old in the USA. Its epidemiological importance lies in its high mortality rate, since it is the cause of 90% of deaths for skin cancer and it is potentially the most dangerous form of skin tumor [1]. The outlook for patients with advanced melanoma is often fatal due to a lack of effective treatments.
In Mexico, melanoma incidence is around 1.7 per 100 000 people, and the Histopathologic Record of Malignancies in 2001 reported that it is the second most frequent. Women are the gender most affected by Melanoma (1.6/1). The median age of presentation in this country is 54 years and in 77% of the cases there is no relation to sun exposure. On the other hand, it is important to point out that there is a lack of formal registration of neoplasias in health institutions of our nation [1, 2, 3].
There are four clinicopathological subtypes that Melanoma presents, which usually are correlated to ethnic differences and to exposition to UV radiation: Superficial spreading melanoma (SSM), Lentigo maligna melanoma (LMM), Nodular melanoma (NM) and Acral lentiginous melanoma (ALM) [1, 4]. SSM and LMM, are the most common among Caucasians and their presence has been directly related to sun exposure. Nodular melanoma is less frequent (10%) than SSM (70%), but both melanomas share pigmentary characteristics in patients. It is probable, however, that these two types of melanoma have a direct relation with sun exposure. However, this risk factor has not been proven in NM, given that this type can be found in any place on the body, not just in skin areas frequently exposed to sun light.
The most frequent subtypes of Melanoma in our population are, NM and ALM [4, 5] (Figure 1). Studies supporting the hypothesis that ALM may be a biological and genetically different subtype, will be mentioned in the following sections. Its distinct development pattern suggests that it may possess molecular and cellular uniqueness.
This may be because of different genetic alterations that control the transformation of melanocytes to acral melanoma, leading to the need for a specific-therapeutic target towards this subtype of melanoma with a high rate among Mexicans and Latin-Americans.
An indolent ALM subtype on the foot of a 58-year-old male patient, with 8 months of evolution. Nodular melanoma (NM) and Acral Lentiginous Melanoma (ALM) are the most frequent subtypes of Melanoma in our population. The lower extremities (mainly on the feet) are the most common anatomic locations reported for ALM.
Several studies have identified certain variables associated with an increased risk of developing melanoma: European ancestry, phenotype, UV radiation exposure, personal or family history of malignant melanoma, and molecular alterations are some of the most relevant [6]. Genetic alterations, will receive particularly emphasis later in this review. It is important to mention, that the risk factors traditionally associated with melanoma are related principally to Caucasians, where most clinical and basic studies are carried out. However, there are not enough studies supporting the predisposition of such factors for the subtypes of melanoma occuring in Mexican or Latin-American population.
Yamaguchi et al, reported that the risk factors traditionally described such as UV exposure, have a small influence in the pathogenesis of dark skin population. It has been postulated that UV radiation plays a smaller role in the pathogenesis of melanoma in the darker-skinned population. This is due to the fact that with an increase in melanin content, the larger melanosomes (in darker skin), absorb and scatter more energy than the smaller ones in lighter skin [7].
Although various phenotypic characteristics enhance or reduce the risk of developing melanoma, sun exposure has been reported as the main cause of SSM, LMM and NM subtypes. The incidence of this disease is much higher in people who tend to burn rather than tan. (8)
UVA rays constitute 90% of solar radiation. However, UVB rays are greater risks for those who traditionally work or have recreational and daily activities outside. Among those with SSM and LMM, 75% of the affected individuals are sunburned by UVB rays. However, ALM has not been related to this risk factor. In addition, it is known that excessive sun exposure at early ages (childhood and adolescence) has a negative outcome in DNA reparation. The most important exogenous factor for melanoma is UV radiation exposure, particularly intermittent exposition, and it is known as the only etiological agent that can be modified. The increase in sun exposure and the damage to higher levels of the atmosphere because of contamination has resulted in an increase of the amount of radiation [9,10,11].
Sun exposure increases the expression of α-melanocyte stimulating hormone (α-MSH) and of the peptides of pro-opiomelanocortin in the skin. Melanocyte- stimulating hormone belongs to a group called the melanocortins. α-MSH is the most important melanocortin for pigmentation and shows a high affinity for melanocyte stimulating hormone receptor (MSHR). Once α-MSH binds to MSHR, cellular cAMP is activated, as well as other signal transduction pathways. The final result is the production of eumelanin.
