Medical advances: future trends

Assistive technologies could radically change the way care is delivered in the future.

Remote intensive care monitoring systems could enable hospitals to deliver intensive care using staff at a single remote location to observe patients across multiple intensive care units (ICUs). These staff would communicate with local ICU staff through dedicated 'hot phones' and video conferencing, with patient information provided by audio/video monitoring. Software with automatic alerts and links to other hospital systems, such as pathology, could provide physiological monitoring¹. 

Use of internet-based interfaces to undertake remote consultations with clinicians and other care staff, to access personal care records and connect users with family members, may become commonplace. Such systems are already being developed in the United States, Singapore and Israel.

Home-based technologies that support individuals (and their carers) to manage their long-term conditions will be more widely used as the evidence of their impact increases and unit costs fall. There is the potential for millions of people to access and use such technologies in this way. 

Smart phones can be used as a platform for capturing real-time patient information and to live-stream patient data to a clinician, allowing them to interpret and respond to information remotely. As well as accessing pathology and radiology results, professionals are able to monitor a patient's vital signs either in real time or as data plotted over time.

Mobile phones also offer opportunities for patients to access personalised health support and encouragement, including diet plans, medication schedules, exercise regimens and push messages, with reminders, motivational messages and alerts when there is a clinical problem².

On a practical level, a move from small-scale technology pilots to wide-scale implementation will need to overcome several barriers:

• the evidence base on cost-effectiveness is relatively weak, deterring risk averse investors

• clinicians may not be convinced that the benefits outweigh the costs

• service users could prove reluctant to accept and use assistive technologies, if they feel they are used as a substitute for face-to-face contact

• politically, reducing hospital-based care in favour of remote care in the community is also likely to be challenging.

1. New England Healthcare Institute (2007). Report. Tele-ICUs: Remote Management in Intensive Care Units

2. CSC Leading Edge Forum (2010). Report. The Future of Healthcare: It’s Health, Then Care

Advances in medical devices, diagnostic testing and imaging are expected to continue apace enabling more care to be delivered closer to home. Intelligent devices and enhanced diagnostics could radically alter the way conditions are detected and treated, improving clinical outcomes and quality of life for the whole population.

The use of computer-aided diagnosis could extend to conditions such as osteoporosis and Alzheimer's (1,2), while rapid compressed magnetic resonance scanning, miniature high-resolution ultrasounds, chromatography and mass spectroscopy are expected to enter general use^3,4.

Non-invasive tests identifying conditions through chemical signatures in the breath of patients and blood tests for biomarkers are being developed^5,6,7,8. Precision treatments for cancer are expected to become widespread as evidence on their effectiveness emerges^9,10.

Enabling services to be delivered locally and at lower cost using small, cheap devices, such as ECG monitors, is part of a move to 'frugal technologies'. Despite set-up costs, delivering care in this way in the community or people's homes could release resources from secondary care.

Robotic dispensing, electronic prescribing tools, implantable wireless microchips delivering daily medication and intelligent pills that are able to monitor drug use could all reduce medication errors^11,12,13.

1. Doi K (2007). Article journal. ‘Computer-aided diagnosis in medical imaging: historical review, current status and future potential’. Computerized Medical Imaging and Graphics, vol 31, pp 198–211.

2. Doraiswamy PM, Sperling RA, Coleman RE, Johnson KA, Reiman EM, Davis MD, Grundman M, Sabbagh MN, Sadowsky CH, Fleisher AS, Carpenter A, Clark CM, Joshi AD, Mintun MA, Skovronsky DM, Pontecorvo MJ (2012). Article. ‘Amyloid-β  assessed by florbetapir F 18 PET and 18-month cognitive decline: a multicenter study’. Neurology, July 2011.

3. Shiraishi J, Li Q, Appelbaum D, Doi K (2011). Journal article. ‘Computer-aided diagnosis and artificial intelligence in clinical imaging’. Seminars in Nuclear Medicine, vol 41, no 6, pp 449–62.

