ADVANCED - Tom Rowland · come from their phantom limbs. The goal is to make artificial limbs that can accurately reproduce feeling. This is only possible because even years after

ADVANCEDHEALTHCARE14 AUGUST 2008

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CONTENTSBionic futures 3Cosmetics 4Prosthetics 5Cochlear implants 6-7Pain relief 8-9Diabetes 12-13Airways 11Hearing 14

ADVANCEDHEALTHCARE A TITLE FROM MEDIAPLANET

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IntroductionADVANCED HEALTHCARE

Recent developments have led to an incredibleacceleration in the advancement of healthcare.

In prosthetics revolutionary bionic tech-nologies are already changing the lives ofamputees and in the hospitals the use of robotsis enabling astonishing results in surgery.

Care facilities are increasingly using tech-nology to treat and monitor patients, whilenanotechnology and other progressiveapproaches promise enhanced treatments forconditions that will hopefully soon be a thingof the past.

At Touch Bionics we have achieved incredi-ble success since launching the i-LIMB handlast year, and hundreds of patients across theworld are now benefiting from it.

For many companies now making waveswith new technology in the health market,the road is a long and arduous one.

The primary challenge faced by most is thetransition of a new technology from itsresearch and development phase into a real-world, commercially successful product.

Companies developing technology for thehealthcare sector face a significant first hurdlein raising the funding that is usually required tobring a product to market – a process now fur-ther complicated by reduced investor confi-dence.

But funding is not only a concern at theR&D stage – there is also a big issue over howthese new technologies will be supported in themarket.

Whether they are taken-up by nationalhealth systems or covered by private medicalinsurance plans.

Patient and clinical acceptance is the keystep along the road to success for a compa-

ny seeking to access the healthcare market. Any company can find early adopters, but

how long will it take for the wider majority tomake the move towards a new technology?

Many firms have successfully answeredthese questions and are now makingwaves on the international stage withtechnologies and products like the i-LIMBhand that are truly making a difference topeoples’ lives.

The most successful, high-growth tech-nology companies secure their success byensuring they provide unparalleled cus-tomer support and product availability tothe best organisations in their field.

And this needs to be achieved wherev-er they are in the world – today’s majorclinical centres are not only located inthe big western cities as they once used to

be – new and strong economies beckon.With the right levels of investment and

a global willingness to drive innovationbeyond R&D and into real world applica-tions, the rewards of next generationhealthcare will benefit us all.

The i-Limb hand has five individually powered digitsand won the 2008 Royal Academy of EngineeringMacRobert Award - the UK's premier prize forinnovation in engineering - for Scottish-based TouchBionics. Chief executive Stuart Mead on the sky-highbarriers British companies still face translating abrilliant idea into a global money-spinner.

▲ Stuart Mead

A fistful of dollars

IN ASSOCIATION WITH

▲ The i-Limb won this year's top UK award for engineering

Bionics can be defined neatly as theuse of technology to boost, amplify,augment, improve or mend thehuman body and we have hadbionic tendencies ever since the firstcavemen picked up a rock andturned it into a stomach-comfort-ing calorie booster by cracking anut. The mobile phone improves thepower of the ear, binoculars amplifythe eye.

Since the dawn of time bionicshas been changing the way weexperience the world, opening upour windows of sensory perceptionjust another crack. When combinedwith advances in microelectronics,tissue engineering and drug synthe-sis it might one day blow those win-dows out of their frames.

There is cause for greater opti-mism than the science fictionwriters of a previous generationcould muster. Dr Who’s Cyber-men are mindless automata, ant-

like clones devoid of individuali-ty.

In Aldous Huxley’s 1931 classicBrave New World people are part ofa totalitarian state, free from war,hatred, poverty, disease, and pain.

The mentally challengedEpsilons, who do the mostmenial jobs are out of theirheads on the pleasure-givingdrug Soma for the entirety oftheir leisure time.

But it does not have to be likethat. Many of the developments wereport on in this report modify thebrain’s electrical signaling to have adramatic impact on the surround-ing world but so far there is no evi-dence of the human will becomingsubjugated as a result.

In fact the reverse is the case; thetechnology turns out to be just asophisticated crutch that helpsrelease and expand the humanmind.

A bionic arm that works just bythe power of thought because sur-geons have painstakingly connect-ed nerves that were left in the stumpafter an amputation to some mus-cles in the chest. As the musclestwitch a pressure-sensitive padpicks up the movements and amicroprocessor translates them intodigitised instructions that are thenpassed to servomotors that controlmovement.