Eumelanin, the primary pigment that colors the skin, hair and eyes in humans, also protects the body from UV and other hazardous radiations that can damage skin cells. When eumelanin has been crystalized, it forms both a geometric and a chemical disorder at the same time. It turns out that both kinds of disorders, may play a complementary role in producing eumelanin’s broadband absorption. The tiny crystals of eumelanin have a chemically ordered state with intrinsic randomness: the orientations of the stacked molecules are arbitrary and the sizes of the crystals are different. That combination of order and disorder contributes to eumelanin’s broadband absorption (12). Recently, it was reported that eumelanin is a naturally existing nanocomposite that has very critical macroscopic properties as a result of its nanostructure properties. All eumelanin molecules share very similar chemistry, although there are more than 100 variations. It has been proposed that the small variations from one molecule to another may contribute to the disorder that broadens the ability to absorb UV light (13).
Additionally, different alleles for melanocortin 1 receptor (MC1R) gene have been identified. The subtypes related to loss of function reduce the production of cAMP after stimulation of α-MSH, and thus increase the expression of pheomelanin. This is observed in individuals of light skin, increasing the risk of developing melanoma by the formation of free radicals after UV ray exposure.
Recently, a study was performed in 789 patients with diagnosis of melanoma. In order to characterize these patients according to their levels of sun exposure, three groups were established in the study: intermittent, chronic, and absence of exposure [14]. The vast majority of patients were in the first group. These melanomas were present in skin locations exposed to sun radiation in an intermittent manner. SSM and NM belong to this group. Multiple common and atypical nevi may constitute a marker of risk of these melanomas. The second group was formed by patients with melanomas in skin areas with chronic sun exposure, showing all the damage and premise typical of this location. LMM belongs to this group. Finally, the third group corresponds to melanomas present in skin areas with no sun exposure, usually diagnosed in late stages. This group includes ALM and mucosa melanoma, which usually are thicker at diagnosis and have worse prognosis [15, 16, 17]
Acral lentiginous melanoma (ALM) distinguishes itself from the other subtypes for many characteristics, mainly histological and clinical-prognostic. A huge controversy regarding the cause of its worse prognosis, has been going on since its description.
ALM usually occurs on palmoplantar or subungual areas (Fig 2), lacking hair. Similar to NM, it is very aggressive when its proliferative vertical phase develops. It is more commonly found in individuals with dark skin (35-60%), oriental population and Afro-Caribbean. Considering its localization, it is thought to be UV-protected by the thickened stratum corneum and the nail matrix. ALM is rare in Caucasian populations (1-5%), but has a higher incidence among our population and Latin-Americans with dark skin(8, 9, 18). However, for individuals with lighter skin in our population, SSM is the most frequent.
According to the data of The National Cancer Institute Surveillance, Epidemiology and End Results, ALM is the least frequent histological subtype in the USA, with a 2-3% frequency. However, it shows a higher percentage among afroamerican people and Asians.
Reed described for the first time ALM as pigmented lesions of the extremities, mainly of the plantar and palmar regions, that were characterized by a phase of lentiginous (radial) growth, which evolved in months or years to the invasive vertical phase.(19)
Arrington was the first to notice that this type of melanoma was more prevalent among the African American population and that their prognosis was less favorable due to being diagnosed at an advanced stage. Yet, it was not documented by the SEER as a different histological subtype until 1986 [20]. Usually, ALM is not associated with nevi, family history or gene susceptibility known to melanoma. In its great majority, ALM are diagnosed as thick melanomas which in most cases are usually presented in their late phase, with a worse prognosis and a lower survival rate than the most common subtypes of melanoma associated with chronic sun exposure [20].
Pereda et al, reported the Clinical presentation of ALM in patients from Spain. In seventeen of them, ALM was found on a foot and in six on a hand. Four ALMs of the hand were subungueal. Most of the foot ALMs were located on the sole (twelve cases) [22].
A subungueal tumor of a 71-year-old male patient with an advanced ALM (thick Breslow), on the thumb of the left hand. ALM is the most prevalent subtype in Mexicans and LatinAmericans. It is usually found on hands and feet: palms and soles, wrists and heels, and under the nails. ALM and NM are usually diagnosed in later stages, unlike SSM and LMM. The most affected sites are by far the feet and nails. Initially, they may be misdiagnosed as a mole, an ulcer, an abscess, a wart, a nail bed dystrophy or as the result of a trauma.
