drug shortness of breath

>>roni zeiger: hello everyone. thanks forbeing here. itã­s a pleasure to be back at google. my name is roni zeiger. i was herefor about six years until just a couple weeks ago. and, uh, itã­s especially sweet to getto present, uh, to introduce a friend, eric topol, who, um, is actually a little bit ofa hero to me. i wonã­t get to weepy donã­t worry.[laughter] >>roni zeiger: but heã­s um, heã­s a professorof translational genomics at the scripps institute, south of here, also director of that institute.heã­s also the co-founder, um, of the west wireless institute down in san diego. heã­salso a cardiologist. and, if youã­re starting to get a sense that this guy is, um, sortof a rocket scientist and a brain surgeon,

heã­s almost all of those things. um, he,uh, heã­s been central in developing a lot of medications, um, and other technologiesthat many of us in the field of medicine take for granted and use every day. and, perhapsmost importantly, if someone asks for a doctor on an airplane, eric will not only volunteer,but heã­ll bring his iphone, put it on their chest and get a cardiogram. so, so this isa guy that you really want to travel with. [laughter]>>roni zeiger: so, letã­s go on a, on a journey with him now.[applause] >>eric topol: great! thanks, thanks a lot.okay. itã­s great to be here with you. great to be at google, iã­ve never been here before.and, uh, well it should be fun. i know maybe

because so many people are young here, theyã­renot so into their health or the health world. but, those of you that are here, i hope willhave an interesting, uh, informative experience. iã­ll certainly enjoy it. so first, i putthis quote up because i thought that would set the tone for what weã­re gonna talk aboutduring this hour. and this is a voltaire 250 years ago, and iã­m afraid itã­s not muchdifferent today. and, uh, the whole notion that doctors are doing things with good intentionsbut they donã­t have the information. and, thatã­s going to change very quickly. so,thereã­s a very noted, uh, very famous austrian economist whose name was joseph schumpeterand he, uh , was responsible for the idea that great innovation in an economy with entrepreneurshipcould change an economy and that graph of

old economy going to new economy shown here.and this term of creative destruction is really credited for having pushed forward, and thatã­swhat i think applies to the opportunities in medicine and health care and thatã­s reallyan exciting thing that we can do. so, since schumpeter is one of my heroes, i was reallysurprised when i was reading the economist, my favorite weekly read, reading the schumpetercolumn, this is just a week ago. and iã­m looking at this column saying, ã¬oh, now forsome good news.ã® i have no idea what it was gonna be about. then i found out it was abook review. this book, uh, and it was very positive about a godsend for those that sufferfrom armageddon fatigue. so hopefully you will find this to be a very upbeat experienceas the viewer did there. and, of course, the

economist is interesting 'cause they donã­t,theyã­re unsigned. so i donã­t even know who schumpeter is on the economist. but, um, whatwere gonna talk about is, how digitizing human beings, which is what generates this remarkableinformation, is going to reboot the future of medicine. and, before i get into that topic,'cause thatã­s really how we can do this, i wanted to get a sense of how many of youare on twitter here. everybody? not everybody, but the majority. see, most times when i talk,the people who are really worried about their health, happen to be at least 50, 60, 70,and they donã­t even know twitter exists, for the most part. this is a different group,and itã­s fun to talk to folks who are more plugged in. i get most of my valuable informationfrom twitter. iã­ll show you a couple of slides

that i made this morning, through twitter.so thatã­s, kinda for me, a, a, great reservoir, if everybody shares their, their informationthat they get to, with everyone else interested in a particular space, itã­s great. so, iwanna convince you of three things. the first one hopefully will be the easiest, becauseweã­re here at a, a, major force thatã­s done this. our world has been schumpetered. thesecond is that medicine is going to go there, and itã­s just started now. the third is thatwe need consumers to drive this whole thing forward, because otherwise, uh, at least someof us will not be around to see it. and, i certainly want to see this thing take hold,and improve the whole way we render, uh, prevention and healthcare in the future. so, i wannastart off on the digital side of thisã– and

thatã­s your kind of comfort zone i knowã–onzero-one and just to point out, and i think youã­re very well aware of this, in the lastdecade there was just a remarkable jump forward, the likes of which weã­ve never seen. and,of course, in the, uh, in context for example, there are now more cell phones on the planetthan there are toilets or toothbrushes. thatã­s a pretty big, uh, thing that who would everhad th--, when marty cooper invented the cell phone in 1973, who would ever of thought thatwould actually happen, and so quickly, particularly in the last decade. and then these deviceshave been remarkably transformative. and, the span of time from the ipod in 01ã­, allthe way through, uh, the blackberry then was renamed crack berry, now more recently slackberry. then thereã­s iphones, prototype phone.

and, of course, i guess here i should haveput a droid phone up there, but, sorry about that. then thereã­s the ebooks and, uh, thetablets. and this is nine years. and these devices and iã­m looking around thinking,ã¬well how come youã­re not looking at your device right now, because youã­re basicallysurgically attached to them?ã® and youã­re giving me the great privilege of a few minutesof attention, before you delve right into your mobile devices. so theyã­ve been veryremarkably transformative. and, in fact, everything that we do, well beyond how we communicate,uh, how we think and behave has been very much influenced by these wireless devices.in fact, when you think about that, if life could have changed so quickly in this spanof nine years, how come it couldnã­t do that

in the medical sphere? and that really gotme thinking. so, in fact, this current issue of the economist, um, uh, is this article,this schumpeter column, ã¬slave to the smartphone.ã® i donã­t know if you think youã­re a slave,i certainly feel iã­m an eslave to the smartphone or tablet. because thereã­s so much informationcoming in and you certainly want to try to communicate with your, with your network.so, whatã­s going on now is that itã­s not; it isnã­t even just one screen that we areattached to; itã­s now become multiple screens. and, now itã­s a tablet, itã­s a pc, a computer,itã­s a smartphone. and now we have a new species of man, a homo distractus. as demonstratedhere, a homo distractus has a new add on feature, cause later this year i understand thereã­sgonna be these google glasses. and i havenã­t