4. Science Now (2012). Article. ScienceShot: Medical Imaging, In A Snap 

5. Phillips M, Cataneo RN, Saunders C, Hope P, Schmitt P, Wai J (2010). Journal article. ‘Volatile biomarkers in the breath of women with breast cancer’. Journal of Breath Research, vol 4, no 2, 026003.

6. Mazzone PJ, Wang X-F, Xu Y, Mekhail T, Beukemann MC, Na J, Kemling JW, Suslick KS, Sasidhar M (2012). Journal article. ‘Exhaled breath analysis with a colorimetric sensor array for the identification and characterization of lung cancer’. Journal of Thoracic Oncology, vol 7, no 1, pp 137–42.

7. Study details. Non-Invasive Biomarkers For Early Detection Of Lung Cancers 

8. Bossuyt PMM (2011). The Thin Line Between Hope and Hype in Biomarker Research JAMA. 305(21):2229-2230.

9. Ahmed HU, Hindley RG, Dickinson L, Freeman A, Kirkham AP, Sahu M, Scott R, Allen C, Van der Meulen J, Emberton Ml (2012). Journal article. ‘Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study’. Lancet Oncology, vol 13, no 6, pp 622–32.

10. Dieterich S, Gibbs IC (2011). Journal article. ‘The CyberKnife in clinical use: current roles, future expectations’. Frontiers of Radiation Therapy and Oncology, vol 43, pp 181–94.

11. Manias E (2011). Journal article. Use of Electronic Medication Management Systems to Facilitate Appropriate and Safe Use of Medications. iHealth Connections, 2011;1(2):134–8.

12. Cressey D. News. Say hello to intelligent pills: Digital system tracks patients from the inside out. Nature News. 17 January 2012.

13. Farra R, Sheppard NF Jr, McCabe L, Neer RM, Anderson JM, Santini JT Jr, Cima MJ, Langer R (2012). First-in-human testing of a wirelessly controlled drug delivery microchip. Science Translational Medicine, vol 4, no 122, 122ra21.

We expect to see significant pharmaceutical innovation over the next 20 years, with the potential to improve disease treatment, morbidity and mortality across the population.

Antibody-drug therapies could replace traditional chemotherapy, delivering drugs directly into cancer cells¹; monoclonal antibodies could be used to treat neurodegenerative diseases, such as multiple sclerosis² and Parkinson's; and synthetic compounds could be developed that can tackle obesity and diabetes simultaneously^3,4.

Therapeutic vaccines could prevent a wide range of cancers by triggering the immune system to recognise and destroy cancer cells^5,6,7, while preventative vaccines may finally be able to provide lifelong protection against tuberculosis, malaria, HIV, flu and hepatitis C^8,9,10.

Multi-drug therapies will be able to use existing drugs more effectively, preventing drug resistance¹¹, and treatments for lifelong conditions such as epilepsy will be refined, reducing unwanted side effects¹².

However, there is uncertainty over whether anticipated breakthroughs can be realised given pressures on research and development budgets¹³.

'Genetics play a fundamental role in determining health: by the age of 60, six out of ten people are likely to develop a disease that is at least partially genetically determined.'

Precision medicine could revolutionise our ability to predict, prevent, monitor and treat conditions, radically improving patient outcomes and overall population health.

We expect use of low-cost genetic sequencing to increase with genetic profiling available to detail a person's predisposition to certain diseases. Genome mapping data could be used to stratify cohorts for preventive screening^14,15,16.

Pre-clinical trials, animal studies and clinical trials are discovering genetic differences in responses to complex cancer therapies. Combined with research to sequence tumours and categorise subtypes, these developments mean clinicians can match patient subgroups to treatments, reducing the risk of side effects and targeting treatments to those patients most likely to respond^{17,18,19,20,21}. Clinical biomarkers have the potential to assist prognosis and treatment and trials are underway to develop gene therapies for a variety of conditions including HIV^{22,23,24,25,26}.

However, progress to develop therapies for progressive neurological disorders and validate biomarker tests has been slow. Recent evidence suggests that the effectiveness of biomarkers may have been overstated²⁷. This vision of the future also raises concerns around ethics and data protection, while lifestyle profiling could lead to over-medicalisation.

