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12 years, 8 months ago

Osteoarthritis and joint replacement surgery

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In 2010, tennis legend Billie Jean King had both her knee joints replaced and it changed her life. Years playing the high-impact sport left the 39-time Grand Slam winner with joint pain and stiffness in her knees. Now at 68, she is playing tennis again. Like Billy Jean, thousands of people are opting to replace their traumatised joints and patients are fast becoming younger.
 
An escalating incurable and costly condition
As populations age peoples' joints are increasingly affected by osteoarthritis, a painful and incurable condition. Dr Anestis Iossifidis consultant orthopaedic surgeon, Croydon University Hospital, UK, says, "Osteoarthritis is the most common disease of the joints and one of the most widespread of all chronic diseases and the most common cause of severe long term pain and physical disability".
 
At any one time, 30% of American adults are affected by joint pain, swelling, or limitation of movement. The prevalence of osteoarthritis increases markedly with age and by 65 can be observed in over half of the American population.
 
Worldwide an estimated 630 million people have their lives blighted by osteoarthritis. In the UK the disease affects about 8.5 million people; a figure set to double to 17 million by 2030. The condition forces 33% of sufferers to retire early and each year this is estimated to cost the UK economy £3.2 billion. 
Causes and future treatments
The management of the disease is broadly divided into non-pharmacological, pharmacological and surgical treatments. There are a number of drugs under development and there are several drugs on the market whose clinical effectiveness and long-term safety still need to be determined.
 
Scientists believe they are close to discovering the cause of osteoarthritis, offering the hope of more effective treatment. A team from the University of Southern Denmark found that shortened ends of chromosomes are linked to the onset of osteoarthritis.
 
Abnormally short chromosome caps, called telomeres, were found in cells from damaged knee joints and those near the areas of severe damage were "ultra short".  Researchers suggest that these lengths of DNA play an important role in the development of the osteoarthritis and it is hoped that this finding will lead to a more effective treatment for the disease. 
 
In 2012 The Lancet reported, "An important first step", which could also lead to new treatments for the disease. Researchers from Newcastle University, UK, discovered eight sections of our DNA that are responsible for osteoarthritis. They suggest that, at least two or three of these genetic regions could be used to treat the condition since they all contain genes responsible for the production of cartilage: the tissue between bones that is damaged by osteoarthritis.
 
A 2013 article in Cell Death and Disease found that urocortin, a naturally occurring protein is crucial for the survival of chrondrocyte cells that produce and maintain healthy cartilage. According to Professor Paul Townsend from the University of Manchester and co-lead researcher of the study, "boosting the level of urocortin could be a huge breakthrough since it would help to provide long-term benefit for osteoarthritis and also act as a preventative agent".  
 
Researchers acknowledge it will be some time before an effective treatment is developed and in the meantime, the incidence of joint replacement surgeries are expected to increase, particularly among younger patients.
 
Knee replacement surgery evolving
While all joints are affected by osteoarthritis, knee replacement surgery is fast becoming a treatment of choice when there is severe joint pain or dysfunction, which is not alleviated by less-invasive therapies.
 
The treatment modality is rapidly evolving and benefits from ongoing advances in surgical techniques, medical technology and prosthesis design. Combined with the use of minimally invasive surgery, gender-specific prosthetics and computer-assisted navigation systems; orthopaedic surgeons are now able to offer patients total and partial knee replacement procedures that are associated with minimal risks, smaller incisions, faster and less painful rehabilitation, reduced hospital stays and durable, well-aligned, highly functional knees.
 
Today, 95% of all knee replacement procedures can be confidently predicted to be successful and, even 10 to 15 years after the operation, will still be giving good service. However, given that more people are electing to have joint replacement surgeries at increasingly younger ages; 10 to 15 years might not be long enough.
Baby boomers electing to replace their warn-out knees
According to a 2012 US study published in the Journal of the American Medical Association, between 1991 and 2010, the incidence of knee replacement surgery increased by 161.5% for Medicare recipients alone. Today, in the US, knee replacement surgery is one of the most common surgeries being performed and costs between US$11,000 and US$50,000 per knee.
 
During the nine year study period, 3.2 million Medicare beneficiaries underwent knee replacement surgery, which at the lowest end of the cost spectrum, amounts to about US$3.2 billion for new knees for Medicare patients.
 
Many active middle-agers are wearing out their joints with running and sport and suffering osteoarthritis years earlier than previous generations. In the US, baby boomers are turning 65 at the rate of 8,000 a day and a significant number of these are opting for joint replacement surgery earlier in life rather than long term medical therapies.
 
According to the American Academy of Orthopaedic Surgery the fastest-growing patient group opting for joint replacement surgery is between 46 and 64. By 2016, over 50% of all US knee-replacement surgeries are expected to be performed on people under 65.
 
Projections suggest, in 10 years time, over three million knee replacements will be undertaken each year in the US alone and the demand for new knees could outpace there availability.
 
The future is replacement revisions
Arthritis Research UK is investigating the success rates of knee replacement surgery in younger age groups.  According to its medical director, Professor Alan Silman, in 2010 there were some 90,000 knee replacement operations performed in the UK and increasingly these are being carried out on people under 50.
 
Today, younger patients are more informed about surgical procedures and are more likely than past generations to demand specific treatments. "Patients with osteoarthritic knees", says Professor Silman, "demand earlier surgical intervention."
 
According to the UK's Office of National Statistics, a third of babies born in 2012 will live to 100. Longevity is one of the successes of 20th century medical science and today, millions are retiring with a third of their lives still ahead of them.
 
No one knows the longevity of knee replacements in younger patients. According to Professor Silman, "We may well be faced with doing a lot more replacement revisions when these patients reach their 70s".
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12 years, 8 months ago

Brain tumor

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Two years ago, Ben Brabyn, a forty year old former British Royal Marine and investment banker turned entrepreneur, visited his doctor with headaches that another doctor had diagnosed as sinusitis. The second doctor suspected a brain tumour and immediately called for an ambulance to take Ben to Charing Cross Hospital, London. Scans showed a fist-sized tumor on the right side of his forehead, see above. Undetected, Ben's tumor could have killed him within days
 
Any brain tumor is serious and life-threatening because of its invasive nature in the limited space of the intracranial cavity. The threat a brain tumor poses depends on its type, invasiveness, location, size and the state of its development. A tumor may be particularly deadly because it can push against or invade important parts of the brain, as well as cause a lot of swelling that can result in blackouts, fits and other serious health challenges.
 