seen exactly what they are and this is onespeculate of design of them, but if you really have augmented reality, uh, as well as beingable to potentially read things, uh, from the web or your e-mail from your glasses,thatã­s gonna be yet another screen to, uh, to add to the homo distractus. it starts ata very young age, uh, this whole process. so, youã­re not so far removed from that.[laughs] >>eric topol: and, i uh thought that was prettyyoung, when i looked at that, and then i didnã­tã­ realize itã­s actually starting at an evenyounger age as shown here. and so, this is a, i think, a phenomena thatã­s very, veryinteresting. and i know that so many of you are digital neighbors here, the vast majority,so you can appreciate that for those of us

whoã­ve had to learn this whole world in themid-stream of our lives, has been much more challenging. so thereã­s some questions iã­mgoing to ask you, and theyã­re obvious, but iã­ll ask them anyway. uh, but, i wanted togive you a sense of time compression. so what was zero in 2004, and then was 800 millionin 2010, was? >>eric topol: i know you know the answer tothis. >>male #1: i think it was the number of users. >>eric topol: yeah. there you go. ok, i likethat answer. so, that of course, represents a competitor. but, youã­re well aware thatthatã­s gonna be about a billion, unless thereã­s an awful lot of defriending that occurs betweennow and then. to go to google plus, or i donã­t

know what. uh, or just abandon social networking,which i think is most unlikely. of course, the evaluation of this company is predicatedon the like button and this is a beginning of a social network dedicated company of digitizingpeople. weã­ve been doing that for a long time, at google, much longer. what year wasgoogle founded? >>eric topol: ninetyã–ninety eight? anybodyknow here? ã«98. ok, so youã­ve been in this world of digitizing people, in some respect,for a long time. and of course, the worst thing that could happen is you wake up andyou donã­t have any friends. thatã­d probably be good if you were trying to, uh, promoteyour social network. but these companies, your company, facebook, amazon, apple, havedone an extraordinary job of digitizing people

at a very superficial level, not medical,of course. weã­ll get into some exceptions of that. but, what it shows is that you cancollect some data. and this, of course, can be very important for, uh, individuals likesand affinities and important for, uh, consumer engagement and purchasing and that sort ofthing. but, the way to this goes is medical, and thatã­s where this can go over time. soi thought you might have seen this article, perhaps, in the atlantic, uh, just a coupleweeks ago. about, uh, iã­m being followed, how google and 104 other companies are trackingme on the web. have you seen, or read that article? yeah? no? you donã­t, anyways itã­sa very interesting article. it talks about how no matter what youã­re going to get digitized,essentially. not using those terms. and then

this other feature article in the new yorktimes magazine, was about, uh, the idea that the retail, itã­s not just google and 104other companies that are, that are set up to do this, but in fact thereã­s target andall the retail companies that are doing this. and so they know, for example, a woman ispregnant before her family even knows that sheã­s pregnant because of the data that canbe, uh, acquired. so i thought you might enjoy this if you hadnã­t already seen it. thisis how to protect yourself from getting digitized by google. um, have you all seen this already?i saw this and i broke out in hysterical laughter. because something i said, ã¬oh my gosh, playthe music loud so they canã­t hear what youã­re typing, unplug computer from power source,medical gloves to obscure fingerprints and

finger scans on keys.ã® you know, but obviouslythis isnã­t just applying to google, this is applying to the fact that you may be gettingdigitized to some extent. and you donã­t really have a way, all these things are not gonnawork, of course. so, thatã­s the way life is today. then thereã­s this social network.this is uh, of course, zero in 2006, zero. now two years later after the beginning offacebook, and now well over 300 million per day. and you know what that is? thatã­s thenumber of? >>audience member: [inaudible] >>eric topol: somebody said it. yeah. so,that is of course part. now the big three, perhaps in the us, um, but thereã­s all theseother social networks around the world and

are, of course, many of them are country,continent specific. you know, thereã­s brazil with orkut, then thereã­s qq in china, andthat sort of thing. well this together, has created a force that no one couldã­ve predicted.and, you know, i think when eric schmidt said, we missed the friend thing, we all missedthe friend thing, it wasnã­t just at google. but now this friend thing with sharing pictures,and emotions, and thoughts, and videos, has had, of course, monstrous, uh, phenomenalimpact. and thatã­s why revolutions have occurred, the arab spring, the occupy wall street movementand so many other things are power to the people by crowd cheering, crowd activating,and crowd sourcing, really a remarkable time in our history and in our civilization becauseof this electronic bounty of people. so, this

is an example of a rudimentary social networkthat has had a medical impact. and this is, uh, as far as we know, the first person onfacebook, whoã­s punitively, his life was saved, a young boy who was very sick and,uh, he couldnã­t get a diagnosis. he went to two pediatricians and then, uh, his motherposted his picture on facebook, and one of her facebook friends made the diagnosis ofkawasakiã­s disease. and thatã­s what led to, uh, the right treatment and of courseheã­s doing very well. and now, there are, uh, an explosion of these online health communities.and this is a good thing, but itã­s also been an awakening because now so many people witha chronic condition, whether it be diabetes or, or a type of cancer or things like multiplesclerosis, they go on these patientã­s like

me and other communities, uh, together, theyfind people with the same condition, and now these virtual peers become the people whothey trust the most. theyã­ve never met them, but they trust them much more than their doctors.which is really a uh, in many ways, a seismic shake up of the relationship between doctorsand patients. and so much so, that this to me is shocking, this is nearly 4,000 doctorswho were polled, as to, ã¬do you know that thereã­s these things, like patients likeme?ã® and only 11% and this is recent just a few months ago.[laughs] >>eric topol: only 11% even knew they existed.but if they talked to their patients, they would find that thatã­s who their patientsare spending their time with and getting guidance.

