The power and pitfalls of omics part 2: epigenomics, transcriptomics and ME/CFS
Simon McGrath concludes his blog about the remarkable Prof George Davey Smith's smart ideas for understanding diseases, which may soon be applied to ME/CFS.
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The Future of Medicine

Discussion in 'Other Health News and Research' started by Waverunner, Apr 26, 2012.

  1. Waverunner

    Waverunner Senior Member

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    A great article by Harriet Hall. What I found shocking is that it takes 17 years from medical discovery to daily clinical practice. If this is true, the clinical practice is still around 1995, a year where most people didn't even know what the Internet was. When I look at a standard haemogram/blood count and what it illustrates, this claim seems to be correct however.

    http://www.sciencebasedmedicine.org/index.php/the-future-of-medicine/

    Published by Harriet Hall under Book & movie reviews,Science and Medicine

    Eric Topol, MD, has written a book about the convergence of the digital revolution and medicine. It is full of fascinating information and prognostication, but I wish he had given it a better title. He called it The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Medicine will not and cannot be destroyed. It will be improved and transformed, perhaps, but not destroyed. And any new developments will have to be evaluated for safety and effectiveness by the good old time-tested methods of science.

    The future world of medicine is really exciting: science fiction is becoming real. As I read Topols book I serendipitously found it paraphrased by a character in another book I was reading, Chop Shop, by Tim Downs.

    I see a world where no one ever dies from an adverse drug reaction; where physicians have an entire range of medicines to choose from to treat a deadly disease; where medications target tumors like smart bombs and leave surrounding tissues unharmed; where genetic susceptibility to disease can be determined in childhood, and possibly even prevented.

    (If you havent yet discovered Downs hilarious Bug Man detective series about a crazy forensic entomologist, you have a treat in store.)

    But back to non-fiction. Our world is changing almost too rapidly to comprehend: the Internet reaches everywhere, and there are far more mobile phones in the world today than toilets. We have hardly begun to tap the current potential of new technologies, and unimagined further developments await us. Topol is a qualified guide to this new world: he is a respected cardiologist and geneticist who ha s been on the forefront of wireless medicine and who was a major whistleblower in the Vioxx fiasco. He knows whereof he speaks, and he writes lucidly and accessibly.

    Monitoring. Sensors now available or in development can do amazing things. They can monitor chronic diseases and provide remote electronic early warning of medical crises. Biosensors in cars could prevent accidents by detecting impending seizures, heart attacks, diabetic reactions, etc. Monitoring is a good thing, but you can have too much of a good thing, and some of what Topol advocates smacks of overkill. One of his patients sends him e-mails with 3 or 4 daily measurements of everything from blood pressure to oxygen saturation. Topol monitors his own sleep witha Zeo device. This is nice to know information but its impact on health outcomes is not so clear.

    Lab on a Chip. A biosensor can be incorporated into a cell phones SIM card to do everything from detecting malaria to analyzing electrolytes. A phone camera can take a picture of a skin lesion and use a sophisticated algorithm to determine if it is melanoma. Digitizing breath might detect lung cancer. A high-tech tattoo worn on the skin can be read by your cell phone to measure your blood sugar.

    The Office Visit of the Future. Virtual office visits may replace face-to-face encounters. Tools like video chats, telemedicine, and e-mail are already available.

    Electronic Health Records as a Research Platform. Electronic databases have enormous potential: they can be useful in drug development, post-marketing surveillance, gathering statistics about disease, and monitoring adequacy of treatment. Just one example: if every patient on a drug were entered into a single database along with comparable patients not on the drug, even a rare adverse effect could be detected, and less rare effects could be spotted earlier. If we could include DNA sequencing in that database, we might learn which genotypes were susceptible to a certain side effect and could avoid prescribing the drug to such patients. We have the capability to do this today, although implementing it would be far from easy.

    The Privacy Issue. Hacking into databases is a danger to patient privacy today, and the danger will grow in proportion to the amount and value of the data. No one has yet built a truly hack-proof system, and its unclear that if it will ever be truly possible. As with medicine itself, the benefits must outweigh the risks. But consider what it would be worth to the large insurance companies and employers of the future, if they could discriminate based on genetic profiles and other private medical information.

    Genomics. Our ability to sequence patients genomes opens up whole new worlds. Topol characterizes genome analysis as hypothesis-free research, but I dont think thats quite accurate. We can screen lots of data looking for the unexpected, but we are still working with hypotheses about how that screening can produce results. Topol is enthusiastic about currently available direct-to-consumer genetic testing; Im not so sanguine. He says if his genome showed a high risk of blood clots he would be more inclined to get up and walk around on long flights. Maybe. Does genomic testing really change behavior? At least one study showed it didnt, but Topol was impressed that these patients expressed an increase in the intent to undergo screening tests like colonoscopy. I think supervision and interpretation of these tests by doctors is a reasonable precaution; Topol thinks it would constitute unfair interference with health freedom.

    Genetic analyses can assist in drug development by teasing out who benefits and who gets rare side effects. With knowledge of gene specific effects, some rejected drugs might have been approved for a subset of patients.

