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#coronavirus #CoVID-19  #frontlinehealthcareworkers #keyworkers #healthcare

• The coronavirus CoVID-19 has created the greatest health-cum-economic-cum-societal crisis in history and put unprecedented pressure on overstretched and unprepared healthcare systems
• Before the coronavirus outbreak, primary care in England already was in crisis, fuelled by an aging population, a large and increasing demand for its services and a shrinking supply of health professionals
• In 2019, before the outbreak, 75% of primary care doctors (GPs) across 540 clinics in England were over the age of 55 and nearing retirement and a large percentage of newly trained GPs were seeking employment abroad
• Patients who could not get GP appointments used A&E departments as convenient drop-in clinics for minor ailments, which significantly increased healthcare costs and burden
• For decades successive UK governments have tried in vain to transform the nation’s primary care services predicated upon face-to-face patient-doctor consultations
• Several well-funded long-term national plans advocated increased digitization of some routine primary care services
• But before the coronavirus outbreak only 1% of all primary care consultations were online
• What these national plans could not achieve in decades appears to have been achieved in days by the UK’s NHS’s response to the coronavirus outbreak
• Today, millions of patients in England are having face-to-face appointments with their GPs replaced by telephone or video consultations
• Could CoVID-19 transform the UK’s traditional primary care model?

The next ‘big thing’ in healthcare
 

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The coronavirus CoVID-19
 

In December 2019, initial reports of a new coronavirus - CoVID-19 - emerged  when patients from Wuhan, the sprawling capital city of China’s Hubei province, which has a population of some 11m, presented with pneumonia of unknown origin. By December 2019 the virus had spread to other countries and on 11^th March 2020, the World Health Organization characterised the outbreak as a pandemic. CoVID-19 is an illness caused by a member of the coronavirus family that has never been encountered before but is believed to come from animals.There have been other coronaviruses. For example, severe acute respiratory syndrome (Sars) and Middle Eastern respiratory syndrome (Mers) are both caused by coronaviruses that came from animals. In 2002, Sars spread virtually unchecked to 37 countries, causing global panic, infecting more than 8,000 people and killing about 800, but it soon ran itself out. Mers first emerged in 2012, cases of which have been occurring sporadically since. Mers appears to be less easily passed from human to human, but has greater lethality, killing 35% of about 2,500 people who were infected. CoVID-19 is different to Sars and Mers in that the spectrum of disease is broader, with around 80% of cases leading to a mild infection. There may also be many people carrying the disease and displaying no symptoms, making it even harder to control. CoVID-19 affects your lungs and airways and can cause pneumonia. So, people with an  inflammatory lung disease that causes obstructed airflow from the lungs, such as asthma and chronic obstructive pulmonary disease (COPD), are particularly vulnerable; as are people with weak immune systems, which make them susceptible to infections that might be more severe or harder to treat. In January 2020, China’s national health commission confirmed human-to-human transmission of CoVID-19, and there have been such transmissions in countries throughout the world. Those who have fallen ill are reported to suffer a general feeling of being unwell, fever, dry cough, tiredness, breathing difficulties and a loss of taste and smell. In roughly 14% of cases the virus causes severe disease, including pneumonia and shortness of breath. In about 5% of patients it is critical, leading to respiratory failure, septic shock and multiple organ failure. As this is viral pneumonia, antibiotics are of no use. The antiviral drugs we have against flu will not work. Recovery depends on the strength of your immune system. Many of those who have died were already in poor health. Initially, scientists were challenged to accurately assess how dangerous CoVID-19 was because there were inadequate data. A challenge  to  collecting data was because of a shortage of tests and also because people who had contracted the coronavirus were emitting, or “shedding,” infectious viruses early in the progression of the illness; sometimes before they develop symptoms.

The 1918 Spanish Influenza remains the most devastating virus in modern history. The disease swept around the globe and is estimated to have caused between 50m and 100m deaths. A cousin of the same virus was also behind the 2009 swine flu outbreak, thought to have killed as many as 0.58m. Other major viral outbreaks include the Asian flu in 1957, which led to roughly 2m deaths and the Hong Kong flu, which killed 1m people 11 years later. 