A bionic hand so sophisticatedthat the fingers move independent-ly and when covered with the latestartificial skins work to manipulateobjects with dexterity as well aslooking like the real thing.

We can manipulate the electri-cal signals going to the brain aswell as those coming from it.

The synthesis of a new genera-tion of pain killers in the wake ofpioneering work by Britishresearchers into selective sodium

channel blockers should allow usto more effectively filter the elec-trical signals going back to thebrain within the next few years.

No longer will the only optionsfor many in pain be short acting,mind-numbing pharmaceuticalsevery bit as addictive and perni-cious as Huxley’s Soma.

In their place will be more gentlefilters that allow the subtleties oftouch, hot and cool to flow on, free-

ing the mind from the irritatingconstraints of the body.

Oscar Pistorius, the 21-year-old South African double-amputee sprinter who runs withthe aid of carbon-fibre pros-thetic legs may have failed bytwo seconds in his bid to quali-fy for the Olympics in Beijing,but the way is open for him tocompete against able bodiedathletes in London in 2012.

Dawn of CybermenWe have always been bionic creatures, says Tom Rowland,but now the distinction between man and machine is beingblurred in dramatic new ways.

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Bionic futures ADVANCED HEALTHCARE

▲ Jesse Sullivan had his arms burned when he came into contactwith a high voltage cable. Now he has been fitted with the latestbionic replacements.


other amputees who need a pros-thesis but would like it to look asnatural as possible.

Dorset Orthopaedic has devel-oped a service to produce custom-made coverings for an artificiallimb that are sculpted to match thecontra lateral side of the patient andblend with the surrounding skin tis-sue.

The product called “Heather'sCosmesis” aims to give the amputeea semi-customised, realistic-look-ing limb. The idea is that can beordered from anywhere in theworld.

The high definition silicone cov-ers are designed to fit over an exist-ing prosthesis and come in a single

colour that is matched nearest to thepatient’s skin tone from one of 25colour swatches.

“Unlike many off-the-shelfpull on covers, the Heather’sCosmesis is individually crafted,giving attention to the footdetail”, explains Bob Watts, man-aging director of DorsetOrthopaedic.

The price of Heather's Cosmesisis £2,000 and is only offered tobelow knee clients.

Dorset Orthopaedic has providedlimbs for Heather Mills since 1993.

“We find that many of ourclients gain a huge psychologicalboost having the knowledge thatthe focus will no longer be on

How Heather Mills keeps herother leg looking so naturalAdvances in high definition silicone coverings have made vast improvements in the cosmetic lookof artificial limbs and now the ex-model has set up “Heather's Cosmesis” - a business to make highquality styling available to others.

CosmeticsADVANCED HEALTHCARE

The tragedy of loosing or beingborn without a limb has to someextent been mitigated by the mas-sive advances in bio-engineeringand electronic controls of the lastfew years which make normal liv-ing easier but a prosthetic additionused to look artificial no matter howthe owner tried to disguise it.

That no longer has to be the case.Heather Mills, the ex-wife of SirPaul McCartney, was knocked overby a police motorcyclist in 1993and had to have her left leg ampu-tated below the knee.

Now the former model hasestablished an association with aRingwood based company, DorsetOrthopaedic, which aims to help

“Heather'sCosmesis aims

to give theamputee a

semi-customised,

realistic lookinglimb for around

£1,650”

their artificial limb, as quite oftenyou cannot tell the difference”,said Bob Watts.

“Heather wanted silicone cov-ers to be more accessible toamputees. We have developed asemi-bespoke silicone cover withour silicone technicians whichcan be purchased in 25 differentskin tones as an 'off-the-shelf'product, making it more afford-able”, he said.

Heather's Cosmesis is not totallycustom made and is not designed toexactly match a patient’s real leg.

“We will endeavour to matchthe Cosmesis as closely as we canto the pictures you supply uswith”, said Mr. Watts.


Prosthetics ADVANCED HEALTHCARE

The world of advanced prostheticshas been making progress at abreathtakingly fast pace in the lastyear.

Both the man and woman in thispicture can sense pressure and painas if their missing upper limbs werestill present because surgeons wereable to move nerves left behindfrom their arms to the skin close totheir breastbones.

Claudia Mitchell 28 is a formerUS Marine and she lost her arm in amotorcycle accident. She wasrecently fitted with the world’s mostadvanced artificial arm at the Reha-bilitation Institute of Chicago.

Here she is performing a highfive handshake with Jesse Sullivan,a 61 year old, who lost his arms inan electrical burn in 2001.