so that shows you the chasm that exists todaybetween the medical profession and what the needs are and the access, the capabilities,of empowered consumers who want to get this information. now, i know youã­re gonna getthis one right. right? this is the one group that could get this one right. what does thisrepresent? >>eric topol: nobody knows? really? okay,itã­s at the san diego zoo, does that help you? >>eric topol: no? okay, iã­m really surprised.this is historically very significant. this is the first youtube ever video. ok when wasthat? april 2005. well over 6 million hits. now, why is this important? itã­s a stupidvideo, it just says, ã¬here i am at the san

diego zoo!ã® alright? but, the point is thatthis is just not even seven years ago and look at the data for youtube. okay? this isan amazing thing. 800 million unique users per month, 3 billion views per day, 3 trillionhours of video per month. i mean this is staggering, 60 hours of video are uploaded every minute.what are we doing sitting here? we should be watching a video or uploading or both.so this is an amazing amount of data in this video and graphic world that we live in. andso much so, that we are generating data at a clip which no one could ever have forecasted.that is from the beginning of civilization to 2003, there were only a billion gigabytes,which is kind of amazing because we walk around with lots of gigabytes in our pocket. andnow we are generating a trillion gigabytes,

a zettabyte, at least one, every year thatplot of course, is markedly increasing. and thatã­s why it looks like weã­ll have wellover 35 zettabytes by the end of just this decade. so that creates a big problem withdata, especially when you wanna extract out of that data, the useful information thathas heretofore often been only scratching the surface. and this big data term, is terriblyunderplaying the ginormity of this data issue. but, just like moneyball, um, we can havethis in medicine; we can learn a lot more about a particular pitcher or batter by doinga lot more work on that data. and weã­d like to learn a lot more about each individual.prevent them from becoming a patient, by doing this sort of thing. how are we going to dothat in this world of just, ginormous data

flooding? well, the super computer of watsonhas been, uh, and other super computers, has been suggested to be able to save a life.and, of course the reason for that is that because a super computer, watson, can processtwo million pages of content in 3 seconds. now, there are a lot of really good doctorsout there, but i donã­t think they can get to two million pages of content in 3 seconds.and if you have a really complex patient, that you donã­t know whatã­s going on, likewhat happened with wellpoint, one of the largest insurers, they decided to contract watson,because then they could feed all the, get all the information about a new individualpatient to help sort out in a complex diagnosis. thatã­s a good thing. why donã­t all doctors,and all patients, have access to a super computer

in times of need. thatã­s where things willgo, eventually. then thereã­s the cloud, of course. the cloud story, which is amazing,itã­s important that this of course emerged these massive server farms because otherwisewe wouldnã­t be able to store, or even, um, handle, manipulate some of this data. so whatã­sgreat about the cloud is now itã­s even making its way to places like united health. andrecently they have, uh, just last month, uh, declared theyã­re gonna make their cloud data,which is their largest private insurer of health in the united states, available toall their doctors and soon to all their patients who are covered by united health. thatã­sa step in the right direction. but this cloud thing is so overcooked, that i thought thesecartoons might help put it in perspective.

this one is the check is in the cloud, andthe other one, it was much nicer before people started storing all their personal informationin the cloud. ok, so now we have this kind of rapid fire, it started in the 70ã­s, itwasnã­t so rapid then, the cell phone i mentioned, the personal computer, the internet. and thenthings really started taking off. and you see this, uh, clustering. in a short periodof time of wireless digital devices, sequencing social networks, cloud and super- computing,all setting up the potential for this, uh, era of a great inflection in medicine. andthatã­s where iã­m gonna be, of course, trying to convince you, that weã­re on the cusp ofthat right now. of really, uh, actualizing that opportunity. so, book stores and books,thereã­s a really interesting story there.

how many of you only read books as an e-book? >>eric topol: no. one? two? i guess, three.alright. and how many will read only hard copy books? >>eric topol: ok, four. ok, so should i assumethat the rest donã­t read any books or read a combination of the two? help me on that. >>audience: combination.[laughs] >>eric topol: combinaã³okay. okay. anyway,thatã­s alright, if you donã­t read any books, you have a lot of other things to do i understand.um, so, the reason i show this, of course, that thereã­s a prediction that hard copybooks are gonna be no longer with us. and,

of course, weã­ve seen the likes of thingslike borders book store chain of book stores closing. well, today is a big day. today isthe day on the front page of the new york times, the encyclopedia britannica, after244 years, thatã­s the same time when voltaire were saying that we didnã­t know anythingabout medicine. 244 years later, the encyclopedia britannica, is mea culpa, weã­re not goingto print this thing anymore, ever again. thatã­s pretty striking. thatã­s today. and, to me,the final thing about this book, iã­m using the book thing as to, uh, emblematic of theworld changing. i could go into all sorts of other things, but this is the one, i think,that really hits home for me. i did some of my training, my cardiology training, at johnã­shopkins. and johnã­s hopkins has this library

that i lived at a lot, called the welch medicallibrary. and this library was closed on january 1st, the second largest medical library inthis country, no longer functional. does that tell you a story about where we are in a changingworld? in a world thatã­s been schumpetered. so i hope iã­ve convinced you of that factin this opening segment. and if i havenã­t, then this probably would be a good time tomove on because itã­s the best i can do, in this time span.[laughs] >>eric topol: okay. now weã­re gonna talkabout medicine and how it will, inevitably, be schumpetered. because up until now, thedigital macrocosm ginormous infrastructure, thatã­s been developed, which iã­ve very brieflyreviewed with you, that youã­re very much,

uh, in touch with. then thereã­s this medicalmicrocosm cocoon thatã­s done everything possible to not let there be any conversions, or anypenetration of the digital world. the only foray into that has been this very weak lackof, uh, real legs, use of electronic health records, and, of course, accounting for thedifficulties that you experience with google health records, and that sort of thing, becauseitã­s so resistant to the digital world. well, thatã­s gonna change. and this is all gonnacome together. there will be a conversion itã­s just a matter of when. and when thathappens, thereã­s a big, big thing, that weã­ve never had before, and thatã­s the abilityto digitize man, digitize human beings. not to find out what theyã­ve purchased now, orwhat they will purchase. but rather, what

