Ghp august 2015

ghp

August 2015

global health & pharma

www.ghp-magazine.com

Digital Pens: The New Sonic Screwdriver

Looking Ahead to

2020

The King’s Fund analyse the proposed healthcare reforms

MSM: The Natural Solution Paul Klein Breteler discusses the various medical uses of this naturally occurring molecule

Resistance May Not Be Futile GS1: High Standards of Healthcare We speak to Glen Hodgson about how GS1 standards are transforming the NHS

JPIAMR explain what needs to be done to solve the problem of Antimicrobial Resistance

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editor’s note

this month’s features 04 News

Welcome to the August Issue of GHP Magazine.

08 Oxygen Dependent Killing of Bacteria in Wounds of Diabetic Patients

This month, the JPIAMR discusses antimicrobial resistance and what needs to be done to overcome it.

Glen Hodgson, Head of Healthcare at GS1 UK talks us through how the not-forprofit organisation is changing the NHS for the better.

Elsewhere, staying with the NHS, the King’s Fund explain the policy commitments due to take place within the service by 2020.

Anoto digital pens are in the spotlight this month, with the Welsh Ambulance Services NHS Trust discussing how the technology fits into their modernisation plans and Anoto themselves explaining how the pens work and what they can do for healthcare services.

Redefining the Melanoma Care Process Through a Multidiciplinary Telemedicine Platform In order to meet the challenges of the melanoma care process, the telemedicine platform, Dermicus™ and a novel work strategy are introduced in Sweden.

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The disguised threat of bacterial vaginosis is explored in detail as Laccure showcase a new product designed to prevent and cure it.

We hope you enjoy this issue!

12 Digital Pen to Revolutionise Healthcare 14 Modernisation in the Welsh Ambulance Services NHS Trust 16 The Importance of Designing Dementia Friendly Care Environments 18 The Quest for a Superbug Solution 20 Antimicrobial Resistance: No Solution, no Cure!

Paul Klein Breteler talks us through the benefits of MSM and its potential uses in healthcare and Sarah Waller highlights the importance of designing safe environments for dementia patients.

Small pharma is the place to be, according to Abid Kanji, who outlines the benefits of smaller firms in the industry.

inside this issue

MSM: A Miracle Molecule?

At the end of the last century, MSM was welcomed as a strong contender for the title ‘Nutraceutical of the Next Century’. Fifteen years have passed since, and it is time to take a look where MSM stands today.

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28 Bacterial Vaginosis – A Common and Hidden Health Problem Among Fertile Women, Still Often Treated with Antibiotics Several Times a Year 30 The Swedish Government’s Stance on Antibiotic Resistance 36 Cognitive Training: Tackling the Cost of Mental Health in the Workplace 38 Northern Sweden Shows the World How to Implement Remote Virtual Healthcare 42 GS1 UK: Raising Standards

“Currently, the Trust has to manage over 450,000 patient clinical records and other associated clinical forms per annum. The move to digital recording of this information in September 2015 will improve our record keeping but more importantly our ability to audit and evaluate the quality of the care we provide. ”

44 2020 Vision: Digital Efficiency and Innovation in the NHS 46 Why Smaller Pharma Firms Are the Place to Be

Richard Lee, Interim Assistant Director of Operations , Welsh Ambulance Services NHS Trust

Global Health & Pharma, 39A Birmingham Road, Blakedown, Worcestershire, DY10 3JW Tel: +44 (0) 1234 567 890 | Email: info@ghp-magazine.com | Web: www.ghp-magazine.com

news

Health Specialists Call for $2 Billion Global Fund for Vaccines Global health experts called on Wednesday for the creation of a $2 billion vaccine development fund to feed a pipeline of potential new shots against priority killer diseases like Ebola, MERS and the West Nile virus.

The fund would help bridge the gap between early stage drug discovery work carried out at universities and small biotech firms, and the late stage development and large-scale clinical trials needed to get a new vaccine to market.

“We can no longer sit back and ignore the chronic lack of progress in developing new vaccines, and improving existing ones,” said Jeremy Farrar, director of the Wellcome Trust global health charity, who co-wrote a paper calling for the creation of such a fund.

Farrar praised the enormous global effort made to get clinical trials up and running to try to test experimental vaccines during West Africa’s Ebola outbreak, but he added: “If just one of those promising vaccines had been through (early stage) phase I trials before the outbreak started, public health workers could have begun vaccinating people at the start...potentially saving thousands of lives.”

At least $2 billion would be needed at the outset, Farrar said, an amount that should be achievable even at a time when resources are scarce.

“Witness the cost of addressing the Ebola emergency - estimated at $8 billion to date with the final figure likely to be far higher,” he and his colleagues wrote.

The money for the global vaccine fund should come from governments, foundations and the pharmaceutical industry, as well as from non-traditional sources such as the travel and insurance industries, the experts said in the paper, published in the New England Journal of Medicine.

“The lesson we take from the Ebola crisis is that disease prevention should not be held back by lack of money at a critical juncture when a relatively modest, strategic investment could save thousands of lives and billions of dollars further down the line.”

Such a fund would pay for things like manufacturing vaccines to internationally accepted standards, and early and mid-stage clinical trials designed to test safety and proof-of-concept that a vaccine can generate an immune response.

The proposed fund would invite competitive proposals from scientists, institutions and biotech firms, with an independent panel of scientists and funders required to review applications for financial support, the experts said.

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New Method Of Closing The Incision During Scoliosis Surgery Nearly Eliminates Infections New Technique Reduces Complication Rates for Complex Cases Where Patients Are Most at Risk.

Patients with scoliosis who undergo surgery may be less likely to develop an infection or other complications after the procedure when a novel wound closure technique pioneered at NYU Langone Medical Center is utilized, according to new research.

The study was published online this past July in the Journal of Pediatric Orthopaedics.

In this new technique, surgeons use a multilayered flap closure that enables doctors to close several layers of muscle and fascia while maintaining blood supply from the donor site to the recipient site.

The researchers believe this new method reduces complication rates by eliminating “dead space,” or pockets around spinal hardware and fusion sites where infection can start. The technique also creates a better barrier to separate surgical hardware and bone grafts from the skin’s surface.

“This game-changing method for closing incisions after surgery can benefit all patients with scoliosis, especially those most at risk for complications depending on the cause of their spine problems,” says corresponding study author David S. Feldman, MD, professor of orthopaedic surgery and pediatrics at NYU Langone. “All of our patients with scoliosis - from the basic to most complex cases - can feel confident knowing their safety is our top priority.”

A conventional, non-standardized closure method after scoliosis surgery often involves a bulk skin closure performed by an orthopaedic surgeon where no flaps are mobilized.

In this retrospective study, NYU Langone researchers reviewed 76 charts of patients aged 8 to 25 years, with non-idiopathic scoliosis - a type of scoliosis caused by an underlying syndrome or neuromuscular disease -- who had undergone a posterior spinal fusion surgery. Forty-two patients had their incisions closed using conventional techniques, while 34 underwent the new, multilayered flap technique.

Approximately 19 percent of patients who underwent the conventional, non-standardized closure methods experienced a wound complication, which was in line with previous estimates of infection rates for people with non-idiopathic scoliosis. However, patients who underwent the novel, multilayered muscle flap closure method experienced a 0 percent complication rate.

osis face a lower complication rate at 1 to 2 percent of cases.

The new closure method has been increasingly used at NYU Langone since 2009, and is a collaborative effort between the Departments of Orthopaedic Surgery and Plastic Surgery.

But until now, there has been little published about the best technique for spinal wound closure after surgery to prevent complications for patients, especially those at highest risk due to scoliosis caused by an underlying condition.

“The success of this procedure speaks to our Medical Center’s commitment to collaborate with other medical specialties to ensure our patients receive optimal patient care,” says senior study author Michael S. Margiotta, MD, assistant professor of plastic surgery and neurosurgery at NYU Langone.

Scoliosis is a disorder in which there is an S-shaped or C-shaped, sideways curve of the spine. Severe cases are often treated with spinal fusion surgery, where a surgeon will repair the abnormal curving of the spine by fusing steel rods, hooks, screws or other metal devices to straighten the spine and support the bones of the spine. Bone grafts are placed to hold the spine in the correct position and prevent it from curving again.

In most people with scoliosis, there is no known cause for this curve, which is known as idiopathic scoliosis. However, a small subset of scoliosis cases are non-idiopathic, meaning the curvature was caused by an underlying disease, such as a neurological condition like cerebral palsy. These patients are between 25 and 76 percent more likely to experience complications following spinal fusion surgery and between 4 and 23 percent more likely to have an infection, compared to those with idiopathic scoliosis. This is because these patients are generally sicker and more likely to experience complications overall. Patients with idiopathic scoli-

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These infections can be debilitating to patients and their families, and place significant burdens on the health care system through follow-up wound care, additional treatments or possible surgical procedures.

“There was a time when complex scoliosis cases, including revision surgery, had infection rates approaching double digits,” says study co-author Thomas Errico, MD, chief of the Division of Spine Surgery at NYU Langone. “We have now lowered infection rates to under 1 percent, a remarkable accomplishment thanks to attention to detail and teamwork of the dedicated surgeons in our Orthopaedic Surgery and Plastic Surgery departments.”

news

NHS in Transparency Drive The publishing of monthly data and the news that services must tell patients how to get in touch with their local Healthwatch highlights drive to improve transparency in the healthcare service.

The publishing of the monthly data, which began this month, was recommended by Sir Bruce Keogh, NHS England’s National Medical Director to NHS England’s Chief Executive Simon Stevens in a letter published in June entitled ‘making waiting times work for patients’.

The public nature of the data means patients and users of the services as well as ministers and those in positions of power within the service can utilize the data and see exactly what is going on within the service on a monthly basis.

Additionally there have been updates to the rules directly affecting patients, ensuring the NHS is more transparent in terms of where patients can go to make complaints about services or seek further information from an impartial body.

This means that more people will be aware of where to go to share their experiences and how they can help healthcare services learn and improve.

Services are already required to respond to reports and recommendations made by local Healthwatch, allow them to visit services in a formal capacity to find out what people think of them, and act on complaints local Healthwatch make about providers failing to disclose patient safety issues, and all of these requirements remain in the new contract.

The improved transparency from the service highlights the move towards greater ease of consumers shaping the way the NHS is run by keeping them informed, both of their personal rights to access to an independent interested party and data which will improve their knowledge of how the service is run.

As of April 2015 all healthcare services except GP services, opticians, dentists and chemists, have to provide clear information to patients, their carers and representatives about how to contact their local Healthwatch, an independent consumer champion.

This rule has come about as part of the NHS Standard Contract for 2015/16 mandated by NHS England.

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Alcohol Abuse in Wales Increasing Dramatic rise in drink and substance abuse in Wales will help propel Government plans to introduce minimum pricing strategy.

New Report Finds Rural Healthcare Needs Drastic Overhaul Healthcare for older people in rural parts of Scotland is ‘not fit for the future’ according to a new report by RCN Scotland.

Going the Extra Mile, written in collaboration with Age Scotland, finds that funding and care structures, particularly in rural areas, are not improving fast enough to keep up with the aging population.

•

• Figures released by the Welsh government show that in the period 2013 to 2014 just under 13,500 of the 24,806 referrals to rehabilitation services were for alcohol abuse. Referrals for heroin and cannabis also increased, whereas there was a drop in the number of referrals for cocaine abuse had dropped.

Wales already has plans in the pipeline to introduce a Public Health Bill setting minimum prices for alcohol, with a draft version currently under consultation.

•

MUP (minimum unit price) policies would be effective in reducing consumption, alcohol-related harms including deaths, hospital admissions, crimes and workplace absences and associated costs; • MUP would have a small impact on ‘moderate drinkers’, with the most substantial effects being experienced by ‘high-risk drinkers’; • Introducing an MUP of 50p is estimated at being worth £882m to the Welsh economy in reductions in illness, crime and workplace absence over 20 years.

The draft plan focuses on evidence from other countries (including Switzerland, Sweden, and Alaska, USA) which demonstrates that an alcohol price increase leads to decreases in consumption and alcohol related mortality.

• • •

•

•

The report sets out seven goals to delivering community care in remote and rural areas: Shifting resources to the community Taking a whole-system approach to recruitment and retention Developing and supporting the advanced nurse practitioner role Ensuring nurses and other professionals are confident users of technology Significantly improving broadband infrastructure to connect services with patients and support a mobile workforce Bringing services and communities together to change attitudes and improve digital participation, particularly among older people Supporting older people to live independent and active lives

Theresa Fyffe, RCN Scotland director, commented on the drastic changes that needed to be made to the services in the future.

In relation to Wales, a study by the Sheffield Alcohol Research Group showed benefits of introducing a minimum unit price (MUP) for alcohol, including:

“Patients in remote and rural parts of Scotland already struggle to access services, and the geographical distribution of patients makes delivering a flexible service closer to home much more difficult.