The most frequent location of ALM is in the feet (Figure 1), mainly the plantar region and the first finger, as in subungual areas in the majority of non caucasians racial groups. This has led to the conclusion that trauma may be an important factor of ALM, and not sun exposure [22]. Even when the superficial region of the palms and plantar region are similar, in the plantar region there is a continuous exposure to pressure, friction, maceration and irritation. Nevertheless, there are counterarguments towards this theory, including that the hands are more exposed to UV radiation and acute trauma. In addition, it has not been possible to prove changes in the incidence of plantar melanoma when some African tribes began urbanization and the use of shoes.
Another important factor in the predominance of plantar ALM, is the fact that there is a 50% greater amount of melanocytes there than in the palms [23, 24]. The research of Ghadially proposed that trauma during less than 12 months, did not increase the risk of melanoma in the Xiphophorus fish model [25]. Troyanova [26] described mechanical trauma on previous pigmented skin lesions as a risk factor for the formation of melanoma and remarks that trauma has to be carefully checked. Recently, an amelanotic subungueal melanoma arising after trauma was reported by Rangwala [27]. Melanomas formed on burns scars and tattoos have also been frequently publishedin recent years.Of 687 Chinese melanoma patients, 15.2% showed a strong association between trauma in the extremities and melanoma [28].
Clinical experience coming from medical attention given to patients of melanoma treated in two of the major oncological centers of our nation, shows that AM occurs in no photo exposed areas [5], mainly in lower extremities (more than 80% of the cases) and in subungual regions (Figure 3). This information has been reported by the Mixed Tumor Unit from the Oncologic Service (General Hospital of Mexico) and the Dermatologic Center ”Ladislao de La Pascua”, Mexico City [18]
ALM on the foot of a 61-year-old male patient, with indolent growth. The Oncology Unit of the General Hospital of Mexico reports that more than 50% of ALMs are presented on the lower extremities (mainly on the soles and subungueal areas. Being the toe by far, the most affected).
A subungueal tumor of a 54-year-old male patient with an advanced amelanic melanoma. ALMs are usually diagnosed in the later stages unlike SSM and LMM. It was misdiagnosed as a bleeding ulcer of progressive growth.
A plantar tumor of a 65-year-old male patient. The lower extremity is the most common anatomic location reported for mexicans. Initially this case was diagnosed as a pigmented lesion of a fast vertical phase progression.
Melanoma arises through a complex process of cellular mutations and a loss of keratinocyte control over growth and differentiation. As malignant melanoma progresses, it develops through interaction between dysfunctional melanocytes and the tumor microenvironment. This in turn, allows the formation of nevocyte nests at the demal-epidermal junction and is accompanied with changes in both, keratinocytes and local adhesion molecules (29). The progression from healthy melanocyte to melanoma occurs through mutations within the tumor and through alterations of the cellular environment.
In the skin, tissue homeostasis is critical in cellular regulation and melanoma breaks this regulation through multiple processes. Defining intercellular molecular dialogues in human skin promises to provide key information about the transformation of melanocyte to melanoma. A great number of genes and proteins have been reported to play an essential role in this transformation. The most important are: B-RAF, c-KIT, PTEN, p16, p53, cyclin1, ARF, K-RAS (30).
It has been reported by a meta-analysis that the presence of at least one-first degree relative with melanoma increases to double or more, the risk of developing this disease.
Many genetic studies in melanoma-prone families lead to the identification of CDKN2A as the main familial melanoma gene. This gene is located at the chromosome 9p21 region. CDKN2A encodes two different proteins: INK4A (p16) and ARF (p14). In order to produce these two proteins, the use of alternative promoters and different first exons is necessary. Exon 1α is used for INK4A and 1β for ARF. The second exons of the two transcripts are translated in distinct reading frames, encoding two completely different proteins (with no amino acid homology). Nevertheless, both proteins share potent anticancer activities. INK4A inhibits the G1 cyclin-dependent kinases (CDKs) 4/6, which phosphorylate and inactivates the retinoblastoma protein (RB). After that, the S-phase is allowed to occur. Loss of INK4A function promotes RB inactivation resulting in cell cycle progression. ARF (Alternative Reading Frame) inhibits MDM2 mediated ubiquitination and degradation of p53. Loss of ARF, inactivates p53. Alterations of p16 are associated to familial melanoma in 20% and in 40% to sporadic melanoma [31].
As it was mentioned earlier, more than 90% of melanomas are diagnosed in white and light skinned populations. The majority of the international studies have addressed these populations, since they are at higher risk of developing melanoma. Thus, most reports are drawn from data of white and light skinned populations. The main alterations reported in SSM and NM, are B-RAF and N-RAS mutations.