A pressure pad close to the relo-cated nerves transmits electricalsignals to the brain so both can feelsensations just as though they hadcome from their phantom limbs.

The goal is to make artificiallimbs that can accurately reproducefeeling.

This is only possible because

even years after amputees lose theirlimbs the peripheral nerves in theirarms are often still capable ofreceiving electrical control signalsfrom the brain, signals that origi-

nally would have told the musclesin the hand how to contract andmove. By placing electrodes nearthese nerves it is possible to deci-pher the brain's intentions andapply them to motors in a pros-thetic limb.

To generate sensations an elec-trical signal is applied to nerves inthe forearm that were originallyused to relay sensation signals fromthe hand to the brain.

Sensors could be placed in aprosthetic hand to measure contactforces and temperatures while amicroprocessor turns the data into astream of electrical impulses thatthe brain decodes as the feelings theskin of the lost limb would have felt.

This year the world's first bionichand won Britain's top technologyprize.

The i-LIMB is a prosthetic devicewith five individually powered dig-its. It won this year's Mac Robertaward from The Royal Academy ofEngineering.

Using advanced electronic andmechanical techniques and manu-factured with high-strength plas-tics, the lightweight hand is the firstof a new generation of prosthetics.

The Duke of Edinburgh present-ed the Touch Bionics team with a£50,000 prize and a gold medal.

The i-LIMB hand is controlled bya control system that uses a tradi-

tional two-input myoelectric (mus-cle signal) to open and close thehand’s life-like fingers.

Myoelectric controls utilise theelectrical signal generated by themuscles in the remaining portion ofthe patient’s limb. Electrodes that siton the surface of the skin pick upthis signal.

Existing users of basic myoelec-tric prosthetic hands are able toquickly adapt to the system and canmaster the device’s new functional-ity within minutes. For newpatients, the i-LIMB hand offers a

prosthetic solution that has neverbefore been available.

The modular construction of thei-LIMB hand means that each indi-vidually powered finger can bequickly removed by simply remov-ing one screw. This means that aprosthetist can easily swap out fin-gers that require servicing andpatients can return to their every-day lives after a short clinic visit.Traditional devices would have tobe returned to the manufacturer,often leaving the patient without ahand for many weeks.

“Give me five” – the new bionic limbsthat respond to thought, move morenaturally and can even feel sensationBionic arms that can sense pressure, temperature and pain and move when the brain commands areunder development with teams from the UK and the US producing spectacular results. By Tom Rowland.

“A newperspective on

spare-partsurgery. A singlescrew releasesfingers that

requireservicing”

▲ Former Marine Claudia Mitchell greets Jesse Sullivan.Rehabilitation Institute of Chicago


Grace Weightman could not hear atall for two years after being struckdown with a form of meningitiswhich obliterated her cochlea butthe extent of her deafness turnedout to be fortunate; the NHS couldnot argue that future new treatmentcould be compromised by radicalsurgery now.

The implants cost up to £40,000for a full course of treatment andthe NHS rations most children tojust one implant, arguing that oper-ating on two ears now shuts offoptions for improved treatment in

the future, says her father, William.“All children who are deaf

should be able to get bilateralimplants. It makes such a differencebut we only got them after a hardfight because our daughter had notbeen born deaf,” he the pressuregroup 2ears2hear estimates that itwould cost £6.9 million a year togive double implants to all childrenpresenting with profound deafnessand £25 million to upgrade allpatients.

“I know that if Grace doesnot have one microphone for a

few days it makes about a 40per cent loss in her hearing. TheNHS is denying other childrenthe right to hear with bothears,” he said.

Only about five per cent ofchildren implanted in Britainget the bilateral option; inCanada, the US and Spain it is100 per cent.

It would cost £6.9 million ayear to give double implants toall children presenting with pro-

found deafness and £25 millionto upgrade all patients, saysJason Broekhuizen from thecampaigning group 2ears2hear.

Parents Catherine and Williamown a farm at Houghton Le Spring,near Sunderland. Because ofGrace’s affliction they started a chil-dren’s centre “Down at the Farm”.

We wanted to create an envi-ronment where Grace and otherchildren like her were happy andcomfortable”, said her father.

Little girl can hear properlythanks to double ear implantsA girl of four who became deaf can hear again and enjoylaughing with friends and her pet rabbit thanks to bionic ears.By Tom Rowland.

