The day started with FutureMed chair Daniel Kraft giving us a summary of the happenings in regenerative medicine and how the field has traveled on Gartner’s hype curve, and is now beginning to produce some large advances. Yesterday we covered two examples of how the field is maturing through the work of luminaries Robert Hariri and Mike West, who are both taking different but complementary approaches to stem cell therapies. Daniel, a pioneering stem cell researcher himself, noted that bone marrow is a rich source of adult stem cells. His work using these cells for regenerative medicine led him to the creation of a harvesting device called the MarrowMiner, which, using a flexible catheter, harvests bone marrow through one hole instead of many, and delivers 10x the number of stem cells. It’s a wonderful tool both in efficiency as well as patient experience (minimal discomfort) relative to the previous methods. MarrowMiner 2, an iteration off the first device, is entering commercialization soon and it’s sure to make both stem cell acquisition and bone marrow donation a better process.

Peter Altman from BioCardia took the stage next. He first discussed the insight that medication delivery is shifting from systemic (whole body either through pill or vein) to targeted (through local injection or molecular targeting). Local delivery of a medication is nothing new. In fact, pacemakers have long had a steroid on the tip of the pacing lead to reduce the extent of fibrosis over the tip. Yet, the concept is starting to pick up more steam as therapies such as stem cell based regeneration of cardiac tissue are being used more broadly. His company has a unique delivery technology for the heart called Helix that is essentially a spiral needle that an interventional cardiologist can use to directly inject into the muscle of the heart. This was previously quite difficult because jabbing a straight needle into the wall of a beating heart is quite difficult thanks to, well, the fact that the heart is beating. By creating a helical needle, BioCardia is enabling physicians to get around this since it can be screwed into the wall of the heart prior to injection.

The next block of FutureMed centered on patient engagement. Lucien Engelen, from the REShape & Innovation Center in the Netherlands, shared his opinion that largely due to advances in computing systems medicine is finally at a place where it can really listen to the needs of the patient to become more patient centered. He thinks we’ve not, as a field, done even close to an adequate job building the tools and systems for patients to understand their own health, interact with the complicated medical system, and share advice with each other. To this aim, he and his team have launched a few projects, one being a crowd sourced mapping of automatic external defibrillators, and the other a new video conferencing system that makes engaging with a patient over video not only easier and more secure, but more customized to medicine, including features such as the ability to record a conversation with your doctor for later playback.

Echoing similar sentiments, next up we had Dave deBronkart, also known as e-Patient Dave, who told his remarkable story of how he went from working in software to being a patient advocate and a representative of the “patient of the future.” Receiving an X-ray for a possible shoulder injury, Dave and his doctor discovered a large cancer metastasis in his lung. Further exploration showed that the cancer originated in his kidney and had spread to other organs even beyond the lung. Dave had in large part accepted his mortality but kept exploring his options. In a twist of fate, Dave found a kidney cancer patient community that pointed him to a new therapy IL-2. This ended up saving his life. Dave, rightfully asked why the best possible information didn’t exist in traditional channels and wondered how many patients were missing things that their doctors could not possible keep up on. From that moment on he became an advocate for the development of better patient-focused health policies, systems, and tools, and has developed an avid Twitter following as @epatientdave.

Dave noted that even relinquishing control of the medical record into the hands of the patient can have an impact and that current efforts like Microsoft Health Vault and Google Health aren’t cutting it in terms of porting health data into a place and format where it’s useful for the patient. He highlighted a recent effort by the VA to allow patients to download their data in raw form. At first this made the hospital network extremely uncomfortable. Questions popped up such as what patients would do with their data and if it was irresponsible to allow the download of data in raw form without a user interface. Thankfully, the VA decided to stomach their concerns and create a big blue button that provided an easy raw download. The effort has been incredibly popular and hundreds of thousands of patients have gotten hold of their medical data.

After Dave, Christopher DeCharms from Omneuron kicked off the neuroscience track of FutureMed. Some recent developments in neuroscience have shaken up the field. For example, his company is helping back pain patients by putting them under real-time fMRI, exploring which areas of the brain light up in response to pain, and teaching the patients to control that area (see Nature News). In other areas he notes developments in deep brain stimulation, allowing for both the dramatic improvement of motor disorders as well as the ability to use electrodes to control brain and computer interfaces. He also cited an amazing study out of Japan where scientists showed patients certain contrast patterns such as a plus sign or the letter ‘n’ and using fMRI, reconstructed these patterns simply from the brain data.

Philip Low was up next, neuroscience’s latest darling and founder of NeuroVigil, a company that, according to Philip, just landed one of the highest pre-money seed valuations in history. Before getting into his own technology he did a brief survey of advances in neuroscience. First, he spoke about optogenetics, the fast advancing technique in neuroscience of using light to switch neurons on and off. At a high level, the firing of neurons depends on a precise orchestra of ions flowing in and out of channels in the walls of the neurons. A new type of ion channel that can be opened through light stimulation was discovered and this enabled the field of optogenetics. By inserting a gene for this new type of channel, scientists are able to disrupt the normal firing of a neuron by shining light on it in the brain. Since researchers are able to precisely target which types of neural cells are given this gene (through viral vectors), they’re able to shut off exactly what type of neurons they're interested in studying. Quite literally, by shining light at the brain, you’re able to shut off any part of the brain you’d like.

The research has dramatic clinical and research potential. Philip also talked about new efforts to categorize and organize neurons by studying their synaptic organization. He showed a 3D model of a dendritic tree, which represented one of the most advanced recent efforts to tease out the structure and organization of individual neurons in order to better learn how they work together.

Philip then dove into his own revolutionary work. First, he was able to use complex mathematics to get the same quality EEG data from one lead that previously required dozens of them. Then he used that data to discover a brand new sleep stage that turned out to be hidden inside of REM sleep. Following up further, he was able to identify that this stage is actually genetically directed (identical twins have the same patterns), and finally, he realized that an incredible amount of clinically valuable data exists in frequency ranges previously ignored by sleep scientists. He noted that this work has immediate clinical application because sleep disorders are powerfully correlated with mental illness and neuropathological disorders such as Alzheimer's. In fact, in Alzhemier's patients, sleep disorders are often the first reason they are admitted to the hospital. His technologies, able to detect incredibly subtle variations and abnormalities in brain activity during sleep, might soon be able to diagnose Alzhemier's and mental illnesses like depression and schizophrenia. To this aim his company NeuroVigil is building the largest collection of brain EEG data on earth, and as more data gets added, analysis becomes even more powerful. As NeuroVigil runs clinical trials for its diagnostic potential, it’s immediately useful as a worn-at-home replacement for sleep studies and a monitor for adverse neurological events during medication clinical trials. We’ve interviewed Philip before and it’s wonderful to watch how quickly this dazzling technology is rumbling the foundations of neurosciences. Kudos Philip.

