La destruction créative…

La destruction créative…
La suite!
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•
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Prof. Dr. Philippe A. COUCKE
Département de physique Médicale/ Radiothérapie
Centre Hospitalier Universitaire Liège, BE
Définition de destruction créative
• Transformation qui accompagne
une innovation radicale!
• Terminologie introduite par Joseph
Schumpeter (économiste
autrichien du XX siècle).
• Le monde est “Schumpeterisé” par
l’infiltration massive des
applications digitales.
Et dans ce contexte quid de la médecine ?
• « L’évidence » issue de la recherche
clinique est dérivée de population qui
ne traduisent pas la réalité/variabilité
individuelle.
• Les agences (FDA, EU) ont une
aversion pour les risques et de ce fait
suppriment des opportunités
remarquables d’innovation qui
peuvent changer la médecine.
www.medscape.com : Data re-analysis changes 35% of trial conclusions; 2014-09-10
JAMA 2014; 312: 1002-1003, 1024-1032.
La pratique “imprécise” de la médicine
changera de façon dramatique par le
principe du « Big Convergence »
La convergence technologique
Maturing
internet
Cloud
computing
Remarkable
miniature
pocket
computers
Ever
increasing
bandwidth
Near
ubiquitous
connectivity
1969
1976
2001
2009
1953
Mid 2000
2001
The Human Genome Project to
“crack the code”!
Graig Venter & Francis Collins
genomic revolution
1953
Watson & Crick
1969
Salvador Luria (theorist
of molecular biology and
Nobel Prize)
1976
Genentech founded by
Dr HW Boyer & RA
Swanson
Mid 2000
Academic
sectors
exploring
convergence.
2009
NAS New
Biology Report.
La transition en médecine poussée par
The Super Convergence
La digitalisation de l’être humain n’est rien d’autre que le décryptage de toutes les lettres de
son génome.
La transition “old to new medicine”
• La médecine est remarquablement conservative à
tel point que l’on peut la taxer de sclérosée voire
même ossifiée.
• Sans la participation active des consommateurs
(patients) dans cette révolution, le processus sera
inexorablement ralenti.
• La médecine doit évoluer d’une médecine de
population vers une médecine individuelle. Eric TOPOL
Les signes avant coureur du Tsunami
Les C’s introduisent les D’s
Les C’s
• Connection Constante:
– Netizen = Internet + Citizen.
– Digerati = Digital + Literacy.
• Collaboration & Crowdsourcing:
– Réseaux sociaux.
– « Pooling » des connaissances.
• Consommation Customisée:
– Personalized Digital Advertisement.
– Sensation d’empowerment (sherry picking).
• Cloud Computing:
– Accessibilité ubiquitaire
– Capacité informatique illimitée
Les C’s ouvrent la voie pour les D’s
• Disruption & Déstruction:
– Innovations radicales amènent à la transformation.
– Prochaine victime technologique: la télévision…
• Data Deluge:
– Gordon Moore (1965):
• “Doubling of capability of digital devices every 18 months”.
– En 2010:
•
L’univers digital a passé le zettabyte (1021)
– Nombre de capteurs sans fil:
• 10x106 in 2009,
• Projection: 645x106 in 2015
• Data Driven Culture:
– L’info-structure et l’infra-structure permettent une
accessibilité ubiquitaire à l’information.
– Le monde médical est à peine conscient de ces
changements…
Les mots “hype” en médecine 1
evidence-based
• IOM:
– “any valid evidence supports well below half of
the practice of medicine”.
• Ce qui constitue EBM aujourd’hui, est ce qui
est le mieux pour une population, pas pour
une patient particulier:
– Exemple: essai CAPRIE
• N = 19000
• Diminution risque relatif de 8,7% (p=0,043)
• Mais !
–
–
–
2 patients sur 100 en tirent un réel bénéfice.
30% ont une altération génique qui rend le Plavix® inutile!