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In this Commentary
 

This Commentary is produced by HealthPad, which is an online health solutions company. (see below). We begin the Commentary by briefly describing the underlying reasons for the UK’s primary care crisis, which include: (i)  the changing and aging population and the consequent increased demand for healthcare, (ii) the shrinking supply of health professionals, and (iii) failing national initiatives to improve the provision of primary care. We then draw attention to some well funded national plans, whose intentions have been to harness the power of information and digital strategies to reform and improve primary care services in England. We also cite research, which suggests that these plans have failed. The Commentary briefly describes a number of innovative online healthcare solution companies, (HealthPad is one).  The majority of these are private initiatives, which have taken advantage of the UK’s high smartphone penetration rates and advanced wireless networks to enter the UK’s healthcare market with an intention to transform the sector. Notwithstanding, to-date the overall impact of these companies has been marginal, due in part, to the general resistance of private enterprises playing a significant role in England’s public NHS, which offers free healthcare to all citizens at the point of care. However, they represent a nascent UK online healthcare solutions market, which is well positioned to benefit from the nation’s response to the coronavirus outbreak, which has forced more primary care services to be delivered online. To increase their footprint these companies, which are largely driven by technology, will need to become more strategic and consolidate. And this will take time. We conclude the Commentary by looking to China and WeDoctor to understand the potential that online services can make to the delivery of healthcare in England. WeDoctor is a Chinese mobile app launched in 2010 to help patients book doctor appointments. Over the past decade it has added more functions to help unclog China’s fragmented and bureaucratic healthcare system and has become a US$5.5bn healthcare company, which connects some 210m registered users with 360,000 doctors.

 
UK’s primary care crisis
 

There are three drivers to the UK’s primary care crisis: (i) the changing and aging population, which increases the demand for healthcare, (ii)  the shrinking supply of healthcare professionals to a point where GP workloads are becoming unsafe, and (iii) failing national initiatives to improve the provision of primary care. Let us briefly describe these.

 
Changing and aging population
 

The UK’s population is changing and aging, which is fuelled by improvements in life expectancy and a decrease in fertility. According to the UK’s Office of National Statistics, in 2016, there were 12m UK residents aged 65 years and over, representing 18% of the total population. 25 years before, in 1991, there were 9m, accounting for 16% of the population. By 2040, it is projected that there will be an additional 8m people aged 65 years and over in the UK: a population roughly the size of present-day London, which will account for 25% of the total population.

 

A report by Deloitte,  a consultancy, suggests that as people age so their propensity for illness increases and more than a quarter of the UK’s population of some 66m have long-term chronic illnesses. This places a significant extra burden on the nation’s overstretched primary care services by utilizing about half of all GP appointments. Deloitte’s analysis is supported by a British Medical Association’s 2019 GP Patient Survey, which found that GP clinics are now caring for 0.72m more patients than they were in 2018. Findings of a 2016 report by the UK’s Royal College of General Practitioners (RGCP), suggest that GPs see 1.3m patients a day and do more than 370m consultations annually: 60m more than in 2010. A research study on GP productivity carried out by the King’s Fund and also published in 2016, suggested that between 2010 and 2015 the total number of telephone consultations increased by 15%, but still only accounted for 1% of all patient-doctor consultations.

 
Shrinking supply of GPs
 

As the UK’s population has grown and aged and the consequent demand for healthcare has increased, so there has been a sustained fall in the number of GPs. This  dynamic is described in a Nuffield Trust report published in May 2019, which confirms the findings of a joint report from the Institute of Fiscal Studies and the Health Foundation for the NHS Confederation, which concluded that, “The fall in GPs per person reflects insufficient numbers previously being trained and going on to join NHS England, failure to recruit enough from abroad and more GPs leaving for early retirement”. As to the future, a  2019 report by three leading think tanks - the Nuffield Trust, the Health Foundation and the King's Fund - predicts that GP shortages in England will almost triple to 7,000 by 2024. According to NHS Statistics, Facts and Figures, currently there are just over 42,000 GPs working in England, down by nearly 1,500 since 2016.

 

Failure to stop or slow these trends means today, primary care services in England struggle with staff shortages and a rising demand for care. A 2019 Pulse Magazine survey found that  GPs in England are seeing more patients than is safe. A probe undertaken by The Times in 2019 suggested that the  national shortage of GPs has left some surgeries with one permanent doctor caring for as many as 11,000 patients and one in 10 GPs are seeing up to 60 patients a day, double the number considered safe.

