Systems medicine and integrated care to combat chronic noncommunicable diseases

Systems medicine: helping us understand the complexity of disease

Advances in genomics and other -omic fields in the last decade have resulted in unprecedented volumes of complex data now being available. These data can enable physicians to provide their patients with care that is more personalized, predictive, preventive and participatory. The expertise required to manage and understand this data is to be found in fields outside of medical science, thus multidisciplinary collaboration coupled to a systems approach is key to unlocking its potential, with concomitant new ways of working. Systems medicine can build on the successes in the field of systems biology, recognizing the human body as the multidimensional network of networks that it is. While systems medicine can provide a conceptual and theoretical framework, its practical goal is to provide physicians the tools necessary for harnessing the rapid advances in basic biomedical science into their routine clinical arsenal.

Inequalities in multimorbidity in South Africa

BACKGROUND

Very little is known about socioeconomic related inequalities in multimorbidity, especially in developing countries. Traditionally, studies on health inequalities have mainly focused on a single disease condition or different conditions in isolation. This paper examines socioeconomic inequality in multimorbidity in illness and disability in South Africa between 2005 and 2008.

METHODS

Data were drawn from the 2005, 2006, 2007, and 2008 rounds of the nationally representative annual South African General Household Surveys (GHS). Indirectly standardised concentration indices were used to assess socioeconomic inequality. A proxy index of socioeconomic status was constructed, for each year, using a selected set of variables that are available in all the GHS rounds. Multimorbidity in illness and disability were constructed using data on nine illnesses and six disabilities contained in the GHS.

RESULTS

Multimorbidity affects a substantial number of South Africans. Most often, based on the nine illness conditions and six disability conditions considered, multimorbidity in illness and multimorbidity in disability are each found to involve only two conditions. In 2008 in South Africa, the multimorbidity that affected the greatest number of individuals (0.6% of the population) combined high blood pressure (BP) with at least one other illness. The combination of sexually transmitted diseases (STDs) and other condition or conditions is the least reported (i.e. 0.02% of the population). Between 2005 and 2008, multimorbidity in illness and disability is more prevalent among the poor; in disabilities this is yet more consistent. The concentration index of multiple illnesses in 2005 and 2008 are -0.0009 and -0.0006 respectively. The corresponding values for multiple disabilities are -0.0006 and -0.0006 respectively.

CONCLUSION

While there is a dearth of information on the socioeconomic distribution of multimorbidity in many developing countries, this paper has shown that its distribution in South Africa indicates that the poor bear a greater burden of multimorbidity. This is more so for disability than for illness. This paper argues that, given the high burden and skewed socioeconomic distribution of multimorbidity, there is a need to design policies to address this situation. Further, there is a need to design surveys that specifically assess multimorbidity.

Systems approaches to computational modeling of the oral microbiome

Current microbiome research has generated tremendous amounts of data providing snapshots of molecular activity in a variety of organisms, environments, and cell types. However, turning this knowledge into whole system level of understanding on pathways and processes has proven to be a challenging task. In this review we highlight the applicability of bioinformatics and visualization techniques to large collections of data in order to better understand the information that contains related diet—oral microbiome—host mucosal transcriptome interactions. In particular, we focus on systems biology of Porphyromonas gingivalis in the context of high throughput computational methods tightly integrated with translational systems medicine. Those approaches have applications for both basic research, where we can direct specific laboratory experiments in model organisms and cell cultures, and human disease, where we can validate new mechanisms and biomarkers for prevention and treatment of chronic disorders.

The Connective Matrix of Emerging Health Technologies

Modern communication systems (Web 1.0, Web 2.0, cloud computing) and mobile wireless technologies (smartphones, iPads, monitoring devices) have, as with all industries, progressed in healthcare over recent years from being a minor, to being a very significant component of the environment. This paper will discuss how advancements in information technology, wireless communication systems and sensor technology have provided new opportunities concerning practices for managing Chronic Disease (CD). This paper will also address future software, touching on Web 3.0 and how, combined with Web 2.0 and cloud computing, has the potential to produce the ultimate architecture of participation. Understanding the benefits of such systems, devices and their increasing emergence and connection with modern healthcare settings, is vital for implementing future successful e-health solutions for people with CD.

An integrated framework of personalized medicine: from individual genomes to participatory health care

Promising research developments in both basic and applied sciences, such as genomics and participatory health care approaches, have generated widespread interest in personalized medicine among almost all scientific areas and clinicians. The term personalized medicine is, however, frequently used without defining a clear theoretical and methodological background. In addition, to date most personalized medicine approaches still lack convincing empirical evidence regarding their contribution and advantages in comparison to traditional models. Here, we propose that personalized medicine can only fulfill the promise of optimizing our health care system by an interdisciplinary and translational view that extends beyond traditional diagnostic and classification systems.