Within hours of being admitted to hospital, surgeons removed a large panel of bone over Ben's right eye and excised his tumor, which turned out to be a benign meningioma. Most meningiomas are benign and tend to be more common in middle-aged or elderly women than in men.  Ben is now fully recovered. 
 
Brain tumor deaths are increasing
Each year, around 165 million people in Europe are affected by some form of brain-related disorder, which suggests that almost every family in Europe is likely to be affected. Not everyone however will be as lucky as Ben Brabyn.
 
In the US, over 688,000 people are living with primary brain tumors, some 138,000 are malignant and about 550,000 are non-malignant. Since 2004 the incidence of brain tumors in the US has increased by 10%.  In 2013 in the US, an estimated 70,000 new cases of primary brain tumors are expected to be diagnosed. In 2012 an estimated 13,700 deaths were attributed to primary brain tumours.  

Brain tumors are the second-leading cause of cancer deaths in American children. In 2013, approximately 4,300 Americans younger than 20 will be diagnosed with primary brain tumors.
 
In the UK the situation is equally bleak. Over 9,000 people are diagnosed with brain and spinal cord cancer annually and it kills nearly 5,000. Over the past decade there has been a 16% increase in brain tumor deaths. The largest group of primary brain tumors is gliomas; a broad term that includes all tumours arising from the gluey supportive tissue of the brain. These make up 30% of all brain and spinal cord tumors and 80% of malignant brain tumours. 
 
Malignant brain tumors
Over the past 30 years, the outcomes for patients with malignant brain tumors have been poor and have not changed substantially. Compared with the survival rates of other cancers, brain cancer has one of the lowest: only about 19% of those diagnosed with brain cancer in the UK between 2006 an 2010 were alive in 2011.
 
Average survival rates remain between 12 and 15 months and those surviving more than three years are rare. Not only are brain tumors devastating for patients and their families and friends, but the cost of their treatment is high and rising rapidly. In Europe alone the cost of treating brain tumors is estimated at €1.5 million every minute.
 
R&D increasingly dependent on charities
Although brain cancer is the second leading cause of cancer-related deaths in children and young adults, brain cancer research is relatively poorly funded. Over the past few years, several pharmaceutical companies have closed their neurosciences R&D because financial returns do not justify the investment. This means that fewer therapies are being developed and as a consequence the costs of brain related drugs are rising.
 
The burden for brain tumor R&D is increasingly falling on charities and the overwhelming majority of these tend to serve the big cancers. In the UK for example, 60% of cancer research funds go to five of the 48 main types of cancers. Research into brain tumors receives one of the lowest levels of funding: about 1.4% of total UK research-spend. Also, partly due to the complexities of the brain, brain cancer research does not benefit significantly from cancer research in general.
 
But there is hope. According to Stuart Essig, a leading figure in the American Children's Brain Tumor Foundation and Chairman of Integra LifeSciences Corporation, the world's largest neurosurgical company, "Many children's tumor specialists are excited about treatments currently being researched and developed. They expect to see advances in several areas: less traumatic surgeries, new chemotherapeutic drugs and combinations of drugs that effectively could replace surgery and radiation therapy, chemotherapy with fewer side effects, treatments that marshal the body's own immune system to kill cells and gene therapy."  
 
A leading clinician's view
"Although a brain tumor is a devastating diagnosis for both patient and doctor, there is some good news", saysChristos Tolias, a leading UK neurosurgeon from King's College Hospital, London and the London Neurosurgery Partnership.  "Benign tumors can often be removed using a combination of surgical and non surgical methods, which are constantly evolving".
 
"Neurosurgical techniques, such as endoscopically assisted transphenoidal approaches (through the nose) and image guidance (computer assisted navigation), permit the successful removal of large tumors with minimal trauma for patients. Also, Gamma or Cyber Knife therapies can result in excellent outcomes without surgery".
 
"When we're dealing with a glioma; more invasive therapy is necessary and the results are still not very effective. However, special techniques such as gladiolan guided surgery (special dye, which allows the tumor cells to be visible in the operating room) as well as more aggressive resections combined with multidisciplinary support, are steadily achieving meaningful results for patients".
 
Christos Tolias and his colleagues are, "excited about some novel treatments at the experimental stage in King's College. One, in clinical trials, is designed to boost the immune response and there is basic research being carried out that may allow us to deploy gene and cellular level treatments". But, Tolias stresses, "The need for continued research support is imperative".  
 
Recognising the Symptoms
However, as Ben Brabyn discovered, early detection is extremely important. But because the brain is so well protected by the skull, diagnoses is challenging and detection only occurs when diagnostic tools are directed at the intracranial cavity. Thus, late detection is frequent and often when the presence of the tumor has caused unexplained symptoms.
 
Warning signs depend on the size and location of the tumor and can be general and misleading, but common symptoms include: (i) short-term memory loss and difficulty concentrating and using words, (ii) severe headaches that mainly occur in the morning, (iii) nausea or vomiting, (iv) seizures in people who do not normally suffer them, (v) problems with speaking, reading, writing and recognising names of objects and (vi) vision problems.
 
Costly but effective screening
The safest and quickest way to detect a brain tumor is with an MRI scan. However, most patients do not receive their first MRI until they are already experiencing symptoms, which is often too late. Although expensive, MRI screening, as part of a regular annual medical check-up, is the most effective way of detecting a brain tumor. 
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12 years, 8 months ago

Medical Tourism

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Medical tourism started in ancient Greece when pilgrims travelled to Epidauria, a healing sanctuary of the God Asclepius in the Saronic Gulf.  Asclepius's rod, a snake-entwined staff, remains a symbol of medicine today. 
 
A multi-billion dollar global industry
Over the past 20 years, medical tourism has grown rapidly to become a global market of some US$60 billion with an annual growth rate of about 20%. Today, over 50 countries identify medical tourism as a national industry.
 
It is different to international medical travel, where wealthy patients travel to exclusive private clinics in search of the latest technology and the highest quality service. Medical tourism is when patients  from wealthy countries travel to hospitals in emerging countries, such India and Thailand, for medical treatment at a lower cost.
 