Réduction absolu du risque de thrombose:
Les mots “hype” en médicine 2
recommandations et directives d’experts
• Sont basées sur des opinions et non des faits!
– Doivent être considérées comme “eminence”-based!
• L’EBM (souvent de piètre qualité) et les directives sont
conseillés pour octroyer un certain degré d’immunité contre
les poursuites pour erreur médicale…
Les mots “hype” en médicine 3
evidence-based
• Le concept du “One size fits all”
– On présume que la même dose est active
pour chaque patient:
• Pour l’industrie: facile à manufacturer à moindre
coût
• Pour le médecin: facile à utiliser en pratique
clinique.
– Le screening (exemple PSA pour cancer
de la prostate) est efficace pour tout le
monde:
• Screening de la population comme si nous
avions tous le même profil de risque.
Medicine for the common good
is not good enough !
Eric Topol
Empowered patient = someone who has figured out
that healthcare is no longer practiced in a paternalistic
and beneficent way!
Trisha Torrey founder of Every Patient’s advocate
Limitations de l’empowerment
• Accessibilité
• Qualité
• Information incomplète
Mais
On respecte de plus en plus les consommateurs
compte tenu de leurs capacités de comprendre
les principaux résultats et conclusions..
Il ya une convergence médiatique remarquable sur la manière de rapporter
l’information médicale.
L’amélioration de la “literacy”
Changera le donne de fond en comble!
• On accède à l’information médicale sur
Wikipédia 5 milliards de fois par mois.
• 50% des médecins US utilisent
Wikipédia professionnellement
• « Wikipedian–in-residency » financé
par Wellcome Trust suite à l’initiative de
Cancer Research UK (CRUK)
www.medscape.com: Cancer Research UK working to improve info on Wikipedia
Aujourd’hui l’homme de la rue connaît notre degré
d’ignorance….
Car il/elle a accès à l’information!
Avant l’émergence d’internet, les médecins étaient
considérés comme les grands prêtres détenteurs de
toutes les connaissances et de l’expertise, à l’abri de
la remise en question des « gueux » ignorants…
Le mouvement est inéluctable!
• La convergence globale est en route…
L’ère des big data est en route…
Believe is a matter of religious conviction and has nothing to do with
science
You want data!
Predicting is difficult…
Especially predicting the future!
Au niveau du diagnostic
Check up en 10’ avec un smart phone
10 Minutes check up with smart phone
Check up en 10’ avec un smart phone
Check up en 10’ avec un smart phone
Oto Home $79
Check up en 10’ avec un smart phone
Vous pouvez
ne pas aimer
…
Mais la
démarche est
inéluctable
Au niveau du diagnostic
Un peu plus complexe…
Schumpetering Laboratory Medicine
2013
This Device Diagnoses Hundreds of
Diseases Using a Single Drop of Blood
By Davey Alba
11.10.14 |
10:18 am |
Permalink
Nano-biosensors
Technion Wolfson Faculty of Chemical Engineering
• Détection non invasive:
– Cancer
(sein/poumon/prostate/vessie
/mélanome/leucémie)
– Diabète
– Infection à Candida
– Schizophrénie
– Asthme
– Phénylcétonurie
– ….
Handheld genotyping of pathogens
The next convergence
Hand-held genome sequencing
UCSC Genome Browser app comes to iPad
Friday, June 3, 2011
Next convergence:
A saliva sample is put on the device and the
genotype, ultimately the sequence, can be rapidly
generated, displayed. What about interpretation?
Near Infrared
Technology
Brain Light Absorption
Cancer screening BRA insert
April 2014 Apply Sci discoveries
Screening based on temperature fluctuations sensors. Data sent to a user’s smartphone. Temperature readings sent back to a global library,
runned through a proprietary algorithm: 74% correlation with mammography in early stages of breast cancer.
