November 17, 2019

Exponential Medicine 2019 - Day 2 - Cool Stuff Summary

INTRO / SUMMARY

Day 2 - Monday November 5, 2019

Cool Stuff Summary: this collection of slides is certainly not a comprehensive summary of the conference, but some of the points I wanted to remember. Occasionally [My comments are inserted in brackets with bold italics]

The Day 2 live stream is  available on YouTube. I wasn’t able to attend this year’s Exponential Medicine in person.

Watch this article as a video


Exponential Medicine 2019 Summaries

Day One   |   Day Two (current article)  |   Day Three   |   Day Four

Trends out of Day 2

The most powerful presentations today showed the continuous progress being made in medical diagnostics and therapeutics that are powered or delivered via mobile phone accessories. This has the ability to significantly expand the global reach of medical care. Such tools also will transform how we structure care systems. Very exciting area to watch.

Genome engineering continues to progress remarkably quickly.

Scientific research into aging and lifespan appears progressively more ‘mainstream’, and less ‘fringe’.

One of the critical parts of providing effective healthcare - compassion, empathy, & human connection - are brought to the front for conversation; as well as how technology both hinders and can improve this.

Session 6
The Neobiological Revolution

“The accelerating ability to both read and write DNA and to understand and manipulate human biology has major implications for the future of healthcare and humanity.”

6.1.  Neo.Life

Jane Metcalfe, Founder Neo.Life Cofounder WIRED   @janemetcalfe

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6.2. Humane Genomics

Andrew Hessel, CEO, Humane Genomics   @andrewhessel

The plant is the perfect factory.

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New DNA based storage.

e.g. The startup Catalog, can store all 16GB of Wikipedia into a piece of bacteria

https://www.cnet.com/news/startup-packs-all-16gb-wikipedia-onto-dna-strands-demonstrate-new-storage-tech/

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The iGEM competition (website) (Wikipedia) brings together thousands of high school students (and university), where they they are ‘programming’ DNA. This winning High School project reprogrammed E. coli to grow glow in the dark silk.

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We are now moving into Whole Genome Engineering - being able to fully design an build organisms from scratch.

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This has been happening with viruses for some time.

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It has become easy to order viruses online.

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Over the last 25 years we have gone from being able to synthesize proteins, to being able to make a eukaryote. The next step is being able to produce a whole chromosome.

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6.3. Allergies

Kari Nadeau MD, PhD, Director of the Sean Parker Center for Allergy & Asthma Research at Stanford University, Section Chief of Allergy and Asthma at the Stanford School of Medicine

Why are food allergies on the rise?
The five Ds

  • Diversity of Diet - helps reduce risk of allergy developing
  • Dirt - exposure to dirt helps reduce risk of allergies
  • Vitamin D - lack of vit D associated with increased allergies
  • DNA - allergies can be inheritable
  • Dry skin - allergies can enter through the skin

Companies are using blood tests to start to be able to predict allergies and asthma. This can reduce the time to diagnosis as skin-prick-tests can have waitlists.

Image below:  A sample chip is shown, that can test for 96 allergens on a chip at once. It connects directly to the phone, and is operated on the device by an app. Device still in beta-phase.

Possibility of a “cure” for allergies? Opportunity may be within sight. “Peanut pill”  and “Peanut patch” - to be able to desensitize

Examples of very good allergy clinics: Latitude Food Allergy Care: & New England Food Allergy Treatment Center

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Session 7
Digital Health & Medicine. From Inception To Impact

“As mobile sensors, data and informatics converge, novel approaches to diagnosis, disease management and discovery are making their way to our wrists, and now physical and virtual clinics. What are the lessons, and potential going forward?”

7.1  AliveCor

Dave Albert, MD, Founder, & Chief Medical Officer, AliveCor @DrDave01
Suraj Kapa MD, Director, Augmented and Virtual Reality Innovation, Professor of Medicine Mayo Clinic @SurajKapa

AliveCore currently doing: 1.7 million EKGs a month

AliveCor is able to detect from EKG:

  • Patients with low ejection fraction based on EKG.
  • Atrial fibrillation
  • Physiologic age
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The rate of detection by EKG with AliveCor of a low ejection fraction (low heart function), or the risk of atrial fibrillation (heart arrhythmia) performs quite well when compared to other medical test.