The biodiversity hypothesis and allergic disease: world allergy organization position statement

Biodiversity loss and climate change secondary to human activities are now being associated with various adverse health effects. However, less attention is being paid to the effects of biodiversity loss on environmental and commensal (indigenous) microbiotas. Metagenomic and other studies of healthy and diseased individuals reveal that reduced biodiversity and alterations in the composition of the gut and skin microbiota are associated with various inflammatory conditions, including asthma, allergic and inflammatory bowel diseases (IBD), type1 diabetes, and obesity. Altered indigenous microbiota and the general microbial deprivation characterizing the lifestyle of urban people in affluent countries appear to be risk factors for immune dysregulation and impaired tolerance. The risk is further enhanced by physical inactivity and a western diet poor in fresh fruit and vegetables, which may act in synergy with dysbiosis of the gut flora. Studies of immigrants moving from non-affluent to affluent regions indicate that tolerance mechanisms can rapidly become impaired in microbe-poor environments. The data on microbial deprivation and immune dysfunction as they relate to biodiversity loss are evaluated in this Statement of World Allergy Organization (WAO). We propose that biodiversity, the variability among living organisms from all sources are closely related, at both the macro- and micro-levels. Loss of the macrodiversity is associated with shrinking of the microdiversity, which is associated with alterations of the indigenous microbiota. Data on behavioural means to induce tolerance are outlined and a proposal made for a Global Allergy Plan to prevent and reduce the global allergy burden for affected individuals and the societies in which they live.

Lifetime experiences, the brain and personalized medicine: an integrative perspective

The aim of personalized medicine is to base medical prevention and therapy on the unique health and disease susceptibility profile of each individual. Starting from this idea, we briefly discuss the meaning of the word 'personalized' before analyzing the practical content of personalized healthcare. From a medical perspective, knowledge of a person encompasses both biological and biographical perspectives. The latter includes significant events and experiences throughout the person's lifespan, from conception to the present, in which epigenetic influences play an important role. In practice, we believe personalized medicine should emphasize the development and maintenance of a healthy nervous system. The neurobiological processes involved here depend heavily on the psychosocial environment, in particular the presence of responsible, caring adults and integration in a reasonably fair society. A healthy brain subsequently promotes good health throughout life, both through direct, favorable influences on the body's intrinsic biological pathways, and indirectly by enabling the person to engage in supportive relationships, make wise decisions and take good care of him/herself. From a public health perspective, we conclude that hi-tech personalized medicine based on detailed bio-molecular mapping, monitoring and tailored drug interventions holds promise only as part of a wider, socio-culturally informed approach to the person.

The COPD control panel: towards personalised medicine in COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease whose assessment and management have traditionally been based on the severity of airflow limitation (forced expiratory volume in 1 s (FEV1)). Yet, it is now clear that FEV1 alone cannot describe the complexity of the disease. In fact, the recently released Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2011 revision has proposed a new combined assessment method using three variables (symptoms, airflow limitation and exacerbations).

METHODS

Here, we go one step further and propose that in the near future physicians will need a 'control panel' for the assessment and optimal management of individual patients with complex diseases, including COPD, that provides a path towards personalised medicine.

RESULTS

We propose that such a 'COPD control panel' should include at least three different domains of the disease: severity, activity and impact. Each of these domains presents information on different 'elements' of the disease with potential prognostic value and/or with specific therapeutic requirements. All this information can be easily incorporated into an 'app' for daily use in clinical practice.

CONCLUSION

We recognise that this preliminary proposal needs debate, validation and evolution (eg, including 'omics' and molecular imaging information in the future), but we hope that it may stimulate debate and research in the field.

CREST biorepository for translational studies on malignant mesothelioma, lung cancer and other respiratory tract diseases: Informatics infrastructure and standardized annotation

Advances in molecular epidemiology and translational research have led to the need for biospecimen collection. The Cancer of the Respiratory Tract (CREST) biorepository is concerned with pleural malignant mesothelioma (MM) and lung cancer (LC). The biorepository staff has collected demographic and epidemiological data directly from consenting subjects using a structured questionnaire, in agreement with The Public Population Project in Genomics (P(3)G). Clinical and follow-up data were collected. Sample data were also recorded. The architecture is based on a database designed with Microsoft Access. Data standardization was carried out to conform with established conventions or procedures. As from January 31, 2011, the overall number of recruited subjects was 1,857 (454 LC, 245 MM, 130 other cancers and 1,028 controls). Due to its infrastructure, CREST was able to join international projects, sharing samples and/or data with other research groups in the field. The data management system allows CREST to be involved, through a minimum data set, in the national project for the construction of the Italian network of Oncologic BioBanks (RIBBO), and in the infrastructure of a pan-European biobank network (BBMRI). The CREST biorepository is a valuable tool for translational studies on respiratory tract diseases, because of its simple and efficient infrastructure.