After lunch we had Ryan Howard, CEO of Practice Fusion, give us a tour of how his company’s completely free, cloud based, electronic health record system fits into what he called the current “industrial revolutions for EHRs.” We’ve covered Practice Fusion extensively on Medgadget and they’re really starting to take off. Their target market is not inpatient hospitals, but rather private practice medical centers that would benefit from EHR but might not be able to afford the slew of equipment and software licenses that accompany running a non-cloud based traditional EHR. Even today they’ve got the biggest collection of health record data (by patients) in the US, topping even the VA and Kaiser. They’re also trying to catalyze innovation in the developer community and recently launched a challenge called Analyze This! in which they took a dataset representing the medical records of 15,000 patients, made it anonymous following HIPPA standards, and released it to the developer community for hacking. This has already resulted in innovative applications such as QuaMe, which allows a patient to compare his or her own medical data with others of similar demographic and medical characteristics. The data is available here for those who want to join in on the fun.

Changing topics, up next was Raymond McCauley, CSO of Genomera, a recently launched company that’s building a platform for people to conduct, what amounts to, their own clinical studies. Individuals on the platform can sign up for or create a particular study of interest and then build, using the company's API measurement instruments that serve as data inputs to the trial. These instruments might either consist of simple text field entries or more behaviorally based interactive tests. In addition to discussing Genomera, Raymond highlighted some trends in genetics that include the ongoing speedy reduction in the price of sequencing and how it's leading to research centers like the Beijing Genomics Institute (BGI), which are tying to sequence a vast array of life forms.

After Raymond was a provocative talk by Andrew Hessel about the state of synthetic biology. He began by noting that at a high level DNA has become a programming language. In order for this analogy to work, we’d need to master reading, comprehension, and writing of DNA, and we’re just entering a time when all of these elements are coming together. It’s cheaper than ever to sequence (read) DNA, we’ve got a growing comprehension of function, and the synthesis (writing) of DNA is now available even to the hobbyist. There are software tools to design DNA and printers that can print it. Events like MIT’s iGEM (International Genetically Engineered Machine), a genetic engineering contest aimed at undergraduates, are catalyzing scientific enthusiasm among the new programmers of biology, students who will soon become adept at sculpting genes for purposes of their own.

In the world of synthetic biology, yeast will be the new platform and new strains of organisms will be crafted using building blocks of code. We’ll likely see start-up biotech companies tomorrow that look like today’s software companies, and that will produce equally incredible innovations ranging from oil eating bacteria to drug synthesis.

It seems clear that this level of gene programming is almost certainly to yield new organisms and life forms previously unknown to man. In the next 100 years we’ll in all likelihood, literally build a new world - it’s a strange and paranoia-inducing reality. Outside of ethical concerns, there’s real potential, as the devices to create DNA become increasingly distributed, or “desktop,” for individuals to maliciously craft viruses and other pathogens. Given how inexpensive this technology will be, and that there are few if any material constraints on synthesizing DNA, this will be more or less unstoppable. Though Andrew shares these concerns, he’s optimistic and thinks the ways to address this is through transparency, open-source platforms, and careful checks and balances like using watermarked printing or implementing security standards for all DNA printers.

Next we travelled over to Intuitive Surgical to learn more about and play with their da Vinci robots. Catherine Mohr, director of medical research for Intuitive, told us a bit about the company and their devices. We’ve covered da Vinci extensively on Medgadget so we’ll refrain from too much detail, but some new insights we gained from Catherine were that the foundational intention behind Intuitive Surgical was to take fields that were not using minimally invasive surgery and enable them to become so using their robot. In other words, if a certain specialty was only doing 15% of their surgeries laparoscopically, their goal was to bring that to 100%. Also, interesting enough, though Intuitive is known for prostatectomies, their first intended use case was actually in cardiology. Them landing on urology was more or less accidental – surgeons just found the tools most useful. Catherine says that they “took aim at the heart and ended up hitting the crotch.”

After the overview of the technology, we were ushered over to the da Vinci showroom to play with their robots. They had six machines set up for us and with no training, they let us sit down and figure out how to work them. It was, shall we say, intuitive. Once you’ve got your fingers in the little Velcro holders, it’s immediately possible to manipulate the clips, grab objects (in this case little rubber bands), and use both of your new stable and precise robot hands effortlessly.

After Intuitive we went back to NASA Ames where we had a banquet complete with wine, music, a magic show, and a graduation ceremony in which all participants got Singularity University FutureMed diplomas. Tomorrow is the last day of FutureMed and it’ll be a partial day, ending after lunch, with talks covering global health and the hospital of the future.

The program kicked off today with Todd Brinton from Stanford’s biodesign program. If you haven’t heard of Stanford Biodesign, they’re one of the leading centers in the world for the design and creation of medical technologies. Led by Paul Yock and Tom Krumel, they were one of the first places to include interdisciplinary collaboration and a methodological need-finding approach to innovation in medical technologies. Todd pointed out that too often people try to jam technologies into a need instead of building technologies to fit a need. Stanford Biodesign has a twelve-month fellowship program where they send participants on a mission to find needs in medicine (for the first half of the fellowship) and then invent and implement solutions that fit these needs (in the second half). The school recently put out an exceptional textbook called Biodesign: The Process of Innovating Medical Technologies (we've covered it) that's a must read for those looking to innovate medical devices.

