Advances in medical science

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Advances in medical science
Jan von Overbeck Chief Medical Officer Swiss Re
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The art of medicine

• The art of medicine consists in amusing the
  patient while nature cures the disease.
• Voltaire

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Life expectancy what is progress ?
The Chances of Death Karl Pearson 1897
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Mortality shift 1900 - 1990
Causes of death in the 1900s
United States death rates around 1900
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Mortality shift 1900 - 1990
Causes of death in the 1990s
United States death rates in the 1900s
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Death rates are decreasing for some leading
causes of death
Death rates per 100,000 age-adjusted population
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Pneumococcal septicemiabefore and after
penicillin
Relative mortality
1930
- 72
1965
Ann Int Med 1964
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The HAART revolutionMortality from HIV/AIDS
Relative mortality
1992
- 84
1998
SHCS, 1999 JAMA 2822220
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Life expectancy

• Two-thirds of the increase in life expectancy at
  birth occurred before 1950
• A tribute to public health measures
• Two-thirds of the increase in life expectancy at
  age 65 occurred after 1950
• In large part due to better medical care

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Increasing life expectancy
Olshansky et al. Science 2001
Age (years)
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Software or hardware ?
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We are living better
Trends in people gt65 without disabilities
Percent of people without disabilities is rising
of persons gt65 without a disability, per 100,000
Manton and Gu, 2001 PNAS 986354-59
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Determinants of health

• Determinants of health
• Behavioural patterns
• Genetic predisposition
• Social circumstances
• Health care
• Environmental exposures

Premature mortality
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Advances in MedicineSpectrum of possibilities
Repair
Prevention
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Advances in MedicineSpectrum of possibilities
Genetic Cloning Stem Cells Imaging
Nanotechnology Environment
Prevention
Repair
Early diagnosis
Diagnosis
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Living longer, living betterSelected medical
innovations

• Diagnostic Drugs Procedures tests
• CAD Stress test ß blockers CABG
• Angiographiy ACEs PTCA/Stents
• HMGs
• Cancer Mammography Chemotherapy Breast-sparing
• CT Scan Radiotherapy surgery
• HIV/AIDS Antigen tests AZT Blood bank
• Viral load Protese Inhibitors screening
• GI Diseases Endoscopy H2 Antagonists
  Polypectomy
• H. Pylori PPIs
• Psychiatrics Antipsychotics
• diseases TCAs and SSRIs
• Paint/Joint Arthroscopy NSAIDS and Coxibs
  Arthroscopic surgery

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Death rates for heart disease
Heart disease (390-398, 402, 404-429)
Ageadjusted death rates
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Hospitalizations due to CAD have risen..
First listed Dx for hospitalizations pe 10,000
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.because many symptomatic CAD patients are
actively managed
Number of procedures per discharge, per 10,000
(not age-adjusted)
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Death rates for CAD were expected to rise
Actual expected death rates CHD, 1950-1992
Age-adjusted death rate per 100,000 population
Health Gain due to improved healthcare
and lifestyle improvements
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Pathogenesis of atherosclerosisand vascular
remodelling
Endothelium Dysfunction
Intimal Thickening
Unstable Plaque
Ruptured Plaque
Normal
Atheroma
Prevention Intervention
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New paradigms in treatment
Mild chest disconfort
Severe chest pain
Prodromal unstable angina
Pro-active Therapy
Reactive Therapy
-100
-0
1 3 6 12 12-24 h
Cardio-protective
Damage control
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CAD and cardiac markers
Acute Coronary syndrome non-ST
Stable angina
Unstable angina
Non-Q wave MI
Q wave MI
EGG-ST
EGG-ST
CK-MB
Troponin
CRP
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Stent and restenosis
NEJM, October 2003
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Stent and sirolimus
Moses et al, 2003 NEJM 349 1315-23
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Change in life expectancy
Martin et al. Science 2003
Age 50
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Advances in MedicineSpectrum of possibilities
Genetic Cloning Stem Cells Imaging
Nanotechnology Environment
Prevention
Repair
Early diagnosis
Diagnosis
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Advances in MedicineImaging
Prevention
Repair
Early diagnosis
Diagnosis
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PET Scan
Blue and black denote inactive areas.
Normal brain activity
Alzheimer disease
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Virtual colonoscopy
schematic map of air-filledcolon generated from
CT scan
3-D view from endoluminal fly-through
generated from the same CT scan
Pickhardt, et al. NEJM, 2003
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Diagnosing Cancer new ways ?Replacing histology
?
Proton Magnetic Resonance Spectroscopy
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Meningioma
Glioblastoma
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Advances in MedicineCloning
Educating the clone !
Prevention
Repair
Early diagnosis
Diagnosis
Which life is insured Genotype or Phenotype?
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Design your child Dells concept
The traditional genetic gambling machine The
couple
Design and assemble your dream child
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Human reproduction
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Human Cloning
Normal
Cloning
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The promise of stem cell research
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Repairing damaged heart tissues with bone marrow
cells
Stauer et a. 2003 Circulation 107929-934
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Nanotechnology

• Molecules resembling a straw , at least 100nm
  long
• Mingle-layer straw-construction, made of carbon
  (fullerene carbon nanotube)
• Prey

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Impact on human health
Entry into blood stream via skin, nose,
digestive system, lung
Nanoparticles skip the immune system BUT Particle
cell/substrate Immune response (allergies)
Body distribution incl. brain
Enzyme inhibitor
Piggyback bacteria
Chemical reaction
Overload
FOS (Free radicals)
Biodegradable
Non-biodegradable
Elimination
Accumulation?
Acute toxicity?
Chronic toxicity?
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Determinants of health

• Determinants of health
• Behavioural patterns
• Genetic predisposition
• Social circumstances
• Health care
• Environmental exposures

Premature mortality
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SARS Linking the cases
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Overweight and health
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Exercise capacity and mortality
Normal subjects
Myers et al. NEJM 346793 2002
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Man made micro-environmentSmoking culture
Socially accepted destructive behavior how is
that possible?
When active vs. passive smoking Family history?
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Trends in life expectancy at birth in Russia
1991
Life expectancy at birth (years)
Shkolnikov et al, 2001 Lancet 357917-21
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Causes of death and difference in life expectancy
75
men
Other
70
Amenable to intersectoral
health policy
Tuberculosis
Life expectancy at birth
65
Ischaemic heart disease
Amenable to medical care
Life Expectancy in Russia
60
Life Expectancy in UK
55
Andreev et al, 2003 Int J Epidemiol 32437-446
1965
1968
1971
1974
1977
1980
1983
1986
1989
1992
1995
1998
Year
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Ecology, environment
49
Privacy, confidentiality and research
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The art of medicine

• The art of medicine consists in amusing the
  patient while nature cures the disease.
• Voltaire
• Natural history ?
• Basic mortality ?
• Medical interventions ?

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Population mortality
100000
80000
60000
40000
20000
0
15
30
45
60
75
90
0
SM88/93
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New health technology

• Advances in medical care that improve
  cause-specific and all-cause mortality? UW
  manuals ?
• Advances in diagnostic technologies measuring
  impairment specific risk?UW requirements ?
• Advances in diagnostic technologies that assess
  overall state of health? Standard/prefered
  risk ?

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Cloning medical advance ?
54
What kind of future for our kids ?
What is progress? Sustainability?