Targeted drugs and treatments have implications for the development of pharmaceuticals, potentially reducing both the time required to bring treatments to market and also the pool of eligible patients and potential profits. This trade-off may inhibit the speed at which new therapies enter mainstream use.

'Total NHS spend on pharmaceuticals increased from £2.3 billion in 1990 to £12.2 billon in 2009 (28,29), with pharmaceutical use within hospitals accounting for an increasing proportion of costs, up from 22 per cent in 2003 to 31 per cent in 2009.'

However, the Office of Health Economics (OHE) estimates that NHS spending on pharmaceuticals could begin to fall, or at least be contained, over the next six years because:

• Cheap generic alternatives to widely prescribed pharmaceuticals, such as statins, will be available as patents expire.

• Many pharmaceuticals currently in development are specialist drugs targeted at small populations. Although they are costly to develop and expensive to buy, the volumes bought are low, limiting their cost to the system.

Historically pharmaceutical costs have risen year-on-year and this is likely to continue, despite OHE forecasts, if pharmaceutical costs continue to shift away from primary care (where generic versions are entering the system) towards more innovative, specialised and expensive drugs within hospitals.

Contributing to current pharmaceutical spend are drugs that are widely prescribed, but ineffective in a large number of cases. The concept of personalised prescribing will reduce this spend, but could render this market unviable for pharmaceutical companies. Companies may find it more difficult to patent targeted replacements³⁰: recent rulings in the United States have restricted the patent protections granted to biotechnology companies and the continuation of this trend could fundamentally change the way that drugs are developed and funded, further driving up costs³¹.

It is also important to note that research and development expenditure by pharmaceutical companies has grown rapidly, rising tenfold between 1975 and 2006^32,33,34. The current rate of innovation may stall unless pharmaceutical companies can recoup research and development costs^35,36.

1. Ledford H (2011). Journal article. Toxic antibodies blitz tumours. Nature 476, p380–381

2. Graham-Rowe D (2011). Online journal article. Antibody offers hope for multiple sclerosis treatment. Nature,  24 October 

3. Cho H, Zhao X, Hatori M, Yu RT, Barish GD, Lam MT, Chong, L-W, DiTacchio L, Atkins AR, Glass CK, Liddle C, Auwerx J, Downes M, Panda S, Evans RM (2012). Journal article. Regulation of circadian behaviour and metabolism by REV-ERB-α and REV-ERB-β. Nature: 485, p123–127 

4. Couzin-Frankel J (2011). Online article. Novel Drug Shrinks Monkeys' Waistlines. Science: 9 November 2011 

5. Koski GK, Koldovsky U, Xu S, Mick R, Sharma A, Fitzpatrick E, Weinstein S, Nisenbaum H, Levine BL, Fox K, Zhang P, Czerniecki BJ (2012). Journal article. ‘A novel dendritic cell-based immunization approach for the induction of durable Th1-polarized anti-HER-2/neu responses in women with early breast cancer’. Journal of Immunotherapy, vol 35, pt 1, pp 54–65.

6. Kovjazin R, Volovitz I, Kundel Y, Rosenbaum E, Medalia G, Horn G, Smorodinsky NI, Brenner B, Carmon L (2011). Journal article. ImMucin: a novel therapeutic vaccine with promiscuous MHC binding for the treatment of MUC1-expressing tumors. Vaccine, vol 29, pp 4676–86.

7. Telegraph. Science news. Universal cancer vaccine developed 

8. Balazs AB, Chen J, Hong CM, Rao DS, Yang L, Baltimore D (2011). Journal article. 'Antibody-based protection against HIV infection by vectored immunoprophylaxis'. Nature, vol 481, no 7379, pp 81–4.

9. Rappuoli R, Aderem A (2011). Journal article. 'A 2020 vision for vaccines against HIV, tuberculosis and malaria'. Nature, vol 473, pp 463–9.