It is a tyrosine and threonine kinase that participates in the signal transduction known as Ras/Raf/MEK/ERK/MAP kinase. BRAF functions to regulate the MAPK/ERK pathway, which is conserved in all eukaryotes. This pathway acts as a signal transducer between the extracellular environment and the nucleus, activating downstream transcription factors to induce a range of biochemical processes including growth and differentiation, proliferation and migration associated to the ability of tissue invading [32, 33, 34]. Through direct secuentiation of PCR products, three substitutions of simple bases have been demonstrated. The most prevalent (95% of the cases) is constituted by the transversion of T1799A, occurring on exon 15 of BRAF, and causes the substitution of the amino acid valine for glutamic acid in position 599 (V599E). Such position has recently been modified to V600E.
Other BRAF mutations that cause carcinogenesis exist, such as K601E or those affecting exon 11, but they rarely occur in melanoma. A fusion of BRAF to AKAP9, by a paracentromeric inversion of the long arm of chromosome 7 has been observed in cases associated to ionized radiation exposure. This produces an oncogene, AKAP9-BRAF, which also results in a constitutive activation of the MAP kinase pathway [35, 36, 37].
Exon 15 BRAF mutations in melanoma were first reported in 2002. The number of reports of BRAF mutations in primary melanoma tissue increases continually. Varying prevalences in primary melanoma tissue have been detected, from 41% to 88% in SSM. These BRAF alterations alone, are not capable of demonstrating neither the immortalization of malignant cells, nor the progression of the disease further more than a nevus [37].
A pilot BRAF mutation study in ALM patients was carried out by collaboration between the Genetic Service of the General Hospital of Mexico and the Molecular Oncology Laboratory of the School of Medicine at the National Polytechnic Institute. DNA sequencing of seven ALM samples of Mexican patients (General Hospital of Mexico) showed no T1799A mutation in any of the studied samples (M. Sc. Thesis, 2012) [38].
RAS are among the most frequently mutated oncogenes in human cancers. They show different mutation patterns and spectrums in all members: NRAS, HRAS and KRAS. The isoforms share a high degree of similarity, although each one displays preferential coupling to particular cancer types.
RAS play a fundamental role in the signaling pathway of MAP kinase. Extracellular signals such as hormones, cytokines, and various growth factors interact with their receptors to activate the small G-proteins of the RAS family. This pathway includes BRAF and it contributes to the control of cellular proliferation, particularly malignant cell proliferation. RAS also controls apoptosis through the PI3K-PTEN-Akt pathway.
SSM shows mutations almost exclusively in NRAS. A prevalence of 5% to 10% NRAS mutation has been reported. However for hereditary melanomas, the prevalence increases to 80%. Most cases of NRAS mutation are in codon 61. NRAF and BRAF mutations are mutually exclusive [39].
There are similarities between this type of melanoma and those without sun exposure. However, there are differences with ALM since they show much lower mutational characteristics.
KIT (CD117) encodes a tyrosine kinase receptor for stem cells factor and plays a key role in melanocyte development, migration and proliferation. KIT is found on chromosome 4 and may be altered in a variety of different types of cancers. It is mutated in 28% of LMM, 36% in ALM, and is absent in melanomas with intermittent sun exposure. KIT over expression during the vertical growth phase of melanoma development supports the hypothesis of its participation in late stages of the disease. It is the target of several small molecules inhibitors such as imatinib, being a therapeutic target for this type of melanoma. Different roles of KIT among different types of melanoma, give additional evidence that each subtype can be considered different biologically and genetically [40].
ALM and mucosal melanomas have an inverse correlation among mutations of BRAF and NRAS. The increase in the copy number of Cyclin D1, CDK4, KIT and ABCB5 has also been reported.
It is an important regulator of transition of the cell cycle for phases G1/S. It also participates in the phosphorylation of RB protein by binding kinase 4, cyclin dependent. Many studies have revealed a highly organized sequence of events indispensable for promotion of continued proliferation. The decision to continue cell cycle progression occurs when cellular RAS induces the elevation of cyclin D1. These levels are maintained through G1 phase and are necessary for the initiation of S phase, thus resulting in immediately reduced cyclin D1 levels. One requirement for DNA synthesis, is the reduction of cyclin D1 to low levels during the S phase. This forces the cell when it enters G2 phase, to induce high cyclin D1 levels once more. Thus, cyclin D1 is proposed to be a switch activator in the regulation of continued cell cycle progression [41, 42].