Cochlear implantsADVANCED HEALTHCARE

“In the UK5% of children

are offeredimplants in bothears comparedto 100% in theUS, Canada and

Spain”


Cochlear implants ADVANCED HEALTHCARE

The quality of the hearing sensation dependson the quality of the processor and thesoftware – the algorithms used to analysespeech,” says Tiziano Caldera Sales DirectorUK of Advanced Bionics.

HiRes Fidelity 120 is Advanced Bionic’s anew sound processing option designed toimprove hearing in challenging listeningenvironments such as in noisy restaurants oron telephones and to enhance appreciation ofmusic.

It is designed to increase spectralresolution from as few as 12 spectral bands inconventional implants to as many as 120spectral bands by providing a power sourcefor each implanted electrode.

The firm’s Harmony implant comes with asingle switch so the microphone automaticallydistinguishes between environments with highbackground noise and quieter ones.

Additional accessories such as mobilephone adaptors, rechargeable batteries andthe in-the-ear microphone “T-Mic" providehigh comfort for the users.

ADVANCED BIONICS

Neurelec’s system has a very low power consumptionwhich is a huge asset argues Guillaume Rosanis, r&delectronics manager at Neurelec cochlear implants.

Average battery life is four days with the Digi SP processor,longer than other brands, he claims.

The implant, Digisonic SP, is ceramic so all the componentscan befitted inside a single housing. If a metal housing is usedthen the receiver coil has to be located separately to ensureuninterrupted reception from the processor.

Surgery is more simple. The entire device is secured with twoscrews without extensive drilling into the skull being requiredand there is a claimed saving of 30 per cent in surgery time.

The end product is claimed to be the lightest and smallestprocessor on the market: only 12 grams in weight and 9 mmthick.

The most exciting future progress should be the develop-ment of a new fully implantable technology that dispensesentirely with the external microphone.It will pick up poweron a daily basis when the patient puts a charging devicenear their ear.

Founded in 1989, MED-EL today is a fast growing medicaldevice enterprise offering pioneering technologies and thebroadest range of hearing implant systems.

These systems and a variety of system components providefor selecting the best possible solution for individual cases ofhearing loss: The Maestro cochlear implant system includingFineHearing, the advanced sound processing technology; thefirst fully integrated system for combined electric acousticstimulation (EAS); and the unique Vibrant Soundbridge mid-dle ear implant system featuring the smallest audio processoravailable.

With FineHearing MED-EL offers novel sound processingtechnology that, for the first time, is able to process the finedetails of sound.

“These advanced technologies allow users of our Maestrosystem to experience a more natural and rich hearing experi-ence than ever before” explains Cassandra Brown, ManagingDirector of MED-EL UK.

“Even challenging situations such as listening to music orconversations with a lot of background noise are no longer ahurdle.”

MED-EL

The Nucleus Freedom from Cochlear Europe uses ‘intelligent’ digitalsound technology designed to behave in much the same way as naturalhearing, allowing recipients to focus on the sounds that are most impor-tant to them.

It offers continuous enhancements and advanced customisable fea-tures. The modular design accommodates all ages and lifestyles.

New “SmartSound” software unique to the Nucleus Freedom providesbetter hearing in even more day-to-day situations.

SmartSound2 can adapt to the different listening situations in the sameway natural hearing does.

The Nuclues Freedom is a splash- and sweat-resistant processor, deliv-ering improved confidence for wet situations.

Amanda Whiffin, general manager Cochlear UK says: “Cochlear is theglobal leader in implantable hearing solutions. We in the UK provide thetools to hear and the inspiration to explore the world of sound. Our pas-sion, creativity and innovation is what enables the Nucleus CochlearImplant system and the Baha to deliver sound to more than 100,000 inover 100 countries worldwide. Cochlear's promise - Hear now. Andalways - articulates our lifetime commitment.”

COCHLEAR EUROPE

▲How they work

Unlike hearing aids, which amplify sound, cochlear implants consist

of two parts, one to pick up sound through an external microphone

located behind the ear {1} and transmit sound as a radio signal via

an antenna {2} to an implanted receiver {3}. Electrodes {4} then

stimulate auditory nerves {6} bypassing the normal hearing

pathway. {Picture: Neuralec}

NEURALEC

Four companies, Advanced Bionics, Cochlear Europe, MED-EL andNeuralec, make cochlear implants. We survey developments.

1 23

6

5

4


A young street busker from Pak-istan who could walk on hotcoals and drive stakes throughhis limbs without seeming tofeel any discomfort led scientiststo a genetic discovery that maysoon revolutionise the treatmentof pain.

Professor Geoffrey Woods atCambridge University beganstudying the child to understandwhy he was unable to feel painbut was otherwise completelyhealthy. He died aged 13 frominjuries sustained while playingwith friends.