 

GPs across the UK work an average 11-hour day. In that time, they typically see patients for 8 hours and spend the other 3 on administrative tasks such as checking test results and reading letters sent by hospitals.  A 2019 British Medical Association survey found that more than 80% of GPs said the pressure to attend to multiple tasks at once meant they were unable to guarantee safe care, while 91% said excessive workload was the main reason the NHS was struggling to recruit enough staff. The situation has resulted in patients having to wait longer - up to three weeks - for a GP consultation. It seems reasonable to suggest that GPs with too many patients and using traditional face-to-face delivery methods will fail in their duty of care, which obliges them to inform patients about their health and reach shared clinical decisions about treatments. This requires that patients understand their condition/s and are well informed. In many cases, a 10-minute  face-to-face GP consultation might not be the best way to achieve this.

 
Failing national initiatives to improve primary care
 

Subsequent UK governments have struggled to reduce the primary care crisis with well funded national plans. In 2019, the British Medical Journal published findings of a survey to report UK GPs’ views and experience of national healthcare initiatives introduced in England to address the workforce crisis in general practice. The survey was conducted in the same region as a similar survey undertaken in 2014. This allows for a comparative analysis to see how GPs’ views have changed over time. Findings confirm that primary care in England remains in crisis and suggest that numerous national initiatives to improve general practice are perceived by GPs as, “reactive in approach”. To reduce the primary care crisis, respondents suggested, “more GPs and better education of the public". 

 

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The UK’s NHS
 

Healthcare in the UK is mainly provided by the National Health Service (NHS), which is a vast public institution funded largely from general taxation to the tune of some £134bn (US$161bn) a year. Created in 1948, the NHS  provides free health services at the point of care for everyone living in the UK and has become the largest single payer health system in the world, and the biggest employer in the UK with 1.2m full time equivalent (FTE) workers, which is the fifth-largest workforce in the world. NHS England is a vast bureaucratic and fragmented organisation, which has proven difficult to change. Private provision of NHS services has always been controversial, even though some services, such as dentistry, optical care and pharmacy, have been provided by the private sector to the NHS for decades and most GP practices are private partnerships. It is challenging to determine how much the NHS spends each year on the private sector because central bodies do not hold detailed information on individual contracts with service providers, especially where these contracts may cover relatively small amounts of activity and spending. Notwithstanding, estimates suggest the share of the NHS’s total revenue budget that is spent on private providers is about 7.3%. 

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National plans to improve the NHS
 

The planning and authorising of NHS services is the responsibility of regional Clinical Commissioning Groups (CCGs). Although CCGs are constantly changing because of mergers, as of 2019, there were 191 CCGs in England supporting about 7,000 primary care clinics, some 42,000 GPs and about 15,800 FTE nurses who work in GP clinics, and 1,257 hospitals, which include NHS Trust-managed hospitals and private hospitals that provide services to the NHS. In total, the NHS employs around 150,000 doctors  and over 320,000 nurses and midwives.
 

Successive UK governments have been aware of the impact of technological advances, changing healthcare needs and societal developments on healthcare and have introduced a succession of well-funded national plans to change and improve the NHS. For example, in June 2018, the UK’s Prime Minister announced a new five-year funding settlement for the NHS that amounted to an extra £20.5bn (US$25.2bn) between 2019 and 2024, which represents a 3.4% real average annual increase.
 

NHS long term plan to transform primary care
 

To unlock the funding, national bodies were asked to develop a long-term plan to help the NHS cut costs and improve services. The suggested plan articulated the need to integrate care in order to meet the needs of a changing population and was in line with the Forward View, a planning document published in 2014 and the General practice forward view,which was first published in 2016 and updated in subsequent years. The long-term plan committed the government to an extra £2.4bn (US$3bn) a year to speed up the transformation of primary care and suggested GP clinics join together to form networks typically covering 30,000 to 50,000 patients and provide them with multidisciplinary integrated care. The plan also suggested ‘significant changes’ in the existing performance management and payment of NHS GPs [the Quality and Outcomes Framework (QOF)] in order to encourage more personalised care.

 
NHS long term plans and private online healthcare solution companies have delivered little change
 

Three of five principal objectives of the latest NHS long term plan are to: (i) “give people more control over their own health and the care they receive”;  (ii) “increase the contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems and avoid Type 2 diabetes”, and (iii) “provide more convenient access to services and health information for patients”.

