The faces of personalized medicine: a framework for understanding its meaning and scope

Gender-specific pathway differences in the human serum metabolome

The susceptibility for various diseases as well as the response to treatments differ considerably between men and women. As a basis for a gender-specific personalized healthcare, an extensive characterization of the molecular differences between the two genders is required. In the present study, we conducted a large-scale metabolomics analysis of 507 metabolic markers measured in serum of 1756 participants from the German KORA F4 study (903 females and 853 males). One-third of the metabolites show significant differences between males and females. A pathway analysis revealed strong differences in steroid metabolism, fatty acids and further lipids, a large fraction of amino acids, oxidative phosphorylation, purine metabolism and gamma-glutamyl dipeptides. We then extended this analysis by a network-based clustering approach. Metabolite interactions were estimated using Gaussian graphical models to get an unbiased, fully data-driven metabolic network representation. This approach is not limited to possibly arbitrary pathway boundaries and can even include poorly or uncharacterized metabolites. The network analysis revealed several strongly gender-regulated submodules across different pathways. Finally, a gender-stratified genome-wide association study was performed to determine whether the observed gender differences are caused by dimorphisms in the effects of genetic polymorphisms on the metabolome. With only a single genome-wide significant hit, our results suggest that this scenario is not the case. In summary, we report an extensive characterization and interpretation of gender-specific differences of the human serum metabolome, providing a broad basis for future analyses.

A Nurse-Led Multidisciplinary Intervention to Improve Cardiovascular Disease Profile of Patients

The aim of this study was to evaluate the impact of a structured screening and nurse-based intervention on cardiovascular risk factors. In patients with established cardiovascular disease, a cardiovascular risk profile was assessed, and lifestyle was evaluated by using an automated questionnaire. A multidisciplinary team proposed an integral individualized plan of care on the basis of these assessments. During follow-up, a nurse-led lifestyle intervention program and the best medical treatment were offered. A total of 328 outpatients were included. After screening, a follow-up term of at least 1 year was reached in 176 patients (59.9%). Low-density lipoprotein cholesterol and systolic blood pressure were significantly reduced. A reduction in the amount of smoking, alcohol consumption, and unhealthy eating habits was observed. However, the amount of physical activity was unaffected, and body mass was increased. A structural evaluation of cardiovascular risk factors and an integrated nurse-led approach can successfully reduce risk in cardiovascular patients.

Pharmacogenomics in the nursing literature: an integrative review

BACKGROUND

Pharmacogenomics is a rapidly growing component of personalized health care, and nurses must be competent to deliver genomic-focused nursing care.

METHODS

We conducted an integrative review of pharmacogenomics in the nursing literature. A comprehensive search of the nursing literature was conducted using the key words pharmacogenomics and pharmacogenetics. A total of 47 unique articles were included.

RESULTS

Articles represented mainly narrative reviews, with limited discussions of the implications for nursing practice, education, or research. As such, they provide limited direction for advancing either clinical practice or scientific inquiry.

CONCLUSIONS

This review serves as a call to action for more systematic and empirical publications addressing pharmacogenomics in nursing practice, education, and research. Nurses must be involved in and contribute to interdisciplinary conversations and burgeoning clinical practice initiatives related to pharmacogenomics.

Melding regulatory, pharmaceutical industry, and U.S. payer perspectives on improving approaches to heterogeneity of treatment effect in research and practice

Effective pursuit of the science and management of heterogeneity of treatment effect (HTE) relies on the mutual understanding of the perspectives of, and collaboration among, the various stakeholders in health care. In this article, we compare, contrast, and endeavor to find areas of alignment across the perspectives of three such stakeholders -regulators, the biopharmaceutical and device industry, and U.S. payers. First, we discuss how evidence of HTE is generated and could be improved upon. For pharmaceuticals, much of the initial research is conducted by the pharmaceutical industry, guided by basic science but also delimited by potential markets, regulatory approval requirements, trial size considerations, and payer expectations for evidence of value. Once a drug is marketed, further evidence can be generated via combining trial data, conducting meta-analysis, and analyzing real-world results through observational research designs; we explore how these efforts can benefit from cooperation across these stakeholders. Second, we discuss the equally important utilization of HTE evidence so that physicians and patients have access to and can benefit from the learnings from this research. Research findings must be translated into actionable information and guidelines that can be incorporated into everyday practice. Doing so requires interaction and collaboration among all involved, based on facilitated communication as well as further evaluation research. We provide examples of several cross-sectorial initiatives that are under way in this area. Finally, we explore some economic aspects of HTE research as part of the drug development, marketing, and treatment process. Understanding the economic incentives present is fundamental to aligning those incentives to improve the availability and utilization of HTE evidence. Clear understandings among regulators, pharma, and payers about high-value targets, methods to efficiently generate and communicate information, and value propositions can lead to "win-win" scenarios for patients, individual payers, the health care system overall, and the future of drug development in producing new medicines.

Economic incentives for evidence generation: promoting an efficient path to personalized medicine

The preceding articles in this volume have identified and discussed a wide range of methodological and practical issues in the development of personalized medicine. This concluding article uses the resulting insights to identify implications for the economic incentives for evidence generation. It argues that promoting an efficient path to personalized medicine is going to require appropriate incentives for evidence generation including: 1) a greater willingness on the part of payers to accept prices that reflect value; 2) consideration of some form of intellectual property protection (e.g., data exclusivity) for diagnostics to incentivize generation of evidence of clinical utility; 3) realistic expectations around the standards for evidence; and 4) public investment in evidence collection to complement the efforts of payers and manufacturers. It concludes that such incentives could build and maintain a balance among: 1) realistic thresholds for evidence and the need for payers to have confidence in the clinical utility of the drugs and tests they use; 2) payment for value, with prices that ensure cost-effectiveness for health systems; and 3) levels of intellectual property protection for evidence generation that provide a return for those financing research and development, while encouraging competition to produce both better and more efficient tests.