“The future may therefore demand a more mobile and flexible nursing workforce along with technologically competent and confident staff and patients.

“The ambition to deliver good quality, integrated care and support in people’s homes and closer to their communities needs to apply to the whole of Scotland. We hope that this report will help inform decision makers in making this ambition a reality.”

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Oxygen Dependent Killing of Bacteria in Wounds of Diabetic Patients Amir Saeed1,2 and Gunnar Sandstrรถm1* Dept. of Laboratory Medicine, Div. of Clinical Microbiology Karolinska Institutet, Karolinska University Hospital Stockholm, Sweden 1

University of Science and Technology, Kathoum,Sudan 2

*Corresponding author Gunnar Sandstrom e-mail gunnar.sandstrom@ki.se

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industry insight Abstract In the present study diabetic patients of both sexes at an aged ranging between 47 to 58 years were treated for wound infection on their feet due to diabetes mellitus. The patients were treated for five days twice a day in an oxygen rich foot bath. The oxygen foot bath had good effect on bacteria localized in the wound on feet since 66% of the patient totally recovered from bacterial infections on their feet. Furthermore, witnesses from the included subjects and their physicians clearly point at a patient amelioration.

Introduction Diabetic foot ulcers occur as a result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the diabetic subjects compared to the normal population.

Diabetes causes non enzymatic glycation predisposes ligaments to stiffness. Neuropathy in diabetic subjects causes loss of protective sensation and loss of coordination of muscle groups in the foot and leg, both of which increase mechanical stresses during ambulation.

Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes.

Diabetes is the leading cause of non-traumatic lower extremity amputations in the World, with approximately 5% of diabetics developing foot ulcers each year and 1% requiring amputation.

Physical examination of the extremity having a diabetic ulcer can be divided into examination of the ulcer and the general condition of the extremity, assessment of the possibility of vascular insufficiency, and assessment for the possibility of peripheral neuropathy (Hsiao-Chuan L, et al. 2014).

The staging of diabetic foot wounds is based on the depth of soft tissue and osseous involvement.

A complete blood cell count should be done, along with assessment of serum glucose, glycohemoglobin, and creatinine levels (Guideline, 2014, International Expert Committee 2009, Vehik K, Beam CA, Mahon JL, et al. 2011).

A vascular surgeon and/or podiatric surgeon should evaluate all patients with diabetic foot ulcers so as to determine the need for debridement, revisional surgery on bony architecture, vascular reconstruction, or soft tissue coverage.

In the present study we show an alternative way of treating foot wounds and the method can be used to avoid deep soft tissue wounds by preventive use of oxygen rich foot bath.

Material and methods Patients This study was limited to infected wounds of 15 diabetic patient presented to a diabetic clinic in Khartoum, Sudan between January and February 2015. The age of the patients range from 47 to 58 years and both sexes were represented. Determination of infection was made clinically by looking for signs of inflammation. None of the patients has taken

any antibiotic for the last 30 days prior to the study.

No other history of illness besides diabetes mellitus was known when the study started.

Treatment of subjects The patients in this pilot study were treated by foot bath with 2% of BioCool ® twice a day for 5 days.

When the results obtained from this first group of subjects indicated that we had achieved the objective of the study, the study was terminated. The BioCool ® can be used at a concentration between 0.05 to 4.00 % deepening on which microorganism killing is aimed at. The temperature of the foot bath should be 37 C for optimal effect. This has previously been tested and 2% have been found to be optimal for killing of all types of microorganisms both pro and eukaryotic ones (Sandström G., Eriksson J-O., and Saeed A., 2014).

Material Substance: The test substance ( BioCool ® ) was obtained from the company BioCool AB, Skellefteå, Sweden. Hereafter described as test substance. The test substance has been described on the open market as BioCool ®. The mechanism by which the microorganism is killed is a chemical reaction resulting in singlet oxygen. Singlet oxygen is known from other biological systems to have killing effect on microorganisms (Kniel et al., 2003) . The substance has previously been tested and found to kill Escherichia coli (Nandi et al., 2010). The Swedish governmental owned company FOA-test performed the test. In the present study test substance was tested at concentration of 2%.

Specimen Collection Two cultures were taken from every wound, before and after treating with the substance. The wound and area surrounding it was cleansed with sterile physiologic glucose solution by means of a sterile compress passed over the wound surface to reduce the amount of contaminating bacteria. The swab was held in contact with the wound for at least 5 s before any debridement was done. At the end of debridement, a deep tissue was taken. Deep tissue was defined as the last non-viable tissue removed from the deepest area of the wound.

All swabs were placed in a tube and delivered to the microbiology laboratory was usually made within 30 min. Cultures were performed by standard procedures. Bacterial isolates were identified to the species level.

Results In table 1 it is described the outcome of treatment of patients with the substance. Out of the group of subjects treated with the substance 66 % showed no growth of bacteria at all although all of them had signs and symptoms of deep infection wounds to start with. The other 34 % of subjects showed a clear decrease in bacterial growth after treatment although not a complete lack of bacteria in the wounds. The normal flora of the subjects was not affected dramatically since the normal flora was fully recovered when treatment was stopped. Moreover no difference between sexes could be found and no effect failure due to age was noted.

Patient 7-15 had the following bacteria Staphylococcus aureus, Beta haemolytic streptococcus,

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industry insight Pseudomonas aeruginosa and Klebsiella spp. These patients were excluded from the study since for one way or another they had to stop treatment for the study. Such reasons could be risk of gangrene, antibiotic treatment or amputation of legs.

Table 1.

No. of Patient Sex Age Before treating

with the substance 1.

F 58 Staphylococcus aureus

Pseudomonas aeruginosa 2.

M 53 Staphylococcus aureus

Beta Haemolytic streptococcus 3.

F 51 Coagulase-negative Staphylococcus aureus

and enterococci 4.

M 50 Staphlococcus aurues

Pseudomonas aeruginosa 5.

F 47 Klebsiella spp.

6.

M 44 Staphylococcus aureus Proteus spp.

After treating with the substance No growth Beta Haemolytic Streptococcus

No growth No growth No growth Staphylococcus

Discussion Hyperbaric oxygen therapy (HBOT) is a medical treatment in which the patient breathes 100% oxygen inside a pressurized treatment chamber. The aim is to increase the oxygen level in the tissue. It is used in cases where partial or total tissue hypoxia occurs such as acute limb ischemia, diabetic foot lesion, and arterial ulcers.

Limb-threatening diabetic foot infections are usually polymicrobial. Commonly encountered pathogens include methicillin-resistant staphylococcus aureus, β-hemolytic streptococci, enterobacteriaceae, pseudomonas aeruginosa, and enterococci. Anaerobes, such as bacteroides, peptococcus, and peptostreptococcus, are rarely the sole pathogens but are seen in mixed infections with aerobes. Antibiotics selected to treat severe or limb-threatening infections should include coverage of gram-positive and gram-negative organisms and provide both aerobic and anaerobic coverage. Patients with such wounds should be hospitalized and treated with intravenous antibioticsm (The DCCT Research Group. 1993, Boulton AJ, Malik RA, Arezzo JC, Sosenko JM., 2004, Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ., 2003., Armstrong DG, Lavery LA, Wu S, Boulton AJ.,2005) Mild to moderate infections with localized cellulitis can be treated on an outpatient basis with oral antibiotics such as cephalexin, amoxicillin with clavulanate potassium, moxifloxacin, or clindamycin. The antibiotics should be started after initial cultures are taken and changed as necessary.

Acknowledgement We acknowledge the support of substance (BioCoool®) and technical support from the staff of BioCool, AB, Skellefteå, Sweden.

References 1. Hsiao-Chuan L, et al. Enterovirus infection is associated with an increased risk of childhood type 1 diabetes in Taiwan: A nationwide population-based cohort study. Diabetologia. 2014 2. [Guideline] Diagnosis and classification of diabetes mellitus. Diabetes Care. Jan 2010;33 Suppl 1:S62-9 3. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes.

Diabetes Care. Jul 2009;32(7):1327-34Vehik K, Beam CA, Mahon JL, et al. Development of Autoantibodies in the TrialNet Natural History Study.

Diabetes Care. Sep 2011;34(9):1897-1901 4. Sandström G., Eriksson J-O., and Saeed A: Successful Treatment of Trichophytonrubrum Onychomycosis and Warts (Verruca Plantae) with BioCool®. International Journal of Applied Science and Technology Vol. 4 No. 1; January 2014 5. Kniel, K. E., Sumner, S. S., Lindsay, D. S., Hackney, C. R., Pierson, M. D., Zajac, A. M., . . . Fayer, R. (2003). Effect of organic acids and hydrogen peroxide on Cryptosporidium parvum viability in fruit juices. [Research Support, U.S. Gov’t, Non-P.H.S.]. J Food Prot, 66(9), 16501657 6. Nandi, N., Sen, A., Banerjee, R., Kumar, S., Kumar, V., Ghosh, A. N., & Das, P. (2010).

Hydrogen peroxide induces apoptosis-like death in Entamoeba histolytica trophozoites. [Research Support, Non-U.S. Gov’t]. Microbiology, 156(Pt 7), 1926-1941. doi: 10.1099/mic.0.034066-0 7. The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977 -986, 1993 8. Boulton AJ, Malik RA, Arezzo JC, Sosenko JM: Diabetic somatic neuropathies. Diabetes Care 27:1458-1486, 2004. Also available in free full text online from http://care.diabetesjournals.org/ cgi/content/full/27/6/1458 9. Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ: Activity patterns of patients with diabetic foot ulceration. Diabetes Care26 : 25952597,2003 10. Armstrong DG, Lavery LA, Wu S, Boulton AJ: Evalution of removable and irremovable cast walkers in the healing of diabetic foot wounds.

Diabetes Care 28: 551-554,2005

The substance (BioCoool®) is here shown to be an alternative treatment of infected feet. The effect of the substance has been disclosed to be optimal at 2% but from 0.05 to 4% the substance at 370 C can be used as previously shown. If the oxygen bath will be used on a daily basis a concentration of 0.05 % is recommended (Sandström G., Eriksson J-O., and Saeed A., 2014). Not only affected nails and warts are showing dramatic improvement but also skin and feet in general are refined (Sandström G., Eriksson J-O., and Saeed A., 2014) Moreover, witnesses from the included subjects and their physicians clearly point at a patient amelioration.

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Digital Pen to Revolutionise Healthcare Anoto Group AB has produced technology which can transfers handwritten notes into a digital format quickly and efficiently.

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industry insight Anoto group, a global leader in digital writing solutions provides the ability for people within any organisation to capture data. People adopting any new technologies and processes is vital and still remains one of the biggest challenges faced by organisations today.

An Anoto digital pen works and feels like a traditional pen. It consists of small-sized, cost-efficient components which allows for an impressive battery life, enabling what is probably the most versatile digital pen on the market. With the capacity to capture up to 50 full A4 letter size pages of handwritten data, users save time and significantly reduce the risk of error from poor handwriting. With built-in Bluetooth and USB capabilities, users also have the ability to store their written data in a reliable and safe manner as well as enabling easy transfer of data.

The digital pen and paper solution is already being used within the healthcare industry, in areas of the NHS which include physiotherapy, occupational therapy and midwife services capturing precise and reliable patient data digitally. This intuitive approach to safeguarding accuracy is vital within the healthcare sector and in helping to improve patient care by saving healthcare professionals time and improving efficiency of transferring the patient information.

Reducing administrative workloads drastically, the digital pen and paper solution is popular with staff and is now being deployed further afield within the healthcare industry. Recently, The Welsh Ambulance Service Trust deployed 1,700 digital pens to staff across the service, ensuring that their paramedic staff can generate an electronic patient record at the scene and then immediately transfer this record to their back-end clinical systems.

Anoto’s innovative approach enables organisations within the healthcare industry to leverage existing working practices to remove the obstacle of user adoption while embracing a world leading data capture technology.

The combination of Pen & Paper is the purest form of information collection, so adopting a digital Pen & Paper solution is the most intuitive and natural step towards digital transformation. With a digital solution that is gaining visibility within the healthcare industry as well as other commercial sectors, more trusts and businesses are investing in this proven digital solution. Growing steadily, Anoto has taken orders from around the world, with clients in China, Korea and India as well as closer to home, with the digital writing technology already heavily used in the company’s home country of Sweden, as well as across the rest of Europe and the UK.

‘The We-Inspire Inc. solution is a natural extension of Anoto’s products and ecosystem and it is an exciting opportunity to expand our business.’

We-Inspire Inc. is an award winning firm, having won Best Visual Collaboration Solution for Creatives at InfoComm in July this year. Anoto’s partner Optika Display also did well at the annual conference and exhibition for professional audio visual buyers and sellers, winning the award for Best Personal Workspace for Creatives.

In addition to their subsidiary company Anoto has recently acquired XMS Penvision AB, an innovative Swedish software company specializing in digital writing solutions whose signature product, Formidable, is the foundation for Anoto Live Forms, an Anoto Enterprise Solutions application for signatures, document and mobile data capture. Aquiring XMS Pensvision was a shrewd move for Anoto, who can now control the supply of Formidable and the price they pay for it. Revelsby made it clear that this acquisition would complement the firm’s existing departments and products.