Researchers looked at his rela-tives and found that some hadexperienced no pain at any time intheir lives although they bore thescars associated with excruciating

trauma; many had fractured boneswhile some were missing the frontof their tongues after biting them-selves.

Using this information DrWoods identified a rare muta-tion in a single sodium channelgene, which disrupts the flow ofsodium ions in specific nervefibres that sense damage.

Other families across the worldhave also now been added tothis list Neurological tests on the fami-lies revealed they respondednormally to touch, temperature,tickling and pressure and hadno signs of nerve disease.

With the sodium channelblocked the electrical nerve sig-

nals are unable to get throughand the brain remains undis-turbed. A second related sodi-um channel is also necessaryfor many pain sensations, andselective blockers of this chan-nel are already in clinical trials.

“We have now got com-pounds that block these twochannels and are extremelygood analgesics in animal mod-els. It is fast moving and excit-ing,” said Professor John Woodof University College London.

His team has now managed toblock one specific sodium channelso that all of the inflammatory painand mechanical pain are removedbut the response to heat remainsnormal.

We have known for some timethat sodium channel blockers aregood pain-killers, but side effectshave limited their usefulness.

Pain reliefADVANCED HEALTHCARE

Scientists are developing drugs that mimic a genemutation that blocks pain and are confident that newtypes of pain-busting drugs that act with minimal sideeffects will soon be available. By Tom Rowland.

“Sodiumchannels are not

part of thecentral nervoussystem and canbe neutralisedwithout side

effects ProfessorJohn Wood of

UniversityCollege

London”

w

w

v

w

Boy who walked onhot coals leads theway to improvedpain management


Pain relief ADVANCED HEALTHCARE

However, drugs that specificallyact on the two sodium channelsfound on damage sensing nervecells have been given far easier tar-gets, he explained.

“I hope it is going to be a realturning point in pain treat-ment,” he said.

Because the sodium channelsare not a part of the centralnervous system they can beneutralised without theside effects associatedwith more conven-tional channel block-ers, which may evenbecome lethal as thedose is increased.

The selectiveblockers should hit thepain without interferingwith other systems in thebody.

Other clusters of pain-freefamilies who are in every otherrespect completely normalhave been found in Canada andJapan and the UK

“Pain-free but otherwisenormal humans provide perfectvalidation data in terms ofmaking these new drugs” saidDr. Wood.

This is because researcherscan see in advance that peoplewith the blocked sodium chan-nels will not suffer adverse sideeffects.

“The genetics has been doneover the last 10 to 15 years andthe drug companies have fol-lowed up. It is very positive andoptimistic,” he said.

The first selective sodium-channel blocking drugs would be targeted at inflammatory

pain and should start tobecome available after phase 3clinical trials in two

to three years time he said.Drugs targeted against thechannels lost in pain-freehumans are a few years behindthis, as safety issues are rigor-ously addressed.

To go from the gene to drugsso quickly required bothcuriosity-drive research andthe transnational activity ofdrug companies said ProfessorWood.

“These studies, pioneered byGeoffrey Woods should soonhave an important impact onour health and quality of life,”he said.

▲ Oticon

Epoq

▲ MED-EL

PULSARci100 and SONATAti100

▲ Cochlear Europe

Ears in miniature Advanced Bionics

Helix Hearing devices are getting smaller and neater

▲

“Discovering painfree families meansresearchers can see

in advance thatpeople with blockedsodium channels will

not suffer adverseside effects”

A blood glucose test is a wayof checking the level of glu-cose in the blood and is high-ly important in helping peo-ple with diabetes managetheir condition.

People with Type I diabetes,and increasing numbers withType II diabetes, use insulin tocontrol their glucose levelsand many are now using con-tinuous pumps to deliver theinsulin. These people mayself-test anywhere from fourto ten times per day. Theimportant thing is to getgood, accurate readings toavoid unnecessary hypo- andhyperglycaemic episodes.

Traditionally, self testing ofblood glucose is carried outby pricking the finger tip todraw blood and then placingthe sample on a chemicalstrip that either changescolour, or changes in its elec-

trical characteristics and isthen measured by a meter.

Improved technology formeasuring blood glucose israpidly changing the stan-dards of care for all peoplewith diabetes. There are sev-eral methods of blood glucosetesting currently available.