Next up was a panel by Allan May and Geetha Rao, who have worn both investor and entrepreneur hats in medical technology and gave a state of affairs of the medtech venture space, as well as provoked the audience with some thoughts and hypotheses as to where things are going. Allan noted that the overall pool of medtech venture money has recently fallen from $32B to $12B and companies like Intuitive Surgical, which were able to get large capital injections years ago, would never be able to start today. Not to say that’s a trend that’ll last forever (like all things, VC is cyclical), but there’s a movement away from large, capital intensive investments, while the only companies that are pursuing these sorts of advances right now are the big gorillas like Medtronic and Abbot. He and Geetha did note that though VC in medtech is on the decline, angel capital is still abundant, and in fact, likely mirrors VC in size (though hard data around this is notoriously hard to capture). Geetha and Allan proceeded to talk about the new value propositions that are peeking investor interest and are leading to large exits. These companies are increasingly producing innovations that reduce costs, approach problems in unique, more costs effective ways, and provide clear and immediate monetary value.

Tim O’Reilly, infamous founder of O’Reilly media gave a talk next on what he calls the “global consciousness.” As a society, we’re building and aggregating knowledge and services that are reflections of large bodies of people rather than individuals – systems that get better the more people use them. Pooled together, this global brain is creating great challenges and opportunities. Information is increasingly available in real time and innovations are increasingly coming from “hackers,” people who leverage open data creatively. These people, in a way, are the world’s (and your companies) R&D department.

Continuing with the thread of global consciousness, UCSD professor and social scientist James Fowler, spoke of his work analyzing social networks. He and Nicholas Christakis have made a splash recently with their book Connected: The Surprising Power of Our Social Networks and How They Shapes Our Lives, which highlights the influence our friends and connections have on even physical traits of ours, such as obesity. James imagines using this knowledge to help target treatments and map the epidemiology of disease. Unexpected relationships will change the way we approach problems. For example, even though men are more likely to drink heavily, this behavior is not principally dictated and influenced by their male friends, but rather their female friends.

So, if as a society we want to curb binge drinking among males, we should craft interventions to address the females. James is also directly involved in massaging Facebook data in a soon-to-be-published randomized controlled trial of social network influence.

Changing tracks a bit, next up we had a five-person panel of pharmaceutical executives talking about the upcoming “Pharmageddon”, and exploring why the pharmaceutical industry as a whole is suffering from pipeline drought and what’s next on the horizon. Some themes emerged in the discussion: the failure rate of pharmaceutical R&D is too high, we’re guessing too much and these guesses are becoming increasingly difficult; there’s a ways to go in basic biological understanding that gives pharma a platform to focus R&D; trials are increasingly difficult and expensive to conduct; and there’s a chance the industry as a whole has simply reached an asymptote and will be shaken up over the next ten years and branch into biotherapeutics, engage in aggressive partnerships with non-pharma medical companies and begin to sell outcomes rather than medications.

After lunch, David Webster, the global lead of IDEO’s Health & Wellness practice joined FutureMed along with IDEO’s Lionel Mohri to deliver a workshop about how the design and innovation firm IDEO helps clients craft products and services that match human needs. They briefly introduced IDEO’s work in health (including Bayer’s USB glucometer) and launched into a workshop to bring us through a compact version of IDEO’s innovation process. They split people up into small teams and had them go through a rapid-fire design challenge: how might we improve the physical and mental well-being of our workforce?

They dumped a set of materials on stage and pushed us through the IDEO process of empathizing with the user, synthesizing the observations, brainstorming, and prototyping designs. At the end of the session, we shared our concepts through our drawings and physical prototypes.

After IDEO we had a brief talk by Ash Damle, CEO of MedGle. They’re building what they call a collaborative clinical decision making tool for both patients and clinicians. They’re trying to glue together symptoms, demographics, and other inputs to help doctors and patients with differentials and with finding the right information.

After Ash was a sensational talk by Robert Hariri, CEO of Celgene Cellular Therapeutics, an innovator in translating stem cell therapies to patients. They’re using placental derived stem cells as a platform for their therapies for a number of reasons, and are already seeing spectacular results. An early application is in Crohn’s disease, a poorly understood immunological gastrointestinal condition that has historically had very few high quality treatment options. Robert’s team has had remarkable clinical trial results using their placental cell platform PDA-001 (all cells are procured through donation) to treat the disease. He showed us before and after endoscopies of Crohn’s patients and the results were startling – almost a compete remission of the disease. Celgene is currently applying this platform to broad spectrum of human disease such as multiple sclerosis.

Robert proceeded to blow us away even further with their work in organ and tissue engineering. They’re decellularizing organs and using their stem cell technologies to repopulate the left over non-cellular structures (think scaffolding) with new tissue. Celgene completed this successfully by creating a beating mouse heart and are moving into pigs. They’re hoping for a day in which humans could be transplanted with pig hearts, but with the pig cells removed and replaced with human cells.

Lastly, Celgene is using the structural framework of placentas to create sheet collagen that can be used in wound repair. They’re creating patches that are currently being tested in burns and the results are absolutely stunning. They showed pictures of a patient who had extensive burns with one segment of the burn treated with the current standard and the other with their collagen patches, and after a few months to allow the patient’s own skin cells to populate the collagen scaffolding, you couldn’t even tell the difference between the patient’s non-burned skin and their new skin. Further, the moment you put the collagen patch on the skin a patient’s pain is decreased dramatically – a huge victory in it of itself - simply astonishing.

The afternoon consisted of a visit to the Autodesk office and gallery in San Francisco, where they’ve got a smattering of examples of how their computer tools are used to build nearly every type of object from micro-mechanical devices to complete buildings. The office felt more like a chic design firm than a CAD company, and it's clear that as computers have become the modern day hammer, Autodesk’s tools have immensely impacted humanity at all levels.

At the end of our visit, a speaker from Autodesk gave us a peek into their move into medicine. As biology is becoming increasingly manipulatable, they’re building CAD tools for bioscientists to sculpt and simulate small molecules, DNA, proteins, the works. An early example of what will be capable in the years ahead was from their partnership with the Wyss Institute to create tools that help scientists build DNA Origami, a new field in nano-biology that uses inert DNA and it’s natural properties to create complicated nano-structures. He showed a soon to be published picture of a DNA cargo box that can be triggered to release a payload by a molecular stimulus. For a number of reasons DNA might become exceptionally powerful in nano materials science.