Medanta is such a hospital in Gurgaon, a garden suburb of New Delhi, India, just 10 minutes from the Indira Gandhi International Airport. It has 1,250 beds, 350 critical care beds and 45 operating rooms, which work 24-7, 365 days a year. The hospital is spread over 45 acres and its high standards of care and competitive prices draw medical tourists from all over the world.  
 
Joint Commission International, the private accreditation agency, now lists more than 500 hospitals worldwide that have earned its approval. Patients visiting these hospitals can expect to pay one-third to one-tenth the cost of the same treatment in a US hospital, enabling them to afford lifesaving and life-enhancing procedures, performed by excellent doctors, in well-equipped hospitals, without long waiting periods.
 
Value seeking patients
Medical tourism has become the most visible part of a generalised growth in the international trade in health services. Services typically sought include elective procedures as well as complex specialised surgeries. Virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available to medical tourists.
 
Often, it makes more sense for a patient to receive healthcare abroad especially when certain specialisms or state-of-the-art treatments are not available at home, or subject to a long waiting list. Legal and ethical obstacles, such as stem cell or donor-related treatments are drivers behind the increase in health tourism. However, cost plays an important role and many health tourists merely seek equivalent treatment in countries that are able to provide it more cheaply.
 
A typical liver transplant in the US can exceed $250,000; the same surgery in India at an accredited hospital is $40,000. Knee replacement in the US can cost $50,000, or you can travel to India and pay $7,000. Many US health insurers are happy to pay for out-of-country care and thereby decrease their costs. Some US employers providing healthcare coverage are encouraging medical tourism by offering to share their savings with employees.
 
Where to go
India's advantage is that it is the cheapest of any of the world's medical tourist destinations, while being the equal to other major destinations in terms of quality of staff, equipment and health procedures. With many new state-of-the-art hospitals and western trained doctors, it is easy to see why India is the leader in medical tourism accounting for about 25% of the Asian market. In 2009, however, India introduced a cosmetic surgery tax, which disadvantaged it compared to its Asian neighbours.
 
Southeast Asia is now a prime market for medical tourism. Industry experts expect the number of medical tourist visiting Asia to grow by 20% annually, creating a regional market of some US$10 billion by 2014. India, Malaysia, Singapore and Thailand account for about 90% of the total medical tourism in Asia.
 
Thailand is the most popular destination, treating the highest number of patients compared with other Asian countries and accounts for 40% of medical tourists in Southeast Asia. Thailand's prices are slightly higher than India's, with its main advantage being a better overall tourist experience and offering greater bundling of services. However, Thailand's medical tourist arrivals and market are beginning to slow.
 
Malaysia on the rise
For the past three years, Singapore's medical tourism has been growing at 12% annually and is projected to continue to grow at this rate for the next few years. Malaysia is the fastest growing medical tourism market in the region with 33% growth in the last three years. Around 40 of Malaysia's 113 private hospitals now serve medical tourist.
 
More than 80% of Malaysia's medical tourists visit from Indonesia, where the healthcare lag has yet to catch up with the rising middle class. Patients visit from China: 30% of Malaysia's citizenry is of Chinese descent. Patients also visit from the Middle East. As a moderate Muslim country, Malaysia offers cultural compatibility to the Islamic patient. Australians fleeing rising healthcare costs seek comfort in Malaysia's universal command of the English language.
 
Malaysia now competes with India for the value-seeking patient, as well as the affluent patient seeking access to specialties in the region. Global healthcare consumers from Europe and North America are also beginning to locate Malaysia on the medical travel map. 
 
Everyone's a medical tourist
Medical tourism has become a collaboration between local, state and national governments, marketers, medical institutions, trade associations, insurance companies, travel agencies and hoteliers. South Korea for instance has dedicated one of its islands to medical tourism, which is just a two hour flight from five mega Asian cities. Most countries offer a comprehensive medical service, but as the industry matures expect to see market segmentation.
 
Significant economic advantages for host countries
Medical tourism offers significant economic advantages for host countries. Besides increasing economic activity and tax revenues, medical tourism draws tourists to destinations, which they may otherwise not have visited and potentially strengthens a destination's brand. It helps to reverse brain drains and improve local education by attracting skilled and experienced professionals and keeping local trained doctors and graduates from leaving to seek employment elsewhere.
 
The industry also helps to reduce the seasonal nature of some tourist markets. Elective surgery has more flexible scheduling and therefore can be used to soak up excess capacity for tourism providers during the off-peak season.
 
Some significant challenges
By far the biggest challenge for the industry is associated with transplant surgery and the unethical harvesting or organs, which is more apparent in some countries. Also, implanted organs are sometimes invaded with viruses, which recipients discover only after returning home and then require corrective therapy.
 
The Future
Medical tourism will increase as healthcare costs continue to rise and consumerism spreads.  However, medium term capacity constraints are expected to slow the industry's growth. In the longer term, health insurers and patients are expected to leverage cost and performance data in order to take advantage of regional differences in pricing, quality, customer satisfaction and waiting time.
 
Western centres of medical excellence, which have developed partnerships with medical establishments in emerging countries, are well positioned to play an important role in the future of the industry.
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12 years, 9 months ago

Changing patterns of healthcare delivery

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A&E is the barometer of the NHS.  In 2012 some 22 million people attended A&E in the UK. A 50% increase in the last 10 years, while the UK population only increased 7% over the same period.

The Royal College of Surgeons has warned that the knock-on effect of this is last minute cancellations of planned surgeries. Official figures show that for the first three months of 2013 some 20,000 planned operations were cancelled.
 
Transferring resources out of hospitals
Minded of the seriousness of the A&E challenge, the Academy of Medical Royal Colleges, the NHS Confederation and the patient group National Voices combined to report that the NHS urgently needs to transfer resources out of hospitals and into the community by expanding GP surgeries, health centres, district nurses and social care.
Such a significant transfer might be helped by enhancing the ways that health providers engage people about their health, which is about improving communications while reducing face-time with health professionals. This is important if Matthew Parris is right. Writing in The Times, recently he warned that patients' allegiance to traditional health providers is weakening. Online communications technology has the potential of strengthening this.
 
Both health professionals and patients have embraced health technology as transformational. Doctors are in love with iPads, consumers are loading wellbeing apps onto their phones and patients with chronic diseases are using smartphone attachments to measure and monitor their vital signs.
 
Exploiting technological trends to improve healthcare
However, technology alone is not the answer. Technologists have an undying faith in technology, which they view as the primary driver of change.  This is mistaken because people select, install, develop and manage technology. It is therefore people and the choices they make, not technology, which is the primary driver of change.  

