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Improving the quality of healthcare usually means significant cost hikes. Acute kidney injury (AKI), however, which kills between 12,000 and 42,000 people in England each year, can be reduced at little cost, and could save the NHS between £434 million and £620 annually.
 
Severe dehydration is one of the main causes of AKI. Informing at risk patients of the importance of drinking water could reduce the incidence rate of AKI. 
 
The silent killer
AKI relates to the rapid loss of kidney function. Often it has no symptoms and frequently goes unnoticed by medical staff. AKI's most common in people over 65, and may affect as many as one in six hospital patients who are admitted as an emergency. If left untreated, the condition can result in permanent kidney damage and death.
 
AKI usually develops before patients enter hospital, and is often caused by dehydration, or an adverse reaction from seriously ill patients to over-the-counter medicines such as ibuprofen. AKI also can develop after some heart surgeries when the kidneys may be deprived of normal blood flow. 
 
Once in hospital, AKI is easily diagnosed by a standard blood or urine test. After diagnosis, the condition can be treated by ensuring that patients stay hydrated or by changing their medications.
 
Chronic kidney disease (CKD)
Chronic kidney disease (CKD) is a condition in which kidneys are damaged and can't filter blood as well as healthy kidneys. Because of this, wastes from the blood remain in the body and may cause other health problems.
 
Various chronic diseases have detrimental effects on the kidneys. Rapidly rising global rates of chronic diseases portend a consequent rise in kidney failure and end stage renal disease (ESRD). Over the past two decades, worldwide there has been a 165% increase in dialysis treatments for ESRD.
 
Despite the magnitude of the resources committed to the treatment of kidney disease and the substantial improvements in the quality of care, kidney patients continue to experience significant rates of mortality and morbidity. Partly, this could be the result of poor delivery of medical information.
 
 
Variation in kidney care
The 2013 Kidney Care Atlas provides evidence to support this thesis by describing variations in the healthcare that people in England with kidney disease receive. 

Some variation is to be expected because CKD is more common in older people and ethnicity is a strong influence on the pattern and prevalence of kidney disease in communities. Some variation, however, is unwarranted, and the magnitude of variation in some instances is large.
 
The Quality and Outcomes Framework (QOF)
The Kidney Care Atlas underlines the importance of GPs providing quality healthcare information to patients in formats they prefer. GPs in England are incentivized by the Quality and Outcomes Framework (QOF), which rewards "good practice".
 
Under the QOF system, doctors are incentivised to establish and maintain a register of patients with CKD and provide them with information about their condition. Ninety per cent of GPs provide such information in leaflets, whereas increasingly patients prefer healthcare information online and in video format.
 
Data in the Kidney Care Atlas suggests that kidney patients need to be more effectively informed about readily available, inexpensive therapies that can slow and prevent the progression of CKD.  This could be achieved by simply substituting videos for leaflets and integrated into the QOF system.

Takeaways
Videos, unlike doctors, never wear out and can be accessed by thousands of patients simultaneously, 24-7, 365 days a year from anywhere, at anytime and on any device. Doctors who use videos to inform patients suggest this relieves pressure on GP surgeries and A&E departments. 

Ten short videos could reduce kidney disease by encouraging people at risk of CKD to:
  1. Ensure their blood sugar levels are excellent if they're diabetic
  2. Regularly check and control their blood pressure.
  3. Regularly have blood and urine tests
  4. Immediately treat urinary tract
  5. Control blood cholesterol levels
  6. Maintain a diet that is low in sugar, fat and salt and high in fibre
  7. Avoid smoking
  8. Alcohol in moderation
  9. Engage in regular exercise
  10. Mantain a healthy weight 
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Patients want health information in ways that doctors are not providing.
 
Patients want reliable answers to simple questions about the presentation, diagnosis, treatment options, side effects, and aftercare of their conditions. They want answers at speed, and increasingly delivered to their smartphones in video formats.
 
With difficulties gaining face-time with doctors, patients turn to the Internet. Worldwide, some three billion health-related Internet searches are made each year.
 
Patients experience difficulty finding reliable answers to their basic questions among more than two billion health websites. According to research published by the American National Institute of Health, 33% of adults who search the Internet for health information become confused by what they find. This frustrates their therapeutic journeys and makes for fraught doctor-patient relations.
 
Things are changing, however, and now patients have a new free-and-easy-to-use online platform, www.healthpad.net. This provides patients with video answers to their FAQs that can be accessed at speed at anytime, from anywhere on any hand held device.
HealthPad
HealthPad was started by doctors and launched in June 2013. It has accrued a growing exclusive healthcare content library of over 4,000 videos that provide patients with premium, reliable answers to their FAQs across 32 therapeutic pathways. 