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A patient’s physiologic age is an interesting metric that can be deduced from an EKG.

The tracing below, shows a patient’s ‘physiologic age’. In his early 30s he had multiple heart attacks. At age 54 he has a heart transplant (the point where his physiologic age on the chart has dramatic drop). At age 60 he looses weight, and his physiologic age improves further.

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“How do we scale cost effective insights”

  • 22.5% of Americas don’t have a personal doctor.
  • Most of people in world cannot afford an expensive 12 lead EKG machine
  • AI + new tech is opportunity forward.
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Demo between a very costly latest 12 lead EKG machine, compared with AliveCor’s new 6 lead EKG.

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7.2. Camera based diagnostics

Yonatan Adiri, Founder & CEO, Healthy.io @YonatanAdiri

Was previously Chief Technology advisor to the president of Israel.

THESIS: Technology companies continue to improve the quality of the cell phone camera each year. A company could be built that leverages this camera to deliver clinical grade medical insights.

3 Core Principles

  • Deal with volume: Goal is to serve as many people as possible (ie. not only premium phone models)
  • Everything is clinical grade (FDA approved)
  • Leverage computer vision
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Example: Urine Test

Meets the ‘volume’ criteria of a good test for them to work with.

  • 1 Billion tests every year (second most common test after a blood count)
  • 600 million who need at least an annual test (diabetes, hypertension, kidney)
  • 300 million - prenatal tests in OECD countries annualy
  • 100 million - UTI tests

Traditionally patients have the “Walk of Shame” - walk with urine container to the lab desk

Produced a home urine test kit.

Key insight to their success: They didn’t re-invent the dipstick. They changed the workflow.

All their results go into the clinician’s EMR. (notice how this integrates into traditional workflow for the care providers).

Their dipstick works “within FDA accepted tolerance” of a commercial grade lab test machine.

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A huge number of Americans are at risk of chronic kidney disease, or have a condition that requires testing and monitoring of renal function (protein in the urine).

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Compliance with urine protein screening is typically low. Early identification is critical for reducing long term costs.

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The use of in-home urinalysis albumin screening increased compliance from 2/10 to 7/10.

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A radical new financial model is being developed where their diagnostics company only gets paid when they detect people with abnormal renal function. [This is really important to help ensure that the screening is done with a focus on high risk patients, and to prevent ‘patient skimming’ and testing on too many healthy people].

“Pay for protein”  [I think a lot of more healthcare funding models will move towards this].

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Example 2: UTI

A home kit is sold behind the counter at the pharmacy in the UK.

To help ensure people who are high risk do not receive the kit, there is an ”exclusion questionnaire” the pharmacists administers before they sell the kit.

This is a “Pharmacy first” healthcare plan.

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It uses “Clicks leveraging bricks”. The onboarding of the user starts digitally to notify them the home UTI kit exists. However, the product itself is picked up in .

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How do you connect women from digital -> to know to get to store.

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Currently women pay 25 pounds out of pocket for the test. They are In discussions with the NHS to see if the 6 million annual UTI doctor appointments are being saved. If so, the NHS would have an incentive to help pay for it directly so that patients no longer have to.

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Future examples where camera technology could improve care: wound management (look at the 3D scanner on the front of the camera).

7.3  Digital Medicine Society

Jennifer Goldsack, Executive Director, Digital Medicine Society (DiMe)  @GoldsackJen

  • Aimed not for companies, for for individuals
  • Work is being done by the community members.

Digital Medicine: A Primer on Measurement https://www.karger.com/Article/FullText/500413

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7.4  The Green Button

Nigam Shah MBBS, PhD, Associate Professor of Medicine (Biomedical Informatics) and Biomedical Data Science, Stanford Medical School  @drnigam

THESIS: If a clinician is seeing a difficult case, there could be a ‘green button’ in the EHR that they click to obtain a consult; wherein they ask the EHR (via the informatics team) What happens to other patients like mine?

“We have to learn from the data that we collect. There is no other industry, that would do things to 10 million people, and not use that information to inform the next person who walks in the door”

https://shahlab.stanford.edu/greenbutton/

“The Clinical Informatics Consult is an IRB approved project to study the use of routinely collected data on millions of individuals for providing better care. Given a specific clinical question, we provide a report with a descriptive summary of similar patients in Stanford’s clinical data warehouse, treatment choices made, and observed outcomes.”