makes them tick. and thatã­s really an excitingthing. that takes us away from where we are in medicine today, which is at the populationlevel. everything we do is population based. so, for example, when we say all women afterage 40 should have a mammogram every year, thatã­s treating all people the same. whenin fact, many woman, a significant portion, have zero risk of ever developing breast cancer.another example, we give a medicine for a particular condition, letã­s say diabetes,we use metformin. thereã­s 400 million diabetics on the planet, they get the same drug, thesame dose, even though 25% of them are unable to respond to that drug. but thatã­s how medicineis practiced today. we do large clinical trials of thousands of patients, we find a few perhundred benefit, and then everyone gets the

drug. thatã­s wrong, totally dead wrong. andnow, for the first time, we have the tools to understand things at the individual level.and thatã­s extraordinary. and thatã­s what weã­re gonna get into. so, uh, thomas goetz,the editor of wired magazine, wrote this really brilliant feature article in that magazineabout the feedback loop, and the whole point here is, itã­s a feedback loop of data wherethereã­s genomic data or physiologic metric data, iã­ll show you a couple of examples.and that changes things. thatã­s like a real reset of how we understand any given individual. >>eric topol: so, this started in the healthcareworld. uh, fitness world i should say. whereby, uh, nike shoes, i donã­t know how many ofyou have these nike plus shoes that have sensors

in the sole of the foot and they can trackthe distance and the velocity and other metrics of exercise. and then these wireless accelerometers,have any of you tried things like the fit big bodymedia? you have? okay, great. so thoseare, i recommend them to my patients because they encourage you to be more active. and,uh, um, i think that, thatã­s a great thing. theyã­re relatively inexpensive. the mostrecent one, was just um, uh, announced a little over a week ago, the nike fuelband. and sothey encourage people to be more active, thatã­s good. and then thereã­s the use of sensorsfor detecting your quality of sleep, because we live in this wired world of wireless devices.[laughs] >>eric topol: and we donã­t get enough sleep.in fact, the overall sleep of the population

has been declining in a very, uh, worrisomepattern. so thereã­s a device that iã­ve used, there are many devices that monitor sleepthis is the only one that monitors brain waves. and this is a new device, have any of youever used it here? >>eric topol: so we got the same 3 peoplethat have used all these sensors, okay. [laughter]>>eric topol: thatã­s alright. someday your, your experience will wear off on the othershere. anyway, this is a great, uh, home electroencephalogram. who would have ever thought you could haveyour brain waves at home, for $99, going directly to your phone, pretty neat. and, uh, thereã­salso a clock version, which is what they came out with originally, and it shows right onthe clock every minute of sleep. this is a

night of my sleep. you see the orange barsare the awake time, the grey bars are light sleep which isnã­t worth much, the light greenbars are the dream rapid eye movement sleep which is a good thing. and then the best ofall is deep restorative sleep, the dark green .so iã­m using this and, uh, iã­m trying toget to be a better sleeper and very shortly after i started using this, my wife who isa night owl, comes in the room and she looks at the clock and she says, ã¬eric, i knowyouã­re awake, and i wanna talk.ã® [laughter]>>eric topol: ok. and thatã­s good that people at this age can appreciate that, because thatã­s,of course, one of those kinds of things that, uh, you would particularly appreciate gettingolder.

[laughs]>>eric topol: anyway, whatã­s interesting is, uh, you also know, of course when anybodyã­s,their brain is awake. and besides, this was discovered by three, brown university collegestudents. they didnã­t wanna do this. what they wanted to do was not to have to be wokenup out of a deep sleep. so they invented this sensor, just so they wouldnã­t have to wakeup, they wanted only to be woken up when they were in a light sleep. and thatã­s what ledto this interesting device. well, of course, when the wall street journal reviewed thisbook, the creative destruction book, but what was really interesting they picked this asthe call out for the article which was kind of i didnã­t think that was the most significantstatement in the book. but it was kind of

interesting that they did that. now, whatwas also, uh, interesting is that itã­s representative of where medicine is going, because now youhave data for your sleep, compared to ten thousand people of your age group, your peergroup, because as you likely know, as we get older, our sleep deteriorates, and so youwant to have a group that you compare with. and just think about glucose, thatã­s bloodpressure or any metric thatã­s relevant in medicine so you can compare. and now whatã­sreally interesting is that this has become a big fad in, among athletes. and so knowingyour dq score of your sleep, now thereã­s triathletes that are using this, thereã­sthree nba teams that are currently using zeo every night to maximize their athletic performance.and so this is now a very safe way, as opposed

to other historic ways, that athletes wouldtry to improve their performance. well whatã­s also interesting is that now among pro athletesthereã­s a compilation of all the data of pro athletes. and this is a, uh, bar graphthat, uh, summarizes it. the king of sleep among all the pro athletes is lebron jamesaveraging 12 hours of sleep a night. and whatã­s interesting is, no wonder theyã­ve never wonthe playoffs. [laughter]>>eric topol: and then, the other interesting facet of this is the person with the veryleast sleep is tiger woods. and iã­m not gonna comment further on that.[laughter] >>eric topol: now, there are, um, very, uh,kind of early staged devices now that you

can get your blood pressure that are fun.it doesnã­t quite gamify things, but it does make it a lot more fun. so now my patients,instead of recommending the traditional blood pressure cuff, called an omron device, thatgo to cosco, i now send them to ihealth or withings to order it online, again, $99. thesethings are fun, you just press the button, gets the blood pressure, it charts it, itsends it to your doctor or your facebook friends or your google plus circles, whatever. andthen you have it all stored. and then you, uh, have it all stored. and the same thingfor glucose, thatã­s a good thing. thatã­s not where we want it to be, we want it tobe seamless, but thatã­s at least a step in the right direction. well, this is also thecase for diabetes. for, uh, type1, also called