This unique health content library with embedded search facilities, has been contributed by leading health providers from premier North American, European and South Asian medical institutions. 
 
HealthPad does more than reformat print content into digital words and substitute a website for books and journals. The platform leverages the online communications potential, and is an interactive, multimedia utility, which meets the needs, health status and personal backgrounds of patients and patient groups.   
 
Enhanced communications
HealthPad serves the needs of patients by enabling doctors to capture, organize and distribute their medical knowledge more effectively. Doctors can drag-and-drop any type of content into a publishing template: scans, pdf files, ppt. presentations, videos, diagrams, photos, commentaries etc. These data are instantly and automatically re-formatted into attractive rich-media publications. By a click of a mouse, doctors then can choose how they wish to share their publications, ranging from private and secure to public and open.
 
In addition to publishing health knowledge, doctors can use HealthPad to create, develop and manage any number of bespoke online patient groups. 
 
What doctors say about HealthPad
"My HealthPad videos personalize medicine and have positive psycho-social effects. Because of HealthPad 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". Dr. Whitfield Growdon, Onco-surgeon, Harvard University Medical School and the Massachusetts General Hospital.
 
"My patients now don't always have to attend a hospital for reliable information to help them manage their conditions. HealthPad allows me to reduce valuable face-time with my patients while improving doctor-patient relationships and patient compliance by helping them understand their conditions and treatments better". Dr Sufyan Hussain, an endocrinologist specializing in diabetes at Imperial College, London.
 
Drivers of change
The overwhelming majority of UK doctors provide medical information in pamphlet form, while the overwhelming majority of their patients have smartphones and broadband connections and use online services to find jobs, receive their salaries, pay bills and taxes, learn, conduct business and interact socially.
 
Technological change combined with the escalation of chronic non-communicable diseases, especially among the over 55s, is expected to increase Internet searches for premium and reliable medical knowledge and this will force health providers to change the way they communicate with patients.  
According to a recent Deloitte's report, in 2014 UK citizens over 55 will experience the fastest year-on-year rises in smartphone penetration. By the end of 2014, UK smartphone ownership is expected to surpass 50%, and the difference in smartphone penetration by age will disappear.     
This mirrors the rest of the world.
 
Takeaways
If you're a health provider, HealthPad can significantly improve your online communications, enhance the quality of your services and save you money.
 
If you're a patient, HealthPad provides you with free and easy access to exclusive, premium and reliable healthcare knowledge in video formats you prefer, at anytime, anywhere, anyhow. 
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Public smoking bans and eating fibre significantly reduces people attending hospitals for asthma. These are the conclusions of two 2014 studies: one reported in the Lancet and the other in Nature Medicine.  
 
Asthma
Asthma is the inflammation of the air passages in the lungs. It occurs when the immune system mistakes harmless triggers, such as dust mites as threats, which cause the airways to become inflamed, leading to symptoms such as wheezing and breathlessness.
 
Worldwide the economic costs associated with asthma exceed that of TB and HIV/AIDS together.
 
Prevalence
"Asthma affects about 300 million worldwide. The prevalence of the condition has increased following changes to a modern, urban lifestyle. Each year asthma kills about 255,000 people and deaths are related to the lack of proper treatment", says Dr. Murali Mohan, Senior Consultant Pulmonologist, Narayana Institute of Cardiac Sciences, Bangalore, India.
 
Over the past 40 years, the prevalence of asthma has increased in all countries in parallel with that of allergy. With the projected increase in the proportion of the world's population living in urban areas, there is likely to be a significant increase in the number of people with asthma. By 2025, it's projected that there will be an additional 100 million people with asthma. 
Mortality & morbidity
Asthma mortality rates vary and don't parallel prevalence, but are high in countries where access to essential drugs is low.

Another measure of asthma severity is hospitalization rates. For most low and middle-income countries, such data is unavailable. Notwithstanding, in countries where asthma management plans have been implemented, hospitalization rates have decreased.

Childhood asthma is an increasing challenge and accounts for many lost school days and may deprive the affected children of both academic achievement and social interaction. This is particularly the case in underserved populations such as India where there are an estimated 15 to 20 million asthmatics.
 
Smoking and asthma
The Lancet published the first systematic review and meta-analysis examining the effect of smoke-free legislation on asthma. The study examined 250,000-hospital attendances for asthma attacks in the US and Europe between 2008 and 2013. Conclusions show that the rates of hospital attendance for asthma were reduced by 10% within a year of smoke-free laws coming into effect.
Comprehensive smoke-free laws only cover 16% of the world's population, and 40% of children worldwide are regularly exposed to second-hand smoke.
 