10. Agnandji ST, Lell B, Soulanoudjingar  SS (et al) (2011). Journal article. ‘First results of phase 3 trial of RTS,S/AS01 malaria vaccine in African children’. New England Journal of Medicine, vol 365, pt 20, pp 1863–75.

11. Ledford H (2011). Online article. New drug targets raise hopes for hepatitis C cure. Nature, 26 April 2011 

12. Mestre-Ferrandiz J, Mordoh  A, Sussex J. Updated report. The many faces of innovation. A report for the ABPI by the Office of Health Economics, March 2012 

13. Riccaboni M (2012). Seminar briefing. Is There a Productivity Crisis in Pharmaceutical R&D? Office of Health Economics 

14. Hayden EC (2012). Online article. Sequencing set to alter clinical landscape. Nature, 15 February 2012 

15. Chen et al (2012). Journal article. ‘Personal “omics” profiling reveals dynamic molecular and medical phenotypes’. Cell, vol 148, pp 1293–307.

16. Dennis C (2012). News and comment. The rise of the 'narciss-ome'. Nature, 16 March 2012 

17. Dennis C (2012). News and comment. Mouse 'avatars' could aid pancreatic cancer therapy. Nature, 21 March 

18. Chen Z, Cheng K, Walton Z, Wang Y, Ebi H, Shimamura T, Liu Y, Tupper T, Ouyang J, Li J, Gao P, Woo MS, Xu C, Yanagita M, Altabef A, Wang S, Lee C, Nakada Y, Peña CG, Sun Y, Franchetti Y, Yao C, Saur A, Cameron MD, Nishino M, Hayes DN, Wilkerson MD, Roberts PJ, Lee CB, Bardeesy N, Butaney M, Chirieac LR, Costa DB, Jackman D, Sharpless NE, Castrillon DH, Demetri GD, Jänne PA, Pandolfi PP, Cantley LC, Kung AL, Engelman JA, Wong KK (2012). Journal article. ‘A murine lung cancer co-clinical trial identifies genetic modifiers of therapeutic response’. Nature, vol 483, no 7391, pp 613–7.

19. Curtis C, Shah SP, Chin SF, Turashvili G, Rueda OM, Dunning MJ, Speed D, Lynch AG, Samarajiwa S, Yuan Y, Gräf S, Ha G, Haffari G, Bashashati A, Russell R, McKinney S, Langerød A, Green A, Provenzano E, Wishart G, Pinder S, Watson P, Markowetz F, Murphy L, Ellis I, Purushotham A, Børresen-Dale AL, Brenton JD, Tavaré S, Caldas C, Aparicio (2012). Online article. ‘The genomic and transcriptomic architecture of 2,000 breast tumours reveals novel subgroups’. Nature. Published online 18 April 2012.

20. Villarroel MC, Rajeshkumar NV, Garrido-Laguna I, De Jesus-Acosta A, Jones S, Maitra A, Hruban RH, Eshleman JR, Klein A, Laheru D, Donehower R, Hidalgo M (2011). Journal article. ‘Personalizing cancer treatment in the age of global genomic analyses: PALB2 gene mutations and the response to DNA damaging agents in pancreatic cancer’. Molecular Cancer Therapeutics, vol 10, no 1, pp 3–8.

21. Juergens RA, Wrangle J, Vendetti FP, Murphy SC, Zhao, M, Coleman B, Sebree R, Rodgers K, Hooker CM, Franco N, Lee B, Tsai S, Espinoza Delgardo I, Rudek MA, Belinsky SA, Herman JG, Baylin SB, Brock MV, Rudin CM (2011). Journal article. ‘Combination epigenetic therapy has efficacy in patients with refractory advanced non-small cell lung cancer’. Cancer Discovery, vol 1, no 7, pp 598–607.