Before we left Autodesk we also had an onsite lecture by Mike West, who floored us with his work reprogramming stem cells. At some point in the differentiation of a cell it goes from being able to replicate forever into anything, to being a certain type of tissue with a defined lifespan. Mike, a luminary in stem cell research has already used stem cells for the first time in history to create cartilage-producing cell lines for orthopedic repair. This alone is a tremendous innovation, but to go from here to a world where we can use our own stem cells to repair our own tissue, we need to go even further, as therapeutic somatic cells like muscle tissue created from stem cells that aren’t autologous (from your own body) would cause immunological problems.

Early stem cell work focused on using embryonic cells for the reason that they could be programmed and manipulated into certain cell types that might be therapeutic. But what if we could turn back the clock and go from say, a skin cell, which has already been given it’s instructional fate, re-boot it, and turn it back into a cell that’s more or less brand new and can become anything? A cell from your liver, for example, could be rebooted and turned into a muscle cell for your heart. Well, Mike & team have done this, reversing somatic cells into induced pluripotent stem cells (iPS). It's truly spectacular work and leads to a future where you might be able to use a sample of your skin cells to repair your kidney.

After Autodesk, FutureMed organized some social time in San Francisco, which your editor skipped to grab some much needed sleep. Today we’ve got more on regenerative medicine, neuromedicine, and an offsite to go play with Intuitive Surgical’s daVinci robot.

Ben Rosner, the medical director of Archimedes, Inc. introduced the personal medicine track with an overview of the need to personalize medical guidelines to the particular patient and the role that inputs from the "omics" (genomics, proteomics, etc) will play in medicine’s transformation from bucket recommendations to mathematically validated personalized recommendations. Personalized medicine, he noted, got a lot of hype 10 years ago and has still yet to pan out, but his talk and the talks following made it clear that the concept of personalized medicine is at an inflection point of clinical utility and is already shaking up cancer treatment, with other arenas to follow.

Next up we heard from David Ewing Duncan, author and journalist behind the Experimental Man Project, who has subjected himself to just about as many personalized medicine tests as humanly possible and, through doing so, discovered the limitations in the field as well as some of the promises. This is a man who probably knows more about his innards than anyone else on the planet.

Ted Goldstein, Apple computer scientist turned UC Santa Cruz bioinformatician, stepped on stage next to describe his efforts in decoding and making sense of cancer genomes. He and the UCSC team have developed an open cancer genomics browser to help catalyze research in this space. His talk, along with others, left us with the sense that using genomics to provide personalized treatment of cancers is simply exploding. Given that each tumor has diverse, ever-changing, and increasingly actionable genetic profiles, it seems clear that in years ahead clinicians will sequence all tumors and develop customized treatment plan for the specifics of the found genetic mutations. It’s going to flip cancer treatment on it’s head – it’ll matter much less if the cancer is a “lung,” “breast,” or “liver” cancer and much more if it’s an “KIF3A,” “MDM2,” or “MELK” cancer.

Next up was Nader Pourmand, another UC Santa Cruz innovator who gave an absolutely whirlwind talk about his work with nanopipettes. He and his team are currently using 50nm pipettes to interact with, monitor, and manipulate single cells. Their first order of business is injection. They’re able to precisely inject small molecules, RNA, you name it, into a single cell. This allows direct, real time, perturbation of cellular status in a way not previously possible. Not only that, they’re able to observe the activity in cells by attaching DNA aptamers to the end of their pipette tips. For those unfamiliar, DNA aptamers are little strands of DNA that researchers can, more or less, make to be sticky to a molecule / protein of their choice (think antibodies but more selectively binding). Because the binding of a target compound to an aptamer is detectible as an electrical signal in the pipette, and because an increased concentration of target molecules means more binding events, Nader and team are able to determine the real-time concentration of, more or less, whatever they’d like inside a cell. It’s a fascinating tool.

After Nader was another fascinating talk by Eric Schadt, chief scientific officer at Pacific Biosciences. Eric was recently profiled in the NYTimes and Esquire, and there’s good reason for it. Firstly, he and the folks at Pacific Biosciences have developed an incredibly fast sequencing technology by rigging the proteins that synthesize DNA (DNA polymerases) in a way that allows for direct observation of specially tagged nucleotides as they’re incorporated into a growing DNA strand. By observing this, they’re able to sequence DNA in a way that’s as fast as nature is able to build it – extremely fast – and with minimal prep and no amplification needed (PCR). This technology scales so well that it might allow a sort of molecular-epidemiology, where the sewage of an entire city is rapidly analyzed to look for the DNA of various pathogens, etc. In the recent cholera outbreak in Haiti, he and his team were able to sequence the bug, determine useful information about it, and publish in NEJM, all in 4 weeks.

But the sequencing technology is step one... it’s how Eric and team are using the output of this sequencing where things get really interesting. Eric is taking a network approach to genomics rather than looking at specific genes one at a time. With mathematics that are far beyond your editor’s understanding, he’s building what amounts to social nodes of genes and looking at patterns of how they interact. This is leading him to some interesting conclusions about how genomics might be used clinically. There might, for instance, be an entire node of 1,000 genes that relate directly to certain pathology and, in order to treat that pathology, we might have to intervene in the whole node. This work goes completely against the traditional, “every gene is important, alone” approach and is already starting to yield some fascinating results in areas such as the genetic contributors for type II diabetes.

Esther Dyson, entrepreneur and investor, and Carol McCall, health economist, came up next to talk largely about behavior change as it applies to health care. After discussing a number of approaches, including gamification, incentives, etc., Esther made an extremely apt comment that next year she’d like to see some HR benefit folks in the audience of FutureMed. There’s a large push in the employer benefits world to engage with employee health in new ways. Companies larger than 300 people are generally self-insured, and so they’re paying mostly out of pocket for their health care costs. New solutions and systems to engage employees with their health are popping up, and employers are becoming increasingly interested in trying novel solutions. Carol gave a relatively optimistic view of reimbursement for wellness programs by noting that “there are ways for these things to pay for themselves.”

The next to talks, by Peter Alperin and Randy Scott, told of their companies active efforts to commercialize some of the oft discussed personalized medicine advances.

Peter, from Archimedes, a company whose tagline is “moving medicine through mathematics” spoke next about their personal risk assessment tool called IndiGO. Their software creates individualized guidelines for care according to a person’s characteristics, risk factors, and current treatments. Their vision is to plug this into an informative, graphical user interface and get it in front of physicians at the point of treatment.