Studies tend to focus on the impact of smoking on adults, but more than 25% of all deaths and over 50% of all healthy years of life lost are due to children being exposed to second-hand smoke.
 
Processed food
Research, undertaken by scientists from the University of Lausanne, Switzerland and reported in Nature, examines the role that different types of dietary fibre play in the gut and its effect on asthma. Findings show that a high-fibre diet reduces asthma.
 
In recent years, the incidence of asthma has been well documented. Coincident with this have been changes in diet, including reduced consumption of fibre.

The Swiss researchers argue that high and low fibre diets alter the types of bacteria living in the gut. Bacteria, which can munch on soluble fibre flourish on a high-fibre diet, and in turn, produce more short-chain fatty acids, which act as signals to the immune system and result in the lungs being more resistant to irritation.

The opposite happens in low-fibre diets and the mice become more vulnerable to asthma.

The Swiss scientists conclude that a dietary shift away from fibre in favour of processed foods raise levels of asthma.

Takeaway
Albert Einstein said that, "Nothing will benefit human health and increase the chances for survival of life on Earth as much as the evolution to a vegetarian diet".  Were Einstein alive today, he would have added, "and a ban on smoking".
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Cataract surgery, once only for elderly patients, is now increasingly being performed on younger baby boomers.
 
Facts
More than half of the over-65s suffer from cataracts, which are cloudy patches in the lens that make vision blurred or misty. The condition is linked to smoking, poor diet or health conditions such as diabetes.
 
Cataracts can affect your ability to read, write, watch TV, work at a computer, and drive. Severe cases can affect your ability to wash, dress, cook and work.
 
According to the World Health Organization (WHO), 285 million people worldwide are visually impaired, 90% of these live in developing countries where cataracts are the leading cause of blindness. 
Generational differences in rich countries
Baby boomers who have cataract operations are significantly different to previous generations who were more complacent, expected less and typically accepted that with age comes loss of opportunity and function.
 
Baby boomers are part of a 'fix-it' culture. They seek-out solutions rather than passively hope for them. When they sense a limitation they fix-it with such things as artificial joints, Botox, Restylane, Viagra, anti aging cream and increasingly, cataract surgery: now the most commonly performed surgical procedure in the world.
 
The reasons are clear. Baby boomers have disposable income, they are more active, working longer and have greater demands on their vision. Also, they're more likely to have taken advantage of surgery to address myopia, hyperopia, astigmatism and even presbyopia, and they know the excellent results they can get.
Treatment
Currently, the only treatment for cataracts is surgery. According to the WHO, in 2010, 19 million cataract procedures were performed and by 2020, this number is projected to increase to 32 million per year.
 
The overwhelming majority of these procedures are performed in developed countries. Currently, in the US, 1.5 million cataract extractions are performed annually, and in the UK about 0.4 million. 
Traditional cataract surgery
Two decades ago, cataract surgery meant a three-day hospital stay, patients couldn’t move around and it took a while for them to get their vision back.
 
Traditional cataract surgery requires the use of a hand-held blade to make multiplanar incisions in the cornea to access the cataract. A surgical instrument is then used to manually create an opening in the lens capsule that holds the cataract. The goal is to make the corneal incisions precise; make the opening in the lens capsule as circular as possible, in the right location and sized to fit the replacement lens.
 
Technical breakthroughs
Technical breakthroughs mean that now a 45-minute bladeless, laser procedure is positioned to revolutionise cataract surgery.
 
"In the 1980s phacoemulsification significantly changed cataract surgery and reduced admission times and complication rates. In 2001, femtosecond laser technology was introduced clinically for ophthalmic surgery as a new technique for creating lamellar flaps in laser in situ keratomileusis (LASIK). In 2010 femtolaser was developed into a new tool for cataract surgery; although it is not generally accepted yet the technique is developing and is likely to become the gold standard in time," says Mr. Hugo Henderson, Consultant Ophthalmologist and Ocuplastic Surgeon, Royal Free Hospital, London.
 
Cataracts in poorer countries
While baby boomers in rich countries can stave off the debilitating effects of cataracts with a 45-minute procedure, in poor countries cataracts remain the world's leading cause of blindness. 
 
Blindness is particularly devastating in the developing world where it has a profound impact on the quality of life for the blind person and his or her community. Life expectancy of the blind is usually less than half that of someone with eyesight the same age.