Already health professionals are making choices to help transfer healthcare out of hospitals and into communities. They are successfully harnessing the propensity for people to play games to improve patients' cognitive skills, especially after stroke or the onset of dementia. Health workers are exploiting telehealth to provide patients with remote access to healthcare professionals as well as using social networks to improve the connectivity of health workers and enable patients to play a more active role in their own healthcare.
 
What patients want
Communications between health providers and patients benefit by an understanding of patients' healthcare needs and preferences. In today's world of interconnectivity, we know what patients want. 
Sixty six per cent of patients want answers about specific disease states, 56% want information about treatments, 36% want to find the best place to be treated and 33% want information about payment.
Further, 80% of all patients search online for health information and, if they cannot get face-time with their health professionals, they prefer online video answers to their questions directly from doctors. Video has become the preferred medium for content consumption by patients.

However, we also know that 90% of all doctors provide patients with information in pamphlet form. While this difference describes a communication challenge, it also suggests the answer: more doctors should use online solutions to communicate with patients.
 
A new online solution for health providers
Currently, there is no easy solution for patients to quickly and easily obtain reliable online answers to their questions in video format.  Also, there is no easy solution for doctors to post answers to patients' questions in an online video format.

Dr Sufyan Hussain, a specialist registrar and honorary clinical lecturer in endocrinology at Imperial College London, has participated in a beta test of HealthPad, a new free and easy-to-use web-based communication solution for non technical health professionals to create rich media publications for their patients and colleagues: www.healthpad.net.

Doctors post short and easily understood video answers to frequently asked questions about the prevention, symptoms, diagnosis, treatments, side effects and aftercare associated with different disease states and also about wellbeing. The videos are aggregated and stored in a cloud, linked to biographies of contributing doctors on HealthPad and can be easily accessed by patients on smartphones and tablets at anytime from anywhere. 
To-date, Dr Hussain has accrued a substantial personal video content library, which addresses frequently asked questions from his patients who, "don't always have to attend a hospital for reliable information to help them manage their conditions".  According to Dr. Hussain, using HealthPad, "can reduce valuable doctor face-time with patients while improving doctor-patient relationships and patient compliance by helping them understand their condition and treatment better".
 
Video healthcare libraries
Video healthcare libraries, similar to the one Dr Hussain has created, play a significant role in the US to communicate premium, reliable and up-to-date health information to patients and their carers. An important difference with pamphlets and WebMD is that people feel an allegiance to personalised video content in a way that they do not for pamphlets and the written word.
 
Psycho-social benefits of video healthcare libraries
US evidence suggests that patients feel a greater allegiance to health professionals who provide them with sought after information in a format they like and understand and deliver it personally to their smartphones.

Dr Whitfield Growdon, a cancer specialist who teaches at the Harvard University Medical School and has a gynaecologic medical and surgical practice at the Massachusetts General Hospital also participated in HealthPad's beta test and, like Dr Hussain, accrued a significant video comntent library, which he now uses with his patients. "Videos", says Dr Growdon, "personalise medicine and have positive psycho-social effects. Patients feel that they know me before we have even met and are less inclined to be swayed by discordant and often incorrect medical information they encounter on the internet that can create misperceptions and fear".

Video healthcare libraries connect doctors directly with patients and inform about medical conditions and treatment options. They are cheap to create, cost little to operate and develop, they can be quickly and easily updated and accessed 24-7, 365 days a year from anywhere at any time.
 
Significant opportunity for UK health providers
Seventy per cent of patients who search online for health information become confused and frustrated.  

HealthPad, the new platform which Drs Hussain and Growdon contributed, aggregates premium reliable health information in a format demanded by patients and represents a significant opportunity for health providers to transfer medical knowledge out of hospitals and into the communities.
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12 years, 9 months ago

Can a dancing elephant help the NHS?

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Can a dancing elephant help the NHS?
 
In May 2013 Sir David Nicholson, the head of NHS England, announced his resignation. Nicholson was an insider's insider and his in-depth knowledge of the organisation served well his political masters, but he was unable to bring about much needed transformative change.   
 
Escalating costs, changing technology, the growth and spread of diseases and an ageing population all conspire to present the NHS with its biggest challenge since it was created in 1948.
 
Will the new leader be another insider appointed to continue the political chess game with our national health? Or, will the new CEO seize the opportunity presented by lessons from outside the NHS and lead the transformative change that the NHS sorely needs?
 
Lessons from outside the NHS
Twenty years ago IBM, once the most profitable company ever, faced a similar challenge to that confronting the NHS today. In 1993, IBM was on the brink of bankruptcy and considered by various commentators as, "a dinosaur and a wreck". IBM appointed Lou Gerstner, a business leader, to transform the Company. Nine years later, IBM had become one of the world's most admired companies. Gerstner described how he achieved the transformation in a book, Who Says Elephants Can't Dance?
  
What are the similarities between IBM and the NHS?
What lessons can the NHS learn from IBM?
 
Inward looking organisation resistant to change
By the early 1990s, IBM had become an inward looking mainframe manufacturer driven by internal systems rather than customer needs. The PC revolution gave IBM the equivalent of a severe heart attack and put computers in the hands of millions and shifted power and purchasing decisions to individuals.  
 
By 1993, IBM's annual net losses reached a record US$8 billion and it was on the verge of bankruptcy. Before the arrival of Gerstner the Company's reaction to its crisis was to deploy resources more effectively, improve outcomes, control costs, split its divisions into separate independent businesses and attempt to sell some of them.
 
Parallels with the NHS
The NHS is an inward looking public monoploly, funded by the UK taxpayers to the tune of £110 billion a year, high bound with its own standards and procedures.
 
Like the old IBM, the NHS is less sensitive to its rapidly changing external environment, which includes rising patient expectations, expensive new drugs, the impact of an ageing population and the escalation of chronic non communicable diseases.
 
The response of the NHS to its current challenges is similar to IBM's initial response before the arrival of Lou Gerstner. It is focused on cost savings, streamlining its services and privatising specific functions. Such a strategy did not turnaround IBM and will not turnaround the NHS. This is understood by both the National Audit Office and the Parliamentary Select Committee on Health, which have called for the NHS to engage in "transformative change".
 