‘The acquisition of XMS Penvision gives us better control of the value chain, flexibility in pricing and a product suitable for sale through larger resellers.

They have a highly competent team that complements our own in-house software development.’

The digital pen and paper solution, has scope for further growth, particularly in the healthcare industry, with the product offering a unique service which will ultimately impact on the way in which notes are taken and transcribed throughout the healthcare service market.

Ultimately the market for digital writing seems to be moving towards replacing keyboards with digital pens capable of working at a far faster pace and being more efficient and reliable than writing notes out by hand.

Anoto predicts a future where a single Anoto digital pen will enable people to capture data and notes on any surface and then connect, share and interact using this information in a seamless environment, allowing for the fast and effective transfer of data.

The Anoto Group being a global leader in digital writing solutions has over 100 employees and is headquartered in Lund, Sweden, with additional offices located in Basingstoke and Wetherby in the UK, American cities Los Angeles and Boston and Japan’s capital Tokyo.

The firm has set up a California based subsidiary We-Inspire Inc. which specialises in full digital collaboration environments. Stein Revelsby, the firm’s CEO, said of the subsidiary:

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Modernisation in the Welsh Ambulance Services NHS Trust

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industry insight Since 2013, the Welsh Ambulance Service has embarked on a £7m modernisation programme, equipping crews with the latest life-saving technology to provide the best possible treatment for patients.

The Trust is an integral part of NHS Wales, providing both emergency and non-emergency ambulance services in addition to responding to around 430,000 calls a year, which come from almost 100 ambulance stations also operated by the Trust. The non-emergency service undertook one million journeys last year and the Trust has 2,500 operational staff that crew ambulances or manage calls within its three Clinical Contact Centres.

Since 2013, the Trust, which has been operating since 1998, has been going through a process of modernisation in order to ensure all patients receive a high standard of care and to update outmoded practises.

One of the key elements of this modernisation strategy is a one-year pilot of a revised clinical model for the Trust, which has been approved by the Welsh Government and is due to be implemented in October of this year.

This new model will see a clinically led revision of the categorisation of calls and the standards used to measure the Trust’s response. The current performance reporting standards were introduced when the ambulance service became part of the NHS in 1974, and despite minor technical revisions in 2005 and 2011, they only look at the time taken for an ambulance to arrive at the scene of a call. There is currently no assessment of the clinical care provided or the outcome for the patient.

However, this situation is set to change with the new model using response time and a series of clinical indicators to measure the ambulance service’s performance in responding to the most serious calls, such as cardiac arrests or strokes. For these calls not only is a fast response vital, but also the quality of the care provided will shape the eventual outcome.

Measures such as the number of patients surviving cardiac arrest will be used to understand how the Trust is performing, with the new model measuring the service against the treatment provided and the outcome for the patient rather than purely time taken to arrive on scene.

These new performance measures are particularly important because the role of the ambulance service has changed. Previously, ambulance crews took patients to the nearest hospital, however stroke and heart attack patients are now increasingly assessed by an ambulance crew and then taken to a specialist unit for treatment, which may not be the local hospital. This means time is not such an important factor, with more emphasis placed upon the quality of the service, the decision-making of the ambulance crew, the treatment provided en route to a specialist unit and how all that impacts on a patient’s recovery.

Another key part of the Trust’s modernisation programme is the purchasing of new equipment. The Trust has invested £7 in a host of new devices, including new drug boxes, which contain a wider range of medication, colour metric capnographs and emergency lifting cushions, which are being fitted to all of the Trust’s Honda CRV Rapid Response Vehicles.

An exciting new product currently being rolled out by the Trust is the Anoto digital pen, designed to save time and increase efficiency by enabling ambulance crews to write notes which are then immediately translated into digital form, improving clinical audit information, saving a significant amount of time and reducing errors.

Richard Lee, Interim Assistant Director of Operations at the Trust, commented on how the pens were going impact on the ambulance service.

“We are currently finalising the roll out of a digital pen to all emergency service staff. Our clinical records are vital in ensuring that details of the treatment provided to a patient is passed to the receiving hospital unit or their GP or other healthcare professional if the patient is treated at the scene and not conveyed to hospital.

“Currently, the Trust has to manage over 450,000 patient clinical records and other associated clinical forms per annum. The move to digital recording of this information in September 2015 will improve our record keeping but more importantly our ability to audit and evaluate the quality of the care we provide.

We will also be able to link our data with other parts of NHS Wales to track patient outcomes from the original 999 call through to discharge from hospital.

This will allow whole system evaluation and measurement of clinical outcomes.”

He added that the modernisation programme was vital as the ambulance servicebecomes more central in Wales’ unscheduled care system.

“The ambulance service continues to modernise and become a more integrated part of the wider NHS unscheduled and emergency care system. Investment in equipment and technology are central to this transformation but at the heart of all excellent care are our staff who day in, day out, at night, at weekends, in the rain continue to deliver care to our patients. A lot has changed in the ambulance service since 1974 but the care we provide to our patients at their most frightening moments remains at the core of what we do.”

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The importance of Designing Dementia Friendly Care Environments It is estimated that there are 800,000 people with dementia in the UK and this number is expected to double in the next 30 years. The proportion of people with cognitive problems and dementia in general hospitals continues to increase and the need to make the physical environment of health and social care buildings more dementia friendly is now widely acknowledged. This article outlines some of the key features of dementia friendly design and introduces a suite of environmental assessment tools for care settings.

The Association for Dementia Studies, University of Worcester, is a multi-professional university research centre which draws on and contributes to the international evidence base for person-centred dementia care. Using this evidence we deliver education programmes that empower people to provide skilled, competent and compassionate care.

Sarah Waller CBE, RGN, FRSA Developed and led The King’s Funds Enhancing the Healing Environment programme from 2000 to 2015. She is now an Associate Specialist, Association for Dementia Studies, University of Worcester. She can be contacted at dementia@ worc.ac.uk

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industry insight The scale of the challenge In 2009 an Alzheimer’s Society report (1) estimated that over 25% of people accessing general hospital services were likely to have cognitive problems or dementia. This figure is now believed to be an underestimate, with hospitals reporting nearer 40% of the over 75 year olds receiving hospital care being affected though many will not have received a formal dementia diagnosis. Unfortunately too many of these patients still lose the ability to undertake activities of daily living while in hospital and are unable to return home. An outcome that is both devastating for them and their families and has cost consequences for the care system.

The Prime Minister’s challenge on dementia 2020 (2) and the Dementia-friendly Health and Social Care Environments Health Building Note 08-02 (3) both attest to the need to continue to develop more dementia friendly care environments. However, there remains a significant knowledge gap about the critical role that relatively straightforward and inexpensive environmental improvements can play in improving care and supporting the independence and well-being of people with dementia.

Why are dementia friendly environments needed?

Normal ageing has an impact on the senses, particularly sight and hearing, and this is exacerbated by the distortions in perception associated with dementias such as Alzheimer’s disease, the most common form of dementia, and poorly designed care environments can lead to further disablement.

People with dementia may therefore experience increased agitation, disorientation and distress in hospitals as they are likely to: - be confused and agitated in unfamiliar environments particularly if they are visually over-stimulated for example by a plethora of signs and notices - be unable to see things, for example, handrails and toilet seats if these are the same colour as the wall or sanitary ware - experience shadows or dark strips in flooring as a change of level and therefore try to step over them - resist walking on shiny floors because they think they are wet - want to explore and walk around.

However, if hospital environments are appropriately designed it is possible to reduce confusion and agitation, encourage independence and social interaction, and enable people with dementia to retain their ability to undertake activities of daily living.

Developing dementia friendly design principles Key principles for dementia friendly design have been developed by The King’s Fund through a Department of Health commissioned programme (4).

Working with over 25 clinically led multidisciplinary teams from NHS trusts, each of which included estates managers and carers, a set of overarching principles were developed and tested. (Fig 1) Each team completed an environmental improvement project based on the principles which involved: de-cluttering; maximising natural light and improved lighting; laying matt flooring; easing way-finding using colour and contrast, art and better signage.

Large nurses’ stations have been removed with the staff now working in bed bays making them more visible and easing distress. Creating social spaces and better access to gardens has improved general well-being as well as providing opportunities for meaningful activity.

Fig 1 (above) – Overarching design principles (Copyright The King’s Fund 2014)

Estates colleagues report that incorporating these design principles has cost no more than similar sized schemes, provided better value for money and improved sustainability. The completed schemes also demonstrate how the care experience for people with dementia can be improved and show how cost effective design can help to reduce falls and incidents as well as supporting increases in non-pharmacological approaches to managing challenging behaviour.

There have been consequent improvements in staff morale, engagement, recruitment and retention.

Dementia friendly environmental assessment tools Following the programme a suite of evidence based assessment tools have been developed which focus on those aspects of the physical environment known to impact on people with dementia. They assess not only the physical environment, such as floor coverings and use of paint colours, but also the way that the environment encourages people to behave and interact. A service user led approach was taken to their design so that the assessments can be undertaken by people with dementia, family carers and staff together. Over 8,500 copies of the tools have been downloaded and they are in use nationally and internationally. They have evaluated very positively and have helped to educate staff and to secure increased funding for environmental changes.

Further development of the tools, including an application for smartphones and tablets, is now being taken forward through the Enabling Environments Programme by the Association for Dementia Studies, University of Worcester.

For further information and to download the tools for wards, hospitals, care homes, health centres and specialist housing, free please visit http://www. worcester.ac.uk/dementia

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References 1. Alzheimer’s Society.

Counting the cost. London: Alzheimer’s Society, 2009 2. Department of Health, Prime Minister’s challenge on dementia 2020, Department of Health, February 2015 3. Department of Health, Health Building Note 08-02, Dementia-friendly Health and Social Care Environments, Department of Health, March 2015 4. Waller, S, Masterson, A, Finn, H, Improving the patient experience: developing supportive design for people with dementia : the King’s Fund’s Enhancing the Healing Environment Programme 2009-2012.

London: The King’s Fund, 2013

The Quest for a Superbug Solution As the growing problem of antibiotic resistance grabs the news headlines, the need for new strategies to tackle infections remains as large as ever. The UK Medical Research Council (MRC), sets out the challenges and how international, interdisciplinary research will provide the solutions.

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research Picture a world where a cut finger could kill you. You don’t have to look too far ― before the discovery of antibiotics just 80 years or so ago it was common for women to die from post-childbirth infections, and diseases such as tuberculosis were huge killers.

The discovery of antibiotics is still considered one of the greatest medical achievements of the 20th century. Since Sir Alexander Fleming accidentally discovered penicillin growing on a petri-dish of bacteria, antibiotics have saved the lives of millions.

From treating minor cuts and grazes to their use in major operations and serious diseases, these drugs have drastically improved our quality of life and increased our lifespan.

As we now know, antibiotic overuse and misuse – in agriculture and human medicine – has led to a growing number of bacteria in humans, animals and the environment that are resistant to them. Sir Alexander Fleming himself predicted the dawn of this superbug battle, on collecting a Nobel Prize for his discovery: “It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them…”

Certain strains of tuberculosis, methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile, for example, do not respond well to current antibiotics. And we are now seeing the worrying emergence of multidrug-resistant bacterial strains which have shown resistance to many, or even all, available antibiotics.

Fighting resistance through research Tackling the problem of antibiotic resistance (AMR) will depend heavily on research. First, it will be crucial to understand the many factors that lead to resistance. This includes environmental factors such as the use of antibiotics in agriculture and fish farming, and human behaviours like antibiotic overprescribing and hygiene practices. In order to reduce and control AMR, it will be essential to address these behaviours; for example, by changing how farmers and vets produce livestock for human consumption, and changing attitudes towards infection, prescribing, and the use of antibiotics among the public and health care professionals in the UK and abroad.

We also urgently need to develop new drugs and treatments to combat the rise of resistant bacteria.

Identifying parts of resistant bacterial cells that could be used as new drug targets, for example, will allow scientists to come up with ‘next generation’ antibiotics that can kill these cells quickly without harming the patient. The development of more specific, disease-tailored antibiotics will also help us to cut down on the number of drugs being used.

diagnostics that are likely to make it to the clinic.

It will also be essential for different scientists to work together to find new classes of drugs, and to potentially revive old drugs with new science. As we work to address the scale of the AMR problem, we will need to involve experts from further scientific areas such as engineers, environmentalists, social scientists and economists.

To stimulate a rich cross discipline research environment, the MRC leads the seven UK research councils in an historic ‘war cabinet’ , established to co-ordinate and expedite research across all areas impacted by antimicrobial resistance - from labs to livestock, farms to pharmacies, drawing together a range of scientific expertise from the UK and abroad.