The desperateness of this situation is augmented by the fact that a blind person is unable to contribute to the family income. Not only does blindness mean a father is unable to work, or a mother cannot collect water or go to market, but someone with eyesight must care for him or her. Effectively two income-producing individuals are lost. This creates a devastating economic impact on the family and the community.

In the developing world, cataract surgery is available for only a small proportion of those in need. This is partly because of low demand - caused by barriers related to awareness, bad services, cost, and distance - and partly because of deficiencies in the supply of services. 
 
Takeaways
The annual global economic impact of blindness and poor vision caused by lost economic productivity is immense and affects everyone.
 
Eighty per cent of all visual impairment can be avoided or cured.
 
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Are we addicted to foods that make us obese and kill?

Why is it hard for obese people to lose weight despite the social stigma and health consequences associated with being overweight? Is it similar to cigarette smokers who continue to smoke even though they know smoking will give them cancer and heart disease?

Is processed food the new tobacco?

Large growing global epidemic
Over the past 25 years the prevalence of obesity in England has more than doubled and today, most English people are either overweight or obese. Similarly, in the US more than a third of individuals are obese.

It’s estimated that each year, obesity costs the NHS more than £5bn and the US economy about $150bn.

Global epidemicOnce considered a problem only for rich countries, obesity is a rising worldwide challenge. In 1997 the World Health Organization (WHO) formally recognized obesity as a global epidemic and in 2008, claimed that 1.5 billion adults were obese. 

Experts say a couch potato lifestyle and overindulgence in junk food is creating an overweight and obese generation prone to heart disease, diabetes and cancer. In rich countries people have easy access to cheap, high-energy food that is often aggressively marketed.

Call for parents and local authorities to help
The press refers to the “obesity time-bomb” and suggests that misguided parents are bringing up a generation of overweight children who gorge on junk food and sugary treats and rarely get any exercise. UK policy makers say that more should be done to support families to help them tackle the obesity crisis in children and young people.

In January 2014, Professor Philip James told the European Congress on Obesity in Antwerp: “Unless we can act firmly and decisively, we will be condemning a huge number of children . . . to becoming a ‘lost generation’.”

Where should we target our concerns? Parents? Municipal authorities? Or, the food and drinks industry?

Changed environment
Contrary to popular belief, people have not become greedier or less active, but what they eat has changed. Everyday, people are bombarded by food industry adverts to eat more food. New scientific evidence suggests that industrial processed food is biologically addictive.

The tobacco industry
In 1954, the tobacco industry paid to publish a “Frank Statement to Cigarette Smokers” in hundreds of US newspapers. It stated that the industry was concerned about peoples’ health and promised a number of good-faith changes.

What followed were decades of deceit and actions that cost millions of lives. During that time the tobacco industry emphasised personal responsibility and paid scientists to deliver research that triggered doubt and criticised science that found harm associated with smoking.

The food and drink industry

Similarly today, some large food and drink companies fund scientific research to establish health claims about their products.


A 2013 report suggests that scientific research sponsored by the food and drink industry is five times more likely to conclude that there are no links between consumption of sugary drinks and weight gain.

In March 2014, Dame Sally Davies, the UK’s Chief Medical Officer told a committee of MPs that, "research will find sugar is addictive" and that the government, “may need to introduce a sugar tax".

For years the tobacco industry made self-regulatory pledges, aggressively lobbied to stifle government actions and denied both the addictive nature of tobacco and their marketing to children.

Takeaways
Food and tobacco industries are different, but there are significant similarities in the actions they have taken in response to concerns that their products can harm.

Because obesity is now a pandemic the world cannot afford to make the same mistake it did with the tobacco industry.

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Herniated disc surgery is the "bread and butter" for spine surgeons, but might not remain so. In the developed world, populations are rapidly aging, comorbidities are changing and the number of spine surgeons is shrinking.
 
Herniated disc
A herniated or slipped disc is where one of the discs in the spine ruptures and the gel inside leaks (herniates) and causes back pain and sciatica. Once the nucleus herniates, pain in the lower back may improve, but sciatic leg pain increases. This is because the jelly-like material puts pressure on spinal nerves, which causes pain, numbness, or weakness in one or both legs.
 
Incidence
Most cases of herniated discs are age related and presented in men between 30 and 50. Fifty six per cent of adults have bulging discs, 80% of these will experience back pain, but only two to three per cent will have sciatica. Males present with back pain about 10 years before females. The mean onset of back pain is 35 and it's unusual in people under 20 and over 60.
 
Most people with a herniated disc don't require surgery because their symptoms improve over time. About 50% recover naturally within about four weeks.  Within six months, 96% recover. Only 10% have surgery. 
 