Stepping through a time warp
Transformative change for IBM began in 1993 with the appointment of Lou Gerstner as CEO at a time when IBM, similar to the NHS today, was bloated with excess costs and bureaucracy and its people demoralised.
  
Interestingly, Gerstner was neither an insider nor an industry expert, but was recruited from Nabisco, an American biscuit manufacturer and had had previous experience at American Express and the consultancy firm McKinsey & Co. Gerstner likened his arrival at IBM to stepping through a time warp. The world had moved on while IBM stood still. This resulted in a significant mismatch between market needs and IBM's offerings. 
 
When Gerstner took the reins at IBM, the conventional wisdom, both from industry pundits and IBM insiders, was that the only solution for saving IBM from eventual disaster was to cut costs, increase efficiency, divisionalise and sell-off parts. 
 
Complete integrated solutions
Gerstner was determined to keep IBM together and convinced that the only way to do so was to change its culture: away from an inward looking bureaucracy to a responsive service company in-tune with customers' needs. Gerstner recognized that IBM's enduring strength was its core competency to provide integrated solutions for customers with complex problems. This, Gerstner judged to be the unique IBM advantage.
 
Gerstner's approach was to drive the Company from the customer view and, "turn IBM into a market-driven rather than internally focussed process-driven enterprise". And it worked. According to Gerstner, keeping IBM together and changing its culture, "was the first strategic decision and, I believe, the most important decision I ever made, not just at IBM, but in my entire business career".
 
Will the new leader of the NHS have Gerstner's strategic clarity, rottweiler focus and determination to execute?
 
Importance of culture
During his customer focused transformation, Gerstner learnt not to be fooled by bogus measurements and data associated with customer satisfaction and targets. "People", Gerstner said, "do what you inspect, not what you expect".
 
Gerstner's most important and proudest accomplishment was cultural change that brought IBM closer to its customers by inspiring employees to drive toward customer defined success.
 
"Until I came to IBM, I probably would have told you that culture was just one among several important elements in any organization's makeup and success; along with vision, strategy, marketing, financials, and the like I came to see, in my time at IBM, that culture isn't just one aspect of the game, it is the game. In the end, an organization is nothing more than the collective capacity of its people to create value".
 
Lessons for the NHS
In, Who Says Elephants Can't Dance? Gerstner describes three important insights, which helped transform IBM and could help the NHS:  
 
1. A service intergrator controls every major aspect of an industry
2. Every major industry in today's network-centric world is built around open standards
3. It is important to abandon proprietary development, "embrace software standards" and "actively license technology".  
 
In 1993, many people criticized IBM for their selection of Gerstner because he was neither an insider nor a technologist. You can hear something similar were the NHS to appoint a CEO from outside the healthcare industry.  Based on IBM's transformation and the insights described in Who Says Elephants Can't Dance? Gerstner was the right person for the job.
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12 years, 10 months ago

Stroke

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In January 2013 Andrew Marr, the 53-year-old BBC TV presenter and journalist, had a stroke after a bout of intensive exercise on a rowing machine in a gym.
 
What is a stroke?
A stroke is a serious medical emergency where the supply of blood to the brain is disrupted. In over 80% of cases, strokes usually happen because a blood clot blocks the blood supply to the brain. They can also happen when a weakened blood vessel that supplies the brain bursts and causes brain damage, known as a haemorrhagic stroke.
 
Andrew Marr's stroke prompted two questions: (i) Do younger healthy people have strokes? and (ii) Does physical exercise contribute to strokes?    
 
Are stroke victims getting younger?
Andrew Marr was one of 152,000 people in the UK who have strokes each year. Stroke is the third largest cause of death in the UK and the largest single cause of severe disability. There are approximately 1.1 million stroke survivors living in the UK and each year strokes cost the NHS £2.8 billion.
 
The picture is no better in the US, where every 40 seconds a person has a stroke, each year strokes kill 130,000 and cost the US $38.6.
 
Strokes are uncommon, but not rare in men in their fifties like Andrew Marr. Recent research suggests that strokes among the elderly are declining, while strokes among younger people are increasing.
 
Between 1998 and 1999 in the UK, 9,000 people under 55 were admitted to hospital due to stroke. By 2011 this figure had risen to more than 1,600.
 
It is not altogether clear why stroke is increasing among younger people, although experts note its correlation with type 2 diabetes.
 
The importance of specialist stroke units
Andrew Marr said that he believed what he read, that taking, "Very intensive exercise in short bursts is the way to health." Just before his stroke he said, "I went onto a rowing machine and gave it everything I had and had a strange feeling afterwards: a blinding headache and flashes of light". He took no notice and went home. The following morning he woke up lying on the floor unable to move.
 
The most important care for people with any form of stroke is prompt admission to a specialist stroke unit, but even with prompt treatment a stroke can often be fatal. 
 
Physical exercise and stroke
Marr, who is making a good recovery, said his advice would be to be wary of rowing machines, or at least of being too enthusiastic on them.
 
According to Dr Mike Loosemore, an expert in sports medicine at University College Hospital, London, "Intensive physical activity after work doesn't compensate for long periods sitting still in an office during the day (sedentary behavior). Lack of physical activity and sedentary behavior are two seperate risk factors. That's like saying drinking less alcohol can compensate for smoking and it can't".
 
In the first interview given after his stroke, Andrew Marr mentioned that he discovered that he had had a couple of mini strokes the previous year. A mini-stroke, or transient ischaemic attack (TIA), is similar to a stroke but the symptoms only last a few minutes. Due to the short duration of symptoms, many people are unaware they have had a stroke, as was the case with Marr. While not as serious as a stroke, a TIA is an important warning sign that you need to make substantial changes to your lifestyle or start taking medication and usually both.
 
Risk factors and prevention
The main risk factor for a haemorrhagic stroke is high blood pressure as the excess pressure can weaken the arteries in the brain and make them prone to splitting or rupturing. You cannot control some stroke risk factors, such as heredity, age, gender and ethnicity. Some medical conditions, such as high blood pressure, high cholesterol, heart disease, diabetes, overweight or obesity and previous stroke or TIA, can also raise your stroke risk. However, avoiding smoking and drinking too much alcohol, eating a balanced diet and increasing your activity are all choices you can make to reduce your risk of stroke.
 