Cyclin D1 frequent amplification was reported in 44.4% of ALM by Sauter et al, Cyclin D1 was overexpressed in all cases with amplifications and in 20% of cases without amplification. Cyclin D1 may be an oncogene in melanoma and that targeting its expression can be therapeutically useful in the future for ALM [42].
It is a union protein of cyclin D1, found in chromosome 12q14. During early stages of phase G1 of the cell cycle, Cyclin D binds to kinase dependent cyclin 4 or 6 (CDK4 or CDK6) and the resulting complex “frees the brake” that limits the progression towards late G1, going into phase S. The cyclin D-CDK4/6 complex releases a potent inhibitor of the cell cycle progression: the one formed by protein pRB and inactive transcription factors. The types of melanoma having an increase in the number of copies of CyclinD1 and CDK4 have less possibilities of responding to the therapeutic target used in BRAF, such as Vemurafenib.
Human ATP-binding cassette transporter, also known as P-glycoprotein, is related to the subfamily of multidrug resistant genes (MDR). The ABCB subfamily includes eleven members that have different expression patterns. Whereas the functions of several transporters of the ABCB family are not known, there is some information about ABCB5 in relation to its pattern of expression or its associated function [43]. It has been described by Frank et al [44, 45] described it and it was implicated in the regulation of progenitor cell fusion (located in chromosome 7p21-15). Their study used an enriched culture of human epidermal melanocytes isolated from the foreskins of healthy donors and melanoma cell lines. They showed a higher and more intense ABCB5 expression in ALM than in SSM. Herrera-Gonzalez and her team [46], reported a 90% overexpression of ABCB5 in ALM samples of Mexican patients by using RT-PCR. A direct relationship between mRNA expression and the aggressiveness of ALM was also shown.
In regard to the progression of human cancer, it is universally thought, that it develops from a single mutated cell, followed by malignant clonal expansion secondary to additional genomic and genetic alterations. As the malignant cells continue to acquire these alterations, tumor sub-clones with distinct phenotypic advantages (47) for its progression may be produced: for example invasion, proliferation, ability to colonize different organs, etc. In many cancers, regulation of specific signaling molecules also goes awry, affecting a host of other proteins and cellular processes.
In recent years, the histological and phenotypic characteristics of ALM combined with its high proportion among melanomas in Afro-Americans, Asian and Latin Americans, has confirmed the thought that this histological type of melanoma may differ biological and molecularly from its most common counterparts, recognized by its sun exposure and its greater frequency among Caucasians. While ALM is characterized by a high frequency of focal amplifications (mainly involving CCND1, CDK4) and deletions, the most common cutaneous melanomas exhibit few changes in the number of genetic copies. In a similar way, while BRAF and NRAS are mutated in 50% and 20% of the cases respectively, mutation in KIT (which codifies the tyrosine kinase receptor) seems to be absent in the most common cutaneous melanoma. However, BRAF mutations in ALM constitute approximately 16% of the cases reported by Curtin et al. [40, 41]
A systematic sequencing was used for the human genome sequence. New technologies allow sequencing of randomly generated DNA fragments from cancer genomes and thus detect alterations and copy number variation as well as base substitutions, to identify most somatic mutations in an individual cancer genome. Pleasance et al, sequenced the complete genome of the COLO-829 cell line, an immortal and cancer derived from a metastasis of a melanoma from a 43 year-old-male. In their study they identified 33,345 somatic base substitutions [48, 49]
The study of Turajlic et al. [50] is the first to characterize the mutational spectra in ALM. They used a whole genome sequencing to characterize punctual somatic mutations and structural variation in a primary acral melanoma and its lymph node metastasis. Evidence of transcription-coupled repair was suggested by the lower mutational rate in the transcribed regions and expressed genes. Primary melanoma and metastasis, at the level of global gene copy number alterations, loss of heterozygosity and single expressed genes are very similar[50].
These results may be controversial since their sequenced results were on the genome of only one patient. They cite that despite the perception that acral skin is sun protected, the dominant mutational signature reveals sun damage. We judge that there is no solid data regarding the presence of solar exposure on sites where ALM is developed.
Studies suggest that ungual matrix does not provide a complete protection against UV radiation and it has previously been suggested that UVB can penetrate the human nail [51]. There are substantial variations in the number and pattern of mutations in individual cancers reflecting different exposures, DNA repair defects and cellular origins [52, 53]. It is also possible that characteristics of different mutations are induced by the inefficiency of pyrimidine dimers repaired by excision of nucleotide due to the presence of a mutation in ERCC5 [54, 55].