The plan emphasises the importance of developing digital services, and recommends that within five years, all patients should be able to access GP consultations via a telephone or online. This goal is supported by NHS Digital, which is the national information and technology partner to the UK’s health and social care system. Its mission is to harness the power of information and technology to improve healthcare. Over the past decade there has been an increasing number of innovative online private  healthcare solutions companies entering the market. (see below). Notwithstanding, these and the NHS’s well-funded national plans, have failed to dent the primary care crisis by slowing the vast and escalating demand for healthcare and reversing the shrinking supply of healthcare professionals. So, for the past two decades at least, the NHS has tended to operate on the cusp of a crisis.
 

The death of distance
 

According to Deloitte, the UK has more than 90% smartphone penetration. The main driver of high smartphone adoption rates is the take-up among older age groups. By 2023 smartphone ownership among 55-to-75-year-olds will reach 85% in the UK, and the difference in smartphone penetration by age will disappear. Further, the UK’s smartphone market has seen a greater variety of choice of models and the introduction of faster and more reliable wireless networks. This has benefited the online private healthcare solution companies, which have entered the UK market to provide varying degrees of qualified online healthcare information, consultations, networking opportunities, triage and Q&A. According to Shetty, “A doctor only needs to touch a patient if s/he is going to operate on that patient. If a doctor doesn’t need to operate, a doctor-patient consultation can take place remotely. For a patient-doctor communication distance doesn’t matter.” (see video below)

 

 A doctor only needs to touch a patient if s/he is going to operate on that patient
 
Innovative online healthcare solution enterprises
 

The new online healthcare solution enterprises are a combination of private, public and charitable initiatives, which are well positioned to contribute to the transformation of the UK’s traditional primary care model and include: Babylon Health, which provides remote consultations with doctors and healthcare professionals via text and video; BioBeats, a workplace wellbeing platform designed to empower and improve mental health; Docly, a digital messaging healthcare service, which is a spin-off of Min Doktor; Doctorlink, which partners with payers, healthcare professionals and pharmacists to provide a 24-7 platform for NHS patients to assess symptoms; DrDoctor, a patient engagement platform, which enables patients to book, change and cancel their appointments; EggPlant, a software testing and monitoring company, which helps to streamline patient activities; Dr Fox, an online primary care clinic and pharmacy service; Gogodoc, an online GP video consultation service with possible follow-up home visits; Healthcare Communications UK, which provides appointment management software and patient experience surveys; HealthPad, an online platform that manages and distributes healthcare video information between health providers and patients in order to improve outcomes and cut costs, and has accrued a proprietary content library of over 6,000 short videos contributed by leading clinicians that address peoples FAQs across some 30 therapeutic pathways, (HealthPad is the publisher of this Commentary).  HealthTalksOnline, an events and community portal for health; HealthUnlocked, a social networking service that offers peer support to help people manage their health; Healum provides healthcare professionals with a software, which enables them to support and motivate their patients to better manage their conditions; LIVI, provides GP video consultations; Medshr, a platform for medical professionals to discover, discuss and share clinical cases and medical images; Microtest Health, a health informatics company that provides practice management systems for NHS GP surgeries. MSKnote Limited creates clinical applications for healthcare professionals and patients with a focus on musculoskeletal conditions; MyWay Digital Health provides advice and solutions to help patients better manage diabetes; NHS.uk/conditions provides online text-based information and advice about medical conditions; NHS 111, a free-to-call medical helpline; the Now Healthcare Group, a GP video consultation platform and tele-pharmacy; Patient Access, which started by enabling patients to book GP appointments online and order repeat prescriptions and has evolved to allow patients to connect with their GPs remotely and access their medical records online; Patientinfo provides patients and health professionals with online health information. PatientAccess and Patientinfo are subsidiaries of EMIS Health, a leading supplier of  software used by NHS England; Patients Know Best, a social enterprise, which provides patients with access to their medical records and information about treatments; PatientsLikeMe, an online service that helps patients find people with similar health conditions in order to take actions that are expected to improve outcomes; Push Doctor, an online video consultation service; SaySo Medical is a digital communications agency, which connects people in order to improve their health; SystmOne, a centrally hosted computer system that provides primary care professionals with electronic patient health records in real time at the point of care; uMotif, a platform that captures electronic patient-reported outcomes data across a range of conditions and works with pharmaceutical companies to measure patient’s health, outcomes and experience; Unmind, a workplace mental health platform designed to  empower organisations and employees to improve their mental wellbeing; Visiba Care, a digital solutions company, which provides communication and administration software for healthcare practices; VisionHealth provides NHS primary care professionals with software solutions; VisualDX provides clinical decision support systems to enhance diagnoses and therapeutic decisions in order to improve patient safety; WebMD, an online publisher of healthcare news and information, and Zava, an online GP and pharmacy service.