    Topol recognizes that it will not be a simple matter of finding a gene for every disease. Genetics is far more complicated: many conditions are multifactorial, genes interact with each other, and environmental factors affect gene expression. David Gorskis recent article explains the complexity of genetic factors in cancer. In one study he cites, multiple biopsy samples revealed different genetic profiles in different parts of the primary tumor and metastases. Personalized treatment based on genetic analysis of a single biopsy would fail.

    The Nicholas Volker Case. Topol describes this as the first instance of the life-saving power of genomic medicine. A child with a unique bowel disorder was found to have a mutation and was treated with an umbilical cord blood stem cell transfusion. His recovery was attributed to DNA sequencing, but doctors had already been contemplating this stem cell treatment before the mutation was detected. The outcome might have been the same without DNA testing.

    Treating the Individual. CAM providers claim to tailor their treatments to the individual, but they are mainly making things up or relying on pseudoscience. In the medicine of the future, we will have truly individualized treatment based on scientific reality.

    Doctor Bashing Topol criticizes current medical practice for relying too heavily on randomized trials and using population-based rather than individualized treatments. He speaks of Resistance from the priesthood of medicine. He says Of all the professions represented on the planet, perhaps none is more resistant to change than physicians.

    I think thats demonstrably false. Medical practice is constantly changing and evolving in response to new information and new technologies. It is true that it takes an average of 17 years from medical discovery to daily clinical practice and that this can be accelerated. We can do better. But so far there are very few instances where we have the knowledge to tailor prescriptions to a patients genome, and treatments based on studies of large groups are surely better than guesswork.

    CAM

    He quotes a review in The Economist that concluded Virtually all alternative medicine is bunk and characterized the CAM industry as a placebo-delivery service. I dont disagree with that. But Topol is careless about specific CAM facts. Some of his errors:

    To date, the only randomized, rigorously performed trial of a supplement was of glucosamines effect on knee arthritis.
    Glucosamine is quite effective.
    His description of Simon Singhs book and legal troubles is inaccurate on several counts.
    He claims that acupuncture, hypnosis and guided imagery lead to better outcomes, and that this is supported by good studies.
    I noticed this amusing typo: Chronic disease[affects] more than 140 individuals in the United States. Right, a lot more!

    Cautious Optimism

    The future of medicine holds great promise. I dont mean to be a wet blanket, but the challenge will be to temper our enthusiasm with good judgment. We cant assume unalloyed benefit from every technological advance. Just because we can do something like constantly telemonitoring everything from our serum potassium level to our blood pressure doesnt mean we should do it, or that it would be a good use of limited health care funds. We dont want to create a world of cyberchondriacs. Data overload is a problem. Privacy is a major concern. Forgoing face-to-face human interaction may have significant downsides. Whats called for is what scientific medicine has always called for: cautious enthusiasm with scientific testing. Not the destruction of medicine, but the natural continuation of it.
     
  2. hixxy

    hixxy Senior Member

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    That looks like far too much effort for me :( Summary?
     
  3. alex3619

    alex3619 Senior Member

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    I haven't read this yet but I am about to. I have known for years about the 17 year gap in knowledge by medical professionals, based on several old articles that I have trouble finding now. Its very disturbing. Its inevitable given current information sharing infrastructure. Its going to get worse before it gets better. I have had things to say about this elsewhere, I might write a couple of posts on it or maybe a blog. Its an important topic.

    One point: on monitoring it should not be presumed that if you monitor all the bits you understand what is going on. Those bits have to be integrated into useful models of interactions in order to better understand non-simplistic interactions.

    Bye, Alex
     
  4. Snow Leopard

    Snow Leopard Hibernating

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    Some interesting suggestions, though mostly inline with my existing thoughts.

    The whole hack-proof thing is overblown. The risk doesn't need to be any greater than our existing banking systems. All you need is to give the patient a password such that the secure medical records can only be accessed with their permission.

    On the back end, the data can be anonymised in such a way that it can only be accessed in bulk - government departments who deal with data on the public already operate under these principles. (The US census bureau, Australia's ABS etc)

    However, the great leap is that which is not mentioned - towards a predictive/preventative medical practise, not merely a reactive medical practise. The monitoring of the body/bodily fluids to detect disease before it becomes serious.

    Or measuring blood levels of various nutrients and being able to optimise ones diet (or even compound a multivitamin supplement) to optimise health.
     
  5. jimells

    jimells Senior Member

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    Actually I found the comments following the review to be more interesting than the review.

    Yes, I am very cynical, the original 'Debbie Downer', long before I got sick, but I can't help it...

    Anyway, during the course of my life I have witnessed a never-ending parade of hype describing how life will be so much better in the future. Remember how electricity from atoms would be 'too cheap to meter'? How about flying cars and personal jet-packs?

    The best lie told us how hi-tech would end drudgery in the workplace, the increase in productivity would give us shorter hours and more free time (now it's free for the boss to keep us tied to the job 24 hours a day with those hi-tech 'smart phones'), and we'd be able to retire at 55 on a livable pension.

    As Joe Hill wrote a hundred years ago in 'The Preacher and the Slave': "We'll get Pie in the Sky when we Die - THAT'S A LIE!"