insulin- dependent juvenile diabetes, we canmeasure glucose every 5 minutes. but currently, thereã­s separate receiver, itã­s bulky. ifyouã­re a diabetic, you donã­t want to have this big device to be pulling out all thetime because then people would say, ã¬whatã­s the matter with you?ã® you gotta tell them,ã¬well, i have diabetes iã­m looking at my glucose.ã® what i have is a prototype thatiã­m wearing a sensor just like pictured on this, on this slide. uh, you can wear it onyour abdomen, or your arm or wherever. and i can just turn on my phone and, uh, i cansee it when i turn it on 137 and i can just say my glucose at this very moment in timeis 10. and thatã­s good since we just ate lunch at your cafeteria with the unlimitedbuffet. iã­m glad itã­s not a lot higher than

that. but whatã­s also nice is i can just,um, get the data for the trend for, you know, hereã­s the three hour trend for glucose,six hours, twelve hours, 24, whatever i want. and i can send it, if iã­m concerned, to whoeveri wanted to send it to. thatã­s the beginning of an exciting time for example, lifestyleimprovement, if youã­re looking at something, should you eat it or not, and youã­re lookingat your phone and itã­s gonna tell you what your glucose is gonna do when you eat thisbig cookie. well, you might not eat the cookie because you donã­t want to stress out yourpancreas. particularly if you know that youã­re pre-diabetic, or youã­re genomicaly vulnerableto get diabetes. now, roni mentioned this in the intro is that this is a device, that,uh, i can get, uh, i gotta pull up my iphone.

but this is the device where i can get a cardiogram,right on the device. and so, itã­s, you see these two sensors on the back; you make acircuit with your heart like that. and so, um, you know, this pops into the case. i canthen just turn this thing on and get a cardiogram, just gotta um, um, put in, uh, my passwordand the app. get that ready and then iã­ll just show you, that hereã­s my, put my fingerson the back and then weã­ll pop up my cardiogram. now, itã­s really a cool device, because,you say, ã¬my gosh, why wasnã­t this invented tens of years ago?ã® and whatã­s also prettycool is that i have this credit card version, where you can put it in your wallet or youcan put it in your purse has the same two sensors. and then you can hear the chest leads,i donã­t know if youã­ve ever had a cardiogram

but you can get the different leads, likethis. and thatã­s what you heard about being on a plane, it actually happened, where someonein the last row was having chest pain, they called for a doctor on the plane; there werethree other doctors who were surgeons that donã­t really know how to evaluate chest pain.and i donã­t know if iã­d know how to evaluate it fully unless i had a cardiogram. and, uh,this is, you know, at 30,000 feet. you donã­t have a cardiogram to do.[laughs] >>eric topol: but, now i have it and i cansay this person was having a bona fide large heart attack. and that led to an emergencylanding of the plane. and also, when we landed, and the, the passenger was whisked off toget the artery, the heart attack artery opened

up. then the pilots and the flight attendantsall wanted to have their cardiogram done. [laughter]>>eric topol: which was really interesting. okay. so, those are just a couple of devicesto show you, to give you a sense of how this field is moving fast. and, you know, theyã­reactually getting old now, there are a lot of other devices i couldnã­t bring with metoday to give you a sense. this one is really interesting, the holter monitor. you probablydonã­t know what that is, but this was invented in 1949 with a frozen design. and you haveto wear all these wires to find out your heart rhythm over the course of 24 hours. you haveto go in and get it connected, then you have to go to a clinic, then you have to go backto get it disconnected. you canã­t shower,

you canã­t exercise. now you have band aid,you send it in the mail, you send it back. itã­s a netflix model of heart rhythm monitoring.okay and itã­s great. but, you know, itã­s only happened in recent months that this wasavailable. and then, just to, uh, give you a little bit of more sense about what youcan monitor on a phone this is all the vital signs. not just blood pressure, but also youroxygen in your blood, concentration, your blood pressure, heart rhythm, temperature.and, you know, this is an amazing ability to basically have all vital signs on yourphone continuously. so your phone in the future will look like this. this is technically feasibletoday. and it will get your constant read out of all your vital signs. as if you werein an intensive care unit. now you may not

want to look at that data or have that, butit certainly will be interesting to see how that plays out and how it can help preventpeople from having to be in the hospital. in fact, i think there wonã­t be hospitalsin the future, except for intensive care units. why would there be a hospital when you cando all this stuff at a patientã­s home? and itã­s much less expensive, much more comfortable.so why, eventually, are we gonna need hospitals except for very limited reasons. now, justsome other apps to mention that are useful. if youã­re, um, for someone who has a skinlesion that youã­re worried about, you donã­t have to go to the dermatologist anymore. youjust get a picture done, text within minutes saying not to worry, or you should indeedget this looked into. and then, this one is

amazing, if youã­re an optometrist, you betterwatch out because now thereã­s a $2 add on to the phone, it was invented at mit, thatgets refraction of your eyes and then sends that data to your, uh, to get your glassesmade, for $2, pretty remarkable. and then you can pass it around for all your friends,and your social network. and itã­s not, of course, being used that much in the us butits sure getting likes around the world. and this, just speaking of eyes, thereã­s waysto monitor the pressure in the eye, to prevent glaucoma. this is available in europe, constantmonitoring going to your phone. and then thereã­s these things like a wheeze-o-meter that analyzesyour breathing to prevent an asthma attack. and then this morning, i, i encountered thatthere is another, uh, interesting facet to

asthma. this was reported that thereã­s thissmart inhaler, most people, when they use an inhaler they use it wrong. and now thereã­sa video game to make you use it right. and thatã­s really part of this gamification ofmedical devices. itã­s all part of this new era of medicine. thereã­s also the abilityto digitize breath, to say whether or not someone might have lung cancer, at a prettyhigh specificity and accuracy. so, youã­re competitor, apple, has certainly been seen,like google, as a big innovator. and so, in fact, at the time of steve jobsã­ death, itwas thought well may the logo should be changed, and of course, like you, this company hashad a big worldwide impact. and i thought you particularly might enjoy this one if youhavenã­t seen it. this is the cover of the