Nouveaux moyens de suivi
(y compris de la compliance)
Ralph Lauren
Involved in monitoring physiology at US Open 2014
iBG Star ®
Sanofi-Aventis
Soft contact lens to measure glucose levels
Google's Prototype "Smart
Contact Lens": Measuring Blood
Glucose Levels for People with
Diabetes
Joe Jimenez, the chief executive of
Novartis, acknowledged in an interview
that many previous attempts to develop
noninvasive glucose tests had failed,
noting that the company previously tried —
and failed — to develop its own glucosemonitoring contact lenses several years
ago.
What makes this case different is the
involvement of Google's engineers, he
said. "One of the biggest hurdles was
miniaturization, and that's one of the
biggest benefits that Google X brings," he
said. "This is a set of engineers that are
really doing incredible things with
technology."
Chip and skin: How hi-tech 'tattoo' will
monitor patients' vital signs
By Daily Mail Reporter
Updated: 12:00 GMT, 12 August 2011
L
2012
ondon, June 8 : A "tooth
tattoo" made from silk strands and
gold wires could be used to detect
life-threatening illnesses, according
to researchers.
HERE’S YOUR CHIP: New RFID medical
tattoo will ‘warn if you’re sick’
February 10, 2013 B
The Many Ways Google Wants to RFID
Chip Your Body
By Susanne Posel – November 15, 2013
Aging population? Overcrowded earth?
No problem: switch on/off birth control
The idea for the device originated two
years ago in a visit by Bill Gates and his
colleagues to Robert Langer's MIT lab.
Gates and his colleagues asked Langer
if it were feasible to create birth control
As far as contraception innovation
goes, for the past several years, the
Bill and Melinda Gates Foundation has
been leading the pack. Next on the
list? Revolutionizing actual bodily
implants. Say hello to wireless birth
control.
that a woman could turn on
and off and use for many
years.
Implantable nanosensor
The Glucose monitoring Tattoo
MIT Boston July 2011
Le « Tricorder »
Introducing the Qualcomm Tricorder XPRIZE.
A $10 million competition to bring healthcare to the palm of your hand.
Imagine a portable, wireless device in the palm of your hand that monitors and diagnoses your
health conditions. That’s the technology envisioned by this competition, and it will allow
unprecedented access to personal health metrics. The end result: Radical innovation in
healthcare that will give individuals far greater choices in when, where, and how they receive
care.
Vitals set includes:
Blood pressure
Electrocardiography (heart rate)
Body temperature
Respiratory rate
Oxygen saturation
Disease set includes:
Anemia
Urinary tract infection, lower
Diabetes, type 2
Atrial fibrillation
Stroke
Sleep apnea, obstructive
Chronic obstructive pulmonary disease (COPD)
Otitis ("ear infection")
Leukocytosis
Hepatitis A
Absence of conditions
Mononucleosis
Strep throat
Pneumonia
HIV screen
Tuberculosis
Aezon
Drugs don’t work in people
who don’t take them
C. Everett Koop, MD
Surgeon General
Smart pill bottles
Monitoring adherence (compliance)
A Medical Sensor You Can Swallow
By Eliza Strickland
Posted 1 Aug 2012
Proteus Digital Health study finds system detects pill ingestion
99.1 percent of the time. Aug 5th 2014
Proteus Digital Health’s ingestible sensor
FDA approved in 2013
Nouveaux modes de traitement
• Google glass includes:
–
–
–
–
–
–
Computerized central programming unit.
Integrated display screen.
High definition camera.
Microphone.
Speech recognition and dictation software.
Wireless connectivity.
Big Convergence
Google glass potential applications
• Beta version testing ongoing:
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–
–
–
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California: used into an academic curriculum.
Interactive videoconferencing and consultation.
Video streaming of treatment and surgeries.
Extension of PACS image display at surgery.
Hands free photo/video documentation, telephone
calls, looking up procedures and conducting internet
search.