    To me it is amazing that any new treatments are ever adopted, unless they are being promoted by a drug company, or a device manufacturer, or a diagnostic company, or a software company, etc. After all, advances are not widely adopted until the insurance companies will pay the claims, and they won't pay claims for anything that is not widely adopted, your basic Catch 22 scenario.

    So many of the latest 'breakthroughs' and gadgets end up being defective profit machines used to prop up the thoroughly corrupt and petrified institutions dominating present-day society. How many people did Vioxx kill? How many executives went to prison for murder?

    And what good are all these 'Modern Miracles of Science' when 50 million people in the 'richest country in the world' don't have a plastic card which allows access to these miracles, not to mention a few billion people in the rest of the world who aren't allowed to even have sufficient food and clean water?

    Boy am I in a foul mood tonight! Good thing it's almost time for Jon Stewart and Stephen Colbert. They are better medicine than I can get from the medical industry...
     
  6. *GG*

    *GG* Senior Member

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    50 million people what? too much Jon Stewawrt etc.. I think. Some people actually think they are news people, no wonder our country is in such a mess!

    I thought I read it was 2 to 3 years, 17 is stunnning, if accurate!

    Gg
     
  7. Waverunner

    Waverunner Senior Member

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    jimells: It is true that many predictions for the future were wrong but this is nothing to surprise us. it's hard to tell what will happen tomorrow. In contrary to what you said we didn't always have predictions that were overestimating our abilities:

    The progress we have in the multimedia field is just crazy. Imagine what lousy mobile phones we had 10 years ago and what we have now. The problem in the medical field is that government, regulation and big pharma interfere with the market. It is not the consumer or patient who decides what medication he buys and takes but it's the job of doctors, politicians and bureaucrats to decide for you. This leads to the problem that the gap between research and clinical practice is so wide.

    You bring up Vioxx. A perfect example of what is wrong. Neither doctors nor patients actually cared about using it. Why? Because government and big pharma said it was safe. This was the only reason. If people would be aware and if people would have the incentive to actually take responsibility for their lives, they wouldn't take every garbage that is prescribed for them. I think it was Alex who said, that with a little common sense and medical understanding it would be clear for everyone that a COX-2 inhibitor has a wide range of effects including very negative ones. As long as people don't take personal and economic responsibility for themselves or as long as government prevents them from doing so, the progress in the medical field will be much slower than in consumer products for example.
     
  8. SickOfSickness

    SickOfSickness Senior Member

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    I think he means 50 million don't have an insurance card so they can't get most treatments and care.
     
  9. xchocoholic

    xchocoholic Senior Member

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    Imho, the author has been watching too many star trek reruns .. :D

    The future of medicine will be determined by patients like us who use the internet to
    take control of our health. The trend is towards a healthier lifestyle which is why our
    grocery stores are carrying more "healthy" foods. Granted, they're still profit oriented so
    we're going to find garbage foods labelled healthy too. I don't expect anything more from corporations tho.

    The gf market has escalated dramatically in the last 5 years
    due to consumer education, NOT medical professional assistance. Imho, Most of them are still in denial. (Or could it be the power of addiction ?)

    Dr mark hyman has an article on how integrative medicine will be our future.


    Btw. Did you know the nih says it takes 11 years for a celiac to be properly diagnosed and that 97%
    are undiagnosed? Way to go nih. Between the nih, cdc and the fda, we're screwed.


    Tc .. X
     
  10. Enid

    Enid Senior Member

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    The future of medicine - No.1 - listen to your patients !. That way learn.
     
    Snow Leopard likes this.
  11. alex3619

    alex3619 Senior Member

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    In my book I have planned sections on the future of BPS (biopsychosocial) and EBM (evidence based medicine). Its more a wish list than a solid plan just yet, though I have more than a few ideas. I will be compiling additional analyses over time and seeing where that leads me. Both EBM and BPS have their uses, the problem is that they are being mismanaged by special interest groups. Some of those special groups are branches of the UK government, who want efficient (economic rationalism here) use of money for "free" public medicine.

    Yes waverunner, I predicted the Vioxx fiasco about a year before it went public. I discussed it with my doc as he prescribed me Vioxx. Vioxx is safe as a one-off drug for an acute problem, and highly effective if its a COX-2 mediated problem. Its not safe taken repeatedly at any dose - which is why it was banned.

    There are several things I think are essential to the future of medicine. The first has been discussed - patient driven medicine, using online resources. The second is about those resources. We need free medical information - zero paywalls. Along with this patent laws need to be reviewed. Many patents are probably highly irregular, especially those patenting genes, but they have not been challenged enough. I would also like to see EBM open up, become independent of government interference, and diversify control and funding. It should also be far less dogmatic - no rubber stamp approaches.

    BPS on the other hand is, I think, a very good idea - but again very badly managed and practiced. In particular it is being embraced by the bio- and the -social but the -psycho- group appear to be using it as an excuse to rubber stamp their very non-systematic methods. They only pay lip service to systems theory and approaches, and that is why they have failed.

    Bye, Alex
     

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