{"paper_id":"ca8ab1b3-5bf4-4aa8-8e65-447d55effbac","body_text":" Corresponding author: Wu Shun Felix Wong \nSchool of Women’s and Children’s Health, The University of New South Wales, NSW, Australia. \nCopyright © 2021 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. \nThe potential role in HIFU telehealth in the management of fibroid and adenomyosis \nafter COVID-19 pandemic  \nWu Shun Felix Wong 1, *, Yonghua Xu 2 and Lian Zhang 3  \n1 School of Women’s and Children’s Health, The University of New South Wales, NSW, Australia. \n2 Department of Imaging and Interventional Radiology at Shanghai Xuhui District Central Hospital, Shanghai, China. \n3 State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical \nUniversity, Chongqing, China. \nWorld Journal of Advanced Research and Reviews, 2021, 09(02), 027–031 \nPublication history: Received on 15 January  2021; revised on 23 January  2021; accepted on 25 January  2021 \nArticle DOI: https://doi.org/10.30574/wjarr.2021.9.2.0032 \nAbstract \nWe come to realize the importance of “telehealth” during the current COVID-19 pandemic. Telehealth can be defined as \nproviding health care, including preventive, diagnostic, and treatment services, by using information and \ncommunication technologies such as videoconferencing, electronic messaging, and telephone calls (1). With the rapid \ndevelopment of new treatment technology, communication, and fast speed networks, not only telehealth can provide \nmedical services closer to home, but it also should provide the doctors and patients with additional benefits of safety, \neffectiveness, and satisfaction. HIFU is a new non-invasive ablation treatment for many solid tumors. This paper \nillustrates how the potential practice of HIFU ablation for fibroids can be modified to make it suitable for doctors in \ntheir HIFU training for treatment of fibroids and adenomyosis and for patients who need surgery using this new \ntelehealth development.  \nKeywords: HIFU ablation; Telehealth; Fibroid; Adenomyosis; 5G \n1. Introduction\nThe Coronavirus pandemic has made history and revolution in medicine, not because it is a widespread pandemic \ninfecting more than 25 million people; it also affects the way of life of healthcare providers and patients worldwide. \nDuring the pandemic, doctors are advised to reduce face- to-face appointments with patients who might display \nsymptoms of COVID-19 infection, like cough, running nose, headache, and weakness (2, 3). Hundreds to thousands of \npatients requiring medical consultations and subsequent surgeries would not be allowed to enter hospital clinics or \nhospitals because all medical facilities are fully used to cope with the COVID-19 crisis. It is said to minimize the risks of \ncross infections due to overcrowding of high risks patients. While the traditional medical model requiring doctor-\npatient interactions in clinics and hospitals is severely affected, the medical systems in many western countries have \nreached a crisis.  \nThe poor situations occur in women having a non-urgent gynecological disease such as fibroids and adenomyosis with \nheavy bleeding and severe anemia, adenomyosis with intolerable period pain, and many others. Non-urgent operations \nare postponed or canceled; even surgeries are indicated. Everything of the routine healthcare services appears to stop \nto provide services. Actions are taken in many countries to transform medical practice using telemedicine and \ntelesurgery in clinics or sites outside the acute hospitals. Furthermore, this global pandemic on doctors’ education and \ntraining has been affected at all levels and in all countries. Robson and Grabau, 2020 (4) further echoed that the impact \n\n\nWorld Journal of Advanced Research and Reviews, 2021, 09(02), 027–031 \n28 \nof COVID -19 on medical education is unprecedented, far -reaching, and presents a great challenge. Most healthcare \nproviders have realized that they have to adopt or initiate digital solutions (5). \nThe high-Intensity focused ultrasound (HIFU) ablation treatment is one of the latest developments, which is increasingly \nused to treat uterine fibroids, adenomyosis, and solid cancers (6-8). It is a local thermal ablation technique that destroys \ntumors by the thermal effect through the focused ultrasound energy generated from an extracorporal transducer. The \nultrasound beams penetrate the body’s tissues and are focused on the tumor to produce the maximal h eat effect to \ninduce coagulative necrosis. Some patients with fibroids, adenomyosis, or small solid tumors can have HIFU treatment \nunder conscious sedation in an outpatient clinic (9). Nearly all patients tolerate the procedure well, and they spend 1 to \n2 hours rest after HIFU ablation and return home in a couple of hours and back to work within days.  \nMore importantly, the ultrasound-guided HIFU system enables doctors to operate on a computer console under direct \nultrasound monitoring. Coupled with a high -speed internet environment, doctors can now learn HIFU therapy online, \nbe supervised performing HIFU surgery via remote monitoring, and even expert HIFU surgeons can perform HIFU \ntelesurgery via a high-speed 5G network.  \nFrom the beginning of the COVID-19 pandemic, the author has accumulated experience over a few months about using \nHIFU telehealth services via the social communication platform for his patients and training doctors. The following HIFU \ntelehealth applications were taken and listed as follow \n Online medical consultations with patients. A preliminary exchange of information and arrangement of \ninvestigations, including blood tests and outpatient MRI scans, were conducted. However, due to the lack of \nagreed financial arrangement, and legal implications of online medical consultation, patients were still required \nto return for assessment before HIFU surgery. \n Distant teaching and learning of HIFU surgery from online presentations and discussion platforms were \nfeasible and popular during the COVID-19 pandemic (Figure 1).  \n The author adopted webinar meetings on HIFU up to 4 -5 online overseas meetings a month. It is much more \nfrequent and popular than conventional meetings that need him to travel.  \n \n \nFigure 1 A list of HIFU webinar meetings during the COVID-19 pandemic. \nThe well-known commercial platforms are Zoom, Skype, Microsoft team, Facebook…etc. This future communication \ntechnology enables doctors to learn the HIFU surgery at a site away from the hospitals or clinics to share patient’s \ninformation and doctors’ skills. Now online HIFU training and surgery demonstrations had available from some \nwebsites in China.  \n1.1. Monitoring and supervision of surgery at a remote location \nThere are inadequate HIFU experts because HIFU doctors take a long time (about 3-6 months) to get proficiency and \nbecome an experienced HIFU surgeon to operate without supervision. Their level of skill and knowledge is not easy to \nachieve. Therefore many doctors initially need supervision at centers that may not have HIFU experts to supervise. \n\n\nWorld Journal of Advanced Research and Reviews, 2021, 09(02), 027–031 \n29 \nChongqing HAIFU Medical Technology Ltd has established a telemedicine center that provides a monitoring and \nsupervision platform in a large room with multiple large monitors on the wall (Figure 2). \n \nFigure 2:  a telemedicine center at Chongqing HAIFU Medical Technology Company Ltd.  \nDoctors who were performing HIFU ablations for fibroids, adenomyosis, or other solid tumors from other remote \ncenters, including Hong Kong, Taiwan, Singapore…etc. could have remote supervision by a training team of HIFU experts \nat this center. Doctors from new HIFU centers can then perform their HIFU ablation confidently with this backup \nsupport. When necessary, prompt teaching or advice was given over the audio connection. Real-time ultrasound images \nduring HIFU abla tion were monitored, with each step of the procedure supervised. That is a good model to be used \nacross the globe for doctors’ training and supervision in this new area of non-invasive HIFU surgery.  \n1.2. Remote surgical operation (via 5G network) \nThe possibility of operating HIFU remotely and utilizing an expert HIFU surgeon’s technical skill over a long distance \nhas attracted much attention. Coupled with China’s rapid technology development, the authors had reported the world’s \nfirst successful HIFU telesurgery through the 5G network on October 14, 2019, in Shanghai, China (Figure 3). \n \nFigure 3 Dr. Xu conducted a HIFU telesurgery for fibroid ablations on a 30 km away patient. \nWhen long-distance travel or mobilization may not be possible when there is another wave of COVID viral pandemic, \nremote HIFU telesurgery development will enable HIFU ablation to be completed in remote locations or clinics outside \nhospitals. Therefore any HIFU center in a hospital has a dedicated high-speed 5G network line, then remote cooperative \nHIFU treatment between it and a remote HIFU center can be possible. \n \n\n\nWorld Journal of Advanced Research and Reviews, 2021, 09(02), 027–031 \n30 \n2. Areas of future development   \nHowever, areas that must be resolved before remote HIFU telehealth services are popular and feasible. \ni. Online medical consultation and assessment for the suitability of HIFU treatment should be encouraged. Apart \nfrom clinical histories, blood tests, and general fitness for surgery, the appropriateness and suitability for HIFU \ntreatment depend on the MRI scan. Increased online medical consultations with the patients and online pre -\noperative assessment of their MRI images will reduce their need for multiple on -site medical consultations or \ntravel to clinics and hospitals. This also empowers patients to select the most appropriate healthcare provider \nor hospital.   \nii. Tele-monitoring and supervision of HIFU ablation at remote HIFU centers require the setting up of good clinical \npractice training, standard operating procedures,  and close monitoring of treatment procedures. This will \nensure the safety and effectiveness of HIFU treatment.  \niii. For HIFU telesurgery to be practical, the following issues also have to be resolved \n Pre-operative or postoperative HIFU ablation management is equally important, but the advice may not be \navailable in the remote area or neglected. \n The interference from electricity surges and machines broke down in any of the two collaborative sites could \nhalt the operation or create unexpected sequels. \n Indemnity and legal coverage for HIFU telesurgery activities must be established. The legal responsibility for \nany unexpected adverse outcome arising from system errors must be resolved.  \niv. The tele-clinical skill assessment: HIFU ablation system allows remote monitor ing from a remote location (as \ndiscussed above). It thus enables the implementation of a new paradigm for clinical skill assessment. After \ncompleting HIFU training, doctors can perform the HIFU ablation under close monitoring for assessing their \ncompetency, accuracy, and skill at the time of HIFU ablation at a distance.  \nv. The tele -clinical trial – clinical safety and effectiveness of any new therapy require clinical trials for new \ntreatment protocols. Various tele-trials programs have been successfully developed for cancer treatment trials \ncloser to Australia’s home (10). Similarly, the tele -clinical trial framework for HIFU ablation treatment for \nfibroids and adenomyosis can be an important development in the future.   \n3. Discussion   \nToday, we are at the cross way of a ‘telehealth’ revolution. Telehealth has gained acceptance across many healthcare \nservices to deliver patients with care closer to home. It is expected that the telemedicine market is expected to rise. \nSuppose the surgical areas are to be further d eveloped. In that case, the tele -HIFU system will be an appropriate \ntelehealth application for training, supervision, assessment, and long distant HIFU treatment soon.  \nBefore accepting HIFU into the “telehealthcare ” on a broader scale, many other issues will need to be resolved. For \nexample, the HIFU ablation should establish standard clinical protocols, global training, and compatibility of HIFU \nequipment must be developed. The known risks of hackers to create a ri sk of interference with communications \nnetworks or image signals need much attention. When security and privacy in a HIFU telehealth platform are being \ninterfered with, it makes a bad image on record, interfering with accepting this new HIFU telesurgery.  \nEven before the end of this viral pandemic, we should be well prepared to cope with another viral pandemic in the \nfuture. We can therefore now think of it as a ‘telehealth’ revolution. HIFU is a new technology. After its incorporation \nwith telehealth technology, we probably help lower the barriers among hospitals, doctors, and patients to prepare and \nimprove patients’ services despite any future viral pandemic. \nAs we can recognize HIFU telesurgery’s potential increases, there will be business opportunities for communication \ncompanies and medical device manufacturers to embrace the HIFU telehealth revolution over the coming years.  Future \ndevelopment, including additional AI solutions to incorporate into this HIFU ablation system, will improve the \neffectiveness and safety of its treatment and enhance overall patient satisfaction. Digital incorporation in HIFU ablation \nis an opportunity to drive the Industry for more development.  \nFinally, legal implications, patients’ privacy, doctors’ responsibility, network security, and machine reliability must be \nresolved before the widespread use of this area of HIFU development.  \n\nWorld Journal of Advanced Research and Reviews, 2021, 09(02), 027–031 \n31 \n4. Conclusion \nAfter the COVID-19 pandemic, we come to realize the potential role of HIFU “telehealth” to provide education, training, \nsupervision, and remote telesurgery. HIFU technology and fast speed communication network development can provide \nthis non -invasive treatment to women with fibroids and adenomyosis closer to home, with the benefits of safe ty, \neffectiveness, and patients’ satisfaction. Even this ongoing pandemic shows that HIFU telehealth treatment for fibroids \nand adenomyosis had been increasingly used wherever the HIFU service is available. It does not have an increased risk \nof transmission of SARS-CoV-2 or other viral infection. Thus, HIFU telehealth could be the preferred treatment option \nin the future. \nCompliance with ethical standards \nAcknowledgments \nWe acknowledge the contributions of information from doctors involved in providing HIFU services and \ntelecommunication services during the COVID-19 pandemic. \nDisclosure of conflict of interest \nAll three authors are senior HIFU doctors teaching HIFU ablation techniques and have honorary affiliations with \nChongqing HAIFU Medical Technology Company Ltd, Chongqing, China.  \nReferences \n[1] Mathur J, Zammit G, Phelps G. Telehealth: call for formal clinical governance framework. InSight+. 2020. \n[2] Rasmussen SA, Smulian JC, Lednicky  JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and \nPregnancy: What obstetricians need to know. American journal of obstetrics and gynecology. 2020. \n[3] Ge H, Wang X, Yuan X, Xiao G, Wang C, Deng T, et al. 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