According to Dr Loosemore, "The best way of preventing a stroke is to eat a healthy diet, engage in regular activity, avoid drinking too much alcohol and stop smoking. I'd stress activity rather than exercise because activity can be done anywhere at any time. Increasing your activity at work is probably better for you than intensive work-outs in a gym after work. For example, at work you can stand instead of sitting and take the stairs instead of the elevator.It's never too late to increase your activity, eat more healthily, stop smoking or cut down on alcohol".
 
Symptoms and aftercare
The symptoms of a stroke include, (i) sudden numbness or weakness of the face, arm, or leg-especially on one side of the body, (ii) sudden confusion, trouble speaking or understanding, (iii) sudden trouble seeing in one or both eyes, (iv) sudden trouble walking, dizziness, loss of balance or coordination and (v) sudden severe headache with no known cause.
 
Andrew Marr mentioned that the stroke had fortunately not impaired his voice or memory, but had affected, "the whole left hand side of my body, which is why I'm still not able to walk fluently". Stroke does not only cause physical damage, it also incurs psychological and emotional damage on survivors and their families. These effects, which include depression and aphasia (problems with language and speaking), are often profound, last a lifetime and are inadequately supported.
 
eHealth and managing stroke survivors
A stroke both debilitates and isolates a person. More than half of all stroke survivors are left dependent upon others for everyday activities. To give more control to patients medical professionals are increasingly using eHealth strategies to manage the aftercare of stroke patients.   
 
Standard behavioural therapies used to rehabilitate stroke patients, translate well into eHealth strategies and onto apps for smart phones and tablets. These include telemedicine, social media forums and apps to enhance impaired cognition and movement. Increasingly, stroke units throughout the country are using telemedicine, which enable doctors to check patients in their homes. This saves money and increases the quality of care. The introduction of eHealth devices means that stroke survivors can take greater control of their treatments from their homes and, as a consequence, feel more independent and less isolated.
 
Investment in research
Investment in stroke research is critical to the reduction and management of the disease. The majority of stroke research in the UK is supported by the Stroke Association, a charity. Each year the charity disburses about £30 million on research, which is small compared to the annual UK research expenditures on cancer and heart disease.
  
Does austerity promote health benefits?
According to an American public health organisation, 75% of healthcare costs are spent on treating sick people with preventable conditions, but only 3% on preventing people from getting sick in the first place.
 
To help reduce and manage the escalation of stroke, more  might be spent on preventive strategies.
 
Interestingly, following the Cuban Missile Crisis, the incidence of strokes, heart attacks and cancer fell significantly among Cuban citizens as their enforced isolation and austerity obliged them to adopt healthier diets and lifestyles. Could austerity trigger something similar in the UK?
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12 years, 10 months ago

Transforming the management of heart disease

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In the UK there are some 2.6 million people living with heart disease, two million more have early signs of it. Each year, roughly 200,000 people die of cardiovascular complications and the disease costs the UK about $10 billion annually. A similar story can be told for most countries.
 
According to the World Health Organisation, "Coronary heart disease is now the leading cause of death worldwide; it is on the rise and has become a true pandemic that respects no borders".
 
A polypill prevents heart attacks and strokes
According to a 2012 study undertaken by scientists from the University of London, a polypill that combines three generic blood pressure medicines and a cholesterol fighting drug, reduces blood pressure by 12%, lowers bad cholesterol by 39% and could cut heart disease events by 72% and strokes by 64% and, on average, patients receiving the therapy could gain an extra 11 years of life.
 
According to Dr David Wald from Queen Mary College, London, who led the study, "If half of the over-50s in the UK took the pill daily, it would prevent many thousands of heart attacks and strokes each year".
 
Path breaking gene therapy for heart patients
The polypill does not work for chronic heart failure sufferers of which there are more than 0.75 million in the UK alone. Such patients have renewed hope from a new human clinical study, led by Dr Alexander Lyon, Imperial College London, which employs gene therapy to repair damaged hearts.
 
The study is based on 20 years of laboratory research spearheaded by Professor Sian Harding of Imperial College London who discovered that patients suffering from heart failure exhibit low levels of the protein SECRA2a. He also developed a genetically modified virus designed to produce high levels of SECRA2a. Professor Harding then engineered a way for the virus to be introduced into a failing heart to target and reverse some of the critical molecular changes arising in the heart when it fails and thereby restore the diseased organ to its former status.
 
Over a decade ago, gene therapy was widely viewed as a panacea, but it failed to deliver on its early promise. However, recent clinical successes have bolstered renewed optimism in gene therapy and scientists hope that Dr Lyon's study will be a turning point for the technique as well as benefitting people with heart failure.
Underfunding of pensions a threat to heart treatment
A challenge to the costly management of heart disease is the UK government's chronic underfunding of state and public sector pensions, which, to a large extent, is currently paid out of general taxation. Recent government reforms and public sector cuts do not compensate for the lack of growth in the economy and the escalating healthcare costs of heart disease.
 
The enormity of the gap between the monies the UK government receives and monies it pays out in state and public sector pensions is ballooning out of control and will result in a significant cash flow crunch. If nothing transformative is achieved in healthcare, significant and deep cuts to the NHS are inevitable and heart patients will suffer. 
 
More transformative health strategies called for
The challenge for the NHS is not simply to protect the diagnosis and treatment of heart disease for a few difficult years and then expect everything to return to normal. Rather, it is to deliver a step change in the management of heart disease. Both the UK National Audit Office and the Parliamentary Select Committee on Health have raised concerns about the NHS being unable to make genuine efficiency gains. Both bodies suggest that the Department of Health is not sufficiently focused on transformative change. 
 
Significant infrastructural support for transformative healthcare change already exists. While modern society fosters unhealthy diets and lifestyles, which contribute to heart disease, it also facilitates the availability of health information and interactive mobile devices that together can help to reduce and manage the burden of coronary heart disease. 
Transformative change for heart disease is at our fingertips
The management of heart disease is at our fingertips and can benefit from the explosion and the transformative effects of eHealth. At the close of 2012, the UK had 82.5 million mobile subscribers and 36 million of these were Smartphone accounts. By the end of 2013 the number of Smartphone's in the UK is projected to be 44 million rising to 63 million by the end of 2016. 
 
Currently, Smartphone's and tablets have access to some 60,000 mobile health-based apps, a significant number of which can assist with the reduction and management of heart disease. eHealth devices can detect and track vital signs, monitor the progression of risk factors and connect heart patients directly with health professionals without leaving their homes.
 