Nonsurgical treatments
Physical therapy and analgesics are the most common therapy for spinal problems. Maintaining spinal strength and flexibility through exercise is important. Passive manipulation may have a role, but it's not a substitute for strengthening the muscles.
 
Nerve pain, such as sciatica, usually does not respond well to physical therapy and is therefore often treated by an epidural. This is an image guided spinal procedure performed as a day-case using fine needles and probes, which are inserted through the skin and guided by continuous X-Ray or CT screening directly to the site of the suspected problem. 
 
Surgical treatments
Surgical therapy is typically recommended when symptoms have not improved using other treatments and the patient has difficulty standing or walking and there is progressive muscle weakness or altered bladder function. 
 
The most common surgical procedure for a herniated disk in the lower back is a lumbar micro discectomy, which involves removing the herniated part of the disk and any fragments that are putting pressure on the spinal nerve. Endoscopic micro discectomies are increasing, but still relatively new and often only performed with special arrangements, such as being part of a clinical study.

An early adopter
Mr Irfan Malik, a consultant neurosurgeon at Kings College Hospital, London is an experienced early adopter of endoscopic micro discectomy for a herniated disc. 
 
According to Mr Malik, "The procedure only takes about an hour. After the endoscope is removed, a plaster is used to cover the small incision. After the procedure, most patients walk away and go home within a couple of hours. While the success rate of this procedure is about the same as conventional open back surgery, recovery rates are quicker and risks of complications much lower".
Changing Spine surgery
Over the next 20 years, as populations' age, spine surgeons will be challenged to address a different mix of diagnoses and additional comorbidities; such as lumbar spinal stenosis and spondylolisthesis.
 
Nearly 25% of people over 65 suffer low back pain.  In the US alone this translates into over seven million doctor visits annually.  Over the next decade, degenerative spinal conditions are projected to significantly increase pressure on hospitals and primary care offices.  
 
More of these older patients however, are expected to have access to advanced spine care and minimally invasive techniques.  According to Mr. Malik, "Research is driving advances in surgical techniques as well as new devices and tools, which will expand the treatment options for patients."
 
Takeaways
Health providers are beginning to look for new ways to combat the combined challenges of aging populations, shifting comorbidities and projected shortages of doctors. Training is encouraged in surgical specialities where there are shortages and nurses are being trained to conduct initial patient visits.

Increasingly, patients are given e-mail access to clinics to determine treatments, computer portals are being used to streamline the entry process to clinics and video explanations of surgical procedures and teir risks are being developed specifically for patients.
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In October 2013 Professor Olaf Wendler, Clinical Director of Cardiology and Cardiothoracic Surgery at King's College Hospital London performed a new surgical heart procedure for the first time in the UK called less invasive ventricular enhancement or LIVE.  
 
New procedures better for an aging population
The path breaking operation uses a new device, developed by Bioventrix, Inc. that enables surgeons to effectively "exclude|" scarring. The procedure involves re-modelling the patient's left ventricle, which is the part of the heart responsible for pumping oxygen rich blood to the body, whist the heart is still beating.  It's particularly suitable for elderly frail patients suffering from chronic heart disease and the benefits include small incisions, faster recovery and better outcomes.  
 
With traditional open-heart surgery the surgeon makes a ten to twelve-inch incision and then gains access to the heart by splitting the breast bone and spreading open the rib-cage. The patient is then placed on a heart-lung machine and the heart is stopped for a period. This approach, inappropriate for frail older patients with advanced heart disease, can be associated with postoperative infection, pain and a prolonged recovery time.
 
In the next 25 years, the number of people over 65 is estimated to increase by 65%, with a doubling of the number of people over 85. A high proportion of this large and growing elderly group will suffer from coronary heart disease and be too frail for traditional open heart surgery, which carries a high risk of complications and often does not result in acceptable outcomes.
London Centre of Excellence for minimally invasive heart procedures
King's is recognized as a centre of excellence for the treatment of heart disease and has developed a strong and successful interaction between cardiologists, cardiac surgeons and ambulance services.
 
The new procedure performed by Wendler is a result of cooperation between cardiac specialists including Professors Theresa McDonagh, Clinical Lead for Heart Failure and Mark Monaghan, Director of Non-Invasive Cardiac Diagnostics.
 
Such cooperation helped King's to become the first hospital in the UK to carry out primary angioplasty for myocardial infarction (PAMI) and its specialist cardiac unit to become the first in the UK to be open 24 hours a day. 
 
Primary angioplasty pioneered at King's
Patients suffering heart attacks in London are brought directly to King's for primary angioplasty therapy. The procedure involves unblocking clots in the artery, which can cause a heart attack and is achieved by inserting a stent (a small metal tube) via an artery up to the heart. The stent is put in place using a tiny balloon and, when complete, opens the blocked coronary artery.
 