Randy, from Genomic Health, spent his time talking principally about two things: the shift from therapeutics to diagnostics, and his company’s moves in commercializing Oncotype Dx, a genetic test for breast cancer that is dramatically changing the standards of care. He noted that 2% of medical spending is currently in diagnostics, and that the paradigm of finding companion diagnostics to match therapeutics will likely flip to finding companion therapeutics to match diagnostics. His company’s test, Oncotype Dx, gives a single number score that helps clinicians decide if chemotherapy is efficacious for breast cancer patients. The test, according to Randy, was harder to market than develop, but it’s clear benefit and use case is catching on: it’s now used in about 50% of early stage ER+ cancer cases. In large part due to his test, there’s been a 30% decline in chemotherapy use in these types of cancers.

After the morning of talks, we then boarded a bus to head over to the Kaiser Permanente Garfield Innovation center for an afternoon lecture and tour. Only four years old, the center is a playground for physicians, nurses, and patients to innovate process improvements, space improvements, and think deeply about how new systems and technologies can better care. They’ve mocked up their various patient rooms in full, and have tested out a slew of innovations ranging from innovative room layouts, the types of tiles used in the bathrooms, to Doppler based breathing monitors.

Kaiser folks talked a little bit about the innovation processes at Kaiser and walked us through their various environments to show some of the technologies they’re testing. For example, at one point during the tour they summoned a hospital transport robot called the Aethon that politely asked folks to move out of the way until it reached its destination.

In the labor and delivery room, they’ve got lights embedded into the ceiling that can be angled and adjusted automatically through a wand. They’ve also mocked up a full digital operating room and are experimenting with Microsoft Kinect hacks that allow surgeons to explore radiology data without breaking the sterile field. They're also working with new, boom based systems to hold equipment and reduce the number of cables in the OR.

We got the feeling after leaving the Garfield center that there’s virtually no technology they haven’t tried and they’re working hard to think broadly about how these new gadgets and process innovations fit into the lives of the clinical staff and patients.

After the tour of Garfield, we had a miniature break and then immediately jumped into dinner followed by talks from Dean Ornish, head of the Preventive Medicine Research Institute and Woody Merrell, the director of the Integrative Medicine center at Beth Israel, the nation’s largest and most comprehensive.

Dean spoke of the incredible, proven benefit of lifestyle intervention on human health and his efforts over the last 30 years to bring these sorts of interventions to patients. In a victory that took 17 long years of fighting, Medicare recently approved payment for his program last January. He thinks that the message of the clinical and cost saving benefits of these programs is finally hitting clinicians, payers, and politicians, and he's is hoping that we’ll see a huge shift toward greater support of these interventions in the health care community.

Woody closed the night with a look into integrative medicine, defined broadly as the fusion between Western medicine and alternative traditions. He’s a long time advocate for such approaches and is convinced that things like acupuncture and Reiki will and should be applied more broadly in today's healthcare. The birth of his center at Beth Israel was part catalyzed by the realization that patients are themselves turning to these therapies in large numbers and they need to be incorporated into treatment regimens for patients that find them helpful.

The night finished at 10pm. Tomorrow we kick things off at 8:30am with entrepreneurship & innovation, the future of pharma, a workshop from IDEO, and a visit to Autodesk in San Francisco. Stay with us for three more days of exclusive Futuremed coverage...

We've been experiencing technical difficulties while upgrading Medgadget. We had to roll back a couple of days, but are working on fixing the bugs and getting back to business. We apologize for any inconvenience and hope you stay with us as we try to get through this.

-Editors

Let’s start with the basics - The Singularity University (SU) mission is to explore the exponential growth in technological advances of the sort related to the hypothetical technological singularity, a point in time where progress is so rapid that the future is increasingly difficult to predict. Founded by Peter Diamandis and Ray Kurzweil, Singularity University lives and breathes exponential technologies. FutureMed, chaired by Daniel Kraft, is the executive education program exploring how these advances are changing and will continue to change medicine and benefit human health. The 5 day conference consists of lectures, field trips, work shops, and more.

Given SU’s mission, the day naturally started with a talk by the luminary of exponential change, Ray Kurzweil, who opened by noting that the evolution of health care advances have moved from linear growth into exponential growth as medicine has become increasingly an information technology. FutureMed beamed Ray in from Boston using an eerie, but spectacular, teleprompter in which Ray seemed to be floating in space in front of us all, giving everyone the feeling that this icon of the future was in fact coaching us from the future himself.

One fascinating insight from Ray’s talk was that these exponentially growing advances are often the combination of many different paradigms that grow and develop in a sigmoidal fashion. The exponential growth of computational power per dollar, for instance, is driven by say, vaccum tubes, which start slow, progress extremely rapidly, and then level off, only to be replaced by transistors, which did the same thing until integrated circuits came into the picture. Collectively, even though each of these technological paradigms hit a wall at some point, they were replaced by another advance that allowed the final outcome of computational power to continue to scale exponentially. In proof of this, Ray showed us what seemed to be an exponentially increasing number of charts that demonstrated exponential technological growth.

Neil Jacobstein, the president of Singularity University, got on stage to talk about artificial intelligence and its implications in medicine. In the world of health care, he asked us to think of artificial intelligence as an innovation amplifier, in that it might be used to help design new drugs, help physicians form better hypotheses, and simulate the effect of therapy before it’s administered. He noted that right now we’ve got AI systems that are narrowly focused, like chess-playing or jeopardy-playing computers, but in time these will lead to increasingly broad AI. The world of medicine will benefit as this happens.

Ralph Merkle was up next to discuss nanomedicine and how manufacturing principles of larger systems are, and will move more rapidly into the atomic realm. Currently, the tools we have to manipulate atoms are only in 2D, like the famous IBM printing of xenon atoms on nickel, but will soon move to 3D. Once that happens, we’ll be able to build molecular tools such as bearings and universal joints that will allow nanotechnology to develop into something far more functional and medically useful than what we’ve seen so far. He asked us to think about some devices that might be potentially useful, one being a “respirocyte,” a nano oxygen tank of sorts that holds 10x the oxygen carrying capacity of red blood cells and deploys the gas as needed. He imagined a world where a therapeutic injection of these tiny “machines” might allow someone to hold their breath for an hour.