22. Breda L, Casu C, Gardenghi S, Bianchi N, Cartegni L, Narla M, Yazdanbakhsh K, Musso M, Manwani D, Little J, Gardner LB, Kleinert DA, Prus E, Fibach E, Grady RW, Giardina PJ, Gambari R, Rivella S (2012). Journal article. ‘Therapeutic hemoglobin levels after gene transfer in beta-thalassemia mice and in hematopoietic cells of beta-thalassemia and sickle cells disease patients’. PLOS One, vol 7, no 3, 32345.

23. Science Now (2011). Article. Gene Therapy May Thwart HIV 

24. Stieger K, Lorenz B (2010). Article. ‘Gene therapy for vision loss – recent developments’. Discovery Medicine, vol 10, no 54, pp 425–33.

25. Cavazzana-Calvo M, Payen E, Negre O, Wang G, Hehir K, Fusil F, Down J, Denaro M, Brady T, Westerman K, Cavallesco R, Gillet-Legrand B, Caccavelli L, Sgarra R, Maouche-Chrétien L, Bernaudin F, Girot R, Dorazio R, Mulder GJ, Polack A, Bank A, Soulier J, Larghero J, Kabbara N, Dalle B, Gourmel B, Socie G, Chrétien S, Cartier N, Aubourg P, Fischer A, Cornetta K, Galacteros F, Beuzard Y, Gluckman E, Bushman F, Hacein-Bey-Abina S, Leboulch P (2010). Journal article. ‘Transfusion independence and HMGA2 activation after gene therapy of human beta-thalassaemia’. Nature, vol 467, no 7313, pp 318–22.

26. Breda L, Casu C, Gardenghi S, Bianchi N, Cartegni L, Narla M, Yazdanbakhsh K, Musso M, Manwani D, Little J, Gardner LB, Kleinert DA, Prus E, Fibach E, Grady RW, Giardina PJ, Gambari R, Rivella S (2012). Journal article. ‘Therapeutic hemoglobin levels after gene transfer in beta-thalassemia mice and in hematopoietic cells of beta-thalassemia and sickle cells disease patients’. PLOS One, vol 7, no 3, e32345.

27. Ioannidis JP, Panagiotou OA (2011). Online article. Comparison of Effect Sizes Associated With Biomarkers Reported in Highly Cited Individual Articles and in Subsequent Meta-analyses. JAMA. 305(21):2200-2210. Accessed 24.09.2012 

28. Hawe E, Yuen P, Baillie L (2011). OHE guide to UK health and health care statistics. Table 4.8. Office of Health Economics. 

29. Health and Social Care Information Centre (2011). Report. Hospital Prescribing, England: 2010.

30. Greenbaum D (2012). Journal article. Regulation and the Fate of Personalized Medicine. Virtual Mentor: American Medical Association Journal of Ethics 14 (8): 645-652 

31. Greenbaum D (2010). Journal article. New rules, different risk: the changing freedom to operate analysis for biotechnology. North Carolina J Law Tech 11(1):139-160 

32. Health Select Committee evidence (2009)

33. Association of the British Pharmaceutical Industry submission to the Health Select Committee inquiry into public expenditure 

34. Sussex, J (2010). Report. Innovation in Medicines: Can we value progress?. Office of Health Economics.

35. Mestre-Ferrandiz J, Mordoh A, Sussex J (2012). Report. The many faces of innovation. A report for the ABPI by the Office of Health Economics, March 2012 

36. ABPI UK NHS medicines bill projection 2012-2015

Over the past 20 years surgical innovation has significantly improved patient outcomes, rates of complications and length of stay^1,2,3. This improvement will continue as minimally invasive surgical techniques, robotic systems and virtual reality training enter mainstream use.

'Worldwide, the number of robot-assisted procedures increased from 80,000 in 2007 to 205,000 in 2010⁴.'

Robotic systems can enable surgeons to carry out complex procedures with a shorter inpatient stay⁵. Although, robotic systems are expensive and use patented software, the next generation of systems will be smaller and more affordable. Surgeons will use the systems to assist with advanced precision surgery and to perform operations remotely^{6,7,8,9,10,11}.

Virtual simulation tools are already used to train medical students; their use is likely to become more widespread as procedures become more intricate^12,13.