WaveSense is a suite ofpatented biosensor technolo-gies that uniquely employDynamic Electrochemistry toprovide accurate glucosereadings. WaveSense sends

complex electrical signals intothe test strip to identify com-mon sources of error thatmake blood glucose measure-ments inaccurate. In simpleterms, WaveSense personalis-

es the test for each person atthat specific time oftesting.The fundamentaladvantage of WaveSense isthe amount of data that is col-lected and analysed.

Technology is improving care of people with diabetes.

Keeping your blood sugar in control

“Improvedtechnology for

measuring bloodglucose is

rapidly changingthe standardsof care for allpeople withdiabetes”


DiabetesADVANCED HEALTHCARE


Airways ADVANCED HEALTHCARE

One swallow can make a summerA Yorkshire company that pioneered developments in plastic tubes and cups used for care after opera-tions on the head and neck has found huge new markets helping stroke victims and the elderly.

Bionic products do not have to beultra-high technology to have a dra-matic impact on the quality of peo-ple’s lives.

Swallowing safely after sufferinga stroke or other neurological prob-lems is vital if food and fluid is to beprevented from entering the trachea.

If they do get down this vital air-way then the lungs can get be com-promised; over a period of time

patients can become prone to pneu-monia and that in turn can kill.

Many elderly stroke victims andothers with chronic conditions justfade away while the professionalsand staff in nursing homes shrugand point out their advancing age.But it does not have to be that way.

There are simple devices availablethat can halt the lethal lung infectionbefore it gets a hold.

“So long as the carers are aware,there are devices that can reduce to aminimum the risk of aspiration andpremature death,” said MichaelEaton, head of marketing at Kapitex,which is based in Wetherby.

Many of the products were devel-oped in response to coping with theproblems patients had in the after-math of neck surgery when manag-ing their airways becomes key tokeeping them alive.

“Tracheostomy is a holding pro-cedure to make sure a patient can getgood respiration while all otherthings are being managed,” he says.

While it is in place keeping swal-lowed liquids out of the lungs isimportant.

But the plastic devices can be eas-ily used to help other patients withproblems swallowing.

“We have developed a range ofdrinking vessels and motor rehabili-tation products that give physiother-apy to the mouth,” said Mr Eaton.

“If you do not manage an acuteproblem properly then you mightnot live for it to become a chronicone,” he points out.

Many of the problems are mani-fested in people in nursing homeswhere carers may not know thatsimple solutions are available.

The cups are specially shapedto prevent tilting the head back. Ifthe epiglottis fails to react quickly

the airway is not shut in time andpeople cough and choke. Over aperiod of time fluid builds up inthe lung while the patientbecomes reluctant to drink, lead-ing to dehydration.

Chewy Tubes are simple butinnovative oral motor devicesdesigned to provide a resilient, non-food, chewable surface for practic-ing biting and chewing skills.

▲ Specialist cups which do not require head movement

▲ Chewies help in rehabilitation


The second half of the twentieth-century saw heart disease becomethe number one killer in the UK.

The good news is that over thelast few years it has been on thedecline. This appears to be mainlydriven by a reduction in peoplesmoking.

But the battle has by no meansbeen won because this decline is onthe verge of being reversed by thehuge explosion of diabetes that isnot only on its way but is now uponus.

This is important because dia-betes leads to heart disease in mostof those that develop it.

This development has been driv-

en by two lifestyle changes thatthemselves are taking on epidemicproportions. These are higher calo-rie intakes leading to widespreadobesity and low calorie outputstates that follow the adoption ofsedentary lifestyles.

This has occurred despite theproliferation of advice that informsour eating, particularly what weshould eat to stay healthy.

There is a vast array of diets tochoose from. Gyms and exerciseclasses seem to be popping upeverywhere. Despite all of this Type2 diabetes is on the rise and couldreach 4 million by the end of thedecade.

It is not only here that this is hap-pening. The rest of the developedworld such as the USA and Ger-many are witnessing similar prob-lems. But the problem is increasingat literally an exponential rate inemerging economies such as India,China and Russia - compounded bythe fact that in these countriessmoking is also on the rise.

In the general population in thiscountry 33 per cent of people diefrom heart disease but in peoplewith diabetes this rises to a massive75 per cent.

Diabetes is inextricably linked toobesity. Body mass index relatesheight to weight and is one way of

measuring obesity. A level of below25 is considered normal and oneabove 30 is obese.

It is well established that awoman with a low body massindex of 20 has a virtually zerochance of developing type 2 dia-betes in her lifetime but a womanwith a body mass index of 35 has a90 per cent chance of developingthis condition.