 
 Technologically heavy and strategically light
 

Despite a significant number of online healthcare solution enterprises entering the market and the fact that some provide services to millions of people in the UK, this market segment is in its infancy and fragmented. All the initiatives mentioned above have been advantaged by the NHS’s response to the coronavirus outbreak. Notwithstanding, to permanently increase their footprint and significantly influence primary care in England, barriers to private enterprises and to online services will need to be reduced; and private companies in this segment will need to act more strategically and consolidate.

 

Most of these online healthcare service providers are technologically heavy and strategically light. For private companies in this market to grow and increase their influence on the NHS they will need to increase their focus on profitability and scale, which will require them to become more strategic and develop merger-integration skills. To become a dominant player, a company will have to successfully consolidate. Speed and merger competence are paramount. Companies that capture critical ground early and move up the consolidation curve the fastest will be successful. Enterprises that are slow to consolidate will become acquisition targets and disappear. Companies that stay out of the consolidation contest altogether will not survive.

A Chinese example
 

History has shown that many short-term emergency measures have a tendency to  become permanent fixtures. Thus, the UK’s response to the coronavirus CoVID-19 outbreak might permanently reduce the barriers to moving routine primary care tasks to innovative private online enterprises.

 

In an attempt to fully appreciate the potential of increasing online primary healthcare services in England, consider WeDoctor, a Chinese mobile app launched in 2010 by artificial intelligence expert Jerry Liao. Originally called Guahao (Mandarin for “booking”), WeDoctor started as a simple booking platform that made it easier for patients to make appointments with doctors. From these humble beginnings WeDoctor grew by adding extra functions such as reminders for regular medical checks, screening, prescriptions and online diagnoses and consultations. This helped to unclog China’s fragmented and bureaucratic healthcare system and made quality healthcare more accessible to the average person.

 

WeDoctor secured backing from Tencent Holdings, a Chinese multinational conglomerate, Sequoia Capital, the Goldman Sachs Group and the insurer AIA Group. In 2018, the company raised US$0.5bn in a private financing round at a valuation of US$5.5bn. Today, WeDoctor has more than 210m registered users mainly in China for its online appointment booking, prescription and diagnosis services and is linked to about 3,200 hospitals and 360,000 doctors. In March 2020, at the height of the CoVID-19 pandemic, it was reported that, in the latter half of 2020, WeDoctor intends to raise HK$1bn in an IPO on the Hong Kong Stock Exchange at a valuation of HK$10bn.

 

Although NHS England is much smaller than China’s healthcare provision, it is similarly fragmented and bureaucratic. The UK online solutions enterprises described in this Commentary have significant potential simply by helping to reduce GPs large and increasing burden of administration while increasing the connectivity between patients and GPs. This will help GPs to concentrate on what they have been trained to do and improve healthcare for people in most need.

 
Takeaways
 

Over the past two decades, legacy primary care systems and attitudes in the UK have slowed the uptake of online healthcare solutions. Notwithstanding, the NHS’s response to the coronavirus CoVID-19 outbreak might prove to have helped to transform the UK’s traditional face-to-face primary care model by making GPs deliver some of their services online. In a recent interview with the New York Times, Dr Bruce Aylward, Assistant Director-General of the World Health Organization, stressed how the Chinese had responded to the coronavirus outbreak by significantly increasing the amount of medical care the nation provides online.  In light of the discussion in this Commentary, be minded that in Mandarin the word “crisis” is denoted by two characters: 危机, one means ‘disaster’ and the other means ‘opportunity’.