Several studies support the hypothesis that ALM is a different genetic subtype and its inherent heterogeneity represents a challenge in the era of directed therapy [56].
An implementation of smart healthcare solutions can improve the quality of patient care to enhanced patient treatments. These kinds of solutions enable healthcare professionals to deliver the needed and adjusted medical treatment in a smarter and faster way [1]. With the increasing world population, the well-known conventional patient-doctor relationship has lost its effectiveness [2]. Hence, smart healthcare becomes very important and can be implemented at all levels in an organization or society starting from tracking vital signs in the elderly to temperature monitoring for babies. In other terms, smart healthcare technologies are not an end in itself [3]. With the implementation of healthcare technologies, organizations can create efficient workflows to ensure a high-quality in-patient treatment. This ambition is only achieved when technologies are put into use and fully utilized. The focus should therefore be in ensuring efficient use of both existing and new technologies [4, 5].
\nHealthcare technology is an interdisciplinary discipline that links technology and medical/clinical with a focus on developing new diagnostic and treatment methods [6]. Healthcare technology covers a number of technologies, such as medical technology, pharmacology, and biotechnology [7].
\nThe World Health Organization (WHO) has defined and described healthcare technology as the use of medicine, vaccines, procedures and systems—with the associated knowledge and skills—to address a health problem or improve quality of life [8]. Healthcare technology can be defined as technologies used to improve human health [9, 10]. The definition of health technology can be based on the WHO’s definition of health: “Health is not just freedom of disease, but maximum physical, mental and social well-being”
At the same time, one can apply a holistic approach to technology that covers technology, organization, knowledge, and product [12]. A user-oriented technology solution helps to maintain or even develop welfare services [13].
\nSmart healthcare feeds friendly hospital that enables patients and preferred partner in using hospital services with the best and newest health technology [14]. This means that hospitals must focus on developing services that motivate the use of healthcare technologies and focus on optimizing the workflows at clinics [15]. A better basis is needed, because without a better basis there cannot be a continuous focus on optimizing the internal processes and the ongoing support and maintenance of health technology and infrastructure [16]. Almost every hospital has the ambition to have effective use of health technology at the highest international level. The ambition to ensure efficient use of healthcare technology is all about how hospitals contribute locally and regionally to increase the quality of patient treatment and realize efficiency enhancements through health technology [17]. Therefore, healthcare technology plays a central role in supporting hospitals. Investing in healthcare technology has huge benefits. Realizing the need gains benefits through increased technology support and utilizing the experience gained at the individual hospitals. This means consistently developing and optimizing the task solution and patient treatment with health technology [18]. Services must be relevant and based on the needs of hospitals. The implementation should be based on deep knowledge, task solving, and priorities [19]. For effective and efficient use of health technology, it requires the greatest possible use of existing technology before developing new technologies with the necessary support for the users’ daily lives through qualified and efficient support. The journey toward becoming more efficient and therefore not to forget requires a common center and not a local branch. This means a constant balance for local needs, the overall gains for the region, and the ongoing standardization and follow-up [19].
\nResearch in new technology is developing rapidly in the health field. Six of the potential technologies to change the way we understand and safeguard human health is listed as follows [20].
\nIn term the telemedicine covers a broad concept [21]. This includes treatment and monitoring in patients’ own home, for example, through apps, video consultations, and automatic measuring equipment. Most municipalities over the world and regions are investing heavily in these technologies at the moment [22].
\nPhysiotherapists over video can do multi-patient exercises at once, and patients with severe wounds can consult remotely [23]. And people with heart problems can automatically get monitored blood pressure and distance activity. Even though the technology is in use there is still a long way to go [23].
\nHowever, telemedicine solutions do not work as intended [24]. In a small case study, a research team has shown a markedly increased mortality among patients treated via telemedicine [25].
\nNowadays, robots are used for surgeries when doing operation as gastric bypass, uterus, kidney, bladder, prostate, and colon. The advantage is that the robot surgery can be performed without opening the stomach up and the patient can leave the hospital earlier than with open surgery [26]. At the same time, the robot can see the body in 3-D; it is more flexible and has more precision. The result is less blood loss, fewer infections, less scars, shorter hospitalization, and fewer pains [27].