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Just as you donate blood, imagine if you could donate your medical data to continuously help others.

Session 8
Medicine And The Machine:

“Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, will explore ‘Medicine and the Machine’ and discuss the power and pitfalls of artificial intelligence and how technology will change modern medicine.”

Eric Topol, MD, Founder and Director, Scripps Research Translational Institute  @EricTopol

Abraham Verghese, MD, Professor for the Theory and Practice of Medicine and Senior Associate Chair of the Department of Internal Medicine. Stanford Medical School  @cuttingforstone

EHRS

  • Doctors are the highest paid clerical workers in the hospital.
  • The EHR as a single tool, is responsible for more distress in medicine than anything else.
  • Will be over 100,000 human scribes in USA by next year

Eric Topol - should doctors organize, to help fight against the administrative overlords in medicine.

Abraham Verghese -  Helped startup a Centre at Stanford on Presence (The Art & Science of Human Connection  https://med.stanford.edu/presence.html

Mind & Body Lab @ Stanford, led by Dr Alia Crum looks at effect of placebo in care and the powerful biochemical change placebos have. A number of TED talks online, look it up. https://mbl.stanford.edu

“Our lab focuses on how subjective mindsets (e.g., thoughts, beliefs, and expectations) can alter objective reality through behavioral, psychological, and physiological mechanisms.”

Book recommendation, “The Soul of Care: The Moral Education of a Husband and a Doctor” by Arthur Kleinman.  “A moving memoir and an extraordinary love story that shows how an expert physician became a family caregiver and learned why care is so central to all our lives and yet is at risk in today's world.”

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Session 9
Reinventing The Regulator and Services For The Digital Age

“As medical devices, software and AI merge, how can novel solutions be demonstrate their safety and efficacy and be regulated effectively? How do governments leverage digital tools to create health equity and impact?”

Asif Dhar, MD, Chief Health Informatics Officer & Principal, Deloitte Consulting  @asifdhar

PART 1 Move towards viewing health as a community framework.

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PART 2 Software as a medical device.


Dramatic shift in regulatory environment, where FDA looking to partner with groups so that there is continuous oversight of products, through a network of trust between the software organization and the FDA.

This ideally is better for the software company, because it understands the nature of software is something that evolves and creates provisions for this type of a FDA clearance. It also should provide greater transparency into an organization by the FDA

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Progress over the last year in FDA certification of software as a medical device.

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Session 10
Abundance, Bold Thinking & Massive Transformative Purpose

Peter Diamandis MD, XPRIZE founder and Chairman, Co-founder of Singularity University


How can we use technology to help lift up the baseline

Session 11
Virtual reality in healthcare

Brennan Spiegel, MD Director, Health Services Research in Academic Affairs and Clinical Transformation at Cedars-Sinai.    @BrennanSpiegel

What do patients look at all day in the hospital?

The ceiling…

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Or someone poking them, and asking them questions.

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THESIS: can we use VR to help patients escape the bio-psychosocial jail cell (also known as a patient hospital room).

This is what it looks like when patients in pain first put on the device…

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Virtual reality experiences. Such as being on a beach, a mountain side, back at home, are powerful at being able to modulate a patient’s level of pain.

Virtual reality headsets have a significant (P=<0.0001) improvement in the ability to modulate pain from its baseline state.

There is also a significant (P=0.008) improvement in VR Headsets to modulate pain when compared to the same images being shown on a TV screen (instead of the VR headset).

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In their study, the patients needed to be treated with a VR experience to have  an effective pain response was 4. This is similar to results seen for opioids in those patients.

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If VR is a ‘treatment’, it is important to be able to identify a Psychometric profile, to be able to map the right therapy to the right treatment

It can be a powerful tool - even curing panic attacks.

But there are also risks of evoking the wrong emotions or causing harm. How can this be anticipated ahead of time in the matching of the right VR experience.

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How exactly this works still remains unclear. Some theories:

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Crowdsourced research suggestions on where to take VR studies next.