Primary angioplasty is now the gold standard in cardiac units throughout the UK.
 
Previously emergency treatment for heart attacks was a thrombolytic (clot-busting) drug, which was only about 60 to 70% successful and many patients went on to suffer further clots. By contrast, angioplasty achieves a normal blood flow in some 90 to 95% of cases.
London Valve Live '09
Surgical innovations such as those performed by Wendler and his colleagues are predicated on years of R&D. In 2008, King's was awarded Â'£9 million to establish a British Heart Foundation Centre of Research Excellence
 
An important focus of this group at King's is translational or bench-to-bed research. So called, because it enables research discoveries to be translated into new therapies and their outcomes fed back into further research and education.
 
In 2009 a group of world renowned experts in cardiology and heart surgery met in London to discuss how advances in aortic and mitral valve surgery and minimally invasive techniques pioneered at King's were making a real difference to patients with heart valve disease.
 
Delegates watched, via a teleconference, patients undergoing two path breaking procedures, which demonstrated how minimally invasive techniques were changing the way patients with chronic heart conditions were treated.  
 
On show then was a transapical aortic valve implantation, which involves an artificial heart valve being implanted by a cardiac surgeon directly through the left side of the chest while the heart is beating and without having to go on a bypass machine. Also delegates watched an apercutaneous or transfemoral aortic valve implantation, which involves an artificial heart valve being implanted into the heart by a cardiologist through a leg artery, again with the heart beating.
 
Takeaway
"The cardiac units at King"s and Guy's and St Thomas are working to bring clinical excellence and cutting-edge research closer together and make it available for patients in the UK", says Professor Wendler. 
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A cheap spit-test that reveals the secrets of your genome, used by hundreds of thousands of people worldwide has been stopped by the FDA.
 
FDA warning letter
On November 22nd 2013 the FDA sent a warning letter to 23andMe, a privately held personal genetic-testing firm based in Mountain View, California to, "immediately discontinue" providing its saliva collection kit and Personal Genome Service, because it had failed to provide adequate information to support the claims made in the company's marketing.
 
23andMe is so named because of the 23 pairs of chromosomes in a normal human cell. Founded in 2006, the Company is a Silicon Valley favourite led by Ann Wojcicki, wife of Sergey Brin, one of Google's founders. It has raised more than US$100 million from backers that include Google, Genentech and Yuri Milner, a billionaire investor in Facebook and Twitter.
 
Taking more control of your health
Nature took four billion years to develop the code that determines our life. The Human Genome Project, that ended a decade ago, initiated a medical revolution. In 2003 sequencing an individual genome cost between US$10 and US$50 million. Since then the costs have plummeted towards US$1,000, allowing science and medicine to identify genes with disease causing mutations.  In 2008 23andMe's US$99 personal genome test kit was named by Time Magazine as the "invention of the year".
 
Since 2007, 23andMe has invited some 500,000 "genotyped consumers"  to spit into a tube, send it back to the company and thus discover whether they might be prone to a long list of diseases, from diabetes to Alzheimer's or be carries of inherited conditions that significantly raises their propensity of developing certain cancers. Results from 23andMe's test enables people to take more control over their own health. 
Changing paradigm of medicine
In the past year 23andMe hired Andy Page, a former president of Gilt Groupe, a shopping website, as its own president and launched a national television campaign with a goal of doubling the number of people who use its test.
 
23andMe's mass marketing could help to change the cultural paradigm of medicine. The more people get tested, the more they'll ask their doctors about results and the more doctors will have to start incorporating personalised genomics into their practices. But the FDA is not concerned about these benefits; there only concern is that someone theoretically might get hurt.
 
Regulation has a role in protecting consumers from inaccurate testing and misleading information. However, if medical innovation is to benefit millions of patients, should regulators bear the burden of demonstrating that services, such as 23andMe, do more harm than good?  
 
Takeaways
Regulations that govern medicine were developed during medicines battle with infectious epidemics when nobody could even read the molecular scale that controls health and disease today.
 
Drugs then were designed on hunches, and the safe and effective use of drugs depended on gathering statistical information about how they affect high level medical symptoms. Regulators assumed broad areas of biochemical uniformity, conflated differences and steered medicine to whole populations, which led to a one-size-fits-all regulatory system.
 
Such a system can't deal with diseases rooted in complex molecular diversity of human bodies. Today, regulators are ill equipped to deal with big data that drives molecular medicine and they are reluctant to embrace private practice and the statistical methods of the digital age.
 