\nAmong young people, but it also spread quickly in the country’s nursing home, where the elderly also had the pleasure and benefit of the machine, because it was both entertaining and good training—a concept called exergaming, exercise and gaming [28, 29].
\nSince then, gaming technology has really gained momentum in healthcare. Today, games are used, among other things, for rehabilitation after cerebral hemorrhage and for the care of dementia, which through reversal play with old family pictures can get cognitive training and become calmer [30, 31].
\nImagine a home where it is being registered online every time you open the refrigerator door. The floor is pressure sensitive and can follow your walk around the house. In the potted plants, there are small sensors that measure every time you water the plant, and when you turn on the light, it is logged [32].
\nFor some, it sounds like a dystopic surveillance society. But for others, there are great opportunities to prevent hospital admissions among the elderly. The technology has huge potential. For example, pneumonia and urinary tract infections in the elderly can be traced in their everyday rhythms. If one can measure as soon as a breach of the patient ordinary routine occurs, treatment can put in much faster [33].
\nThese days, the body and technology are becoming closer and closer together. The so-called wearables—small pieces of electronics that you carry on the body, for example, in the form of clocks, glasses, or even electronic skin—can become the major revolution in the health world [34].
\nToday wearables are used to collect all sorts of data about your body: sleep rhythm, pulse, location, and, among other things, how much you exercise [35]. In the future, it will be even more comprehensive: reading insulin levels, anticipating ovulation, or monitoring how much sun you get.
\nHealth technology needs to be adapted to the users. Two basic elements of telescopic health must be present before it works: firstly, the technology must work, and secondly, the technology must be available to the many patient groups that need it. It is not the technology itself that is interesting, but what technology can be used for.
\nThere is one basic element of telecommunications health. The technology must be applicable to all the many patient groups, disease groups, and populations that need it, and where it can contribute valuable to health, safety, cohesion, learning, and quality of life [36].
\nThe patient, or the user, is thus the focal point. There is nothing new in that and it has been a good custom in healthcare and health technology for many years. But the demographic development of the Western world requires even more action than before to put action behind the words. Hence, a lot is needed to achieve a well-functioning telecommunications health when technology is ready.
\nOne of the pieces in this great puzzle is about “usability.” It must be easy, safe, useful and motivating for users to use the technology. The technology user interface must be intuitive and tailored to the specific user group, and when needed, the right effort must be organized to equip users to apply the technology properly. Human factors are an important part of health technology [37].
\n“Human factors” are becoming an increasingly important part as more and more patients with psychiatric disorders are being treated through technology [38]. Three aspects in particular are important in designing telecommunications health solutions, namely:
setting precise goals;
following and monitoring; and
giving feedback and promoting motivation [39].
Algorithms are already being researched, which can detect stress on the basis of voting, and early warning score (EWS) and mobile applications are being tested which, by means of individually adapted questions, can help schizophrenic patients maintain reality and achieve greater security [40].
\nThe technology itself is not interesting? Yes and no. It is only because of the many impressive technological achievements that it is even possible to create new value for patients, citizens, and communities. But the technologies only get value when they are realized for effective and usable health solutions. This includes competent involvement of human factors when developing, designing, and implementing telescopic health solutions [41].
\nHealth technology is rapidly evolving and embracing many areas and aspects where both public and private actors are at stake [42]. New terminologies and the development of new technology are constantly demanding health education programs [43, 44]. But there should also be a focus on the meeting between the health professional, the citizen, and the health technology. Furthermore, new technology requires a new set of skills, namely health and eHealth literacy. The concept of eHealth literacy is introduced and defined as the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem [45]. Health literacy refers to accessing, understanding, and using information to make health decisions [10].
\nIn Denmark, telecommunication is a commonly used technology. For example, the purpose of Patient@home is to develop welfare technology for the benefit of patients, the health sector, and society as a whole. Patient@home supports a general development toward more outpatient treatments and expansions to own home followed by home-monitored treatment, care, and/or rehabilitation. The goal of this is fewer and shorter hospital admissions as well as the development of new welfare technology, which in the long term can create jobs, exports, and growth in society. Patient empowerment is a central focus of Patient@home [46]. It is intended that a user-driven development of technologies is in progress so that the patient is supported in taking responsibility for their own health and treatment and at the same time makes it possible to be a patient in their own home [47].
\nFinland is one of the world’s leading countries in terms of health and welfare technology, and it needs to benefit the world [48, 49].