Faciliter le travail du médecin
Home > Science/Tech
Doctor Of The Future Gains ‘Situational
Awareness’ With Google Glass [VIDEO]
By Matthew Mientka | Aug 5, 2013 04:08 PM
EDT
Can Google Glass Help Doctors
Perform Safer, More Successful
Surgeries?
by Beth Buczynski, 09/01/13
Da Vinci Robotic Surgery & Radiosurgery
NOTES
Natural Orifice Transluminal Endoscopic Surgery
Swimming micro-robots
DNA origamis Bar-Ilan Univ. Israël
• Designing objects from DNA
• Programmed nanobots for
selective killing
• Coordination
– Artificial swarm behavior
– Coding interaction rules
– Quorum sensing
• In-built antenna
– control by electromagnetic field
– Internet of things (smartphone)
Remplacer…
• Moyens mécaniques
• Bioprinting
Rex: first « bionic » man exposed at science museum in London. 750’000 euros
18-10-2013
Heart failure
1967
As with other types of organ failure, there was a time
when transplantation was the only option for a failing
heart. But artificial hearts and left ventricular assist
devices (LVADs) have created a bridge to organ
transplantation, allowing patients with heart failure to
live longer while waiting for a donor heart.
LVADs have become so reliable that some in the
medical community believe patients using them should
be moved down on transplant lists, because most
patients with LVADs live longer and with fewer
complications than patients who cannot use these
devices.
And artificial hearts aren't just getting better, they're
getting smaller. In May 2012, Italian doctors saved a
16-month-old boy with dilated cardiomyopathy by
implanting the world's smallest artificial heart to keep
him alive for 13 days until a donor was found. The tiny
titanium pump weighed just 11 g; an adult device
weighs about 900 g
L’exosquelette
MIT prototype
Exo-skeleton: ReWalk
Defense Advanced Research Project Agency
Argo Medical Technologies
The bionic hand
BCI enabled 10-D prosthetic arm control
University of Pittsburgh (96 contact points
surgically implanted in the brain)
John Hopkins Applied Physics Laboratory
December 17, 2014 lisaweiner
3D printed vertebra = 10 USD
Surgeons replace a 12-year-old's
cancerous vertebra with a 3D-printed
implant
By Nick Lavars
August 25, 2014
Beijing Doctors Implant World's First 3D-Printed
Vertebra into 12 Year-Old Boy
•
By Mary-Ann Russon
August 19, 2014 13:32 BST
OrCam
OrCam recognizes text and
products, and speaks to
you through a boneconduction earpiece.
The bionic eye
« Terminator » en vrai…
Cet Américain âgé de 66 ans n'avait pas vu
la lumière du jour depuis de nombreuses
années, en raison d'une maladie appelée
rétinite pigmentaire qui l'a rendu aveugle.
Aujourd'hui, il a pu partiellement recouvrer
la vue grâce à un implant oculaire.
En savoir plus:
http://www.maxisciences.com/aveugle/ave
ugle-depuis-30-ans-il-retrouve-la-vuegrace-a-un-oeil-bionique_art33637.html
Copyright © Gentside Découverte
Octobre 2014
Carbon nanotube artificial retina
Bioengineered / printed human organs
Organovo San Diego
Bioengineer: the heart is one of the easiest organs to bioprint, we'll do it
in a decade
Vein grafts
June 17th 2013: first artificial vein implant in US patient
Organovo Announces Pre-Release
Availability of 3D Liver Contract Services
04/28/2014
SAN DIEGO, April 28, 2014 /PRNewswire/ -Organovo Holdings, Inc. (NYSE MKT: ONVO)
("Organovo"), a three-dimensional biology
company focused on delivering breakthrough 3D
bioprinting technology, today announced that it
has initiated contracting for toxicity testing using
its 3D Human Liver Tissue for selected clients
prior to full release.
