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This signature is then 16 Digital Medicine compared to computer libraries of known strains of the virus that are susceptible or resistant to various drugs in the therapeutic cocktail actoplus met 500mg lowest price blood sugar 24. By tailoring the elements and dosages in the cocktail to the genetic signature of the virus discount actoplus met 500 mg without prescription pediatric diabetes signs and symptoms, far more rapid and efficient clearing of the virus has been achieved. Giving the drug to patients whose cells do not display this receptor means wasting $20,000 on a drug with no clinical effect. Many new drugs will be approved in the next few years conditional upon a genetic test to determine if the therapy is likely to be effective. These uses represent only the beginning of a new era of personal- ized, genetically customized medicine (Figure 2. Within a decade, the genetic signature of a pathogen such as a virus or a cancer cell may form the basis for fabrication of customized therapies, such as vaccines, specifically targeted at that pathogen. Clinical laboratories will use genetic information to identify targets on the cell surface or in the nucleus of the pathogen that can be blocked by antibodies or by agents that retard or prevent dangerous genes from expressing in the first place. Progress in gene therapy has been ham- pered, however, by the vigor of the immune response to new genetic material introduced into the body, as well as by an inability to target new genetic information to the right places in the genome. Control over expression of disease-causing pathogens or genes may be a more achievable goal than inserting the “correct” genetic information. This curative role will be the result of molecular infor- mation technologies—microarrays and computerized cell sorting, principally—focused on acquiring genetic information about the patient and the pathogen. Pathologists will also find themselves competing in genetic diagnosis with the radiologists as they develop molecular imaging technology. Impact on Health Systems The ability to use genetic information to guide and craft therapy will become a key differentiator of hospitals and health centers within the next decade, much as open-heart surgery was during the 1970s. Personalized medicine based on genetic testing represents the leading edge of a huge new service opportunity for our nation’s health system, as well as a powerful tool set for making drug therapy safer and more effective. Previously, the output of these analyses was paper notes with line drawings, x-ray film, and pathology slides. Today, the analyses are in digital form, and the results can be stored, retrieved, and sent electronically. Diagnostic results will flow seamlessly through the so-called “electronic medical record” into structured and timely recommendations to the care team. Clarke once said that at some level of sophistica- tion, technology is indistinguishable from magic. Flow Cytometry Flow cytometry enables a laboratory technician to count and sort individual cells flowing through a highly pressurized thread of water up to a rate of up to 70,000 cells per second, plucking single cells of interest (each less than one-twentieth of the width of a human hair) out of the stream with magnetic pulses and dropping them into wells in a laboratory tray. This remarkable specificity is made possible by computerized interpretation of the diffraction patterns of a laser beam passing through the thread and bouncing off individual cells. The scat- tered light reaches electronic plates positioned around the stream, which record the pattern of light as digital information. Using a computer-controlled magnetic pulse, the operator can pluck specific cells from the stream for further analysis. Flow cy- tometry is powerful enough to detect, for example, fetal cells in a 20 Digital Medicine sample of the mother’s blood and extract them without the need for invasive and sometimes dangerous amniocentesis. It can also count and categorize cancer cells by their shape or the constellation of receptors on their surface. If this becomes possible, flow cytometry will be the tool hospitals use to find stem cells in the blood. These cells will be cultured and redirected to therapeutic levels for treating diseases like Parkinson’s, diabetes, or spinal cord injury. Because they are cultured from an individual’s own cells, the recipient will not require a lifetime of immune suppressants to enable them to do their work. In all cases, the signals are detected by digital arrays and converted to digital information structured and stored by computers. These technologies, revolutionary when they were developed, made noninvasive evaluation of tissues and internal organs possi- ble, tilting diagnosis decisively away from exploratory surgery (and tilting power and clinical influence toward radiology).