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Session 12
Vision.Health Seeing Beyond & Future Of Diagnostics

“Beyond the standard labs and radiology, exponential technologies are enabling new forms of sensing and diagnostics. This session will focus on decoding the opportunities that machine vision promises over the decade ahead.”

Leerom Segal, CEO, Co-founder, Klick Health    @leeromsegal

Kamran Shah, EVP Technology & Media Klick Health

What is different between these two glasses?

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One is hot. The other Cool.

Humans can’t see temperature.

Machine vision and human sight are different.

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Machine vision can augment healthcare procedures & diagnosis

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Has the potential to increase continuous, non invasive monitoring.

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What people see when they go to the doctor’s office today.

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Vision and voice have potential to improve the clinic through their use in the background.

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Why focus on voice and vision?

Voice and vision should compound faster than other technologies, because this technology is being pushed forward by groups like Amazon and Google for product discovery

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Privacy and security tradeoffs come with increased level of integration.

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Areas that voice and vision can improve in healthcare:

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If the door through machine vision saw the person was in a wheelchair, it could stay open longer as they pass through it.

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If machine vision knew that there are no clinical staff in a patient’s room, the system could know tot not sound a code-blue alarm in that patient’s room.

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Women saw on a thermal camera that one breast lit up. This led her to seek medical attention, and be diagnosed with breast cancer.

https://www.bbc.com/news/uk-scotland-edinburgh-east-fife-50139540

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FLIR - Thermal imging cameras built as attachments for the smartphone. ($200-400 USD)

https://www.flir.com/browse/home-amp-outdoor/mobile-accessories/

[If any doctors start using this in their practice, let me know, would be curious to see what use cases you find for it]

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Session 13
Accelerating Cures & Future Of Pharma

“From Big Pharma to patients turned researchers, what are novel approaches and mindsets to discovering, testing and implementing therapies for common to rare diseases.”

13.1  Pharma

Ameet Nathwani MD, Chief Digital Officer, Chief Medical Officer and Executive Vice President, Sanofi

R&D costs continue to increase, and the returns are decreaseing

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13.2. Rare diseases & a race against time

David Fajgenbaum MD MBA, Asst Professor, Division of Translational Medicine & Human Genetics, University of Pennsylvania School of Medicine. Author of ‘Chasing My Cure: A Doctor’s Race to Turn Hope Into Action’    @DavidFajgenbaum

David Fajgenbaum developed a deadly form of Castleman’s Disease while completing his medical training.

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Photo from before and after he left the ICU.

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After completing last-line therapy, he had to research a new therapy in order to be able to treat future relapses.

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Ultimately, he discovered that Sirolimus (a drug typically used to prevent organ transplant rejection) could be effective against Castleman’s.

Since starting Sirolimus David has been able to achieve the longest period of remission.

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They are now able to help establish remission with 1/3 to 1/2 of Idiopathic multicentric Castleman disease patient’s treated with this medication.

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Funding and research for idiopathic Multicentric Castleman’s Disease has dramatically increased as a result of his efforts:

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Rare Disease

  • There are about 10,000 human diseases
  • 2,5000 of them have FDA approved treatments (totalling about 15,000 drugs).
  • 7,000 of them are ‘rare’ diseases - of which 97% of those do not have an FDA approved therapy. This effects about 30 million Americans.
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This story is told in his book Chasing My Cure: A Doctor's Race to Turn Hope into Action.

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13.3  Novel drug discovery

Sean Escola MD PhD, Co-founder & CEO, System 1 Biosciences    @seanescola

Drug discovery is hard. More money has not resulted in more results

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Is this because all the low hanging fruit is picked? The answer is likely: no. Because, the way many drugs were discovered was through a serendipitous process.

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The hard part of drug discovery is figuring out which drugs should be applied to the right conditions In the clinic.

This type of drug discovery is hard, because there are many genes, that interact with weak effects. This makes it hard to do drug discovery and matching based on genetic information alone.

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What is needed, are better models of the brain that can be used in the lab.

Our current models are either animal and differ too far from human physiology, or they are very simple

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System1 Biosciences is growing organoids - which are make it possible to grow parts brain tissue in the lab.

These organoids allow a more advanced study of drugs that is closer to human brain function. Organoids can be derived from human stem-cells.