 

 

#coronavirus #coVID-19 #NHSEngland #NHS #pandemic #primarycarecrisis #ChinaWeDoctor #WeDoctor #DigitalHealthcare 

• The burden of breast cancer throughout the world is significant and increasing
• Research has shown that a cheap pill (anastrozole) halves postmenopausal women’s risk of breast cancer and continues to be effective seven years after women stop taking the drug
• Anastrozole has fewer side-effects and is more effective than comparable treatments
• Government watchdogs both in the UK and US recommend anastrozole
• But the uptake of the drug in the UK is relatively low
• Doctors are not prescribing anastrozole and women are not availing themselves of the drug
• The UK’s NHS should employ new behavioural techniques to influence and change doctors’ and patients’ decisions and increase the uptake of anastrozole to reduce the burden of breast cancer

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• Bioengineers throughout the world are competing to achieve the Holy Grail: an affordable, point-of-care blood test - liquid biopsy - that detects cancer before any symptoms present
• Success in achieving this will save millions of lives, substantially reduce healthcare costs and make investors, researchers and organisations billions
• Despite significant advances no one has yet achieved the Holy Grail and there remains a substantial gap between researchers’ aspirations and reality
• How close are we?

Similar studies   Nottingham University’s CEAC is also working on similar tests to that used by Alfattani for pancreatic, colorectal and liver cancers. Solid tumours like these, as well as lung and breast cancer, represent around 70% of all cancers. Further, a similar test for lung cancer is currently being tested in a randomised controlled clinical study in Scotland, which is believed to be the largest trial of its kind in the world, involving 12,000 people at high risk of developing lung cancer because they smoke. You might also like:   Liquid biopsies to detect pancreatic cancer are near

You might also like: AstraZeneca’s strategy to target early cancer In 2014 Guardant launched a next generation sequencing cfDNA assay called Guardant360 for treatment selection in a number of solid tumour cancers. In December 2018, the company launched an assay referred to as LUNAR to detect a range of early stage and recurrent cancers. LUNAR is based on data that Guardant collected from 80,000 advanced cancer patients using its 360 technology. In October 2019, the company launched ECLIPSE, a 10,000-patient clinical study to evaluate the performance of a second generation LUNAR blood test to detect colorectal cancer (CRC) in average-risk adults. The study is intended to improve CRC screening rates by offering a simpler liquid biopsy that overcomes challenges associated with current testing methods described above.

• Prime editing devised by researchers at the Broad Institute led by David Liu is a significant advance of the original CRISPR gene editing tool discovered in 2012
• CRISPR can cut and edit your DNA to correct defects inside your body’s cells to prevent and heal a range of incurable diseases and has revolutionized biomedicine
• The original CRISPR is fraught with inaccuracies referred to as off target effects
• Prime editing substantially reduces CRISPR’s off target effects and has the potential to correct up to 89% of known disease-causing genetic variations
• CRISPR also has the capacity to edit genes in an embryo in such a way that the change is heritable
• In 2018 Chinese researcher He Jiankui “created” the world’s first CRISPR babies
• This triggered international criticism from scientists and bioethicists
• A principal concern is that CRISPR is easy-to-use, cheap, regularly used in thousands of laboratories throughout the world and there is no internationally agreed and enforceable regulatory framework for its use

Prime editing   Prime editing is different to previous gene editing systems in that it uses RNA to direct the insertion of new DNA sequences in human cells. According to David Liu,  the senior author of the 2019 Nature paper and a world renowned authority on genetics and next-generation therapeutics, “a major aspiration in the molecular life sciences is the ability to precisely make any change to the genome in any location. We think prime editing brings us closer to that goal”.  Because prime editing provides a means to be more precise and more efficient in editing human cells in a versatile way, which eliminates many of CRISPR’s unintentional errors, it significantly expands the scope of gene editing for biological and therapeutic research. You might also like: CRISPR-Cas9 genome editing a 2-edged sword Gene editing positioned to revolutionise medicine

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• Diabetic foot ulcers (DFUs) are a result of diabetes complications and can lead to amputations and death
• Scientists and clinicians struggle to reduce the vast and escalating burden of DFUs
• In wealthy countries like the UK there are specialist multidisciplinary diabetic foot clinics
• New and innovative therapies are beginning to emerge, which accelerates the rate of complete wound closure for DFUs
• Notwithstanding new products coming to market, the best therapy is prevention

How do diabetic foot ulcers heal?

• Hydrocephalus is a chronic condition that occurs when excess cerebrospinal fluid (CSF) collects in your brain’s ventricles and increases pressure inside your head
• Failure to treat the condition can lead to morbidity and death
• First line therapy is the surgical insertion of a ventriculoperitoneal shunt (VPS) to restore your CSF circulation
• A significant risk with the procedure is infection
• To reduce infection manufacturers’ impregnate standard shunts with either silver or antibiotics and market the impregnated shunts at higher prices
• Which VPS (standard, silver or antibiotic) provides patients with the most protection from infection?
• Which VPS is most cost effective for healthcare systems?