new yorker.[laughter] >>eric topol: and then another company cartoon. >>eric topol: well, in this biography, whichi donã­t know if any of you have read here. some of you may have read, i think itã­s avery good book. but iã­m particularly, because it traces a digital revolution over the courseof really three decades. took a while for it to be where it is today, but itã­s now,of course, going in exponential fashion. and then what was striking to me is this quote,because it was occurring near the end of the book. and it said, from steve jobs, ã¬i thinkthe biggest innovations of the 21st century will be the intersection of biology and technology.ã®thatã­s where you sit today in a digital frontier,

and this is the big uncharted opportunity,and i certainly couldnã­t agree more that this is the real story going forward. so nowwe just touch on the one aspect that is really biology. we were talking about physiology,but letã­s get into a little bit of biology and that is genome sequencing. >>eric topol: up until now, in the recentyears, weã­ve been relying on these next generation sequencers that cost 㦠of a million dollars.and then a whole lot more expense for the re agents that are proprietary to run thesequence. the six billion letters that comprise a human genome that has to be sequenced 40times, at least, to be accurate. well, in january, this device, the ion and proton,was released and it said that it could sequence

the human genome in two hours, prior to thisand still today it takes us about ten days. dropping down from ten days to two hours?thatã­s pretty good. well then this device last month was released. this is a usb sizedevice. this is now to get a sequence of a human genome in 15 minutes, for less than$1000. in fact, itã­s quoted as $900. this is, uh, exceeded mooreã­s law at a level thatis unprecedented, uh, you know, in our history. and so whatã­s exciting about this is howyou can apply it. and youã­ve been hearing about the human genome since 2000, if youã­vebeen at least looking into this impact on the future of our world. but, you know, thisis a sequence you can get right to your laptop. then you can take a boy like this, whose lifewas saved by sequencing. nicholas volker.

at this point he was nearly going to die.he had 100 operations. i donã­t know any human being thatã­s had 100 operations, no lessa 5-year-old. and he was very sick in the hospital intensive care, in a hyperbaric chamber.his pediatrician said, ã¬letã­s sequence him and see what is potentially this disease weã­venever seen in a human being before.ã® and that led to a finding the mutation that wasthe root cause, and that let to successful treatment. and now nicholas volker is healthyas could be, cured 6-year-old. and thatã­s a great story because it tells you the powerof sequencing. telling you, digitizing a human being who is so sick that no one knows whatit is, and be able to turn that around into having, hopefully, with this young boy, anormal life. this is a family from san diego,

the beery family. uh, and so, these twins,alexis and noah, were very sick. they had a movement disorder, they couldnã­t reallyfunction. in fact, alexis was in the emergency room, she couldnã­t even breath many times,she had a respiratory arrest. and so they got sequenced. they determined the cause.they determined the right therapy. and now noah is a soccer star and his sister is atrack star, just by sequencing. this is a protocol that we have at scripps, called idiom.idiom, it stands for idiopathic diseases of man. thatã­s a terrible term, idiopathic.itã­s a fancy medical term for we donã­t know, idiopathic. why donã­t we just say, ã¬we donã­tknow?ã® [laughter]>>eric topol: anyway, this is a 15-year-old

girl, who is wheelchair bound, whoã­s brilliant.blogs and is cheerful. but, she has an unknown condition, and weã­re sequencing her alongwith other individuals right now, trying to digitize their biology so we can get the rootcause and hopefully it will prove to be actionable. so we wanna get rid of this term idiopathic,itã­s a bad term anyway, but itã­s also one that we can get rid of because we can sequencepeople and understand what is really going on. then thereã­s of course the cancer warthat was declared decades ago. but now, itã­s the real deal. we can actually do somethingin cancer. this is an example of a tumor called malignant melanoma metastatic. skin cancerall over the body and this is a pet scan that shows the extent of the burden of cancer,and then two weeks later, after an oral pill

directed to the mutation, that was causingthis cancer, a braf gene which is present in about 2/3 of people with this type of cancer,there was no evidence of any cancer. and this occurs in 85% of people, who have this typeof mutation, in this particular cancer. so itã­s a great step forward and it shows youthe power of knowing what is the root cause of a cancer. and then having a therapy directedtowards it. hereã­s another example of a different drug that just got approved. but this is anotherbasal cell carcinoma or brain cancer. medulla blastoma, two weeks later specific againstthis hedgehog gene pathway and then you have no evidence of cancer in over 85% of peoplejust to prove. the problem we have in cancer today, is to do this, we like to have, uh,the tissue to be able to sequence. in fact,

get a whole genome sequence. but today, thetumor specimen from a biopsy or a surgery is deposited into formaldehyde and itã­s ruined.so weã­d like that on track to just being ff, which is flash frozen. so that needs somework. but this cancer improvement, in getting people to get the right therapy, is on theway. and then beyond the whole area of cancer there is many conditions like cystic fibrosis,weã­ve known the gene for many years, but finally have a breakthrough. this is a drugcalled kalydeco which is just approved, itã­s directed against a specific mutation thatcauses cystic fibrosis and only is accounting for, letã­s say, 3 or 4% of cystic fibrosis.but itã­s very potent and works exceptionally well. and then this young girl, who couldnã­tbreathe hardly at all, she now is, as you

see, uh, very mobile and living a normal life.and this drug, as i mentioned, not only did it just get approved, but it had eureka effect.in terms of normalizing things like so called sweat chloride and beyond that, even moreimportantly, that you could see the impact, the breathing, the placebo sugar pill versusthe drug. and here you just see a weight gain of kids, just dramatic, uh, eureka type effect,which is great to see in a small number of people. this is a pretty gory slide, but whatis showing is the drug reaction that can be lethal. the reactions called the stevens-johnson syndrome and it can be particularly induced by a drug tegretol, which is usedcommonly. but now we know the gene that predicts this and we can prevent someone from dyingor having to be so sick from this. because