After Ralph, Brad Templeton, a key member of Google’s self-driving car project got on stage to tell us about the history of self driving cars and give us some insight into how Google’s car works and what this change might mean for both the safety and efficiency of transportation. Human drivers kill 34,000 people per year in the USA alone, and worldwide there are 1.2 million deaths annually from automobiles. Self-driving cars are clearly coming to consumers in the not so distant future, and our concept of transportation will change tremendously. Imagine, for instance, that city streets might seamlessly adapt to traffic needs by changing the direction of one-way streets, manipulating stoplights, etc.

The next set of talks by Dan Barry and Gabor Forgacs focused on 3D printing technologies and how they’ll change both consumer and medical products. Dan, a former astronaut, has been actively exploring how these technologies will change our future. In a world where 3D printing (using both plastics and metals) are the standard for manufacturing, increasingly, the complexity of these objects will actually not cost any additional money. Not only that, customization for the consumer and patient will be considerably easier and common. A dentist office, for instance, might be able to print replacement teeth on site. Or an orthopedic surgeon might be able to print a replacement bone that will fit perfectly into the patient. Dan passed around some incredibly complicated objects that would be nearly impossible to make through other manufacturing methods, yet were crafted with ease using 3D printers.

Gabor Forgacs, researcher and founder of Organovo, discussed how these 3D printing techniques are being applied to organs. In Gabor’s viewpoint, the world of scaffold-based tissue engineering is transitioning into both decellularized (where you use natural ECM structures) and scaffold-free (where you print tissue and let it organize) tissue engineering. He showed some absolutely remarkable research where his team printed a neural graft, severed the sciatic nerve of a mouse, and then installed the graft only to find that the mouse was able to move its hind legs again in 17 days. At the close of his talk, Gabor pointed out that printed organs are not likely to have the same shape and look of our current organs, only similar function. It’s not realistic or sensible, he says, to print a kidney that resembles anything close to a natural kidney. However, masses of tissue that function as kidneys do could potentially be engineered using his techniques.

Next up, Eythor Bender from Berkeley Bionics gave a talk about his company’s eLegs, which allow patients with spinal cord injuries to stand-up straight and walk again. The technology, demonstrated live on stage by Ted, a patient who works closely with Eythor and team, is a moving example of how robotics can affect the lives of patients.

Berekely Bionics has a audacious and remarkable goal to supplement (and in some cases replace) the wheelchair for paralyzed individuals.

eLegs work without an innervation into the patient's nervous system, but rather automatically (based on pressure from two crutches the patient holds) move the extremities in a walking pattern that allows patients to take steps. Their first customers will be rehabilitation centers, but the company is pushing hard to bring the price down to a point where it will be attractive and optimally reimbursable for patients to use on their own.

After Eythor, we had a string of talks on web-enabled health including Thomas Goetz from Wired Magazine, Michael Gillam from Microsoft, and Roni Zeiger from Google.

If you read our TEDMED coverage, you may remember Thomas's effort as part of Wired Magazine to re-design the lab report and make it relevant and actionable for patients. The work was exceptional and folks at TEDMED were left wondering if / when big laboratories like LabCorp and Quest Diagnostics would make this move. Yesterday we learned the great news that Thomas has started a company called 1+1 Labs to bring these reports to patients. Bravo.

After Thomas, we heard from both Michael Gillam, and then Roni Zeiger, who talked about some of the advances they're seeing and pushing from their posts at Microsoft and Google, respectively. Michael spoke about the historically large lag between scientific discovery and translation to clinical practice, and how that has changed and improved over time, as well as how advances might be brought to patients in the future. He pointed out that there’s an emergence of consumerized medical tools and software that directly serve as an intermediary to patients and their doctors. He also noted that there are currently already 85+ devices that are sold to consumers that can connect to health records.

Roni talked about some of Google’s more recent efforts in health outside the PHR space, ranging from the simple but powerful introduction of smarter health realted search queries like “poison control,” which immediately returns the number for the US poison control center, and “suicide,” which displays the number for the US suicide prevention hotline. He also demonstrated Google’s Body Browser, an interactive anatomy tool that lets laymen and experts alike explore the inner workings of the human body.

Next we heard from Health IT gurus Christopher Longhurst, who rolled out the EMR at the Lucile Packard Children’s Hospital, and Daniel Riskin from Vanguard Medical Technologies. Both described the power of implementing health IT smartly and some of the trends and technologies ahead.

Two pieces of information stood out most from Christopher’s talk. One was that Lucile Packard Children’s Hospital was one of the first to publish direct evidence of the reduction of all-hospital mortality after implementation of an EMR. The other was how insanely expensive it is to implement EMRs in an in-patient setting, and how he hopes and believes that these systems will become less expensive and more like commodities in the near future.

Daniel described how the most powerful analytics in health care will come from fully structuring a patient's record. To this aim he spoke about and demonstrated an application called DocTalk that uses speech recognition to automatically translate a doctor’s dictation into structured clinical data. This allows physicians to avoid the painful process of categorizing and organizing every piece of information on patients by him- or herself.

The next section of the conference were rapid fire talks by four up and coming health startups: HealthTap, Massive Health, Basis, and Zipongo. All are working on ways to change behavior and improve health through the smart use of personalized data, feedback loops, and technology. Basis in particular stood out with their soon to be shipped ultra-watch that measures your heart rate, calorie burn, galvanic skin response, and movement. It’s a beautiful device that’s a technological marvel as well. We can’t wait to get our hands on one!

To further the discussion of wearable sensors, Astro Teller, who founded Body Media, took to the stage and spoke about his efforts building both the technology behind Body Media’s sensor and the company to sell it. His candid talk highlighted the challenges such devices have in being relevant, comfortable, and desirable enough to become routine in patients' lives. He also noted the difficulties in getting health care insurer support for such devices, and the need to focus on “decoding the human lifestyle” to figure out the best ways to motivate people to adopt healthy behaviors.

After dinner, Lawrence Sherman spoke about the future of medical education, including the ludicrously poor state of Continuing Medical Education (CME). He noted that in the current system an obstetrician can get CME credits for learning about urology and that around 50% of CME offerings are paid for by the pharmaceutical industry. He advocates not only reformed CME, but reformed primary medical education in which budding doctors are exposed to patients from the very beginning of medical school, and alternative learning modalities are used to make medical education more engaging and efficient.