Advanced surgical techniques could dramatically increase our capacity to treat many conditions, including cancer. However, robotic systems also require significant investment, which could impede innovation and implementation on a larger scale restricting them to specialist or teaching hospitals¹⁴.

Regenerative medicine has enormous potential. This emerging field spans stem cell transplantation, cell reprogramming, synthetic organ creation through tissue engineering and nanotechnology. However, despite the progress of the past 10 years, it is still uncertain how regenerative medicine will develop in the future. Currently, effective and safe regenerative therapies beyond bone marrow transplants remain elusive and expensive.

Synthetic bladders and tracheas, grown in a lab^15,16, have already been used in operations. Early results are promising and this method has the potential to revolutionise the supply of organs for transplantation.

Xeno-transplantation (using organs from genetically engineered animals, particularly pigs) is in the initial research stage. Pig heart valves are already in routine use, but timescales for full organ transplantation are unclear (17,18). Portable artificial 'organs', such as the artificial pancreas, wearable haemodialysis units and artificial sight through retinal implants are possible in the near future^{19,20,21,22,23}.

Within stem cell research, regenerative transplants would enable clinicians to replace failing or dead cells with functioning reprogrammed adult cells²⁴. The ability to reprogramme heart cells could be achieved within 10 years, and other cell types, such as liver and pancreas, within 20 years²⁵. Early clinical studies transplanting embryonic stem cells into mice have been able to restore sight and treat heart failure; scientists are now working towards translating these developments to benefit humans^26,27,28.

The ability to maintain sustainable investment in research and ethical concerns could hamper the speed of progress.

References

1. Maeso S, Reza M, Mayol JA, Blasco JA, Guerra M, Andradas E, Plana MN (2010). Journal article. ‘Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis’. Annals of Surgery, vol 252, no 2, pp 254–62.

2. Reza M, Maeso S, Blasco JA, Andradas E (2010). Journal article. ‘Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery’. British Journal of Surgery, vol 97, no 12, pp 1772–83.

3. Weinberg L, Rao S, Escobar PF (2011). Article. ‘Robotic surgery in gynecology: an updated systematic review’. Obstetrics and Gynecology International.

4. Barbash G, Glied SA (2010). Journal article. ‘New technology and health care costs: the case of robot-assisted surgery’. New England Journal of Medicine, vol 363, no 8, pp 701–4.

5. Health Services Journal. News article. Torbay Hospital robot in worldwide first. 20 July 2012

6. Boggi U, Vistoli F, Signori S, D’Imporzano S, Amorese G, Consani G, Guarracino F, Melfi F, Mussi A, Mosca F (2011). Article. ‘Robotic renal transplantation: first European case’. Transplant International, vol 24, no 2, pp 213–18.

7. Ahmed HU, Hindley RG, Dickinson L, Freeman A, Kirkham AP, Sahu M, Scott R, Allen C, Van der Meulen J, Emberton Ml (2012). Journal article. ‘Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study’. Lancet Oncology, vol 13, no 6, pp 622–32.

8. Dieterich S, Gibbs IC (2011). Article. ‘The CyberKnife in clinical use: current roles, future expectations’. Frontiers of Radiation Therapy and Oncology, vol 43, pp 181–94.

9. Dolghi O, Strabala KW, Wortman TD, Goede MR, Farritor SM, Oleynikov D (2011). Article. ‘Miniature in vivo robot for laparoendoscopic single-site surgery’. Surgical Endoscopy, vol 25, no 10, pp 3453–8.

10. Shah BC, Buettner SL, Lehman AC, Farritor SM, Oleynikov D (2009). Article. ‘Miniature in vivo robotics and novel robotic surgical platforms’. Urologic Clincs of North America, vol 36, no 2, pp 251–63.

11. Economist. Article. Surgical robots: The kindness of strangers 

12. Patel HR, Patel BP (2012). Article. ‘Virtual reality surgical simulation in training’. Expert Review of Anticancer Therapy, vol 12, no 4, pp 417–20.