In addition, the MRC established the AMR Funders’ Forum to encourage a coordinated approach to funding research. It brings together the seven research councils with health departments, governmental bodies and charities that either provide support for AMR research or have an interest in AMR. The Forum provides a strategic overview of AMR research in the UK and to create a shared vision for the future of AMR research and its potential impact on policy and treatments.

AMR is a global problem and since 2012 the MRC has been involved in the EC-funded Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) , which co-ordinates research in 19 European countries, plus Israel and Canada, to address AMR on a global scale. As part of this work, we are leading a mapping exercise to pull together all the research carried out in these countries over the last seven years. This will help us to identify gaps and opportunities for future AMR research. We are also broadening our efforts outside of Europe, working with colleagues in India and China to tackle AMR. Professor Sir John Savill, Chief Executive of the Medical Research Council said: “Only 100 years ago, a quarter of all deaths were due to bacterial infections. We know there’s no magic bullet to the AMR problem. Tackling the issue will depend heavily on research that is connected, multidisciplinary and that takes global perspective. Real change needs proper global investment. What we do know is that the UK model on AMR research is an exemplar of how to bring researchers from all disciplines and backgrounds together. We have the expertise, experience and the imperative. We need to act now.”

Find out more For funding opportunities and further information go to http://www.mrc.ac.uk/research/initiatives/antimicrobial-resistance/

The UK Medical Research Council (MRC) plays a pivotal role in the international race to find solutions to antimicrobial resistance. MRC scientists are taking unique and new approaches to AMR that will help to improve our understanding of resistance, and ultimately, our ability to develop new drugs and therapies.

Cross-discipline collaboration – from farms to pharmacies Strong ties between academia and industry are crucial to helping scientists identify treatments and

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research

Antimicrobial Resistance: No Solution, no Cure!

The reality of antimicrobial resistance (AMR) is that without a solution there is no cure, even to simple infections. Without action the prediction is that in 2050, only 35 years in the future, 10 million people will die each year to an astronomical cost of 100 trillion dollars to society (1). It’s clear that we need to take action to stop this from happening.

Currently European AMR funding is focused on research in therapeutics, largely ignoring other areas such as transmission dynamics and the impact of the environment, understanding in which is crucial in order to reduce resistance.

Association (EFPIA) helps to move JPIAMR supported outcomes into industry. Industry participation in research calls is also encouraged and promoted to encourage working together, because researching all angles forms the foundation of the initiative.

The gap between research funding into chronic diseases and antimicrobial resistance is large but difficult to document. However, national AMR funding does exist but is relatively small and targeted. In addition, countries with low national AMR prevalence allocate more money towards research than countries with greater needs for AMR solutions, a fact which suggests a need for greater coordination across Europe in order to fill knowledge gaps (2).

By engaging nations as members, the JPIAMR platform enables the joining of forces to instigate collaborative actions in areas of unmet needs. The shared SRA ensures that knowledge gaps are quickly identified and filled.

The EU Joint Programming Initiative on Antimicrobial Resistance, JPIAMR, coordinates national funding and supports collaborative action to fill existing knowledge gaps. The goal is to shape cohesive and coordinated AMR funding and actions that maximise on resources and reduce duplication of research.

Mobilising existing and new resources will create a greater critical mass and attract new researchers into the AMR field. A Strategic Research Agenda (SRA), which outlines key neglected areas to tackle, guides JPIAMR and focuses research actions.

More importantly, JPIAMR provides a collaborative platform to take the fight against AMR from awareness and statements to action by supporting European research and facilitating exchange and joint actions. Collaborating with key actors such as the Innovative Medicines Initiative (IMI) and the European Federation of Pharmaceutical Industries

The only way to win the AMR battle is to look at AMR in a holistic way, from diagnostics via the environment to interventions, and align resources to target neglected research domains. We must also engage all relevant stakeholders in these actions to make sure to cover the entire supply chain. The goal of bringing relevant actors together in a call to action in areas of unmet needs places JPIAMR as a very unique actor, complementary to other important players such as the World Health Organisation (WHO) in the AMR landscape.

JPIAMR cannot address all aspects of the AMR problem, but can pave a way forward by producing new research, engaging new researchers and creating networks that create long-term momentum for other areas in society. There is an urgent need for interdisciplinary and public-private sector partnerships to support research in the antimicrobial resistance area. Exchanges between industry, public health bodies and academic bodies will encourage not only sharing costs, but also coordination of the respective research activities. This is where JPIAMR will make a difference.

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research The Strategic Research Agenda JPIAMR has developed a Strategic Research Agenda (SRA), which outlines six priority topics that cover all relevant aspects of antimicrobial resistance. The agenda provides a blueprint to focus worldwide research efforts towards significantly reducing the risk that antibiotic-resistance poses to public health.

The six priority topics are: • Therapeutics: Development of novel antibiotics and alternatives for antibiotics – from basic research to the market.

• Diagnostics: Design strategies to improve treatment and prevention of infections by developing new diagnostics.

• Surveillance: Standardisation and extension of surveillance systems to establish a global surveillance programme on antibiotic resistance and antibiotic use.

• Transmission: Transmission dynamics.

• Environment: The role of the environment as a source for the selection for and spread of AMR. • Interventions: Designing and testing interventions to prevent acquisition, transmission and infection of diseases which is caused by AMR. Calls for research proposals JPIAMR wants to stimulate and facilitate cross-border research projects through calls for proposal.

Each year, various joint calls are launched, many of these involving nations also outside Europe. Through international collaborations, the JPIAMR calls will facilitate the generation and application of new approaches to overcome antibiotic resistance.

Examples of calls include: .

.

. .

1st Joint Call: Transnational call InnovaResistance: Innovative approaches to address antibacterial resistance 2nd Joint Call: Translational research on repurposing of neglected antibiotics and characterizing antibiotics or antibiotic and non-antibiotic combinations to overcome bacterial antibiotic resistance 3rd Joint Call: Transmission – ERAnet Cofund call (to open in December 2015) 4th Joint Call: Research Networks (to open at the end of 2015)

Get involved Research on antimicrobial resistance in Europe is fragmented and few countries have specific programmes dedicated to this field. Therefore, 21 member countries to date have joined forces in the initiative to coordinate research, in order to allow greater impact and avoid duplication.

Argentina Estonia Belgium Netherlands Canada Norway Czech Republic Poland Denmark Romania Finland Spain France Sweden Germany Switzerland Greece Turkey Israel UK Italy JPIAMR encourages and welcomes participation both from new national members and in our activities. Only by bringing together industry, public health bodies and academic bodies to share experience and resources across scientific disciplines will we be able to create long-term reduction of antimicrobial resistance.

If you are interested to know more about the Joint Programming Initiative on Antimicrobial Resistance, do not hesitate to contact us at secretariat.jpiamr@vr.se More information www.jpiamr.eu twitter.com/JPIonAMR www.facebook.com/jpiamr References 1. http://amr-review.org 2. Public funding for research on antibacterial resistance: A systematic analysis in the JPIAMR countries and the European Commission. Publication in review.

3. The Strategic Research Agenda http://www.jpiamr.eu/activities/strategicresearchagenda/

Workshops JPIAMR organises workshops to identify future joint actions. By bringing together experts from all relevant fields relating to a specific topic, the workshops can map the landscape and identify knowledge gaps. The added value of JPIAMR is that through its funding mechanisms and collaborative actions, the initiative can set in motion activities to fill these knowledge gaps.

Examples of workshop topics: • Information Systems • Diagnostics • Research Infrastructures • Transmission Dynamics • Alternative Therapies

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industry insight

Redefining the Melanoma Care Process Through a Multidiciplinary Telemedicine Platform Cutaneous malignant melanoma is the most aggressive form of skin cancer and a significant cause of death worldwide. Sweden, with a population of 9,6 million, has one of the highest incidence rates of melanoma. More than 75% of the melanomas are excised or referred by primary care clinicians. Early detection of melanoma is crucial for disease prognosis. Melanoma specialist skills should therefore be in reach for the general practitioner at patient’s first consultation. In order to meet the challenges of the melanoma care process the telemedicine platform Dermicus™ and a novel work strategy are introduced in the Stockholm area of Sweden.

Background Telemedicine - the use of telecommunications technology for the support of health care at a distance can be traced to the early 1900s, when ship captains used radio to receive medical advice. Dermatology is perfectly suited for this care model since imaging technologies easily captures skin disorders. Teledermatology is effective in the treatment of both paediatric and adult populations. It is also used in the management of chronic conditions, such as psoriasis and non-healing ulcers. In addition, teledermatology offers educational benefits to primary care providers and dermatologists (1).

M-Health is an emerging concept that represents the evolution of e-health systems from traditional desktop “telemedicine” platforms to wireless and mobile configurations. M-Health can be defined as “mobile computing, medical sensor, and communications technologies for healthcare.” M-Health solutions address increasing problems on health services, including the rising number of chronic diseases and high costs of existing national health services (2,3).

Malignant melanoma During the past 10 years, the incidence of melanoma in Sweden has increased by almost 6 percent annually. Since 2000, the number of cases among

women has doubled. In 2012, there were 3.343 new cases of invasive melanoma, and 2.620 new cases of in situ melanoma reported in Sweden. Nearly 85 percent of all patients with melanoma are cured thanks to early detection and control of the disease. Today, about 35.000 individuals with the diagnosis of melanoma are living in Sweden (4,5,6). Over 150.000 excisions of melanocytic lesion are performed on approximately 100.000 individuals each year in order to identify the number of melanomas above. The cost for these excisions was in 2005 calculated to exceed 30 million euros (7). The total cost for skin cancer care in Sweden is estimated to 177,6 million euros and cutaneous malignant melanoma accounts for more than 50 % of these figures (8).

Mobile teledermatoscopy Early and accurate diagnosis of melanoma is crucial for the disease prognosis. However, the accuracy of the clinical diagnosis of melanoma with the bare eye is only about 60 %. By using dermatoscopy, a non-invasive in vivo technique for the microscopic examination of pigmented skin lesions, the diagnostic performance can be improved by up to 50 % for an experienced examiner (9). New-generation mobile phones have made it possible to obtain high-quality microscopic digital images by connecting modern dermatoscopes to such smart phones. In the last few

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industry insight years, mobile teledermatoscopy has become one of the most used applications of teledermatology for consulting and educational purposes (10).

Redefining the melanoma care process In January 2015, a novel work process using a structured management of melanoma patients was introduced by the Regional Cancer Centre Stockholm–Gotland in collaboration with the department of Dermatology, Karolinska University Hospital and several Primary Healthcare Centres. The main objective of this project is to: • Develop a procedure for transfer of melanoma specialist skills • Structure assessments and reports • Educate assessing specialists and referring General Practitioners • Support multidisciplinary teams • Address patient data security The telemedicine platform Dermicus™ was selected for the project in order to meet these requirements: Transfer of melanoma specialist skills The General Practitioner (GP) uses mobile teledermatoscopy to send clinical data and images through a mobile application to the platform. The melanoma specialists analyse the data on the platform and produce a standardised report. Via the secured platform the GP gets access to the diagnosis and the clinical support regarding how to handle the pigmented skin lesion.

Structured assessments and reports The platform offers a standardised Digital Dermatoscopy Diagnose Report based on Revised Pattern Analysis (11) including recommendation on diagnostic excision by the GP or external surgeon / plastic surgeon depending on size and location of the lesion.

The assessment is in a consensus diagnosis setting involving two or more melanoma specialists to yield optimal diagnostic accuracy (9).

Education of assessing specialists and referring GPs The e-learning settings of the platform are used in the educational program and certification procedure of the First Line Clinicians (GPs) and the Digital Dermatoscopy Analysers (Specialists). In order to maintain high quality throughout the whole process the GP program includes Total Body Skin Examination since assessment only of the index lesion will risk missing one in three melanomas (12).

Supporting multidisciplinary teams The platform offers a teledermatoscopic digital service that provides all specialists (GP, dermatologist, surgeon and pathologist) with the collected data supporting the local melanoma referral process.

Patient data security The CE-labelled platform Dermicus™ complies with the requirements for encryption, authentication, secure login and storage of data. In addition, the system meets the Swedish legislation and regulations concerning patient data and the Personal Data Act. Effects of teledermatoscopy Melanoma specialist skills transfer through digital services (teledermatoscopy) to primary care will provide a better selection of suspicious lesions,

thereby reducing referrals of benign skin tumours.

Melanoma specialist assessments at patients first visit results in fewer unnecessary excisions, associated reduced load on pathology laboratories with improved pathology report response times and decreased healthcare spending. Fast and accurate diagnosis of melanoma provides a high qualitative process and an improved patient experience - ultimately early diagnosis saves lives.

Dermicus™ The telemedicine platform Dermicus™ was founded 2010 by MD, PhD Johan Heilborn and developed in close collaboration with colleagues at the department of Dermatology, advised by legal and technical resources at the Karolinska University Hospital.

Dermicus™ is delivered by the m-Health Company GNOSCO that offers services for improvement of internal communication, documentation and education within healthcare and hospitals. The Dermicus™ platform has to date delivered more than 4.000 consultations and maintains more than 16.000 images.