Such devices can be used to reduce the burden of heart disease while transferring a large part of its management to the home.
 
eHealth apps under FDA scrutiny
If you have not been prescribed a mobile app, you soon may be. In March 2013 the US Food and Drug Administration (FDA) announced that eHealth apps, which transform mobile phones into medical devices, will be regulated.
 
However, tablets and Smartphone's will not be considered by the FDA as medical devices, app stores and developers will not be  considered medical device manufacturers and apps will not be forced to seek re-approval for small updates. Also, apps that either contribute to electronic health records or act as personal health monitors will not be regulated. 
 
This suggests that the explosion in eHealth apps for the management of heart disease will continue. Heart patients will become increasingly knowledgeable about eHealth and this will help drive the management of the disease away from hospitals and primary care centres into peoples' homes and encourage individuals to take greater care and more control of their own hearts.
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12 years, 11 months ago

Radiotherapy: If it were a drug it would be a wonder cure

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On the 1st November 2006, 43 year old Alexander Litvinenko invited two Russian colleagues for a traditional English afternoon tea at a central London hotel. Litvinenko, a former KBG officer who escaped prosecution in Russia, received political asylum in the UK and became a spy for MI6 as well as the Spanish secret service.

One guest seruptitiously slipped a lethal dose of polonium-210 into Litvinenko's tea. Three weeks later Litvinenko died of radiation poisoning after suffering hair loss, fever, endema, diarrhoea, nausea, vomiting and coma. Today, in thousands of clinics throughout the world, the same radiation that killed Alexander Litvinenko is successfully used to cure or palliate cancer in millions of patients.

Were radiation therapy a drug, it would be a wonder cure.

A booming global device market

Each year worldwide, there are about 13 million new cancer cases diagnosed, about 0.35 million in the UK and some 1.6 million in the US. The National Institute of Health estimates that the annual cost of cancer to the US is about US$227 billion.

About a half of people in the UK and two thirds of Americans diagnosed with cancer receive radiation therapy and radiation oncology has become big business. By 2018 the annual global revenues from the radiation therapy device market are expected to reach US$3.6 billion. Driven by increases in the incidence rate of cancer and increasing demand from emerging markets, the radiation therapy device market is projected to grow at an annual rate of over 9%.

Accuracy with minimal side effects

Radiation therapy employs high energy radiation along a spectrum of different wavelengths. The type and amount of radiation that a patient receives is carefully calculated to destroy cancer cells, while causing as little damage as possible to surrounding healthy tissue. With advances in technology, clinicians are able to give powerful doses of radiation quickly with pinpoint accuracy, targetting only the tumours, sparing nearbly healthy tissue and keeping toxicity levels low. The treatment has minimal side effects.

The genesis

Radiation therapy has its genesis in late 19th century medical experiments undertaken soon after the discovery of X-rays. Twice Nobel Laureatte Marie Curie discovered radium in 1898 and later coined the word "radiation". Radium was used successfully to treat lupus and later was found in hot spring water, which was then marketed as a cure for arthritis, gout and neuralgias.

In the early 20th century, medical science believed that small doses of radiation were harmless and the effects of large doses temporary. Marie Curie was a casualty of this misconception. The widespread use of radium in medicine ended when it was discovered that physical tolerance of radiation was lower than anticipated and exposure resulted in long term cell damage.

In 1934 Marie Curie died of aplastic anemia contracted by excessive exposure to radiation and is buried in a lead-lined coffin. During her life she regularly carried tubes of radioactive isotopes in her pockets and commented on how beautifully they glowed in the dark. Her laboratory is preserved at the Musee Curie, but all her scientific papers are too dangerous to handle and scholars who want access to them have to wear special protective clothing.

Variation in Service

Radiation therapy provision varies significantly across Europe. This is partly because of the financial and technical investments required to establish and operate radiation therapy centres.

In January 2013 The Lancet published a 33 country comparative European study of radiation therapy provision. Researchers found significant disparities in access to radiation treatment, substantial unmet needs and a fair amount of service fragmentation. The Netherlands, Nordic countries and the UK employ a centralized approach, with services concentrated in a few large centres, while in most other European countries the service is more dispersed and facilities vary in size and capacity. The annual number of cancer patients per radiation therapy system ranges from 307 in Switzerland to 1,583 in Romania.

Exquisite accuracy

The late 1990s was a period of progress in radiation therapy with the advent of 3D radiation therapy, intensity-modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) and today, stereotactic body radiation therapy is widely practiced. This differs from conventional radiation treatment and employs multiple imaging modalities such as PET-CT and MRI, which allows the delivery of high doses of radiation with exquisite accuracy to targeted lesions.

Are healthcare systems and radation therapist ready for the future

Radiation oncology continues to evolve as clinicians and medical scientists climb further up the seed-chain of technology and consider next-generation techniques such as adaptive radiation therapy, which focuses on real-time treatment planning. Recently, the University of Texas, MD Anderson Cancer Center in Houston, US, joined an international research group dedicated to merging radiation therapy and MRI technology, which is expected to deliver images of a patient's soft tissues and tumours during therapy.

The MIMA Cancer Center in Melbourne, Florida, US has invested heavily in radiation therapy and its technological infrastructure. It uses information technology to pull together the interfaces between its treatment planning, treatment delivery and information management systems and provides a repository for images, clinical documentation, scheduling, treatment plans and follow-ups. MIMA is paperless and treatment planning images are immediately sent to treating physicians' image enabled cell phones, which allows them to view images and check data anywhere and at any time. Treating physicians also use their mobile phones to show patients images of their progress.

Such technologies are expected to enhance radiation therapy, but they are also expected to generate petabytes of patient data, increase collaborative and image-dependent workflow and require significant investments in information technology infrastructure.

Are healthcare systems and radiation therapist ready for this?

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12 years, 11 months ago

Activity is medicine

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Keen to provide a lasting legacy of the 2012 London Olympic Games, the UK Government funded a new Institute of Sport, Exercise and Health based at University College London

The Institute is expected to increase exercise in the community and develop strategies to prevent diseases related to inactivity.

Dr. Mike Loosemore, a leading sports physician based at the new Institute, advocates that activity rather than exercise is a crucial, but an underused therapy to prevent, manage and treat many medical conditions.

According the Dr. Loosemore, "We need to increase our daily activity. We spend most of our working day sitting and sedentary behaviour is more damaging to health than smoking."

