Healthcare, medicine & pharmaceuticals

Tech firms and personalised healthcare

Few people could name a medical device manufacturer but everyone knows the names, Apple, Google, Nike. It’s not surprising then, that these trusted technology brands are moving into personalised consumer health. In fact, this may be the best way for personalised healthcare to start to get the credibility it needs with governments and health insurers – especially if it saves money.

The idea of personalised medicine goes further than having people wear data-tracking gadgets (see our story, Strap on your health monitor). It is a specific form of medicine tailored to patients depending on their genetic or molecular profiles. One example was Herceptin, a drug for breast cancer based on a specific genetic mutation in those patients. The approach of differentiating products for different segments was appealing and surely more efficient.

But insurers were unconvinced, mostly because the therapies available so far are much more expensive than conventional ones. Pharma companies are wary of investing in personalised medicine (except for cancer) because the markets for them are naturally smaller. Last, the technologies needed to identify molecular markers and mutations are not fully developed and understanding of the human proteome (protein make-up of individual cells and genomes) is years away.

Three possible ways to bring on personalised medicine are: ease FDA regulations (provisional approval, for example), quantify the incremental cost of new pharma products in the long term (less than $US150 million in one case), and expand the number of patient-centric devices, such as scanners, imagers, or cardiac monitors. People with chronic diseases benefit from mobile health sensors that can measure heart rate, electrical conductance and water retention, for example. These devices, combined with molecular markers, allow doctors to make better decisions about the right treatment for the patient.

While Google and the like are not medical experts; they are trusted providers who can ease consumers into mobile healthcare, continual real-time monitoring, and eventually, true personalised medicine based on genetic markers. The technologies always come first. It takes a while for the more conservative mainstream to catch up.

Why the night shift is bad for you

Since we sleep for a third of our life, it makes sense that sleep research has become an important field. People who work night shifts, or rotating shifts that include nights, may be more at risk of health problems than people who work by day. Our body’s master clock responds to light, influences our autonomic system, and secretes hormones that tell us whether we are sleepy or stressed: interfering with this body clock has all kinds of effects.

Why does the body want to sleep at night? We have two systems that work together, homeostatic and circadian. The homeostatic system accumulates adenosine in the brain while we are awake – too much and we get sleepy. The circadian system responds to external cues, such as daylight - at night, melatonin makes us sleepy. Shift work interferes with these two systems.

Shift workers usually find it harder to sleep in the day because their biological clock wants them to be awake. Yet 20% of US employees work shifts that fall totally or partly outside 6am to 6pm and 1 in 15 work only nights. With the increasingly global nature of business, working through the night is becoming more common and even people not employed to work at night may still choose to get work done then.

A study of LA police who worked nights found they were more likely to be injured and carry symptoms of metabolic syndrome – precursor for diabetes and heart disease – than daytime workers. The BMJ reported a heightened risk of stroke and heart attack for people who work nights and the WHO declared in 2007 that shift work probably can cause cancer. Two recent reports confirm the risks of night shifts – one says shift workers are more likely to be obese, and one says shift workers suffer a decline in cognitive function faster than normal aging.

The incidence of obesity in shift workers is related to the fact that calories burn more slowly during the day than at night, so over time they need less food. Combined with fatigue from working at night, they are also less likely to exercise and often the food available at night is less healthy than during the day. A French study of 3,000 shift workers found cognitive decline – measured using memory and speed tests – over 10 years was equivalent to six and a half years’ of natural aging. Curiously, they had to stop shift work for five years to see any return to normal. Researchers questioned how this would affect people who do hazardous work at night, for example, healthcare workers.

Results of these studies combined with the perils of using electronic screens at night because of their blue light, make us wonder whether shift work should be better paid – and discouraged as a regular practice - or perhaps become subject to specific taxation.

StudentLife by phone

Student life is not all that it’s cracked up to be and, while some flourish, others miss classes or drop out. A new app, StudentLife, was designed to find out how students are coping along the way to try and prevent problems and, ultimately, help to keep them at university.

Students at Dartmouth College, US volunteered to load StudentLife on to their phones and be monitored over a 10-week term. The app recorded physical activity, frequency and length of conversations and GPS and the camera watched for when the lights were turned off to gauge sleep. From these data, the app infers happiness, depression, loneliness or stress. Researchers also had daily interviews with the volunteers, just to keep it human.

Researchers found that ‘flourishing students’ were more often with other people and had longer conversations, while struggling students spent more time alone, more time indoors and had disrupted, or too much, sleep. Disturbed sleep and short conversations is a predictor of stress.

When all mental states were compared with student grades, there was a correlation between negative feelings and poor academic performance over the term. Changes over the term became obvious, for example, when workload increased, sleep, chatting and physical activity all suffered.

The results of StudentLife suggest phones can be used for continuous mental health tracking, and should be more reliable than using occasional questionnaires. Questions of privacy emerge, as they always do with tracking data but, in this case, the user will have complete control. Prevention is better than cure and, if the app helps one student stay at university, perhaps it has done its job.

The doctor will text you now

Like many new technologies, telemedicine or telehealth, was widely used in the military before the rest of us saw it - because it was ‘cost effective’. Convincing governments, regulators, healthcare providers, and consumers is a bigger task. A conference in Rome late last year identified some barriers to adoption, including laws and payments systems that are set up only for face-to-face care and the problem of keeping patient data private. Others say patients may more readily seek advice from other doctors or feel they are being ‘fobbed off’ with care that is not face-to-face. (They may once have said this about banking.)

The largest healthcare market, America, demands that doctors be licensed in all the states where they operate because jurisdiction depends on where patients live. Europe is simpler, where doctors need only be licensed in one country, but members don’t agree on whether to pay for remote care – Germany rarely pays for it at all.

In America, only 21 states demand that telehealth pays the same as face-to-face care and Medicare mostly ignores it. However, there is a shift towards paying doctors for packages of care, rather than just one service, which could include remote care as part of the package. In a recent survey of health providers in America, prompted by the Affordable Care Act, a quarter believe fewer than 10% of their patients would use telehealth and 87% believe most of their patients will not be using it in three years.

Telemedicine is more than just a simple phone call and electronic versions of x-rays or doctors notes need to be very secure. In August last year, Chinese hackers stole data on 4.5 million patients (also see our story, Hacking of medical implants). Until this is sorted out, along with appropriate legislation and recognition of the value of giving remote healthcare, it seems unlikely telehealth will fulfill its early promise.

Treatment for trauma

A new technique for critically wounded people suspends their life temporarily to buy time to operate on them. Funded by the Department of Defence to the tune of $US800,000, it is a new trauma technique dubbed emergency preservation and resuscitation (EPR).

It works by lowering the patient’s body temperature and replacing blood with a saline solution at 10 degrees C. This must be done within 20-30 minutes. The surgeon must then repair any wounds within an hour, to prevent bleeding when the blood circulates again. They use a heart-lung bypass machine to restart blood flow and to warm the patient back to normal temperature.

The EPR technique was first explored by Dr Peter Safar, pioneer of cardiopulmonary resuscitation (CPR), and Dr Tisherman, but Dr Safar died in 2003. Dr Tisherman and his colleagues are trialling EPR on people at University of Pittsburgh and University of Maryland. The FDA says patients must be 18-65, have a penetrating wound, suffer cardiac arrest within 5 minutes of getting to hospital, and fail to respond to usual resuscitation methods.

If successful, this technique could be used on the battlefield; a paramedic could use a portable EPR to put the patient into a suspended state before they go to hospital. This sounds a bit science fiction, but it’s a cool treatment when you need it.