This makes it possible to study the effects of drugs using a lab setup closer to human brain function.

THESIS: drug discovery on organoids (a lab model closer to human brain tissue), will make it possible to discover medications more effectively. Especially in the area of mental health.

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To do this research, they source tissues from people with ‘normal healthy Brians’ and brains with different abnormal states “deep phenotypes”.

These are grown into organoids.

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They can study the difference in genetics, metabolomics, structural imaging, and calcium imaging of the different types of health and abnormal organoids.

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Drugs are then applied to organoids in an abnormal state, to see if they convert the organoid to function in a more normal state.

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Session 14
Lifespan, Healthspan & the Future of Humanity

“Is there an upstream basis that drives the hallmarks of aging? From epigenetics to sensolytics and CRISPR, what are the promises, perils and ethical challenges in altering or optimizing our biology.”

14.1.  Extending longevity

Jamie Metzl JD PhD, Senior Fellow ,The Atlantic Council. Author of Hacking Darwin. Author of Hacking Darwin: Genetic Engineering & the Future of Humanity    @JamieMetzl

[For a while now, it has been clear to me that the end result of the transhumanist movement is a world where all children are grown through genetic engineering. (Or at least those who can pay). When I have presented this idea to everyday people, many have though it was an outlandish proposal of the future.

Today’s presentation is important because Jamie Metzi’s (who advocates many positions congruent with transhumanist ideology) quite publicly re-admitted, that he foresees an age that will have “The end of procreative sex”.  [i.e. children are exclusively conceived through eugenic genetic selection].

My personal opinion, is that is highly problematic for a number of reasons.

A superficial overview of this topic is the dystopian future movie Gattaca. Wikipedia summarizes the film as: “The film presents a biopunk vision of a future society driven by eugenics where potential children are conceived through genetic selection to ensure they possess the best hereditary traits of their parents”

The rate of development of new technologies in many fields (such as genetic engineering) is quickly outpacing society’s ability to have a discussion about the implications, application, ethics, and unanticipated consequences of such tools.

I am glad to see that Jamie Matzi is encouraging this discussion, but remain concerned that not enough voices will join in to provide an authentic counter-voice to the transhumanist movement.]

14.2. Biology of Aging

David Sincalir PhD. Co-Director of the Paul F. Glenn Center for the Biology of Aging at Harvard Medical School     @davidasinclair

If you take away none “aging causes of death”, we are living longer. Though the curve is slowing down.

If we cured cancer today, we’d only get another 6-8 years of lifespan, because a different organ and disease would kill us.

But other animals are able to live a very long time. Such as the Bowhead whale, can live 200 years.

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Research into correlation with daily fluctuations in blood glucose, BMI, and age.

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It is possible to understand a cell’s “Biological Age”. This may be prematurely old, or remain young based on a number of factors.

The company, InsideTracker, claims to be able to calculate your ‘biological age’.

There is emerging evidence that it may be possible to reset cells biological age back to ‘zero’.

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This has wide potential. For instance, this experiment resets the cells of a mouse eye to re-enable sight.

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Now Hear This: Music, Health & Medicine

Frank Fitzpatrick, CEO EarthTones

Some facts about music

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New, over-the-counter hearing aid regulations coming in 2020. This will be big.

Session 15
Hippocratic Oath 2.0

“How will the roles, responsibilities and obligations of both industry and healthcare professionals evolve in our exponential age? Do we need a new Hippocratic Oath. Does Industry need one as well?”

Jordan Shlain MD. Private Medical   @DrShlain

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Patients and consumers are different…

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If your body is an asset, and you wan to live another 20 years, do you have a strategy and a plan to get there?

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Hippocratic Oath 2.0 - focused at a broader oath (more than just doctors), could take….

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Session 16
And In The End...

Michael Hebb, Founder of Death Over Dinner

80% of us want to die at home

But only 20% of us do

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Other

Daniel working on website digital.health - to catalog digital health innovations

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Interview with Paul Stamets - Fungi Guy

https://en.wikipedia.org/wiki/Paul_Stamets

Let me know if anything looks incorrect. I’ve tried to summarize the presentations accurately, but haven’t had chance to externally verify what presenters claimed to be true.

Exponential Medicine 2019 Summaries

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