Causes
 

Some premature babies have bleeding in the brain, which can block the flow of CSF and cause hydrocephalus. Other possible causes of the condition include: X-linked hydrocephalus, which is caused by a mutation of the X chromosome and rare genetic disorders such as Dandy Walker malformation. This  is  a congenital (present at birth) defect, which affects the back part of the brain (the cerebellum) that controls movement, behaviour and cognitive ability. The most common cause of congenital hydrocephalus is an obstruction called aqueductal stenosis, which occurs when the long, narrow passageway between your third and fourth ventricles (the aqueduct of Sylvius) is narrowed or blocked, perhaps because of infection, haemorrhage, or a tumour. Other conditions, such as neural tube defects (like spina bifida), are also associated with hydrocephalus.

Signs and symptoms
 

Early signs of hydrocephalus in infants include bulging fontanel, which is the soft membranous gaps between the cranial bones on the surface of the infant skull; a rapid increase in head circumference; eyes that are fixed downward and poor feeding. In both infants and adults, symptoms include seizures; fuzzy vision, nausea, vomiting and excessive sleepiness. 

Diagnosing hydrocephalus
 

The diagnosis of hydrocephalus may be made before birth by an antenatal ultrasound. However, in many cases, hydrocephalus does not develop until the third trimester of a pregnancy and, therefore, may not be detected on an antenatal ultrasound. Congenital hydrocephalus may be diagnosed at birth. Important considerations include antenatal and birth history of your baby and whether there is a family history of hydrocephalus. Physical examination at birth can also detect hydrocephalus. A measurement of the circumference of your baby’s head is taken and compared to a graph that can identify normal and abnormal ranges for a baby’s age. Of interest to an early diagnosis for hydrocephalus are the developmental milestones in older babies since the condition may be associated with developmental delay, which might require further medical investigations for potential underlying problems. Other tests that may be performed to confirm a diagnosis of hydrocephalus include magnetic resonance imaging (MRI) and a computed tomography (CT) scan. MRI or CT images can reveal swellings of your brain or another condition that might be causing your symptoms, such as a tumour.
 
 In the video below Bassi describes how hydrocephalus is diagnosed:

 

 

 

 

Insertion of a ventriculoperitoneal shunt 
 

Although currently there is no known way to prevent or cure hydrocephalus, with early detection and appropriate intervention, the future for many patients with the condition is promising. The  gold standard treatment option available today is the surgical insertion of a ventriculoperitoneal shunt.

A shunt consists of two thin, long flexible hollow tubes, called catheters, with a valve that keeps fluid from your brain flowing in the right direction and at the proper rate and thereby reduces brain pressure to a safe level. To install a shunt a surgeon will make a small insertion behind your ear and also drill a small borehole in your scull. One catheter is then threaded into one of your brain’s ventricles through the hole in your scull, and the other is inserted behind your ear and threaded subcutaneously down to your chest and into your abdomen where excess CSF can drain safely, and your body can reabsorb it. Your surgeon may attach a tiny pump to both catheters and place it under the skin behind your ear. The pump will automatically activate to remove fluid when the pressure in your skull increases. Shunts can be programmable (externally adjustable by a magnetic device) to activate when the fluid increases to a certain volume, or non-programmable. Most surgeons tend to choose a programmable model, despite the fact that in clinical studies both types perform comparably.
 

In the video below Sanj Bassi describes both VPS therapy and some temporary treatment options for hydrocephalus. The latter includes medicines, which decrease the production of CFS, draining fluid from the spine via a lumbar puncture and draining fluid directly from your head into a bag via an external drainage system.

 

To determine the relative clinical benefits and cost-effectiveness of the three different ventriculoperitoneal shunts (standard, silver or antibiotic) following their de novo insertions, the UK’s National Institute for Health Research funded a large prospective multi-centre randomised controlled clinical study - The British Antibiotic and Silver Impregnated Catheters for Ventriculoperitoneal Shunts Study - (BASICS). Findings were published in the September 2019 edition of The Lancet. These concluded that shunts impregnated with antibiotics significantly reduce the risk of infection and also healthcare costs compared to both standard shunts and those impregnated with silver. Conor Mallucci, Consultant Paediatric Neurosurgeon at Alder Hey Children’s Hospital, Liverpool, UK, and lead author of the study, suggests that shunts impregnated with antibiotics should be, “the first choice for patients with hydrocephalus undergoing insertion of their first ventriculoperitoneal shunt”.