Synthetic windpipe
Man receives world's first synthetic
windpipe
18:00 08 July 2011 by Andy Coghlan
"The big conceptual breakthrough is that
we can move from transplanting organs to
manufacturing them for patients," says
David Green, the president of Harvard
Bioscience in Holliston, Massachusetts.
To build up the new artificial trachea,
scientists harvested the stem cells from the
patient's own bone marrow and planted
them on synthetic scaffolds, made up from
polymers with spongy and flexible texture.
Bio-artificial pancreas
Implantable artificial pancreas for type I diabetes.
Clinical testing foreseen in 2016 and results
awaited in 2017
Ultimate goal: closed-loop pancreas
The future is today!
Accepted 09/08/2014 for publication
in “Cell Transplantation”
Functional regeneration of
supraspinal connections in a patient
with transected spinal cord following
transplantation of bulbar olfactory
ensheathing cells with peripheral
nerve bridging
Brain transplant…. Why not ?
But surprisingly, complete brain transplants
may not be as far-fetched as they seem. A
team at the University of Pennsylvania led by
Douglas H. Smith, MD, has engineered
transplantable living nerve tissue that could
potentially be used to regenerate or reconnect
neurons. Smith believes the external axon
tracts generated in his laboratory, which he
likens to the alien ponytails from the movie
Avatar and "living jumper cables," are a first
step to achieving a complete brain transplant
and could provide functional connections to the
human brain.
"This may sound like science fiction, but we are
currently working on such a connection," says
Smith. "I absolutely believe that brain
transplants will occur," he continues; "however,
for the foreseeable future, we will be limited to
brain repair with lab-grown brain tissue."
Artificial blood
Artificial Blood Is Patient-Ready
In the midst of news that engineered
organs are being implanted into animals
and people, researchers announce the
creation of artificial blood for transplant.
By Jef Akst | April 16, 2014
A new source of blood could be just around
the corner: red blood cells grown from
fibroblasts that have been reprogrammed
into mature red blood cells in the lab. The
blood, developed by researchers at the
University of Edinburgh and the Scottish
National Blood Transfusion Service
(SNBTS), would be Type O negative, also
known as universal donor blood, which
currently comprises just 7 percent of the
blood donor pool.
The Economist (29-03-2014)
Nouveaux modes de recherche
Disease in a dish … 1
Stem cells for sale 2
1Science
2Science
2010;330:1172-1173
2010;330:1173
CDI sells
cardiomycytes
L’industrie pharmaceutique doit
changer!
Genomics and drug development
Diseases In A Dish: Modeling
Mental Disorders
Using skin cells from patients
with mental disorders, scientists
are creating brain cells that are
now providing extraordinary
insights into afflictions like
schizophrenia and Parkinson’s
disease.
Being able to look at an individual’s cells, differentiated to the organ or tissue
of interest, in a dish an determining the appropriate therapy or prevention may
be considered the extreme form of individualized medicine
Pharmaco génomique
• Chaque nouvelle substance requiert une
étude pharmaco génomique dans le
processus de son développement afin de
permettre d’identifier les variations
génomiques pour définir quels patients ont:
– Un bénéfice particulier
– Des effets secondaires majeurs
• Tout ce qui est d’application pour les
médicaments, l’est aussi pour les vaccins
et moyens technologiques !
– Défibrillateurs (10% sont activés au décours
d’une vie ))
– Provenge® (Dendreon), prostate cancer vaccine
•
•
Coût USD 93’000 per patient
Bénéfice en survie 4 mois
Web-based pharmacogenomics panel
Les nouveaux essais cliniques
Hypertension:
– Adducine gene variants and anti-hypertension
treatment
– Monitoring through wireless sensor over an extended
period of time;
•
Diabetes:
– Genomic and molecular biologic analysis of DM/TII in
the individual patient (Key gene TCF7L2).
– Testing drugs in this particular context
– Monitor with wireless sensors for continuous tracking
(to replace HbA1C: overall view over several weeks)
•
Cancer
– BRAF V600E mutation in melanoma patients
– Vemurafenib (FDA approved in 2011), developed by
crystallography approach.