Dr. Loosemore spends much of his time with elite athletes, but believes that an important legacy of the London Olympics is to encourage everyone to increase their activity no matter how small.

"People need to increase their daily activity" he says, "because bouts of intensive exercise do not compensate for sitting for hours. We should focus on increasing the small movements we do every day. Anyone can increase their activity. It doesn't cost anything, it can be done anywhere at any time and it is sure to benefit your health and wellbeing. I'm surprised governments haven't latched onto this." Is Dr. Loosemore right?

 

Health systems treat illnesses rather than change peoples' behaviour

Our health and longevity are influenced by our genetics, environment and behaviour. We have little control over our genetics and environmental risks are reduced through vaccinations.

The only factor we control is our behaviour. Prompted by escalating healthcare costs, Western governments have successfully changed peoples' behaviour towards smoking. Healthcare systems however, are not focused on changing peoples' behaviour before they become ill, but on diagnosing and treating peoples' illnesses.

Exercise is Medicine is a movement that does emphasise the importance of behaviour. Launched in 2007 by the American College of Sports Medicine and the American Medical Association, it is dedicated to changing peoples’ behaviour towards exercise, which it suggests is crucial to the prevention, management and treatment of type 2 diabetes, heart disease and cancer.
 

Couch potato syndrome kills

A 2011 survey conducted by Tata Steel suggested that British children are likely to become a generation of couch potatoes who cannot swim, run or cycle.

The study of 1,500 children aged between six and 15 revealed that half the children surveyed lived sedentary lives and spent their time surfing the internet, chatting on social networks and playing video games.

Couch potato syndrome is a significant global challenge and it can kill. Emerging research evidence suggests that sedentary behaviour effects human metabolism, physical function and health outcomes.
 
When you sit, the electrical activity in your muscles become constant, your body uses little energy and slows down.

The take home message is simple: Sedentary lifestyles lead to weight gain, higher blood sugar and blood pressure levels, which increase your risk of heart disease, diabetes, obesity and cancer compared with those who sit less. 
 

Nothing compensates for long periods of inactivity

A challenge for traditional activity and obesity research is that it relies on self-reporting and people significantly under estimate how long each day they sit.

In 1999 researches from the US Mayo Clinic, challenged long-held beliefs about human health and obesity. Drs. James Levine and Michael Jensen addressed the question, why do some people who consume the same amount of food as others gain more weight?

After assessing how much food each of their research subjects needed to maintain their current weight, they banned exercise and gave all their subjects an extra 1,000 calories per day. This resulted in some gaining weight while others gained little to no weight.
 
The reasons for the difference were not apparent until six years later when the researches employed motion-tracking underwear.

"The people who didn't gain weight were unconsciously moving around more," Dr. Jensen says. "Their bodies simply responded naturally by making more small movements than they had before the overfeeding began, such as taking the stairs, helping with chores, standing rather than sitting and simply fidgeting."

On average, the subjects who gained weight sat two hours more each day than those who had not. Drs Levine and Jenson's research goes against conventional wisdom, which suggests that if you control your diet and exercise regularly, you can compensate for a sedentary lifestyle. This, they argue, is untrue and, "is like suggesting that the effects of smoking can be compensated by jogging". 

Levine and Jenson's findings are supported by researchers from the American Cancer Society who found that benefits from regular daily exercise can be undone if you spend the rest of your time sitting.

Research on inactivity suggests that those who sit for prolonged periods have a higher risk of disease than those who move their muscles every now and then in a non-exercise manner. Also, those who sit for six hours or more have an 18% higher death rate than people who sit for three hours or less a day.
 
Sitting seems to be an independent pathology. Sitting for long periods is bad for your health whether you watch television afterwards or go to the gym. Dr. Mike Loosemore is right: excessive sitting is a lethal activity. 
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13 years ago

Binge drinking: an avoidable epidemic

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Earnest Hemingway, the novelist, used to say he, "drank to make other people more interesting".

Today, binge drinking is a silent epidemic.

Often unrecognized, binge drinking is a serious issue among British and American young women.

In the US, nearly 14 million women binge drink about three times a month and each year nearly 1,400 American college students die from binge drinking.

Professor Dame Sally Davies, the UK’s Chief Medical Officer, highlighted the rising tide of UK deaths from alcohol related liver disease. "We really have young people who are binge drinking and it is damaging their livers.” Liver disease costs the UK NHS £1 billion a year.

A hidden problem

In addition to causing liver disease, binge drinking also increases the chances of breast cancer, heart disease, sexually transmitted diseases and unintended pregnancy.

Researchers at University College London have recently reported that alcohol consumption could be much higher than previously thought, with more than three quarters of people in England drinking in excess of the recommended daily alcohol limit.

Since the beginning of 2010 more than 2,400 more girls than boys have been seen by hospitals because of alcohol. Suggesting that alcohol abuse appears to have a much greater immediate effect on women than men.

The ladette culture of binge drinking is not confined to young women. UK Department of Health figures show that in 2010 there were 110,128 alcohol related hospital admissions for women between 35 and 54. A switch to drinking at home has contributed to the problem of women increasingly drinking.

In February 2013 the debate over a minimum price for alcohol was reopened by a report by the Alcohol Health Alliance, a coalition of 70 health organisations and published by the University of Stirling. It recommends that a 50p minimum charge for a unit of alcohol is needed to end the "avoidable epidemic" of binge drinking deaths.

Dr Paul Southern, a consultant hepatologist at Bradford's Royal Infirmary Hospital in the UK, said that people in their 20s are dying from liver disease caused by binge drinking and children as young as 12 are falling prey to the “pocket money alcohol business.”

According to Dr Southern there is, “only one single effective deterrent (for binge drinking) and that is taxation.” While recognising the problem of binge drinking the UK government has not yet delivered a solution.

A cultural change

While supporting the call to increase the price of a unit of alcohol sold in supermarkets, Professor Dame Sally also suggests that, "We need a cultural change.”

Mobile Apps are now available for predicting alcohol abuse, using research-based questionnaires to help patients determine if they are at risk, while other more light-hearted Apps allow users to see the effect of alcohol abuse on their future appearance.

Innovative ideas to make people think twice, but with little research evidence available, several doctors have come out against such aids saying that they wouldn’t recommend such Apps without empirical evidence in place to support their effectiveness.

In such settings is scientific medicine holding back opportunities for mHealth?

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