Severe chronic allergic (and related) diseases: a uniform approach--a MeDALL--GA2LEN--ARIA position paper

Concepts of disease severity, activity, control and responsiveness to treatment are linked but different. Severity refers to the loss of function of the organs induced by the disease process or to the occurrence of severe acute exacerbations. Severity may vary over time and needs regular follow-up. Control is the degree to which therapy goals are currently met. These concepts have evolved over time for asthma in guidelines, task forces or consensus meetings. The aim of this paper is to generalize the approach of the uniform definition of severe asthma presented to WHO for chronic allergic and associated diseases (rhinitis, chronic rhinosinusitis, chronic urticaria and atopic dermatitis) in order to have a uniform definition of severity, control and risk, usable in most situations. It is based on the appropriate diagnosis, availability and accessibility of treatments, treatment responsiveness and associated factors such as comorbidities and risk factors. This uniform definition will allow a better definition of the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes, education and the discovery of novel therapies.

Atopic dermatitis: a candidate for disease-modifying strategy

The concept of disease modification has been introduced to define the therapeutic strategies aimed to break, stop, or reverse the natural course of a chronic invalidating disease. This strategy is tightly related to the biomarker-based stratification of affected patients using genetic and other biological markers. With regard to the progress in understanding the genetic background of atopic dermatitis (AD), its natural history and its pivotal role in the emergence of allergic asthma, the time is mature to foster the research field of biomarkers in AD and to consider the elaboration of disease-modifying strategies in the management of AD with the goal to stop or even reverse the atopic march.

The power of boolean implication networks

Human diseases have been investigated in the context of single genes as well as complex networks of genes. Though single gene approaches have been extremely successful in the past, most human diseases are complex and better characterized by multiple interacting genes commonly known as networks or pathways. With the advent of high-throughput technologies, a recent trend has been to apply network-based analysis to the huge amount of biological data. Analysis on Boolean implication network is one such technique that distinguishes itself based on its simplicity and robustness. Unlike traditional analyses, Boolean implication networks have the power to break into the mechanistic insights of human diseases. A Boolean implication network is a collection of simple Boolean relationships such as “if A is high then B is low.” So far, Boolean implication networks have been employed not only to discover novel markers of differentiation in both normal and cancer tissues, but also to develop robust treatment decisions for cancer patients. Therefore, analyses based on Boolean implication networks have potential to accelerate discoveries in human diseases, suggest therapeutics, and provide robust risk-adapted clinical strategies.

Persistent systemic inflammation is associated with poor clinical outcomes in COPD: a novel phenotype

Background

Because chronic obstructive pulmonary disease (COPD) is a heterogeneous condition, the identification of specific clinical phenotypes is key to developing more effective therapies. To explore if the persistence of systemic inflammation is associated with poor clinical outcomes in COPD we assessed patients recruited to the well-characterized ECLIPSE cohort (NCT00292552).

Methods and Findings

Six inflammatory biomarkers in peripheral blood (white blood cells (WBC) count and CRP, IL-6, IL-8, fibrinogen and TNF-α levels) were quantified in 1,755 COPD patients, 297 smokers with normal spirometry and 202 non-smoker controls that were followed-up for three years. We found that, at baseline, 30% of COPD patients did not show evidence of systemic inflammation whereas 16% had persistent systemic inflammation. Even though pulmonary abnormalities were similar in these two groups, persistently inflamed patients during follow-up had significantly increased all-cause mortality (13% vs. 2%, p<0.001) and exacerbation frequency (1.5 (1.5) vs. 0.9 (1.1) per year, p<0.001) compared to non-inflamed ones. As a descriptive study our results show associations but do not prove causality. Besides this, the inflammatory response is complex and we studied only a limited panel of biomarkers, albeit they are those investigated by the majority of previous studies and are often and easily measured in clinical practice.

Conclusions

Overall, these results identify a novel systemic inflammatory COPD phenotype that may be the target of specific research and treatment.