For more information please visit: www.gnosco.se Future prospectives GNOSCO was recently granted a VINNOVA project (Swedish Governmental Agency For Innovation Systems) for exploring the use of the platform in non-healing wounds – Dermicus Wound™.

Non-healing wounds are a worldwide problem within the elderly and the risk increases with age (>65 years). One-fifth of Sweden’s population or about 1,8 million are affected and the disorder is rapidly growing. In a recent report the Swedish agency for health technology assessment and assessment of social services (SBU) concludes that the scientific evidence for the treatment of chronic wounds in the elderly is very limited. The majority of the treatments used today need more research of high scientific quality in order to be properly evaluated (13).

Non-healing wounds require significant resources of the healthcare system and account for 2-4% of healthcare budgets. The costs are expected to rise in conjunction with an increased elderly and diabetic population. It is estimated that every fourth person in Sweden will be 65 years or older in 2030 (13,14,15,16,17).

Expected effects of Dermicus Wound™ • Supporting the establishment of multidisciplinary teams • Securing a fast and qualitative process for the patient • Delivering continuous education for primary care providers – GPs and nurses • Ensuring a high quality of wound management in community care • Identifying savings for the healthcare budgets

GNOSCO Redefining healthcare digitally

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References 1. Teledermatology: From historical perspective to emerging techniques of the modern era Part I: History, rationale, and current practice.

Coates, Kvedar, Granstein. J Am Acad Dermatol 2015;72:563-74.

2. Guest Editorial. Introduction to the Special Section on M-Health: Beyond Seamless Mobility and Global Wireless Health-Care Connectivity. Istepanian, Jovanov, Zhan. IEEE Trans Inf Technol Biomed 2004;8(4):405-14.

3. Mobile-health: A review of current state in 2015.

Silva, Rodrigues, de la Torre Díez, López-Coronado.

J Biomed Inform 2015;56:265–272.

4. Rapport från Strålsäkerhetsmyndighetens (SSM) vetenskapliga råd om ultraviolet strålning 2013.

Rapportnummer: 2014:37 ISSN:2000-0456.

5. Cancerfondsrapporten 2014.

6. Nationellt vårdprogram malignt melanom 2014.

Regionala cancercentrum i samverkan.

10. Dermoscopy: Distinguishing Malignant Tumors from Benign. Gulia, Brunasso, Massone. Expert Rev Dermatol 2012;7(5):439-458 11. Dermatoscopy. An algorithmic method based on pattern analysis. Kittler, Rosendahl, Cameron.

Textbook 2011.

12. The Importance of a Full Clinical Examination: Assessment of Index Lesions Referred to a Skin Cancer Clinic Without a Total Body Skin Examination Would Miss One in Three Melanomas.

Aldridge, Naysmith, Ooi, Murray, Rees. Acta Derm Venereol 2013;93:689–92.

13. SBU Svårläkta sår hos äldre - prevention och behandling. En systematisk litteraturöversikt.

Stockholm: Statens beredning för medicinsk utvärdering (SBU); 2014. SBU-rapport nr 226. ISBN 978-91-85413-67-6.

14. Working towards improved wound management in Europe. Läuchli, European Wound Management Association (EWMA). Global Health and Pharma Magazine June 2015.

7. Nevus eller malignt melanom? Rätt kompetens vid diagnostik ger lägre kostnader. Lindelöf, Hedblad, Ringborg. Läkartidningen 2008;105:39.

15. Chronic ulcers of the leg: a study of prevalence in a Scottish community. Dale, Callam, Ruckley, Harper, Berrey. Health Bull (Edinb), 1983;41(6):310-4.

8. Societal Cost of Skin Cancer in Sweden in 2011. Eriksson, Tingshög. Acta Derm Venereol 2015;95(3):347-8

16. The resource impact of wounds on health-care providers in Europe. Posnett, Gottrup, Lundgren, Saal. J Wound Care 2009;18(4):154-61.

9. Diagnostic Accuracy of Dermatoscopy. Kittler, Pehamberger, Wolff, Binder. Lancet Oncology 2002;3:159.

17. Cost of wound treatment to increase significantly in Denmark over the next decade. Hjort, Gottrup, J Wound Care 2010;19(5):173-84.

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Bacterial Vaginosis – A common and hidden health problem among fertile women, still often treated with antibiotics several times a year

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industry insight Bacterial vaginosis (BV) is one of the most frequent vaginal infections in women of childbearing age and it is estimated that more than 300 million women worldwide are infected each year. The condition is rated as the most common cause for women to visit their gynaecologist.

BV is an imbalance in the vaginal bacterial flora resulting in lack of vaginal acidity, inhibition of the normal lactobacilli growth and an overgrowth of mixed anaerobic bacterial flora including Gardnerella vaginalis, resulting in odorous vaginal discharge.

BV is also associated with a wide range of medical problems including complications following pregnancy, surgery and an increased risk of sexually transmitted diseases.1-4 The prevalence of BV is estimated at approximately 15-30% among fertile women and frequent recurrences several times a year are common.5,6,7 BV affects many women’s lives negatively, especially due to odorous vaginal discharge, resulting in embarrassment and social isolation.

Today, antibiotics such as metronidazole or clindamycin, are the most common treatments of BV and in the U.S. recommended by the Center for Disease Control.5,8 Recurrences affect approximately half of the women with BV, which means that many women are treated with antibiotics several times a year.5 The emerging global risk of developing bacterial antibiotic resistance9 makes BV treatment with antibiotics cumbersome. In addition, antibiotic treatment often results in side effects, e.g. vaginal thrush, which also needs to be treated. However, there are alternative treatment options with good efficacy and less side effects. By actively acidifying the vagina to its normal pH-level, a poor microenvironment for the anaerobic bacteria is created so the beneficial lactobacilli have a much better chance to survive and get reestablished. This is a safe approach, counteracting the risk of antibiotic bacterial resistance development.

Laccure® Pessary Laccure has successfully taken its product from discovery all the way through clinical studies, where 80% of the women got rid of their BV after a single dose, to up-scaled manufacturing. The novel product is based on a proprietary substance that releases lactic acid over an extended period of time in order to normalize vaginal pH. The development work has focused on creating a user-friendly product that is not messy, is easy to insert and highly effective. It only needs to be administered once to treat a BV infection, and once a month to prevent recurrences.

The Laccure pessary is a medical device product, class IIa. The intended use covers both treatment and prevention of BV. The product is CE-marked and can thus be sold freely in the entire EU/EES.

izations. Laccure’s owners are now aiming to divest the company to a buyer with appropriate resources for the commercialization of the Laccure Pessary.

For more information please visit www.laccure.com References 1. Eschenbach DA. Vaginitis, cervicitis and endometritis. In: Gorbach SL, Bartlett JG, Blacklow NR, editors. Infectious diseases, 3rd ed. Philadelphia; Lippincott Williams & Wilkins; 2004. p.947.

2. Joesoef MR, Schmid GP. Bacterial Vaginosis: review of treatment options and potential clinical indications of therapy. Clin Infect Dis. 1995;20 Suppl. 1:872-79.

3. Hillier SL, Nugent RP, Eschenbach DA, Krohn MA, Gibbs RS, Martin DH, et al. Association between bacterial vaginosis and preterm delivery of a lowbirth-weight infant. N Engl J Med. 1995;333:1737-1742.

4. Schmid G, Markowitz L, Joesoef R, Koumans E. Bacterial vaginosis and HIV infection. Sex Transm Infect. 2009;76(1):3-4.

5. Fredstorp M. Foul-smelling vaginal discharge.

A hidden health problem at bacterial vaginosis; outcome from an international web-based survey in 2660 women in the U.S., the U.K. and Germany. XXI FIGO World Congress in Gyn & Obstet, Vancouver 2015; Abstract 0988.

6. Koumans E, Sternberg M, Bruce C, McQuillan G, Kendrick J, Sutton M, et al. The prevalence of bacterial vaginosis in the United States, 2001-2004; Associations with symptoms, sexual behaviors, and reproductive health. Sexually Transmitted Diseases. 2007;34(11):864-869.

7. Cauci, S., Driussi, S., De Santo, D., Penacchioni P., Iannicelli, T., Lanzafame, P., et al. (2002).

Prevalence of bacterial vaginosis and vaginal flora changes in peri- and postmenopausal women.

Journal of Clinical Microbiology, 40(6), 21472152. doi: 10.1128/JCM.40.6.2147-2152.2002 8. 2015 Sexual Transmitted Diseases Treatment Guidelines. Center for Disease Control, U.S. Department of Health and Human Services. http:// www.cdc.gov/std/tg2015/bv.htm 9. Laxminarayan R, Duse A, Wattal C, Zaidi AKM, Wertheim HF, Sumpradit N, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis. 2013;13(12):1057-98.

About Laccure AB Laccure AB is a project company of the life science development company P.U.L.S. (Partners for Development investments in Life Sciences). It was founded in 2007 and is based in Helsingborg, Sweden.

The initial development of the company’s product was carried out at Lund University, Sweden, and at Gdansk University, Poland. Further pharmaceutical development and GMP manufacturing for preclinical and clinical studies have been performed in collaboration with a number of contract development organ-

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The Swedish Government’s Stance on Antibiotic Resistance Swedish Government takes a stand against antibiotic resistance with recent ministerial call to action to encourage global decisiveness against the issue.

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industry insight Antimicrobial resistance (AMR) is fast becoming more prevalent as microbes become increasingly resistant to modern medicines. As treatment and infection prevention become increasingly difficult, Sweden has made it clear that it is taking a tough stance against this international issue.

In May the country’s, Minister for Health Care, Public Health and Sport for the governing Swedish Social Democratic Party Gabriel Wikström debuted a ministerial declaration which included commitments to implement the global action plan against antimicrobial resistance (to be dealt with by the World Health Assembly later that same week) and to ensure that heads of government, ministers and global leaders take on the challenge of growing resistance.

Alongside Professor Dame Sally Davis, Chief Medical Officer for England, Wikström called for a high-level meeting on antimicrobial resistance during the UN General Assembly in 2016.

In addition to Mr Wikström and Ms Davis, participants at the meeting, which took place as part of the World Health Assembly in Geneva, included health ministers from China, Germany, Norway, Pakistan, South Africa, South Korea, Thailand, the United States and Zambia, and the deputy health minister from Brazil.

Wikström made it clear that he fully endorsed the World Health Assembly taking a stance against AMR. “When this assembly adopts the Global Action Plan on AMR we are showing the world that we Member States take this problem seriously and are prepared to act. No action today - no cure tomorrow. So I hope - I trust - this session, this Assembly - will also reflect on what we need to see about ourselves. As individuals, as member states, and together. On what we really can do, and on what we really must do. To have the WHO that the world needs.”

As a result of the conference the WHA launched a global action plan to tackle the issue of AMR, which set out five objectives to deal with the problem: 1. To improve awareness and understanding of antimicrobial resistance.

2. To strengthen surveillance and research.

3. To reduce the incidence of infection.

4. To optimize the use of antimicrobial medicines.

5. To ensure sustainable investment in countering antimicrobial resistance.

The plan urges member states adapt these points to their national priorities and specific contexts and mobilizing additional resources for its implementation.

If adoption of the global plan is successful, governments will have in place by May 2017, a national action plan on antimicrobial resistance that is aligned with the global action plan. These individual plans need to cover the use of antimicrobial medicines in animal health and agriculture, as well as for human health. The World Health Organization has pledged that it will work with countries to support the development and implementation of their national plans, and will report progress to the Health Assembly in 2017.

Malnutrition and immunization gaps were also targeted as part of the plan, with member states agreeing

a set of indicators to monitor progress for global nutrition targets set in 2012 as part of a comprehensive implementation plan on maternal, infant and young child nutrition.

The Assembly also agreed a resolution to improve access to sustainable supplies of affordable vaccines as part of a drive to ensure lower income countries are able to ensure vaccination for their entire population.

Wikström called for the support of the WHO during his speech on AMR issue, making it clear that the organisation needed to support those countries who were committed to ending the crisis.

“Therefore we simply must have a strong World Health Organisation. A WHO that adapts and evolves.

Just like the great challenges, and the very real threats we know are adapting and evolving - and lie ahead. A WHO that supports member states so that they can build and sustain strong and resilient health systems. A WHO that has the capacity to act at both a global and a local level.

We cannot abandon overwhelmed nations with fragile health systems. We cannot leave global health security to private organisations with limited resources.

We cannot just pay lip service and turn our backs.

We cannot tie strings to our funding - and so tie hands. Of course continued reform of the WHO is needed. I would like to thank DG Chan for her commitment to reform and urge her to intensify efforts.

The WHO must learn from past mistakes - just as it must be the WHO that leads and coordinates in global health.”

Speaking at the Uppsala Health Summit, on the 2nd June Wikström again made it clear early on in his speech that he was firmly behind the World Health Organisation, and that Sweden would be a keen proponent of WHO and would support their cause to end AMR globally.