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They made the terrible mistake of not being even more secretive and not keeping a unified front buy actoplus met 500 mg low cost blood glucose iphone app, For the result of this mistake is that when their irresolution buy actoplus met 500mg overnight delivery diabetes mellitus urine, the weakness of their arguments, divinations and grounds, the bitterness of their contestations, full of hatred, jeal- ousy, and self-consideration, come to be revealed to every- one, a man would have to be preternaturally blind not to feel that he runs a great risk in their hands. But to the credit of the medical profession there were always renegades and traitors within the ranks. The editor of The Lancet, Thomas Wakley, in 1825, freely admitted that If patients are content with the medical treatment, what- ever it may be, it is a proof of their ignorance, and nothing more. That some patients in hospital may properly be treated we do not deny, but that others are killed, we as 24 positively assert. For this he blamed human nature: man is a most gullible animal and the temptation is too great not to make capital out of it. Jokes about the follies of medicine have a different func- tion when uttered by a layman rather than by a professional. In the first case their purpose is to cut doctors down to size and demystify their art. In the second case, the levity is part of private medical humour, a sort of cynical defence mechanism enabling the doctor to cope with the stress of his task. When in 1889, the President of the British Medical Association washed medical dirty linen in public, he was reprimanded by 21 the editor of the Provincial Medical Journal. In the same editorial, however, an account was given of a private medical function of the British Medical Association, at which the speaker related an anecdote greatly appreciated by the com- pany. Shaw compared doctors to tradesmen and shopkeepers,with a pecuniary interest in people being ill. Sir Clifford Allbutt, one of the most prominent representatives of the profession at that time, said: I think we shall all agree that Mr Bernard Shaw when he takes up his sword certainly slashes down to the quick, and I think that we must admit at that quick there is a great deal of truth to be found, and expressed with a great deal of gentleness towards our profession. Compare the politeness and gentility of that generation of physicians with the hysterical outbursts of our contempor- aries when a layman, such as Illich, dares to raise a question or two about the direction of medicine today. Shaw elabor- ated on his views on medicine in his Preface on Doctors, published with The Doctors Dilemma in 1911. His own health philosophy was summed up in these sentences: - Do not try to live for ever. When comparing medicine then and now, the main differ- ence is between a profession and a trade, between a vocation which grew up in the humanist tradition and the medico- industrial complex governed by monetary gain and political 28 Healthism interests. The change was so slow that only a few shrewd observers, such as Illich, noticed it. Then economists came up with a bizarre theory, which has become widely accepted, according to which the basis of a sound economy is a continual increase in the con- sumption (that is, waste) of goods. To arouse an interest in new goods, it is important to adver- tise and to convince potential customers that they could not possibly be without them, even though they may not have realised it up until now. Once the need becomes universal, production can be defended by pointing out that it meets a need. As health services become increasingly complex, a third party interposes between the doctor and the patient - the health manager. Managers control the purchase of technol- ogy, its marketing and advertising, so that new markets can be created. Some $10 billion a year is spent on slimming (pills, books, clubs, 30 Healthism special diets). The healthy must be persuaded that feeling healthy is not the same as being healthy, otherwise they could go through their whole life without noticing how bad they were. Once healthy, but scared, health consumers start queu- ing outside, demanding their right to be let in (since health, as they were told and now believe, is their inalienable right), health producers can claim, with some justification, that they are doing their best to meet the demand, though the shortage of the demanded commodity (health, in this case) will, regret- tably, lead to some increase in price. It would seem that the two approaches are not antagonistic, since curative and preventive medicine have always been part and parcel of medical practice. However, anticipatory medicine is not the same as traditional preventive medicine which was limited mainly to vaccination against specific diseases, and the reduction of the spread of infection by maintaining a clean water supply, abattoir inspection, control of the food chain, etc. The transition from preventive to anticipatory medicine is a leap from an empirical, pragmatic approach to a theoretical and visionary one. One general practitioner, shared his unease about the new fashion of anticipatory care with the readers of the British 33 Medical Journal. There are no indi- viduals any more but an army which must be fit to discharge its military task. He believed that this kind of medicine required a completely different frame of mind from that of a traditional doctor, who listens to the patient and tries to makes sense of complex messages of fear and reported symp- toms. As an economist, Tussing naively believed that in this way diseases would be 34 prevented and health expenditure greatly reduced.

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