Does current regulatory policy stifle innovation and suppress investment in medicine that can provide better health at lower cost? 
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Chris Anderson and the da Vinci Surgical System
 
In 2013, a new surgical procedure was used for first time in the UK at St George's Hospital, London to remove of a cancerous kidney tumour.
 
The procedure combines the da Vinci surgical system with an injection of a dye into the patient's kidney. The dye illuminates healthy tissue and shows up under the da Vinci's camera as a bright green light and as a consequence the procedure is called Firefly.
 
Chris Anderson, a consultant urologist at St George's is one of the early adopters of robotic surgical techniques after receiving specialist training in 2005 at the world renowned Henry Ford Robotic Center in Detroit.  Anderson has built-up a leading renal cancer unit at St George's and introduced the Firefly technology into the UK. He says, "Partial kidney removal is a complex operation that requires complete removal of the tumour and reconstruction of the remaining healthy kidney. By combining the da Vinci system with Firefly we are able to achieve our goal better than in the past".
 
Robotic surgery
Kidney surgery is enhanced by robotics. In recognition of the increasing importance of high tech surgical therapies, the N Sethia Foundation funded the UK's first robotic surgery training centre at University College Hospital, London. In pride of place in the new Chitra Sethia Centre for Robotics and Minimal Access Surgery is the latest da Vinci surgical system.
 
Professor John Kelly, the Centre's director, said, "The system provides the surgeon with a much greater movement than the human wrist is capable of. As a surgeon, you can see the instruments and tissue in 3D and highly magnified. The movements are very controlled and precise and of course we want to see this translate as improved outcomes for our patients".
The da Vinci surgical system
The da Vinci surgical system is a sophisticated robotic platform designed to expand the surgeon's capabilities and offers state-of-the-art minimally invasive options for kidney and other major surgeries.
 
The surgeon sits at a control console, which senses the surgeon's hand movements and translates them electronically into scaled-down micro-movements to manipulate tiny instruments and a high resolution 3D camera at the surgical site inside the body. The system also detects and filters out any tremors in the surgeon's hand movements, so that they are not duplicated robotically.
 
Approved by the FDA in 2000, by 2013 over 2,000 da Vinci systems had been sold and an estimated 200,000 annual surgeries are currently conducted using the system. More commonly it's used for prostatectomies, but increasingly for cardiac valve repair, gynaecologic and kidney surgical procedures.   

The kidneys and cancer
Kidney cancer kills, it's difficult to diagnose and it's on the increase.
 
The kidneys are two vital bean-shaped organs located on either side of the body just underneath the ribcage. Their function is to filter blood and remove waste products, which they convert into urine.
The kidneys also help to control the balance of fluid, salt and minerals in the body and to maintain blood pressure.

Over the past decade kidney cancer diagnosis has increased by 33% in England, while in the US there has been an increase of 50% in the past 30 years. Risk factors include excessive alcohol consumption and obesity.
Kidney cancer is the eighth most common cancer in the UK and in 2010 some 9,600 people were diagnosed with the disease. In Europe an estimated 73,000 people were diagnosed with kidney cancer and worldwide more than 273,000. The disease kills and the death toll is increasing. In 2010 in the UK 4,100 people died of kidney cancer, 31,300 in Europe and more than 116,000 worldwide. 

The majority of deaths from the disease could be avoided by early diagnosis: hence the importance of reporting "
blood in your pee".  Other symptoms include needing to urinate often or suddenly, pain while urinating, pain below the ribs that doesn't go away and a lump in your stomach.
 
A nephretomy 
An established surgical therapy for kidney cancer is a nephretomy: the complete removal of the kidney. Usually, this involves making an incision between the lower ribs on the side of the tumour, removing the diseased organ, some surrounding tissue and often the lymph nodes close to the kidney to check if they contain any cancer cells. 

Although a major surgery, it is preferred by some surgeons who believe that it reduces the chances of the recurrence of the disease.  A person can live a completely normal life with just one kidney.
 
Takeaway
Given the growing incidence of late stage kidney cancer, the battle against the disease increasingly includes high-tech surgical therapies such as the da Vinci surgical system.   
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In 2013 the Hollywood actress Angelina Jolie announced that she had both her breasts removed because she carried the BRCA1 gene.
 
Her bilateral prophylactic mastectomy highlights the fact that a woman whose mother or father carries a faulty BRCA1 gene has a 50% chance of also carrying it and a 60 to 80% higher risk of developing breast cancer.
 
Angelina Jolie exemplifies what many women with a family history of breast cancer are doing: testing for the BRCA1 gene; if positive, electing for a bilateral prophylactic mastectomy and after surgery, reconstructing their breasts.
 