\nFinland is at the top of the world in terms of IT skills. This is reflected in a well-developed healthcare sector, where virtual reality, cloud-based data platforms, medicine robots, sensor systems, and more, which belongs to everyday life. Today, Finland ranks as the world’s third strongest country in health technology, and health technology is the country’s largest tech export product [49].
\nThe world faces convincing health challenges in an increased demand and fewer resources. Personal health technology enables a personalized, engaging, preventive, predictive effort in the field of prevention, diagnosis and monitoring, treatment, and assistive technology [50].
\nImplementation of welfare technology stands high on all municipalities’ agenda. Society is challenged by increasing life expectancy, fewer “warm hands,” and greater demands for charitable services [51].
\nWhen a patient is affected by illness or mister functioning, there is a need for rapid and effective efforts to resume an independent life, and, therefore, welfare technology is an optimal tool that can both contribute to training, support, and compensation and thereby help to promote the rehabilitation process. We already have the technologies.
\nThe challenge is to put them in play in everyday life for the benefit of both patient’s and healthcare professionals.
\nThere must not be health technology for the sake of health technology. The technology must be a need to and not nice to have the because it is something that gives value, either for healthcare professionals or patients- and very much for both healthcare professionals and patients. The staff’s knowledge and motivation are crucial for a good implementation.
\nDoes the healthcare professional not have the necessary knowledge of how a technology works, loses the face, seems unprofessional, and the technology is not being used? Instead, the staff should be thoroughly dressed so that they can safely operate and, not least, facilitate the citizens to use the technology [52].
\nPatients can seek their knowledge in the future and have less need to get the healthcare professionals’ expert knowledge. What they need is to be facilitated in how they use their knowledge and move on. Health professionals will change from being some who have the expertise to be someone who facilitates patients in using health technology [53].
\nHealthcare professionals’ motivation and engagement are also important to focus on in the implementation phase if they need to be adaptable and open to learning. Learn to take the new technologies, learn how to use them, and learn the new working methods that come with you.
\n\n
Experience of doubtful necessity
Implementation of welfare technology requires change in the organization. One of the most for achieving this change is that healthcare professionals experience the changes as compelling necessary. Does that mean that there must be an order from management that now they will use the technologies? No, the experience must come from the healthcare professionals themselves. Healthcare professionals must be able to see the benefits of using the technologies; for example, they can avoid heavy lifting with lifts and thus prevent many colleagues from being sick due to back problems [54].
If we can go to point out such things in collaboration with the healthcare professionals, so they can see that there is actually a scam here, they get an experience of imperative necessity. At the same time, it is important that we avoid self-satisfaction and “as we always have done.” If we fall into it, then there is no change.
Compose a working group
Next step is to put together a working group of motivated healthcare professionals who have an experience of imperative necessity and who wants changes. The workgroup should preferably consist of healthcare professionals, but there must also be a management level that can go in and take the organization and allocate the necessary resources, as well as being a technologist, with an overview of what technologies does the organization have and what they can used for. The working group must be present, where things happen.
Vision and strategy
The task of the working group is now to set the road. They must formulate the visions and strategies for where they are heading and how they will achieve the goal: to implement welfare technology. A strategy that ensures that staff feel safe using technology and taking it into service must be formulated.
It requires a clear vision and a clear strategy which are to be communicated internally within the working group and which are then communicated easily and clearly to the entire organization. These are not only for the healthcare professionals but also for the patients who come in as they may be able to use it when they get home [55].
Short-term goals against the goal
It is important that during the process that the workgroup can set some short-term goals that lead the organization toward the long-term goal: implementing welfare technology. The staff wants to experience and momentum and not get the whole change at once. There may be small instructional videos that present the solutions along the way or walked in living labs where staff can do things, so they are not used to using a new technology for the first time on a citizen, thus appearing insecure and unprofessional in working situation [56].
Give the healthcare professionals some resources and opportunities to practice, for example, in a living lab in a living room, safely and without being hurt because you do not know which button to press.
Consolidation via success stories
Finally, the technology must be consolidated by emphasizing all the small success stories that have been underway in the implementation phase. The healthcare professionals and patients must be able and encouraged to share and experience each other’s successor so that everyone can see that the technology can be used and that it works [57].
Healthcare technology is facing major challenges in relation to both human and financial resources. Therefore, there is a need for innovation. In the area of health and care, it is all about finding solutions where the technology makes us better able to service the patients remotely to free up resources, so that the patients achieve a much greater freedom and independence when the technology allows them to carry out several tasks from home via the technology themselves.
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