Type 2 diabetes is a potentiallypreventable condition. This hasbeen borne out by several studies inwhich lifestyle changes that includ-ed healthy eating, weight reductionand exercise (example = DPP dia-betes prevention programme) were

Ducking diabetes - a strategy forlonger lifeThe incidence of diabetes is exploding and75 per cent of people with it die from galloping forms ofheart disease - yet in some diabetes is avoidable and in others pilot studies have shown that help isat hand ...if it is caught early.

DiabetesADVANCED HEALTHCARE

applied to prevent its development. Prevention using lifestyle modi-

fication has been shown to be supe-rior to even medical interventionsuch as the taking of medication bythose at risk.

Obesity and its consequencesfrequently enter the political arena.Only recently did David Cameron-weigh in with his opinion that it wastime for people to take someresponsibility for their own healthrather than letting things happen tothem and depending on the state tosort out the consequences.

One thing is certain: when itcomes to type 2 diabetes preventionis infinitely better than cure. In fact

BY DR AKHIL KAPUR, CONSULTANT INTERVENTIONAL CARDIOLOGIST, THE LONDON CHEST HOSPITAL, BARTS AND THE LONDON NHS TRUST


Diabetes ADVANCED HEALTHCARE

no cure exists for this condition andat present there is no prospect ofone either.

Even so it is clear that the gov-ernment does have a part to play.People cannot be dictated to whenmaking lifestyle choices. But it ispossible to assist them in makingthe right choices.

The recent proposal for access tofree swimming for everyone overretirement age is a welcome devel-opment that contrasts with previouspolicies that have resulted in theselling off of school playing fields.

Better food labelling has alsohelped.

But what can be done for thosein whom prevention is no longerpossible?

There are initiatives that canhelp. At least one million people -the so-called missing million - inthis country are believed to haveundiagnosed diabetes.

A programme of identifyingthese patients early would aid bettermanagement of their condition.Picking up heart disease earlier inpatients with diabetes would also

reap tremendous rewards. This isbecause heart disease in patientswith diabetes is on average moreaggressive than in those withoutdiabetes.

Until recently these patients werestudied together with all other heartdisease patients even though it isrecognised that there are features ofheart disease in patients with dia-betes that set them apart from otherheart disease patients.

They suffer from a more aggres-sive disease process and from rapidprogression of their disease and it isargued that they should therefore bemore aggressively managed.

More recently there has been amove to study these patients sepa-rately so that treatment can be bet-ter tailored to them.

Dedicated studies and trials look-ing specifically at these patients arenow under way and one such studyin which the United Kingdom ledthe way will be presented at theEuropean Society of Cardiology inSeptember.

This study is called the CARDia(Coronary Artery Revascularisa-tion in Diabetes) Trial and willhelp determine which is the bestform of treatment, either bypasssurgery or coronary angioplasty

and stenting, for patients whohave diabetes and widespreadcoronary disease which wouldpreviously have required surgery.

The United Kingdom is leadingin other ways. Local initiativesare often the catalyst for theadoption of more widespreadprogrammes. In a deprived partof East London one such initia-tive has already started. The bor-ough of Newham has the highestrate of death from coronary dis-ease in the country.

It is also considered to be thecapital of diabetes in Europe. Adedicated clinic has been set upwithin the cardiology departmentof Newham University NHS Trustfor patients who have diabetic coro-nary disease.

The purpose of this is to diagnosethese patients earlier and once diag-nosed treat them aggressively.Catching these patients early hashuge potential benefits.

If left undiagnosed diabeticcoronary disease will presentacutely more often, that is, withheart attacks and even deaththan it does with a non-acutepresentation to a GP or cardiol-ogist which is how most othercoronary disease presents.

Diabetic coronary disease ismore difficult to diagnose becausepatients do not always feel chestpain.

Running a clinic like this affordsthe opportunity of seeing patientswith diabetes who the clinic andtheir GPs believe are at high risk ofheart disease.

Catching them early thereforeallows the clinic to institute earlierproven treatments that they knowwill reduce their long-term riskthereby reducing their chances ofhaving a heart attack.

If necessary the patients can befast tracked to diagnostic inter-ventions to detect their coronarydisease and then if necessary onto operative procedures such aspercutaneous coronary angio-plasty and stenting which canrelieve their coronary narrowingsand blockages.

There is pilot data from thisclinic which confirms that risk isbeing reduced in these patients.These data are also being present-ed at the European Society ofCardiology this September and ifthis clinic proves successful thereis a plan to roll this out to otherhigh risk areas in a bid to protectand hopefully save more lives.