Hollywood myths do women a disservice
In a New York Times article, entitled My Medical Choice, Jolie informed women about BRCA gene mutations and the challenges of breast surgery. Her efforts are overshadowed by the notion that breast surgery is quick and easy.

Hollywood images propagate the myth that reconstructive surgery quickly restores breast symmetry, improves body image, quality of life, self confidence and wellbeing. In reality, it's major surgery with significant risks that entails an extended series of operations and follow-up visits and can take three to nine months to recover from. 
 
Reconstructive surgery can leave women with scar tissue, persistent pain in the back or shoulder and hardened breasts that never look or have the same sensation as before treatment. Also, breast implants can rupture and cause infection. Within five years, 35% of women who have implant reconstructions undergo a revision.

A breast with an implant will not age naturally, while the surviving breast will. Up to 50% of implants used for breast reconstruction have to be removed, modified, or replaced in the first 10 years. So, a patient is likely to need more surgery to remove or replace implants during their lifetime. 


Increasing concern that women are not informed 
Breast cancer is the most common form of cancer in the UK and each year about 45,000 women are diagnosed with it, of which almost 12,000 die. Screening and new generation drugs have significantly improved breast cancer survival rates, but the number of women having breast reconstruction surgery is increasing.  This is partly because the incidence of breast cancer is increasing in younger women who are more likely to have the surgery.
 
According to Marc Pacifico, Consultant plastic surgeon at Queen Victoria Hospital, East Grinstead, "It's very important that women are fully informed about the risks and benefits of breast reconstruction surgery". 
Implants or tissue reconstruction
The type of reconstructive surgery a woman chooses depends on the location of the breast tumour, the size and shape of the breast that is being replaced, age, wellbeing and the availability of autologous tissue.
 
Techniques to reconstruct breast include: implant-only reconstruction, autologous reconstruction using the patient's own tissue and a combination of both.
 
Implants and tissue reconstruction
Breast implants are usually a two-stage procedure. First, an expander is placed under the chest muscle and slowly filled with saline solution during visits to the doctor after surgery. Second, after the chest tissue has relaxed and healed, the expander is removed and replaced with an implant. The chest tissue is usually ready for the implant six to 24 weeks after mastectomy.
 
Tissue reconstruction involves moving a flap of skin, muscle and fat from a patient's back or abdomen to the breast area, while keeping intact a pedicle or tube of tissue containing its supplying arteries and veins.
 
Free flap reconstruction involves tissue being detached from a donor site before it is moved. Microsurgical techniques are then used to rejoin its arteries and veins to those in the breast area. An advantage of this procedure is that tissue can be harvested from areas of a patient's body not adjacent to the breast, such as the buttock or thigh.
 
Gold standard versus implants 
Many surgeons regard free flap reconstruction as the gold standard. This is because a new breast is soft and natural-looking and it avoids some of the potential challenges associated with breast implants. Tissue reconstruction has the added advantage that the breast ages and changes size in a similar way as the other breast.  
 
However, free flap surgery is longer, more complex and leaves scars and only available in centres where there is microsurgical expertise.
 
Harvesting fat from one part of the body and re-introducing it to help reconstruct breast tissue is challenging because the body may reabsorb between 20 to 90% of the harvested fat, which then results in further interventions and unreliable outcomes.
 
According to Anne Wilson, a RAFT Surgical Research Fellow working on a project with Professors Peter Butler and Alexander Seifalian from University College London, "The introduction of stem cells into the fat-transfer procedure may reduce or eliminate the problem of the body reabsorbing the fatty tissue. For a woman undergoing breast reconstruction this would be significant as it would mean fewer visits to the operating room and better aesthetics".
 
Same time or delayed reconstruction
Another important choice women face with breast reconstruction is whether to have reconstruction at the same time as the mastectomy. Immediate breast reconstruction usually means less surgery, the chest tissue is not damaged by radiotherapy or scarring and this often means that the final result looks better.
 
Delayed breast reconstruction may be a better choice for some women who need radiotherapy to the chest area after a mastectomy and this can cause delayed healing and scarring. Sometimes, a woman may not know whether she needs radiotherapy until after her mastectomy. This can make planning ahead for an immediate reconstruction difficult.
 
Takeaway
Each year, some 18,000 mastectomies are performed in England alone. About 40 to 50% of these have breast reconstruction surgery. According to a recent survey by the British Association of Plastic, Reconstructive and Aesthetic Surgeons, more than 33% of respondents said that the risks and benefits of reconstructive surgery were never discussed.   
 
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