– Implantable chip to detect CTC’s.
Mass post-marketing conditional approval surveillance !
Sniffing for Cancer
Nanosensors can detect odors from melanoma
By MONICA ROZENFELD 20 décembre 2013
•
3D Drug printing
3D Printing Could Revolutionize Drugs
Downloadable, DIY drugs could soon
make the idea of "controlled
substances" a thing of the past.
When, exactly? “Maybe 10 to 15 years?
Who knows?” says Cronin. “Maybe five to
10.”
The 'chemputer' that could print out any
drug
When Lee Cronin learned about the
concept of 3D printers, he had a brilliant
idea: why not turn such a device into a
universal chemistry set that could make its
own drugs?
21July 2012
La médecine un nouveau métier…
qui requiert une nouvelle
approche éducative
Le grand public se rend compte
qu’une nouvelle médicine – adaptée
à l’individu – se profile et est à portée
de tout le monde!
Vinod Khosla: Machines will replace 80
percent of doctors
Science
04 September 12 by Liat Clark
Health Innovation Summit in San
Francisco, Vinod Koshla challenged a
room full of doctors to disagree with his
argument -- a challenge that was met with
silence.
Co-founder of Sun Microsystems
At one point, he even compares medical
diagnosis to Google's driverless smart car
technology, saying that the latter is more
difficult to develop than an accurate
diagnostics machine.
If that wasn't enough to ruffle a
few feathers, he continued by
explaining that the major
healthcare disruption he is
envisaging does not need to be
led from within, but may even be
more successful if driven from
without.
IBM to sell Watson’s brainpower
to speed clinical and academic research
Watson, IBM's supercomputer:
• Ability to process 200 million pages of content in less
than 3 seconds
• Used since 2011 by John Hopkins (trained as a
medical student) and Memorial Sloan-Kettering
Cancer Center (MSKCC, feeded with 30’000
case/year ). Used by WellPoint (Anthem)
• Dr. Topol recently discussed how Watson could be
integrated into a clinician's smartphone.
Example: comparative effectiveness research requires months if
done by manual data gathering, done in minutes by Watson
Modern Healthcare August 2014.
Diagnostic accuracy (%) scoreboard:
IBM's Watson Supercomputer May Soon Be The Best Doctor In The World
Lauren F Friedman
Apr. 22, 2014, 10:14 AM
47
58
Will medicine escape to the DIY era ?
The MD robot
In February, the FDA cleared
the first remote presence
(RP) robot for use in
hospitals. The RP-VITA
(iRobot), made by the same
company that makes the
robotic vacuum Roomba,
allows doctors to monitor
and interact with patients
remotely.
Physicians operate the sci-filike device from a remote
position using a joystick or
mouse connected to a
desktop or laptop computer
via an Internet connection.
Home-based connected health
to overtake hospital-based by 2019
Sotera ViSi Mobile Monitor
•
•
•
•
•
•
•
Coûts
Démographie
Accessibilité
Variabilité des pratiques
Information inefficiente
Soins fractionnés
Duplication et approche
défensive
• Adoption tardive de
l’innovation
•
•
•
•
P = Prédictive
P = Préventive
P = Personalisé
P = Participative
Les nanotechnologies…
• Vascular Cartographic Scanning Device
– Fly through the entire vascular system with a
joystick.
• Augmenting the human immune system
with sentinel nano-devices.
• Expansion of human vision (example
night vision).
• Expansion of human lifespans through
removing lipofuscin from lysosomes in
certain types of non-dividing cells
Nanomedical Device and Systems
Design: Challenges, Possibilities,
Visions ( CRC Press (Taylor & Francis):
November 25, 2013).
Sommes-nous prêts?
HBR November 2014
Gartner Research, IDC, Strategy Analytics
Eric Topol
Too many doctors today are trying to
fly a biplane in the jet age…