FutureMed day one wrapped up with an un-conference in which participants taught each other about things of their choosing.

Wow, it was a long but rich day! Tomorrow we start with a half day of personalized medicine and then a field trip over to Kaiser’s Garfield Innovation Center.

The new formulation of Fluzone Intradermal vaccine is the first influenza vaccine licensed in the U.S. that uses a novel microinjection system for intradermal delivery. Fluzone Intradermal vaccine features an ultra-fine needle that is 90 percent shorter than the typical needle used for intramuscular injection of influenza vaccine. Sanofi Pasteur has previously licensed microinjection intradermal influenza vaccines, marketed as Intanza® or IDflu® vaccines, in more than 40 countries including Australia, Canada and countries in Europe.

Fluzone Intradermal vaccine incorporates a new, easy-to-use, prefilled microinjection system designed to consistently deposit vaccine antigens into the dermal layer of the skin of adults. The dermal layer contains a high concentration of specialized cells known as dendritic cells, which play a key role in generating an immune response. In clinical trials, Fluzone Intradermal vaccine produced an immune response at rates similar to Fluzone vaccine administered intramuscularly.

Typically, adult influenza vaccines are administered into the muscle utilizing a needle 1 inch to 1.5 inches (25 mm to 38 mm) in length. Fluzone Intradermal vaccine features an ultra-fine needle that is 0.06 inches (1.5 mm) in length. Fluzone vaccine contains 15 mcg of hemagglutinin per strain of influenza in a 0.5 mL dose. Fluzone Intradermal vaccine contains 9 mcg of hemagglutinin per strain of influenza in a 0.1 mL dose.

Fluzone Intradermal vaccine will be available to health-care providers in the U.S. for the 2011-2012 influenza season.

Press release: FDA Licenses Sanofi Pasteur's New Influenza Vaccine Delivered by Intradermal Microinjection...

From the announcement:

The NESS L300 Plus builds on the proven success of Bioness’ NESS L300 Foot Drop System and is designed to additionally stimulate the muscles of the thigh. The addition of the thigh stimulation cuff, synchronized with a wireless heel sensor to detect when the foot is on or off the ground, controls the knee, making it easier to walk. Historically, patients have relied on rigid plastic braces which restrict thigh and ankle movements and can lead to additional problems, including increased falls.

Product page: NESS L300 Foot Drop System...

Press release (pdf): BIONESS INC. RECEIVES FDA CLEARANCE OF ITS NESS L300 PLUS SYSTEM...

In addition to accurately diagnosing a stroke, the app was also praised for its ability to handle a large number of images seamlessly and to detect subtle, but potentially critical findings in CT scans. Moreover, the mobile nature of the app gives doctors the ability to analyze and diagnose strokes from practically anywhere.

ResolutionMD Mobile was released last April and allows doctors to quickly and securely access medical images from central hospital servers and manipulate them to assist in making an accurate diagnosis. Of note, our friends at iMedicalApps have a review of ResolutionMD, and anyone can download the app for free from the iTunes Store.

Article from the University of Calgary: Stroke diagnosis using iPhone app extremely accurate study finds...

Journal article: A Smartphone Client-Server Teleradiology System for Primary Diagnosis of Acute Stroke

Product page: ResolutionMD Mobile...

Bullimore explained that by viewing the brain in this manner, he discovered that the organ has much in common with computer chips and stock markets in the way they process information. Brain networks represent a balance of efficiency of information transfer and connection cost. Moreover, different patterns of network connections in the brain correspond with different types of thinking, and age and neurological disorders can rapidly affect different network "configurations".

To illustrate some of these concepts, Bullimore performed a live experiment during his talk using Twitter. Members of the audience were asked to tweet during the lecture about the concepts that were being discussed using a special hashtag. At the conclusion of his talk, he displayed an image that showed the interconnectivity of the hashtagged tweets (image above) and explained how the "twitterbrain" network is analogous to the human brain network.

“We found that the #twitterbrain network was somewhat like the brain network in being small-world and modular with highly connected hub nodes," explains Bullimore, "however the brain network was more clustered and less efficient than the twitter network. So at first sight there were some points in common and some points of difference between these two information processing networks.”

Take a look at the video clip below that shows a simple model of the human brain network:

Caption and explanation:

Each node of the network represents a different brain region and is colour-coded according to the larger area is located in. Pairs of nodes are linked if the activity of the two regions is found to synchronize a lot of the time during an fMRI brain scan, and the size of nodes represents how many other regions a given node is linked to.

The resulting network is used to analyze information flow in brains of healthy people as well as patients with disorders such as schizophrenia. To better understand these networks, we can decompose them into communities of nodes which are more densely connected with each other than with the rest of the network. This gives rise to a different picture, where the nodes are layed out in space according to the communities they participate in, rather than their location in real anatomical space.

The above video shows the transition from a network showing the connections between different brain regions in their anatomical locations, and a new layout emphasizing the network's structure, with nodes relocated and re-coloured based on their membership in network communities.

Article from the University of Cambridge: Neuro-tweets: #hashtagging the brain...

Tracing the cause of Salmonella, or any bacterial contamination, along a food supply chain can be difficult due to different environmental conditions, so the foundation of the program was Combase, a database of microbial growth data in various environmental conditions from previous research. Taking into account the temperature, pH, and water activity of actual processing conditions, the program can give accurate probabilistic and kinetic models of Salmonella concentration.

The program's predictions have been validated with comparisons to actual pork products.

Certainly a helpful tool for meat packagers, but as consumers please remember to cook your pork thoroughly to at least 160 °F (71 °C) so any salmonella in the pork supply chain doesn't end up on your plate.

Article from Food Production Daily: New software tool to predict Salmonella levels in pork...

Journal article: Modelling Salmonella concentration throughout the pork supply chain by considering growth and survival in fluctuating conditions of temperature, pH and a(w)

Image credit: NIH

From the product page:

Biomagnetics Diagnostics' triggered optical biosensor is based on protein-receptor binding that brings two or more optically tagged receptors into close proximity using planar optical waveguides, thereby triggering fluorescence changes identified almost instantly by tiny on-board detectors. These devices are specifically designed to be battery operated and ultraportable, allowing for the rapid detection of various viral and bacterial pathogens by relatively untrained personnel outside of the laboratory setting. Los Alamos originally developed the concept of a reagent-less, laser-based system for homeland security purposes, aiming to allow first responders to rapidly identify toxins and pathogens in the field. Broader applications, such as disease diagnostics, blood bank screening and hospital use, offer commercial partners an interesting opportunities.