one genotype, one basic analysis can solvethat problem. and then just last week, i had a op-ed in the new york times about statins.i donã­t know if youã­re familiar with statins, itã­s the most commonly used prescriptiondrug. but unfortunately, itã­s overdosing the country and the side effect of diabeteshas been underplayed. and this graph just shows that 1 in 255 people, in respect ofany statin thatã­s been looked at, get diabetes from these drugs, in the 91,000 patients inall these different trials. but whatã­s most particularly concerning are the potent becausethese are the statins that have the particular liability. and these are like crestor, lipitor,high doses of simvastatin and those are the ones to be on the look- out. but yet, we donã­tknow the genes, the variation of the genes

that are accounting for this problem. nowone other area, just to touch on, about digitizing people, and thatã­s imaging. now, the stethoscopewas invented in 1816, this is that cartoon of rene laennec and that stethoscope doesnã­tlook like that anymore, thank goodness. it looks like this. but we donã­t need a stethoscope,for example, to listen to the heart because we have a portable, high resolution ultrasound device that fits right in the pocket better than a stethoscope. and this device,and in just a minute, you can capture exactly what the heart looks like. and this is, uh,you know, an amazing tool because we can basically digitize the personã­s heart in a minute ortwo, and no longer are we listening to ã¬lub dubã® which isnã­t really that informativewhen you can see everything. this is a normal

heart, and hereã­s an example of a very sickheart, where you see much less ability of the heart muscle to contract, all the chambersof the heart are very dilated, thereã­s a lot less blood flow moving. just to give youa sense, these are images that are acquired in a minute and they can be not just of theheart, the abdomen, they can be of the fetus, for a pregnant woman. all sorts of thingsthat we can do, we couldnã­t do just a year or two ago. the thing that perhaps you mightfind the most interesting, perhaps scary, is the ability to read your mind. and theidea that we can read, see the movies in your brain. you say, ã¬well, that canã­t possiblybe.ã® and about imagining, this is not just mind boggling, this is mind blowing. thisis now the ability to construct brain activation

maps from functional magnetic residents imaginingof the brain. and we can digitize brains, and best exemplified by this uc berkley studypublished last fall, where they took people, young people like you, put them in a magneticresidence imagining, showed them a u2 video, and then they without any knowledge of thevideo they tried to construct what the individual was seeing in their brain. this is what itlooked like. you say, ã¬well, that doesnã­t really like steve martin.ã® or, ã¬it doesnã­tlook like that.ã® but you know what, thatã­s pretty good not knowing anything about thevideo. and this is, you know, vintage 2011. whatã­s that gonna look like in 2013 or 2015?and they just recently published the same sort of thing with auditory signals they canreconstruct the music or whatever the sound

was through the same type of technique. so,i just wanna, last couple minutes, put this together. this is the, uh, crack to try toget in your mind. this is why people die; they have a crack in their artery. whetheritã­s a crack in their artery of their heart or to their brain that causes a stroke. anda crack is something we havenã­t been able to diagnose. this is, has been elusive. wehavenã­t been able to digitize the people who are gonna have a crack. uh, tim russertwas in the nbc studio and he collapsed, had a massive heart attack. but two weeks beforethat he had a normal treadmill test, common scenario. now why did that happen and whyis it so common? because we do these treadmill tests all the time, but they only tell usif thereã­s a tight narrowing thatã­s blocking

the blood supply. most cracks occur wherethere isnã­t a tight narrowing, and we havenã­t had any way to diagnose that. well now, wehave done a study where, in the san diego area, weã­ve had all of the heart attack people,we got blood samples in the early minutes to find the cells that were sloughing offfrom their artery. we found them, identified them, sequenced them and have all kinds ofgenomics that weã­ve done and weã­ve shown that that is a unique signature that we candetect. and, in fact, weã­re publishing on that in just a couple weeks in a leading journal.so, this is important because then we can combine this and develop within embedded sensor.we have all these embedded sensors in our car, well, i think our bodies are more importantthan our car. and you probably take all that

stuff for granted because youã­ve never beensick. but, those of us that have been sick would like to have an embedded sensor to preventsignificant illness. and this is a chip that was just published on at stanford, not faraway of course. a microchip that you can put in the blood to detect whatever you want,we have also been working on a nanochip the size of a gran--, grain of sand just likethis. you take the grain of sand nano sensor and you put it in the blood, like in the wrist,and then you have this molecular signature of a heart attack, and guess what you have?you have the new app for heart attack. or, alternatively, an app for detecting the firstcancer cell in the blood, since most cancers have a vascular supply. and, of course, fordiabetes it takes five years to become a diabetic

that is, uh, immune-mediated diabetes youcould detect in that five year stretch to prevent diabetes, or prevent things like atransplant rejection. here is a cell phone, becoming center stage for the future of healthbecause of this embedded sensor capability. so, the last thing that i just want to mentionis consumers needing to drive this. thatã­s actually why i put this book together. becausethis is a real opportunity that would be left in a stasis mode unless we get moving. and,uh, to me itã­s just remarkable. this is in january in the wall street journal and itwas a survey report of physicians using e-mail. e-mailã­s been around a long time, even beforegoogle. [laughs]>>eric topol: and iã­ve been using e-mail

with patients since ninety, i donã­t know,ã«93,ã­94. i donã­t what, you know. this is amazing, we had had 62% of physicians refuseto use e-mail with their patients, today, itã­s 2012. this is an amazing article fromjama, the leading journal in medicine. it says, ã¬should patients have access to theirlaboratory tests?ã® well, sorry to say itã­s their laboratory tests, how can they ask thisquestion? how about this one? this is, ã¬should patients have access to their office notes,from the doctor?ã® how could you ask that question? just because it might say in thenote, that the patient, that, uh, had something about sob and it means shortness of breath,you know, eventually the person should figure that out, of course, maybe need a little bitof guidance. thereã­s this fellow, who is