“Sweden fully supports a strong WHO. It seems self-evident that only a strong World Health Organisation can deal with global threats to health. An organisation that must, and will adapt and evolve.

And an organisation that will support Member States in building strong and resilient health systems.

Because without such health systems worldwide, as Ebola taught us, we simply cannot fight global health threats like AMR.” He was also keen to emphasise that the issue was an international one and did not apply exclusively to Sweden, with third world countries often being the worst effected by the problem.

“Every year AMR (Antimicrobial resistance) already kills half a million people worldwide. The costs, in human and in financial terms are already huge.

A heavy price for poorer countries who can least afford it.”

With the WHA implementing the international plan to target AMR, the WHO has a tough fight to ensure compliance and success, but the backing of the Swedish Government offers a lifeline and puts pressure on other nations to contribute to the fight against this fatal epidemic.

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MSM: A Miracle Molecule?

By Paul Klein Breteler Kala Health BV www.kalahealth.eu

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research In the nineties of last century, MSM was welcomed as a strong contender for the title ‘Nutraceutical of the Next Century’. The FDA had released MSM as a dietary supplement for the human market, and the godfather of MSM, professor Stanley Jacob of the Oregon Health Sciences University, had just released his exciting first book “MSM, the Natural solution for Pain” , followed a few years later by his second book “MSM, The Definite Guide” 1, 2 Fifteen years have passed since, and it is time to take a look where MSM is standing now.

MSM is an abbreviation of methylsulfonylmethane (or dimethylsulfon), an organic form of sulfur bound to two methyl groups. The chemical formula of MSM is CH3SO2CH3. It is the form in which sulfur appears in nature in all living organisms, and in which it is biologically active. MSM is an odorless, white, crystalline powder that is highly soluble in hot water and in a wide range of organic solvents.

ANCIENT MOLECULE MSM has been present in the oceans, soil, and atmosphere of Earth for eons. It has been collected by plants and eaten by animals for nearly as long. It is part of nature’s great sulfur cycle, upon which all life depends.

To better understand the significance of MSM, we have to go back to prehistoric times when oxygen was still absent. Only after terrestrial flora started to develop hundreds of millions of years ago, the atmospheric oxygen gradually increased. Long before that, oceanic algae started to produce short-chained organic sulfur compounds. Upon algal death and release into ocean water, organic sulfur molecules were quickly converted to DMS, a volatile sulfur compound that escapes into the atmosphere. In this suspended, gaseous state, the DMS reacts with ozone and ultraviolet sunlight to create DMSO and DMSO2, known as MSM. MSM then falls to the earth dissolved in rain drops, where it is collected and concentrated in plants.

DMSO CH3-SO-CH3

MSM CH3-SO2-CH3

and stable nutritional source for the body. In the US, MSM is Generally Recognized As Safe (GRAS).

SUPPLIER OF METYLGROUPS AND SULFUR Research with radio-active labelled MSM shows, each molecule MSM is broken down after consumption into a clean sulfate (SO4) group and two methyl (CH3) groups, without any rest groups. In biochemical text books you may learn, the amino acid methionine would be a main supplier of methyl groups for the body. However, when methionine is broken down the potential toxic rest molecule homocysteine remains. High blood levels of homocysteine have been associated with numerous and serious health problems. Additional use of high doses B-vitamins may be needed to regenerate homocystein into methionine, or further metabolize into less harmful substances (figure 2).

Cystein Vit B6

Vit B12 Folic Acid

Homocystein

Methionine

SO42Sulfate

MSM

SO42Sulfate

SAM-e

(CH3-SO2-CH3)

(CH3) Methyl group

(CH3) (CH3) 2 Methyl groups

Figure 2: MSM versus methionine as donor of methyl groups and sulfur.

air

MSM however, does not only yield more methyl groups then methionine, it leaves no potential toxic rest molecules behind, a crucial difference.

DMS CH3-S-CH3

organic sulphur

inorganic sulphur

algae

sea

msm

dmso

land

Figure 1: The Earthly Sulfur Cycle Short-chained organic sulfur compounds may have been the first and most important sources of energy for algae, and for all life forms that developed afterwards. Some scientist suggest all higher life forms present today may, be genetically programmed to use short-chained organic compounds such as MSM, as preferred source of energy and building blocks. This assumption is supported by the discovery, MSM is one of the least toxic compounds known, and can be taken by animals and humans in almost unlimited amounts, without toxic side effects. Even 48 hours after consumption, half of the MSM is still present in the body and MSM can still be found in the urine after 480 hours. This makes MSM a safe

Though sulfur is a crucial element for the body, the importance of MSM as a sulfur donor may be overrated. MSM may be far more important for the body as a clean supplier of methyl groups, which are the building blocks of all organic molecules. It is difficult to even imagine the importance of methyl groups for our health. Molecules are constantly broken down in the body, and reconstructed. We call this ‘Methylation’, the process of adding methyl groups to a molecule. Methylation is involved in almost biochemical reaction in the body, and occurs billions of times every second in our cells. Proper methylation contributes to a wide range of crucial body functions, including DNA synthesis, immune function, energy production, detoxification and mood balance. Lowered methylation function may contribute to many major chronic conditions, including cardiovascular disease, diabetes, cancer, immune dysfunction, neurological problems and mood disorders.

Detoxification is an ingenious process during which harmful substances are step-by-step broken down in

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research the liver, and excreted. Methylation and sulfonation are key steps in the detoxification process, which makes MSM –as supplier of both methyl groups and sulfate- a potential strong detoxifier. This was illustrated by the following case, a young artist suffering from heavy metal poisoning (as shown by microscopic examination of his blood using the Life Blood / HLB test). For one and a half year he used various pharmaceutical drugs, homeopathic and orthomolecular detoxifiers as well as bioresonance therapy, prescribed by a number of health care professionals. After one and one half years of detoxification the blood picture had hardly improved, still exhibiting severe toxicity symptoms (Figure 3a).

Figure 3: Microscopic blood examination using the Life Blood / HLB Test. The left image (Figure 3a) shows severe heavy metal poisoning, the right image (Figure 3b) shows how the blood returned to normal.

The man then was recommended to stop taking the medications received so far, and to start using high dosages of MSM (15 grams/day) instead, supported by weekly Ayurvedic sweat baths to stimulate waste discharge. Two months later a microscopic examination showed that his blood had returned to normal (Figure 3b).

BENEFITS OF MSM Due to the work of professor Stanley Jacob as Head of the Pain Clinic of the Oregon Health Sciences University, MSM has required most of its fame as killer of chronic pains. Taking into consideration the huge potential of MSM, a disappointing small number of studies have been carried out to reveal its mechanisms of work and its medicinal applications.

• Some studies show MSM may work well treating arthritic symptoms and support joint comfort and mobility, mainly due to its properties to block inflammatory processes and prevent cartilage break down.

• MSM has been shown to reduce exercise induced stress and muscle damage. Though not all mechanisms have been cleared, MSM significantly reduced important markers of lipid peroxidation and protein oxidative damage.

• Other studies show, MSM regulates the expression of reactive nitrogen and oxygen species by regulating certain transcription factors such as nuclear factor kappa B (NF-kB). MSM supplemented to mice showed an increase in liver glutathione levels by a stunning 78%. All these results add credibility to the supposed antioxidant defense capability of MSM as it shows efficacy across different species and from different stimuli of oxidative stress.

• Several studies have shown, people suffering from seasonal allergic rhinitis may benefit from MSM. • As a donor of bioavailable sulfur, MSM has been shown to support the integrity of skin, hair and nails.

MSM AND CANCER In the seventies of last century researchers at the Oregon Health Sciences University demonstrated, even low dosages of MSM given during or prior to the experimental period, would significantly delay the onset of induced tumors in rats. Rats In the MSM group would develop tumors a 100 days later, which –on an average life span of 2 years- would equal 10 years in human life. Anybody understanding the significance of the above, may realize taking MSM on a regular base might be a good idea. But it gets even more exciting.

In 2010 researchers of the Connecticut Health Center, added MSM in a concentration of 200 mmol/l to metastatic mouse melanoma cells, representing one of the most aggressive and deadliest types of cancer. To their surprise, MSM appeared to reprogram the metastatic melanoma cells into normal healthy melanocytes. Their conclusion was, MSM may have clinical potential as a non-toxic agent effective against metastatic melanoma 3.

In 2012 researchers in South Korea found MSM substantially decreases the viability of human breast cancer cells in a dose-dependent manner. These finding were supported by in vitro studies, showing MSM can effectively regulate biochemical systems involved in tumor development, progression, and metastasis 4.

With these promising studies, MSM seems to have definitely entered the field of cancer, the emperor of al diseases. The implications of this development are challenging: will MSM help basic scientists to better understand what signaling pathways play a role in the transformation of healthy cells to cancer cells, and back to healthy cells? Here is even a more challenging one: will we find ways to bring MSM to bodily metastasized tumor tissue in concentrations high enough to work as a non-toxic, therapeutic agent?

The technology is already there, with today’s knowledge it is possible to bind MSM molecules to specific markers that would concentrate MSM in tumor tissue.

Most of the challenges however, will be in the field of legislation, and communication toward the public.

The situation now is, MSM has the official status of food supplement, which means it is free for sale in many countries but health claims will not be tolerated by authorities. Any new version of MSM most likely will be considered a novel food, which implies an extensive safety dossier must be submitted before sale is allowed. And should MSM raise the undesired interest of drug legislation authorities, the free sale of MSM may become in real danger.

LITERATURE 1. Jacob, S. W.; Lawrence, M.D.; and Zucker, M.: The Miracle of MSM. The Natural Solution for Pain. Publ. G.P. Putnam’s sons, New York: 1999.

2. Jacob, S.W.; Appleton, J.: MSM. The Definite Guide. Publ. Freedom Press, Topanga, US, 2003.

3. Caron JM, Bannon M, Rosshirt L, Luis J, Monteagudo L, et al. (2010) Methyl Sulfone Induces Loss of Metastatic Properties and Reemergence of Normal Phenotypes in a Metastatic Cloudman S-91 (M3) Murine Melanoma Cell Line.

PLoS ONE 5(8): e11788. doi:10.1371/journal.pone.0011788 4. Lim EJ, Hong DY, Park JH, Joung YH, Darvin P, et al. (2012) Methylsulfonylmethane Suppresses Breast Cancer Growth by Down-Regulating STAT3 and STAT5b Pathways. PLoS ONE 7(4): e33361. doi:10.1371/journal. pone.0033361

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Cognitive Training: Tackling the Cost of Mental Health in the Workplace

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professional services Mental illness is one of the largest global health crises of our modern times. Recent figures estimate that the global cost of mental illness, including medical and indirect costs, will be over $6 trillion by 20301.

In addition to the considerable personal and human burden of mental illness, mental health costs businesses billions each year in absences and lost productivity.

Employers are struggling to contain the financial and human costs of mental ill health and recognise the importance of preventing the escalation of stress and mental health issues in the workplace. Prevention and early intervention are key – a study in the Netherlands estimated that every €1 spent on treatment saves €4.24 in increased productivity and reduced costs of care2. When it comes to mental health, employers need tailored solutions, which encourage healthy habits, improve employee wellbeing and resilience and boost performance at work.

Two solutions that have been gaining attention for their potential to prevent and tackle the early signs of mental illness, while at the same time improving performance, are cognitive assessment and training.

Forward thinking companies are using cognitive health products often as part of broader workplace wellness packages. Computer assisted cognitive assessment and training is non-invasive, can be self-administered and are cost-effective and tailored to the individual. So how do they work?

Mental health conditions, like depression, are associated with a range of symptoms; emotional, cognitive and physical. Cognition is synonymous with the way our mind operates. It is the ability to plan and organise, solve problems, recall events and people, focus attention and respond with speed and accuracy. A healthy, balanced cognition enables people to perform to the best of their abilities and, just as when we improve our physical health, it provides “cognitive resilience” to manage better when under pressure. However, cognitive dysfunction associated with depression – if left untreated - will result in poorer function at home and at work. The consequences in the workplace include reduced productivity and work quality, and increased absenteeism and presenteeism, where employees are physically present but mentally absent.

Assessing cognitive health can help spot the early signs of mental ill-health. Businesses can now offer their employees screening for cognitive health issues simply and easily via online tools such as MyCognition’s MyCQPro or interactive apps like MoodFx. MyCQPro is a 15 minute online cognitive assessment, which evaluates the health of the five core cognitive domains; executive function, working memory, episodic memory, attention and psychomotor speed via a series of scientifically validated psychometric tests.

The assessment, which can be taken anonymously, empowers individuals by offering them detailed information about the health of their cognition, highlighting cognitive strengths and potential weaknesses.

An indication that someone is struggling in some cognitive areas, or is uncharacteristically withdrawn or angry for example, provides a chance for them and their employer to act early and explore what the underlying issue might be, and if necessary to seek professional help.