Press release: Biomagnetics Unveils World's First Urine-Based Tuberculosis Diagnostics Tool in New Video...

Product page: Integrity Optical Biosensor...

Flashback: Biomagnetics Diagnostics Corp. Introduces an Optical Diagnostic Biosensor

To coincide with Futuremed, our friends at Thinklabs decided to give away the apps for free, since most of you will not able to attend the exclusive event. You're hearing it first here, so be sure to get them this week while they're free. Here's more about the apps with download links further down:

iMurmur uses real patient recordings to provide authentic heart sounds so that learners know how real patients sound, rather than mere simulations. The App includes reference waveforms, diagrams and educational material, and is designed as a quick mobile reference for medical students, residents, teaching faculty, and practicing clinicians. iMurmur is also a valuable tool in nursing and EMT communities. The App can be used on Apple iPhone, iPod Touch and iPad platforms.

Heart Record is a fun, recreational App for non-clinical use that turns the iPhone into a consumer electronic stethoscope. Heart sounds can be captured, displayed and emailed - a terrific way for lay users to listen to the heart without a stethoscope.

Heart Record is a consumer version of Thinklabs Stethoscope App, a professional sound recorder with multi-touch user interface, real phonocardiographic waveform display, email and annotation capability, and many other features. Stethoscope App provides live sound recording from Thinklabs Digital Stethoscopes, enabling clinicians to capture patient heart and lung sounds at the bedside or office for EMR, research, second opinion, telemedicine, and educational use.

Thinklabs is the first company to provide an electronic stethoscope with connectivity for recording and display of heart and lung sounds on the Apple iPhone and iPad.

Download links: iMurmur 2; Heart Record

Thinklabs press release...

Thinklabs Medical homepage...

Calculating appropriate mealtime insulin doses based on blood glucose level and carbohydrate intake can be a challenging task for some patients. The FreeStyle automates this step by recommending the right bolus dose.

Furthermore, it features a touch screen interface, automated logbook, personalization preferences and USB connectivity.

The accompanying FreeStyle Auto-Assist software (available for PC and Mac) helps manage diabetes with reports, reminders and messages. The device will be available beginning in May.

Press release: Abbott's New FreeStyle InsuLinx Blood Glucose Monitoring System with Insulin Calculator Receives CE Mark...

Product page: Freestyle InsuLinx...

Using their EWI method, the Columbia Engineering team imaged the heart with ultrasound five times faster than standard echocardiography and mapped the local deformations of the heart with their images. The researchers then looked at small regions of the heart (just a few millimeters squared) and measured how much these regions were stretched or compressed every 2/1000s of a second. This enabled them to precisely identify at what time each region of the heart began to contract, a.k.a the electromechanical activation, in all four chambers of the heart. They compared their maps with the electrical activation sequence and found they were closely correlated, both at the natural rhythm of the heart and when the heart was artificially paced.

Arrhythmias occur when the normal electrical activation sequence in the heart is disrupted and their prevalence is expected to rise, as people live longer. In some cases, effective treatments exist. For example, a pacemaker can be surgically placed or a catheter can be brought into the cardiac chambers and used to burn diseased regions of the heart or pacing leads can be implanted in the heart to bypass the diseased conduction system and replace it by artificial electrical activation. But doctors can’t always tell where to ablate with a catheter or who will benefit from artificial electrical activation. EWI could help determine in advance which patients can benefit from these treatments or identify with more precision which regions of the heart should be ablated. It could also be used to adapt treatment parameters as the patient's condition evolves.

“Since ultrasound is so safe, portable, and low cost,” added Dr. Konofagou, “we can imagine a future where most physicians can carry a portable ultrasound scanner the size of an iPhone and easily get a map of the activation of the heart during a routine visit.”

Her team has already begun to image patients with arrhythmias and compare their measurements with the gold standard of catheterization and non-contact electrode measurements. If this study is conclusive, they will then move to a larger clinical study.

Press release: Prof. Konofagou Develops Method To Diagnose Arrhythmias...

From a Medtronic press release:

A pooled data analysis from several Medtronic left-heart lead studies for 1,307 patients presented today at Heart Rhythm 2011, the Heart Rhythm Society’s 32nd Annual Scientific Sessions, shows a CRT retention rate of 95 percent at 18 months for Medtronic’s Attain family of left heart leads. In this analysis, CRT retention rate was defined as 18-month survival rate from loss of CRT due to any left ventricle (LV) lead-related events that required operative intervention or termination of CRT. The observed events were LV lead dislodgement, phrenic nerve stimulation (PNS) (electrical stimulation of the nerve that facilitates breathing), and other LV lead failures such as elevated thresholds, loss of capture and lead fracture. Clinically acceptable performance was achieved in the majority of patients in this analysis using a variety of Medtronic left-ventricle leads to accommodate varying anatomies.

Attain Ability Plus enables physicians to reach and maintain the target vein, providing stability in medium-to-large venous anatomies, while Attain Ability Straight allows physicians to maneuver through small cardiac veins. These leads are part of the only portfolio of medical technology to incorporate NASA-developed insulation material that was previously evaluated for space applications, high-performance engines and harsh environments.

The design of the Attain Ability Plus and Attain Ability Straight left-heart leads, combined with their capacity to be delivered via the Attain Select II, a sub-selection catheter (in leads ³ 88 cm in length), assists physicians in placing the lead directly in difficult to reach locations in the heart.

According to clinical studies conducted on these leads, approximately 94 percent of physicians positively rated the ability to position the Attain Ability Plus lead to the desired cardiac veins, with a one-month complication-free rate of 98.5 percent. Additionally, 96.8 percent of physicians positively rated the handling of the Attain Ability Straight and the ability to maneuver it to the appropriate veins, with a low lead-dislodgement rate of 3.2 percent. Both left-heart leads offer multiple pacing vectors, which may help address PNS and help prevent the need to reposition the lead invasively.

More details: Medtronic Announces FDA Approval of Attain Ability® Plus and Attain Ability® Straight Left-Heart Leads for Cardiac Resynchronization Therapy (CRT) Devices