in the bay area, hugo campos, who has a defibrillator,he just wants to get his data of his heart rhythm from the company and they wonã­t lethim have it. and, heã­s on a tear, appropriately, he should get his data. and then the worstof all is the american medical association. they are lobbying the government to preventpeople from getting there dna data. they only want doctors to be the ones to privy to thatdata to mediate giving that to patients. which, of course, thatã­s not, thatã­s i think, violatingthe rights of the individuals. so thatã­s the right to the emergence of citizen scientists.and thatã­s, i think, a great thing. and this just came out. i just saw this this morning.this is a group at mcgill in canada, and they have gamified, uh, the use of sequencing.itã­s very difficult to align sequences, and

they made it into a game, a video game, andthey have found that people with no scientific background could actually figure out how toalign sequences and make it into a fun puzzle, and thatã­s amazing. just to me, that youcould take these sequences and make it into a game to assemble genomes. and that kindof gives you a sense of where the world could go. so, i leave you with this last, uh, thought,which is that, itã­s your charts, office notes, your laboratory tests, your scan results,your bio sensor data, your dna, your tissue, your social network, thatã­s the way medicineshould be. and since all this data is gonna be now going into high gear, your abilityto access it, this is, uh, the time for the, the individual to rise. and thatã­s whatã­sgonna be necessary to really execute the future

of medicine. so, i just, the whole thing puttingit together, we have this old voltaire medicine today. and we can change that by really bringingtogether the new tools that iã­ve reviewed in digital medicine with the digital infrastructure.and that could lead to super conversions, the biggest in our history, and then of course,to this new participatory precise medicine of the future. so i hope i can leave herewith this concept that was the whole goal, that the future is indeed bright. thanks alot for your attention. [applause] >>male presenter: so what should ordinarypeople, um, like non, non, uh, medical people do? is it now up to us to somehow figure outthat we need to not sign the consent forms

before having our brain surgery until theychange it to say, ã¬we will not put your tumor in formaldehyde.ã® >>eric topol: yeah. i think that, well ifyou, if you today demand to your doctor that i want some of my specimen, i want my motherã­sspecimen to be put in freezer, they have to do that, so, but only if you know about it.so, thatã­s really part of the problem is it isnã­t even on the consent form, itã­sjust a matter of knowledge. and that is what we have a big problem, is people just notaware of the opportunity that exists today. >>male #1: are there, um, any sensors to dowith things coming into the body or what youã­re coming in contact with. so, i would think,something that monitored air quality, that

monitored, monitored what was in the foodyou ate, that monitored what chemicals that came in contact with your skin, and that wayyou could see correlations between what people came in contact with and the actual symptomsthey had or the diseases they had. >>eric topol: yes, great point. um, so forasthma, a sensor of the future that some people are working on, is one that will pick up airquality as well as these other things that you, put, um, youã­d be able to prevent anasthma attack, which, of course, can be lethal particularly in children. so thatã­s one example.but youã­re absolutely right, because, you know what we take in our food stuff effectsour micro biome. and so, for example, over lunch we were talking about, ã¬is it all abouta story of calories in calories out? absolutely

not because thereã­s a micro biome, you knowwe have this, um, millions of different, uh, bacterial flora organisms in our gut, whichare changed by our diet. and also by taking antibiotics for example, and that has an reactionof, in some people, uh, pushing them towards obesity or changing their metabolism, or makingthem at risk for diabetes or other named diseases. so youã­re absolutely right, we need to getthat data, itã­s not just what you excrete or what makes you tick. itã­s also your exposome,your environment. and that includes food, you know, um, air and your water, all thosesorts of things. so itã­s a great point. thank you. yeah. >>male #2: uh, in the uh, early 2000ã­s, iasked a family friend whoã­s also a doctor,

about the fad that came out at that time aboutdoing whole body mri scans. and, uh, and he basically said, ã¬donã­t do it.ã® heã­s like,ã¬the problem is that youã­ll find all sorts of things that are wrong with you, that probablywould do more harm than good to treat.ã® [laughter]>>eric topol: yeah. >>male #2: and i think we see the same thingwith like mammography, the recent debate thatã­s been going on with that. so, i guess thisisnã­t really a good argument for not collecting the data, but it is, i think, a need for howdo you analyze it? or do you have any insights into where the thresholds are for when youactually should take action? >>eric topol: right, see youã­re bringingup some central concepts here. the ability

to, uh, engender the incidentalome, whereyou basically back into findings just because you shouldnã­t have done the test in the firstplace, thatã­s one thing. so more judicious use of the right tests for the right person,uh, you know, a lot of people just sign up for the total body cat scan and their justasking for trouble. and, like you also brought up with the mammography, thereã­s a much higherrate of false biopsies, positive biopsies and getting women and their families, youknow, horrified than there is of preventing cancer. so the odds of getting a true abnormalbiopsy is much lower than getting a false positive. so these are, we need much moreprecise tools. who should get the studies or procedures? and how to interpret them.and part of it is this whole bayesian thing

that the test or procedure is only good ifitã­s being done on the right person. hopefully in the future weã­re gonna pick the rightpeople and not have all these incidental findings which wind up causing all kinds of trouble. >>male #2: so do you think, though, that itis a matter of not having precise enough tools, or could it be that even if you have all theinformation you still are in a situation where youã­re not sure if itã­s a problem or not? >>eric topol: well, thatã­s a great point.uh, i think it, a lot of it is the imprecision of people having things done that just doesnã­thave any, itã­s just, uh, this mass medicine problem that we have today. but there stillis an issue, so for example, when you have

a whole genome sequence, youã­re doing itfor, letã­s say weã­re trying to unravel that 15-year-old girlã­s story and we find theseother things in there that we didnã­t anticipate, what do we do with that? see, whenever youhave a lot of data, the chance of you coming into things, uh, in unintended way is gonnabe there. so this is an issue that has to be grappled with. youã­re bringing up a veryimportant, um, concern. yeah. >>female #1: well on that note, thanks somuch for coming. you left us with a lot to think about.[laughs] >>eric topol: sure, yeah. >>female #1: thanks.

>>eric topol: thank you, thanks a lot.[applause]