• CanRisk is a new online gene-based health-risk evaluation algorithm for detecting breast cancer
• It identifies people with different levels of risk of breast cancer, not just those at high risk
• As the infotech and biotech revolutions merge expect authority in medicine to be transferred to algorithms
• CanRisk has the potential to provide a cheap, rapid, non-invasive, highly sensitive and accurate diagnosis before symptoms present
• Breast cancer is the most common cancer in women worldwide and is the 5^th most common cause of death from cancer in women
• Currently mammography screening, which has a sensitivity between 72% and 87%, is the gold standard for preventing and controlling breast cancer
• For every death from breast cancer that is prevented by screening, it is estimated there will be three false-positive cases that are detected and treated unnecessarily
• Lack of resources do not support breast cancer screening in many regions of the world where the incidence rates of the disease are rapidly increasing
• In the near-term expect interest in the CanRisk algorithm to increase

Authority increasingly being transferred to algorithms   Over the past two decades we have increasingly learnt to accept the authority of Big Data algorithms. For example, without question we expect algorithms to give us directions, tell us what movies to watch, who to date, what clothes to wear, where to go on holiday, what flight to take, what hotel to stay in and where to eat. We are  comfortable with algorithms assigning us our credit rating, limiting our overdraft and capping our payments. Furthermore, we are beginning to accept the authority of algorithms in medicine. For example, we are gradually replacing the authority of primary care doctors with algorithms that can diagnose common diseases more accurately and more cost effectively. You might also be interested in: China’s rising MedTech industry and the dilemma facing Western companies

You might also be interested in: Breast cancer and harmful BRCA gene mutations AstraZeneca’s strategy to target early cancer Breast cancer growing rapidly in Asia   Breast cancer was once largely confined to developed Western countries and Australasia, but it has now become the most common cancer in Asia. Although Asian data on breast cancer are patchy, an Economist Intelligence Unit report, suggests that, “since the 1990s, increases in the incidence of breast cancer in Asia, as measured by age-standardised rates (ASRs), is four to eight times that of the global average”. Indeed, as younger cohorts of Asian women age and adopt Western diets and lifestyles (particularly fertility patterns, such as later first childbirth and shorter breast feeding), breast cancer incidence rates in Asia look set to converge with the much higher ones in the West. Further, in LMIC breast cancer is increasing at a more rapid rate than in the West and has become a significant healthcare challenge: 50% of breast cancer cases and 58% of deaths from the disease occur in LMIC.

• Over the past decade MedTech valuations  have outperformed the market without changing its business model
• The healthcare ecosystem is rapidly changing and MedTech is facing significant headwinds which require change
• MedTech’s future growth and value will be derived from data and smart analytics rather than manufacturing
• MedTech leaders will be required to leverage both physical and digital assets

Concern # 3: High asset values slow M&A activity Over the past decade, as markets became more uncertain, monetary policy tightened, technologies advanced and global economic growth slowed MedTech’s, buoyed by the dramatic fall in the cost of capital, increased their mergers and acquisitions (M&A) activity. This optimised portfolios, increased scale, reduced competition and improved profits. Notwithstanding, MedTech’s current high asset valuations make M&A transactions challenging to underwrite, and so, M&A activity has slowed.   You might also like: Is the digital transformation of MedTech companies a choice or a necessity?

You might also like: Will China become a world leader in health life sciences and usurp the US?   According to Euromonitor International more than 50% of the world’s (3.6bn) internet users reside in Asia. Between 2013 and 2018, Asia accounted for 60% of new users coming online and the region has become an economic powerhouse, populated by young, digitally savvy consumers.  China is the largest mobile market in the world with close to 1.2bn subscribers. Significantly, in 2018, China’s rate of growth in mobile internet penetration reached 58% and the number of smartphone connections surpassed 1bn. Similarly, in India, the number of smartphone users is expected to double to 859m by 2022 from 468m in 2017; growing at a compound annual growth rate (CAGR) of 12.9% and expected to reach 859m by 2022.