Urine metabolomics analysis for biomarker discovery and detection of jaundice syndrome in patients with liver disease

Metabolomics is a powerful new technology that allows for the assessment of global metabolic profiles in easily accessible biofluids and biomarker discovery in order to distinguish between diseased and nondiseased status information. Deciphering the molecular networks that distinguish diseases may lead to the identification of critical biomarkers for disease aggressiveness. However, current diagnostic methods cannot predict typical Jaundice syndrome (JS) in patients with liver disease and little is known about the global metabolomic alterations that characterize JS progression. Emerging metabolomics provides a powerful platform for discovering novel biomarkers and biochemical pathways to improve diagnostic, prognostication, and therapy. Therefore, the aim of this study is to find the potential biomarkers from JS disease by using a nontarget metabolomics method, and test their usefulness in human JS diagnosis. Multivariate data analysis methods were utilized to identify the potential biomarkers. Interestingly, 44 marker metabolites contributing to the complete separation of JS from matched healthy controls were identified. Metabolic pathways (Impact-value≥0.10) including alanine, aspartate, and glutamate metabolism and synthesis and degradation of ketone bodies were found to be disturbed in JS patients. This study demonstrates the possibilities of metabolomics as a diagnostic tool in diseases and provides new insight into pathophysiologic mechanisms.

Alzheimer mechanisms and therapeutic strategies

There are still no effective treatments to prevent, halt, or reverse Alzheimer's disease, but research advances over the past three decades could change this gloomy picture. Genetic studies demonstrate that the disease has multiple causes. Interdisciplinary approaches combining biochemistry, molecular and cell biology, and transgenic modeling have revealed some of its molecular mechanisms. Progress in chemistry, radiology, and systems biology is beginning to provide useful biomarkers, and the emergence of personalized medicine is poised to transform pharmaceutical development and clinical trials. However, investigative and drug development efforts should be diversified to fully address the multifactoriality of the disease.

Inflammatory biomarkers in severe asthma

PURPOSE OF REVIEW

Severe asthma remains a condition in search of deeper understanding and of newer effective therapies. Risk factors for developing severe asthma, phenotyping of disease, characterizing the inflammatory response and understanding of poor therapeutic responses to corticosteroids are important areas of research. The development of biomarkers for phenotypic diagnosis and prognostic reasons is important.

RECENT FINDINGS

Severe asthma has been defined as asthma that does not respond adequately to asthma medications, particularly corticosteroids, with continuing loss of control of asthma and future risk of exacerbations and side effects from corticosteroid therapy. This is a heterogeneous condition and cluster analyses have yielded phenotypes on the basis of age of onset of disease, sex, lung function, atopy and questionnaire data. Use of sputum eosinophil counts has further defined a group with persistent eosinophilic inflammation despite corticosteroid therapy, and a noneosinophilic group with uncontrolled asthma.

SUMMARY

Use of a single biomarker provides value in phenotyping and in predicting response to treatment but many more biomarkers such as those derived from -omic approaches remain to be used in the analysis. A systems biology approach to finding novel biomarkers is the way forward to stratify severe asthma so that appropriate and distinct therapies can be selected for each subtype.

Impact of anxiety and depression on chronic obstructive pulmonary disease exacerbation risk

Chronic obstructive pulmonary disease (COPD) exacerbations contribute significantly to morbidity and mortality. COPD is also associated with high levels of psychological distress, which has been linked with higher exacerbation rates. At a recent American Thoracic Society conference symposium titled "Depression and Obstructive Lung Disease: State of the Science and Future Directions" held in 2010 in New Orleans, clinicians and researchers identified a number of important research priorities related to psychiatric comorbidities, including the need to better understand their impact on COPD outcomes, such as exacerbations. This article reviews the current literature and quantifies the prospective impact of anxiety and depression on exacerbation risk in patients with COPD. The limitations of the existing literature and the perspectives for future research are addressed.

Systems-based approaches to cardiovascular disease

Common cardiovascular diseases, such as atherosclerosis and congestive heart failure, are exceptionally complex, involving a multitude of environmental and genetic factors that often show nonlinear interactions as well as being highly dependent on sex, age, and even the maternal environment. Although focused, reductionistic approaches have led to progress in elucidating the pathophysiology of cardiovascular diseases, such approaches are poorly powered to address complex interactions. Over the past decade, technological advances have made it possible to interrogate biological systems on a global level, raising hopes that, in combination with computational approaches, it may be possible to more fully address the complexities of cardiovascular diseases. In this Review, we provide an overview of such systems-based approaches to cardiovascular disease and discuss their translational implications.

Systems medicine and the public's health

Innovative 'systems' approaches to biomedical research offer substantial promise for advancing knowledge and improving health care, as outlined by Bousquet et al. in this issue. However, they are unlikely to improve population health without concurrent efforts to address environmental and social contributors to health, including conditions such as poverty, substandard housing, and restricted access to employment and education. Biomedical researchers have a responsibility to promote realistic expectations for systems or 'P4' medicine, and to join others in calling for broad efforts to promote equitable access to health care and social conditions that promote well-being.See correspondence article: http://genomemedicine.com/content/3/7/43.