While the NHS is still supplyinghearing aids that sit behind the earwith a tube that attaches to a mouldthat is in the ear, the private sectorhas powered ahead with more aes-thetically pleasing designs that fitwithin the ear canal. These are cur-rently the primary resource of theindependent dispensers.

With aids costing an average of£1,000 per ear they can seemexpensive compared to other hightechnology consumer items such asa mobile phone which has manymore functions.

Innovative designs however takea long time to drop in price becauseof the conservative procurementpolicies inside the NHS, argue man-ufacturers.

Hearing aid sales volumes arenot large enough to bring downprices quickly, says Neil Pottinger ofmanufacturers Starkey.

“Over the last eight years theprimary change has been thechange from analogue to digitalhearing aids. We have the bestfeedback cancellation system in

the market,” says Mr. Pottinger.“Under normal and correct fit-

ting procedures feedback hasceased to be an issue while ourdirectional system quickly allowsusers in a busy environment withlots of background noise to identifythe sound they want to be listeningto and nullify the surroundingsounds,” he says.

The new Zon hearing aid is evensmaller and sits inside the ear canalwithout blocking all other acousticinputs. It is also claimed to be morecomfortable to wear because theunit does not clog the entire canal.

“Recent innovations in hear-ing aid technology are helping tochange the picture from foggy to“sharp” for many people withhearing loss,” argues MariskaAlaxander of Oticon.

“The Oticon Epoq, the first hear-ing solution with wireless connec-tivity, has added an exciting newdimension to the way people withhearing loss can process the ‘sea ofsounds’ they encounter in dailylife,” she said.

Unlike traditional hearing aids, apair of Epoq hearing devices con-tinuously “communicates” witheach other wirelessly to support thebrain’s proper interpretation of var-ious sounds in the environment.The result is a unique spatial aware-ness – a 360° hearing experience –that makes it possible for Epoq usersto more easily navigate in complexand changing sound environments.

Epoq improves an individual’sability to determine where soundsare coming from and at the sametime, makes sounds much clearerand more comfortable. Because

No more whistledown thewind in your ear

HearingADVANCED HEALTHCARE

Of the one million hearing aids fitted each year in the UKroughly 750,000 are done through the NHS but the productsavailable on the NHS lag significantly in terms of both thetechnology levels and style.

Hearing aids are one of the longest-serving applications of bionics.In 1588 the writer Giovanni Battista Porta, reported that healers

fashioned ‘hearing aids’ of wood, shaped like the ears of animals knownfor acute hearing - as if some of that natural, animal ability would ruboff on the hard-of-hearing.

Ear-trumpets featuring elongated tubes with a funnel-shaped end,were commented on by Francis Bacon in 1627.

In 1898 the first commercial hearing aid, called a ‘carbon-type’, wasproduced in the U.S. by the Dictograph Company.

Thomas Edison became technically deaf in his teens and he patentedthe ‘carbon-transmitter’, which translated sound into electrical signals.

Alexander Graham Bell, invented the telephone while working toinvent a hearing aid.

In 1899, the Akouphone Company produced the first practicalelectric hearing aid using the carbon-transmitter and a microphone witha battery. It retailed for $400 and needed its own table.

By 1952, the first transistor hearing aids were developed. Thesehybrids featured both vacuum tubes and a transistor. They were muchsmaller.

By the 1960’s the transistor allowed hearing aid designers to create‘over-the-ear’ or ‘behind-the-ear’ models.

Later features like directional microphones, and integrated circuitryhelped users to distinguish between speech and background noises.

Tiny batteries for ‘in-the-canal’ aids with analog sound-systems thatwere almost completely hidden from view were also developed.

In the 1980’s, with the introduction of lithium batteries, hearing aidswent digital.

HEARING HISTORICAL ECHOES

Epoq users don’t have to concen-trate so intently when listening ortalking, they report feeling moreconfident and at ease especially indifficult listening situations.

“They also tell us that they havemore energy to socialise and toengage in situations and activitiesthey previously avoided," she said

Epoq’s wireless connectivity cre-

ates another outstanding benefit forpeople with hearing loss. With theaddition of the Streamer, a sleekcompanion device, Epoq functionslike a wireless headset, streamingconversation from mobile phones,televisions, MP3 players and otherBluetooth-enabled devices directlyinto both ears for interference-freelistening.

▲ The Zon; a new generation ofultra-miniaturised hearing aidsthat allow in peripheral sound

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ADVANCED - Tom Rowland · come from their phantom limbs. The goal is to make artificial limbs that can accurately reproduce feeling. This is only possible because even years after