MyCQPro works alongside MyCognition’s adaptive cognitive training programmes, which, through a processor (patent applied), interpret the results of the cognitive assessment. Training is personalised and focuses on the areas of greatest need for the individual whilst simultaneously, holistically exercising all cognitive domains to provide a complete cognitive workout. The training is adaptive, and is challenging enough to make the effort worthwhile without being too difficult. This approach helps to strengthen the individuals’ core cognitive health – improving their mental wellbeing and resilience. To monitor cognitive improvement over time, the MyCQPro assessment can be repeated as required.

There is a growing body of scientific research that supports the increased role cognitive assessment programmes are taking within HR and Occupational Health. A March 2015 report in The Lancet featuring a randomised controlled trial (RCT) of brain training in Finland3 suggested that it can play a key role in improving mental faculties and preventing cognitive decline. MyCognition’s own research in patients with OCD, schizophrenia and schizoaffective disorder, is ongoing, but has already shown significant cognitive gains in in verbal and visual memory performance using MyCognition’s assessment and training programmes4.

With their popularity growing, the number of brain and cognitive training products available is increasing - ranging from online memory games and crossword apps through to scientifically developed and tested cognitive evaluation assessments and programmes such as MyCognition’s. It is important to remember therefore that each product should be assessed on its merits and matched to the requirements of the company or individual.

With the NHS in England adopting online mental health products such as the Big White Wall and most health insurance companies looking at offering solutions to their customers, it is clear that online cognitive health programmes are becoming established.

This is good news for all in the workplace, whether they suffer directly from poor mental health or not.

A scientifically grounded cognitive assessment and training programme combined with a robust workplace wellness programme could make a huge difference to everyone’s personal and working lives.

Dr Raj Kumar is Chief Medical Officer at cognitive health company MyCognition.

References 1. ‘The Global Economic Burden of Non-communicable Diseases’ - a report by the World Economic Forum and the Harvard School of Public Health - September 2011 - http://www3.weforum.org/ docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf 2. The Economist – Out of the shadows, 2015 3. The Lancet, 2015; DOI: 10.1016/S01406736(15)60461-5 4. Pilot Psychiatric study, 2013/14. Randomised controlled trial with 19 patients with a mean age of 30.5 and a diagnosis of OCD (n=5) or schizophrenia/schizoaffective disorder (n=14).

Subjects were randomized to either Treatment as Usual (TAU) or TAU plus MyCognition’s training programme.

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By Carl Johard. Photo: NHI.

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industry insight

Northern Sweden Shows the World How to Implement Remote Virtual Healthcare Public stakeholders in Northern Sweden have joined forces with Nordic Health Innovation (NHI) to support a collective ambition with the aim of becoming world leaders in the field of future health and social care in rural areas. This plan includes an extensive initiative relating to virtual health rooms in cooperation with municipal healthcare services. Three such health rooms have already been established, and more are in the pipeline.

In many countries all over the world, rural medicine is a high priority area undergoing extensive research.

Sweden’s only R&D department specialising in rural medicine is situated in Northern Sweden, where just under 300,000 people now live in rural areas. This area also has the highest proportion of elderly people and the highest dependency ratio. If this area continues to develop as is currently the case, researchers expect there to be more people of non-working age in Sweden’s rural municipalities than people of working age by the early 2030s. This is a development which will significantly increase and alter the need for healthcare and medical services, but also the chances of recruiting well-trained care personnel.

Against this background, NHI has joined forces with regions and municipalities in Northern Sweden to support a collective medical services policy plan and an ambition with the aim of becoming world leaders in the field of future health and social care in rural areas. This ambition includes continued development of the virtual health rooms in cooperation with municipal healthcare services. The aim is to have at least 20 or so similar virtual health rooms in the four northernmost counties within two years.

A good testbed arena The inland municipalities in Northern Sweden have a temporal advantage on account of the skewed age structure of the population, where between 25 and 30 per cent of residents are over the age of 65. In some municipalities, more than 10 per cent of the population is over the age of 80. “In this respect, we are approximately 25 years ahead of the rest of the world. In inland areas in Northern Sweden, therefore, we have a unique opportunity right now to test medical technology products, working methods and processes of various types on an existing population

with an age structure which will be reality in many countries in 25 years’ time. This demographic advantage, combined with one of the best developed, high-quality broadband networks in the world and cohesive, high-quality patient case note systems, provides outstanding opportunities to test innovative new solutions in the care and medical services sector,” says Peter Berggren, Head of the research organisation GMC (Centre of Rural Medicine) and one of the founders of NHI (Nordic Health Innovation).

“Our ambition is for Northern Sweden to provide a good testbed arena for rural medicine and distance-spanning methods,” he adds. “We have to turn our demographic lead to our advantage. We are aiming to devise hot products and services which will help us to live longer, healthier lives at home, while the same time aiming to provide care in people’s homes to a greater extent.”

Focusing on virtual health rooms The expansion of virtual health rooms is one of the most important initiatives in Northern Sweden relating to rural medicine. At present, a virtual health room is a customised, unstaffed health room with the aim of staying open 24 hours a day for recipients of care in rural areas. It will also be possible to install the virtual health rooms of the future in people’s own homes or on their mobiles. If necessary, doctors will be able to connect to these rooms via video links, and the rooms will be equipped with a range of devices. All local residents will be able to go into one of these rooms and check their blood pressure and take blood, blood sugar and warfarin samples. These devices will be interlinked with district medical officers’ case note systems and medical services case note systems via a central server.

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“This will be a self-service facility where people can easily screen themselves and make initial contact with a doctor,” says Peter Berggren of NHI. Award-winning founders Nordic Health Innovation (NHI), a company with 20 years’ practical experience of remote technology and virtual healthcare in extremely rural areas and which has been developed in close cooperation with the research organisation GMC (Glesbygdsmedicinskt Centrum, the Rural Medicine Center) in Storuman, is responsible for the launch of the virtual health rooms. The founders of NHI are brothers Dr Peter Berggren and Jonas Berggren. Last year, Peter Berggren won the Guldskapellen Swedish Medical Care Innovator of the Year award for “the courage to try new ways of operating and organising primary care through innovative approaches, new technology and a broader perspective on the living conditions of people in rural areas”. That same year, Jonas Berggren won the prestigious Swedish Stora Produktivitetspriset Award in his capacity as CEO of the rapidly growing SSG (Standard Solutions Group).

NHI offers flexible, cost-effective and standardised virtual health rooms to public and private customers with the aim of helping to improve quality of life and increase accessibility even for citizens living in extremely rural areas who are a long way away from doctors and other medical care specialists.

NHI’s health rooms To date, NHI has built up virtual health rooms in the villages of Slussfors and Gällö in Northern Sweden.

The next health room is planned to open in the village of Stugun in the autumn. “For us, these virtual health rooms are a deliberate strategic initiative. With distance-spanning methods, we can ensure that we

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industry insight achieve good, effective healthcare and medical services, while at the same time ensuring that patients do not have to travel as far. These complement the health centres, relieving pressure on them and increasing availability as the health rooms have much better opening hours than standard health centres,” says Björn Eriksson, Regional Director for Region Jämtland Härjedalen.

The health room in Slussfors in the municipality of Storuman has been in use for almost two years now, with very good results. The health room is situated close to the school in the village, with keys and the staffroom for the home help service, offering access to assistance and trained personnel.

“Slussfors is a pilot facility, and we have had the opportunity to try out and develop various devices and ideas here. The health room in Slussfors is working well, and the municipality and medical services resources work together there to help patients with samples if so required,” says Peter Berggren of NHI. 83-year-old Carl-Axel Nordenberg, who was part of the health room’s reference group, has also found the health room to be positive. “It is 50 to 80 km to the nearest health centre for the people living here in the area. Slussfors is just 10 or 20 km away. The health room is extremely valuable for those of us who need a quick initial consultation with a doctor via a link and access to blood pressure readings and blood samples, and it offers us a high level of security. I know of at least one person who discovered that she had diabetes without knowing about it thanks to the health room,” he says.

Focusing on innovations in training NHI and the Rural Medicine Center are now investing major resources in the further development of the virtual health rooms, together with their partners and customers. These initiatives include remotely controlled cardiac ultrasound using robotics, planning and dimensioning tools for support care and medical services, and an app for diabetics which enhances security for adults and children alike.

“We can make the virtual health rooms as good as we like – the only limits are in our own imaginations,” says Jonas Berggren, Chairman of NHI. Training initiatives are also important for ensuring that skilled assistance is always close at hand to the health rooms. “In Gällö in Jämtland, for example, we have launched a training course where municipal home help staff can learn all about the equipment found in the health room. We are also focusing on a self-learning system where residents and relatives can teach one another to use the equipment. We face a major challenge here, because the diagnostic equipment available at present is designed for use by care professionals, not by users. We have to design simple products which can be understood and used by anyone while at the same time safeguarding the diagnostic security required by healthcare and medical services,” says Jonas Berggren of NHI. “Standard manuals are not always the best tools,” adds Peter Berggren of GMC. “Here, we are considering simple 3-D instruction videos instead.”

A separate, unique information exchange Further building up, refining and streamlining the digital doctor service is another initiative high up on NHI’s focus list, as is guaranteeing and streamlining information management to and from care providers’ primary medical data and case note systems.

Not least, this is taking place in close cooperation with NHI partners Microsoft, Sigma IT Consulting and Cambio. Cambio is one of Sweden’s leading stakeholders in the field of medical services systems, while Sigma is a leading Nordic supplier of innovative and effective IT solutions based on IoT and the cloud. Microsoft’s bold ambition to re-invent productivity and business process aligns very well with this initiative.

“We are now working together with Sigma, Microsoft and Microsoft Azure technology to build our own flexible exchange which is being designed to integrate our information from NHI and the Rural Medicine Center with the Swedish hospital healthcare case notes system and the newly formed Swedish e-health account HälsaFörMig. With the e-health account, the intention is to gather all information on an individual’s health in a single location which is private and accessible to that individual him/herself. The aim is for this to work as a public health service which makes it possible for people to review their own health information both historically and at the present time, but also to share this information with medical services and research,” says Jonas Berggren.

The service will be cloud based and the Microsoft servers are located within the European Union.

Security and data privacy are key contractual and architectural elements and the setup will need to fulfill the Swedish and EU requirements in the area.

Major gains and significant effects There are many social benefits to be gained from virtual health rooms and technology which is not dependent on distance.

“We will see a clear improvement. Accessibility for residents is one of the benefits, as well as taking services out to patients and reducing the cost of travel and transport. Several million kronor are spent on medical travel in our region alone throughout the year. It will also provide us with an interface for cooperation and implementation of new concepts and innovations,” says Björn Eriksson of Region Jämtland Härjedalen.

Jonas Berggren of NHI agrees. “The region stands to gain a lot by ensuring that the people who really need medical services are also the people who can access those medical services. It may not be possible to replace all visits to the doctor with a virtual health room, but many visits can indeed be replaced.”

The cost of travel and locum cover are some of the biggest expenditure items for the regions in northern Sweden.

“We recently carried out a health economics study as part of an EU project in which we looked at self-service units where patients could turn up and take their own blood pressure and blood samples.

The results showed that there was a rapid return on investment (ROI),” says Peter Berggren of GMC.

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“Investing in these virtual health rooms is a vital step in the development of our new medical services. This is a way of streamlining and modernising medical services on patients’ terms. Care services will be more accessible and we will see a new, minimum, effective level of care,” says Björn Eriksson of Region Jämtland Härjedalen.

Prouder staff and greater ease of recruitment are another major benefit.

“Some of the staff that we have at the special housing in Gällö in the municipality of Bräcke have opted to undergo training on this. As a result, they feel prouder about their work and are more encouraged to do a good job. We are expecting more people to apply to the care services when they find out more about the new care technology,” Sven-Åke Draxten, Chairman of the municipal board in the municipality of Bräcke.

Major international interest NHI is focusing initially on developing and offering solutions in Scandinavia.

“But in the long term, the needs are the same in other, similar areas all over the world, with corresponding needs for cost-effective, distance-spanning medical services,” says Jonas Berggren of NHI. On an international level, there are many sparsely populated areas which are grappling with similar difficulties. There are major differences in ill-health figures between rural areas and urban areas in Canada, the USA, Australia, Norway, Scotland and a number of countries in Asia, Africa and Latin America, and they also have growing ageing populations with complex needs, as well as major problems with recruiting and retaining doctors and other care personnel.

Therefore, NHI is participating in the Rural Health project Room for Care by establishing a testbed for virtual healthcare in a village in Gunungkidul on the island of Jakarta in Indonesia. The aim of this project is to improve the capacity of the local Indonesian authorities, helping them to improve health and wellbeing among the rural population.

In order to enhance their knowledge, stakeholders in Northern Sweden are also intending to build an R&D network together with other countries with sparsely populated areas. Annual conferences relating to health and social care in rural areas are planned for the next two years, with international participation.