13. Tan SS, Sarker SK (2011). Journal article. ‘Simulation in surgery: a review’. Scottish Medical Journal, vol 56, no 2, pp 104–9.

14. Hottenrott C (2012). Article. ‘Robotic surgery and limitations’. Surgical Endoscopy, vol 26, no 2, pp 580–1.

15. Jungebluth P, Alici E, Baiguera S, Le Blanc K, Blomberg P, Bozóky B, Crowley C, Einarsson O, Grinnemo K-H, Gudbjartsson T, Le Guyader S, Henriksson G,  Hermanson O, Juto JE, Leidner B, Lilja T, Liska J, Luedde T, Lundin V, Moll G, Nilsson B, Roderburg C, Strömblad S, Sutlu T, Teixeira AI, Watz E, Seifalian A, Macchiarini P (2011). ‘Tracheobronchial transplantation with a stem-cell-seeded bioartificial nanocomposite: a proof-of-concept study’. Lancet, vol 378, no 9808, pp 1997–2004.

16. Nature news blog. Nature magazine. What's new about new synthetic organs? 

17. Cooper DK, Ayares D (2011). Journal article. ‘The immense potential of xenotransplantation in surgery’. International Journal of Surgery, vol 9, no 2, pp 122–9.

18. Ekser B, Ezzelarab M, Hara H, van der Windt DJ, Wijkstrom M, Bottino R, Trucco M, Cooper DK (2012). Journal article. ‘Clinical xenotransplantation: the next medical revolution?’. Lancet, vol 379, no 9816, pp 672–83.

19. Jacobs PG, El Youssef J, Castle JR, Engle JM, Branigan DL, Johnson P, Massoud R, Kamath A, Ward WK (2011). Article. ‘Development of a fully automated closed loop artificial pancreas control system with dual pump delivery of insulin and glucagon’. Conf Proc IEEE Eng Med Biol Soc, pp 397–400.

20. Feasibility Study of a Portable Artificial Pancreas System in Type 1 Diabetes Mellitus 

21. Wall Street Journal. Article. Awak to Give Dialysis Patients Freedom

22. Zrenner E, Bartz-Schmidt KU, Benav H, Besch D, Bruckmann A, Gabel V-P, Gekeler F, Greppmaier U, Harscher A, Kibbel S, Kock J, Kusnyerik A, Peters T, Stingl K, Sachs H, Stett A, Szurman P, Wilhelm B, Wilke R (2011). ‘Subretinal electronic chips allow blind patients to read letters and combine them to words’. Proceedings of the Royal Society B: Biological Sciences, vol 278,no 1711, pp 1489–97.

23. Scientific American. Article. Electric Eye: Retina Implant Research Expands in Europe, Seeks FDA Approval in U.S

24. Ilic D, Polak J (2012). Journal article. ‘Stem cell based therapy – where are we going?’. Lancet, vol  379, no 9819, pp 877–8.

25. Foresight Healthcare Panel (2000). Healthcare 2020. UK Department of Trade and Industry.

26. Wu KH, Han ZC, Mo XM, Zhou B (2012). Article. ‘Cell delivery in cardiac regenerative therapy’. Ageing Research Reviews, vol 11, no 1, pp 32–40.

27. Makkar RR, Smith RR, Cheng K, Malliaras K, Thomson LE, Berman D, Czer LS, Marbán L, Mendizabal A, Johnston PV, Russell SD, Schuleri KH, Lardo AC, Gerstenblith G, Marbán E (2012). Article. ‘Intracoronary cardiosphere-derived cells for heart regeneration after myocardial infarction (CADUCEUS): a prospective, randomised phase 1 trial’. Lancet, vol 379, no 9819, pp 895–904

28. Pearson RA, Barber AC, Rizzi M, Hippert C, Xue T, West EL, Duran Y, Smith AJ, Chuang JZ, Azam SA, Luhmann UF, Benucci A, Sung CH, Bainbridge JW, Carandini M, Yau KW, Sowden JC, Ali RR (2012). Article. ‘Restoration of vision after transplantation of photoreceptors’. Nature, 18 April.