There is already well developed international cooperation with organisations such as the National Centre of Rural Medicine (Nasjonalt senter for distriktsmedisin, NSDM) in Tromsø in Norway, Nord-Trøndelag University College and Sør-Trøndelag University College, the Central Norway Regional Health Authority (Helse Midt-Norge) in Trøndelag, Northern Ontario School of Medicine in Canada, Flinders University in Australia and the Centre for Rural Health at the University of Aberdeen in Scotland.

“But rural areas are not the only places with these needs. We are also seeing greater demand for distance-spanning medicine in urban areas. In addition to that, we are seeing demand for virtual health rooms in the field of occupational healthcare,” concludes Peter Berggren.

GS1 UK: Raising Standards

The not-for-profit standard setting organisation recently held their annual healthcare conference, highlighting the vital role they are playing in the NHS, and the exciting new challenges they face in implementing their standards across the board to support patient safety, regulatory compliance and operational efficiency.

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NHS The conference, which was the second annual event, was held in June with a particular focus on the progress and impact of the Department of Health’s eProcurement strategy which was published last year.

The strategy, published under the 2010 to 2015 Conservative and Liberal Democrat coalition government, specifically recommended GS1 standards be implemented in order to improve patient safety and procurement efficiency.

This involves the use of GS1’s barcodes, which allow products and implants to be traced back to the source, ensuring that problems such as the PIP breast implant scandal are never repeated. Glen Hodgson, Head of Healthcare at GS1 UK, explained how the identification process works.

“We set the standards that can uniquely identify in healthcare, every person, every product and every place. A person can be a patient but importantly it can be a care giver too. A product can be anything from a surgical instrument that can be traced and tracked where it was used and to whom, to a device such as an implant, a heart pacemaker or a breast implant. A place could be a hospital, a ward, a bed or an ICU centre. We use the standards to identify who did what to whom, where, when and with what.”

This enables enhanced patient safety, with the standards ensuring that any issues can be traced back to the exact place and person responsible. The implementation of standards also allows improved procurement efficiency and reduced wastage, with NHS Trusts able to see exactly what they have allocated and where. Additionally, Trusts are able to comply more easily with legislation, for example the UDI, Unique Device Identification Legislation, conceived by the IMDRF (International Medical Device Regulator Forum), the United States Food and Drug Administration (FDA) and the European Commission to ensure all medical devices within the healthcare supply chain are marked and identifiable.

The conference aimed to bring together NHS Trusts to discuss best illustrated practice of the implementation of GS1 standards following numerous recommendations from senior healthcare officials, including being mandated in the Personalised Health and Care 2020 framework, designed to act as an outline of how the NHS should use technology and data to improve patient care and the overall effectiveness of the service.

“The GS1 standards, which include the unique identification of patients, products and places, as well as Radio Frequency Identification (RFID) tagging, make a well-evidenced contribution in health and care.

These international standards have been shown to improve patient safety and quality of care by minimising the risk of errors occurring, and are also used for more effective and efficient supply chain management, resulting in significant cost savings. In order to maximise the opportunity that technology offers to promote safe care and productivity, NHS England will, with the HSCIC, develop a joint approach to implement the GS1 standards across the health and care system. They will feature from April 2016 within the NHS England commissioning framework and relevant system specifications.”

This high profile recommendation and impressive programme led to representatives from over 40 NHS Trusts, in total a little over 250 guests, to attend the conference. The conference opened with a speech from John Warrington, Deputy Director of Procurement at the Department of Health, who emphasised that GS1 standards are essential in order to deliver the Five Year Forward View of the service.

There was a broad range of perspectives among the speakers at the conference, with NHS National Patient Champion, Ashley Brooks, Head of Stakeholder and Cultural Transformation at NHS England, Sam Sherrington, and The Right Honourable Lord Philip Hunt - all offering their opinions on how GS1 standards can help the NHS, particularly focusing on cultural change. There was also an opportunity for Trusts to highlight their successes in implementing GS1 standards, which Hodgson pinpointed as one of the highlights of the conference.

“One of the things we were absolutely delighted with at the conference was that we were able to join together the people who have really been exemplars of GS1 standards in the hospital trusts, such as Derby, Cambridge with other trusts, and allow them to share their successes with the wider NHS. Often there’s just not a forum for sharing best practice, so the thing that pleased me most was watching a Trust member demonstrate and be very proud of the solution he’s put forward and have him questioned by his peers. It was a fabulous exchange of best practice that will now really help underline the momentum that is there. It’s all well and good for the government to say that we need change but it needs to happen out on the ground, in the Trusts where they are now seeing the benefits.”

The conference brought about a number of interesting developments for GS1. The day after the conference was held, on June 11th, the Lord Carter Review was released in which GS1 standards are specifically recommended to improve the structure of the NHS. “The introduction of GS1 and PEPPOL standards will allow every NHS hospital in England to save on average of up to £3 million each year, while improving patient care.”

In light of the conference, Hodgson was invited to an audience with the Parliamentary Under-Secretary of State for Health, and sponsor of the Lord Carter Review, Lord David Prior, where Hodgson was able to discuss with him about the benefits of GS1 standards for the NHS and Lord Prior was able to reaffirm the new Government commitment to the Department of Health’s strategy.

The outcome of the conference illustrates just a tiny proportion of the mass industry support that GS1 standards have, highlighting their importance for the ongoing improvement of the NHS, which will benefit both hospital Trusts, healthcare supplies and patients alike.

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2020 Vision: Digital Efficiency and Innovation in the NHS

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NHS Every year The King’s Fund’s Digital Health and Care Congress brings together a diverse group of people, united by an interest in digital health, to share and discuss the ways that digital products and services are changing and improving health systems.

This year’s congress was sold out yet again, demonstrating the huge interest in this area. By Matthew Honeyman, Researcher, The King’s Fund.

Among the many fascinating talks and discussions, two key points to highlight involve a number of important announcements that are very relevant as the NHS races to meet two prominent policy commitments by 2020: to achieve an unprecedented £22 billion of productivity savings, and to make all patient records digital and accessible in real time across all settings for patients and staff.

First, the top-down view. At the National Information Board’s leadership meeting, held at the Fund at the same time as the congress, there was a notable new focus on the contribution that better use of information and technology can make to the £22 billion productivity challenge. For the first time, chair Tim Kelsey shared the board’s estimate of that contribution, saying that digital efficiency and innovation could make around a third of the savings required (up to £8.3 billion in total). This eye-catching figure is supposed to come from the role technology is expected to play in enabling many of the ambitious reforms and new models of care outlined in the NHS five year forward view.

The credibility of this top-down estimate will be tested in the coming months, as the board works to join it up with any savings realised from work on the ground. In future, expect to see a lot more emphasis on how technology can save money as well as improve the quality of care for patients, an assumption that has been questioned in the past.

Tim Kelsey also trumpeted the progress that the NHS has already made in some areas. For example, nearly all GPs (97%) now offer patients online appointment booking, repeat prescriptions and access to summaries of their records. That’s up from just 3% a year ago. But while the technical capabilities are now in place, they are not always easy to use.

The challenge is to make these channels as routine to use as others, like phoning or dropping in to a GP surgery. GPs and their suppliers would do well to learn and spread lessons from design-thinking to improve the ways these systems operate and fit into patients’ lives, seeking and harnessing user feedback to continuously improve the experience, making it easy to use. The same will be true for the many new uses of technology and data due to be introduced before 2020 for both staff and patients.

They invited other areas to join their ‘Ripple’ programme to work together to understand how an NHS with a single record can be achieved across the system, not just in Leeds. Ripple will develop and document a set of open tools, systems architecture, the governance and the ways people can use it. The team plans to make this all open source, publishing it freely and allowing its reuse; a gift to the rest of the NHS and its patients.

So what are the benefits of using an open-source model? One benefit is that anyone can use or adapt the code for their particular application without having to buy it and without being locked in to an individual software supplier. Open source is most commonly used to develop software but can apply to the design and production processes for any product or service.

Open source is a model that has struggled to gain traction in the NHS; its advocates blame ‘vendor lock in’ to proprietary platforms, its critics claim it lacks a viable business model without ownership.

But now that could change. The Leeds team’s ambition is that the NHS benefits from an approach that helps new innovators to build on the work of others, instead of starting from scratch or buying into proprietary platforms.

Though it’s early days, the Leeds Care Record is an example of innovation from within the NHS. And this is the sort of innovation that needs to be spread, sharing the lessons and tools for replicating it; something Leeds hope to achieve with its new community. Along with strategy and standards set from above by the National Information Board, this is the kind of change from within needed to meet the challenges for 2020.

This article originally appeared on The King’s Fund website: www.kingsfund.org.uk

The second announcement comes from the local level, but it could have system-wide impact too. Rob Kenyon and Tony Shannon shared the achievements to date of the Leeds Care Record – a single patient record shared by multiple NHS organisations, GPs and the local council in Leeds.

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Abid Kanji is Associate Director at NonStop Recruitment

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industry insight

Why Smaller Pharma Firms Are the Place to Be You don’t have to work in the industry to know that big pharma is facing big challenges. The on-going threat of the patent cliff, along with a slowdown in the rate of research and development, has meant things aren’t looking as positive as they once were for the major players. However, as these companies look to cut costs, one of the methods they have adopted is, in effect, to outsource early-stage research and development to smaller firms, which has naturally led to increased employment opportunities. So with this in mind, what are the benefits of working for a smaller company over a larger one?

It almost goes without saying that working for a smaller firm will give you a greater chance of shaping and steering its direction than you would get at a major company. Working for an organisation like Glaxo or Pfizer, for example, can make it difficult to feel like you’re having a big impact on the business as a whole.

However, at a smaller firm your work is likely to have a direct correlation to the success of the company and you’re considerably more likely to be recognised for your efforts. In a similar vein, you’ve also got more chance of having your voice heard. If you have a strong belief that the direction the company is taking is the wrong one, or you spot a potentially profitable gap in the market, then working at a smaller firm can mean your opinions will be listened to. At a larger organisation you’d first have to fight through layers of middle management before getting to senior level and even then your idea may not be heard, let alone adopted.

As a result of the increased exposure, and partly due to the fact that you’ll have less competition, working for a smaller firm also gives you a much higher chance of securing a promotion and climbing through the ranks in a shorter space of time. This also obviously depends on your individual qualities, your ability to take responsibility, your boss and a range of other factors, but generally you’re likely to have greater access to development opportunities at a smaller firm. SMEs are also more likely to promote from within than their larger counterparts as the damage that could be caused to company culture by one bad external recruit is considerably worse in a smaller business.

Another consideration to take into account is that projects move at a much quicker pace at smaller companies. If you’re feeling frustrated by having to cut through masses of red tape and fight against bureaucrats at every level, a smaller firm may be for you. Here, there are fewer stakeholders to seek approval from, meaning that projects can be undertaken at a much faster rate, which will only benefit the company’s position in the market.

A factor that you perhaps haven’t considered is that working for a smaller pharmaceutical or biotech firm can also potentially give you access to a serious

amount of money in the future, as many organisations choose to offer stock options to their employees. Let’s not pretend that everyone who works for a SME in this field will become a millionaire, but in this industry smaller firms can grow into big ones in a short space of time. All companies need is one ‘blockbuster’ drug or scientific breakthrough and they could be following in the steps of firms such REDX, which is already an AIM listed company just five years after its creation. For the sceptics, just consider that the founding employees of Apple and Google are now worth millions of pounds, at the very least. And while a smaller pharma firm may not have the potential to grow to the size of these businesses, you could profit if your employer were to strike gold.

Of course, working at a smaller firm isn’t all sunshine and rainbows and there are factors that should be taken into account when considering a move. For one thing, smaller companies are most at risk of being affected by market conditions, particularly those that focus on one or two ‘blockbuster’ products. This can mean that the organisation could potentially be bought out or face difficulties in a downturn.

For sales staff in particular, working at a smaller organisation can also create additional challenges, not least that you won’t have a hefty expenses account to impress potential clients with. You’ll also have to consider that you may not have the robust marketing team to support your sales activities and won’t be able to rely on your brand name in the same way you would at a major firm.

There’s also the issue of the company not having as much cash to invest in technology and products for its staff. While you won’t be limited to an old Bunsen burner and lab coat, it’s likely that smaller firms won’t have the absolute cutting-edge resources that a Glaxo, Novartis or AstraZeneca have access to and for technical roles this can be an issue to consider.

In very rare circumstances you may find that some of the smallest companies might not be on formulary with insurance providers, which would significantly affect your ability to take the product to market and sell it. However, this is something that can be clarified before committing to work for the organisation.

While you may face some challenges working at a smaller pharma firm, the majority of these factors are rather minor and are outweighed by the potential to have greater responsibility over your work, improved chances of securing a promotion and the ability to potentially earn a significant amount of money further down the line. So for professionals looking for a new pharma role, maybe it’s time to forget the major players and look to the smaller firms. As the sector continues to evolve it’s likely that more nimble and agile companies will prosper in the future, so get on board while you still can.

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