Inadequate diabetic care: global figures cry for preventive measures and personalized treatment

Evaluation of kidney injury molecule-1 as a disease progression biomarker in diabetic nephropathy

Background & Objective:

Kidney Injury Molecule-1 (KIM-1) is a peptide whose release into circulation is specific to tubular injury. This study aimed to estimate levels of kidney injury molecule-1 in diabetic patients with and without kidney disease. And evaluate the role of KIM-1 as an early screening marker of progressive kidney injury.

Methods:

This follow-up study included n=85 subjects from the diabetic clinic of Jinnah Post Graduate Medical Center (JPMC) in collaboration with Aga Khan University from November 2016 till September 2017. They were divided as: i) Group A1 (n=30) participants with diabetes for <5 years without microalbuminuria ii) Group A2 (n= 30) subjects with diabetes for 6-10 years with microalbuminuria; iii) Group B (n=25) subjects as healthy control group. All study participants were followed for 6 months and their blood glucose, urea, creatinine, electrolytes, albuminuria and serum KIM-1 were assayed.

Results:

High KIM-1 at baseline was present in group A2 patients as compared to controls and group A1 (p<0.001). Higher levels were seen after six months in group A1 along with the presence of micro albuminuria (p<0.001) suggesting kidney damage. Moderate positive association were seen for KIM1 with creatinine levels (r=0.530; p<0.001), and HbA1c (r=0.576; p<0.001) in all patients. While a strong positive association was seen for blood urea nitrogen as a marker for kidney function both at baseline (r= 0.728; p=0.000) and follow up (r=0.747; p=0.001). Multiple logistic regression controlling for age showed that KIM1 was independently associated with BUN (r=0.727; p<0.001), creatinine (r=0.510; p<0.001) and HbA1c (r=0.401; p=0.008) in all groups.

Conclusion:

Rising KIM-1 levels with progressive kidney damage with or without derangement of kidney function is reported in this study. This finding may pave a way towards identifying KIM1 as a prognostic marker for kidney injury.

Efficacy of Ginger (Zingiber officinale) in Ameliorating Streptozotocin-Induced Diabetic Liver Injury in Rats: Histological and Biochemical Studies

Ginger (Zingiber officinale) was reported to have an antioxidant, antidiabetic effect. This study was done to investigate its therapeutic effect against functional and structural alteration in liver of diabetic rat (intraperitoneal streptozotocin (STZ) in a dose of 60 mg/kg/bw). Thirty adult male rats (three-months-old and 250 g weight) were sorted into five groups (N=6). G1 used as control, G2 was diabetic rats without any treatment, G3 was diabetic rats given oral ginger in a dose of 500 mg/kg/bw, G4 was diabetic rats treated with metformin (500 mg/kg/bw) while G5 received ginger orally. The experiment lasts for six weeks, animals were anesthetized by ether, body weight was recorded for all animals. Blood was collected for further analysis of lipid profile, liver enzymes and total antioxidant. Liver was dissected, weighted and samples were processed for histopathological study. The results showed significant decrease of glaucous level and liver enzymes in ginger treated rats. Total antioxidant was preserved. Ginger lowered blood glucose, level, regained body weight and liver index to near normal values. Diabetes induced degenerative changes and micro-vesicular lipid deposition in hepatocytes with moderate portal area fibrosis. Ultrastructure study confirmed such changes beside demonstrating increased lipid deposition in fat storing cells. Ginger was found to ameliorate those changes in treated animals. Results were matching metformin effects. In conclusion, Ginger as a natural safe Herbal medication can be used to support liver functions in diabetic status.

A systematic review and meta-analysis of randomized controlled trials on the effects of magnesium supplementation on insulin sensitivity and glucose control

A systematic review and meta-analysis was conducted to evaluate the effect of oral magnesium supplementation on insulin sensitivity and glucose control in both diabetic and non-diabetic individuals. PubMed-Medline, SCOPUS, Web of Science and Google Scholar databases were searched (from inception to November 25, 2015) to identify RCTs evaluating the effect of magnesium on insulin sensitivity and glucose control. A random-effects model and generic inverse variance method were used to compensate for the heterogeneity of studies. Publication bias, sensitivity analysis, and meta-regression assessments were conducted using standard methods. The impact of magnesium supplementation on plasma concentrations of glucose, glycated hemoglobin (HbA1c), insulin, and HOMA-IR index was assessed in 22, 14, 12 and 10 treatment arms, respectively. A significant effect of magnesium supplementation was observed on HOMA-IR index (WMD: -0.67, 95% CI: -1.20, -0.14, p=0.013) but not on plasma glucose (WMD: -0.20mmol/L, 95% CI: -0.45, 0.05, p=0.119), HbA1c (WMD: 0.018mmol/L, 95% CI: -0.10, 0.13, p=0.756), and insulin (WMD: -2.22mmol/L, 95% CI: -9.62, 5.17, p=0.556). A subgroup analysis comparing magnesium supplementation durations of <4 months versus ≥4 months, exhibited a significant difference for fasting glucose concentrations (p<0.001) and HOMA-IR (p=0.001) in favor of the latter subgroup. Magnesium supplementation for ≥4 months significantly improves the HOMA-IR index and fasting glucose, in both diabetic and non-diabetic subjects. The present findings suggest that magnesium may be a beneficial supplement in glucose metabolic disorders.

Ayurpharmacoepidemiology Perspective: Health Literacy (Knowledge and Practice) Among Older Diabetes Patients Visiting Ayurveda Teaching Hospitals in India

Older Indian diabetics lack proper health literacy making them vulnerable to complications. Assessment of health literacy was done by hospital-based cross-sectional study. Face-to-face interview was conducted by pretested structured questionnaires. Diabetes patients aged ≥60 years consisted of 56.22% males and 43.78% females; in addition, 34.2% respondents were without formal schooling. Diabetes was known to 63.56% respondents. Total knowledge and practice score of the respondents was good (18.9% and 35.1%), average (30.7% and 46.9%), and poor (50.4% and 18%), respectively. Knowledge and practice score was strongly associated ( P < .01) with religion, educational status, and diabetes duration with positive relationship ( R² = 0.247, P < .01) between knowledge and practice score. The study highlights lack of health literacy among older diabetics undergoing ayurveda management. Baseline statistics will pave the way toward ayurpharmacoepidemiology.

Integration of Provider, Pharmacy, and Patient-Reported Data to Improve Medication Adherence for Type 2 Diabetes: A Controlled Before-After Pilot Study

Background

Patients with diabetes often have poor adherence to using medications as prescribed. The reasons why, however, are not well understood. Furthermore, most health care delivery processes do not routinely assess medication adherence or the factors that contribute to poor adherence.

Objective

The objective of the study was to assess the feasibility of an integrated informatics approach to aggregating and displaying clinically relevant data with the potential to identify issues that may interfere with appropriate medication utilization and facilitate patient-provider communication during clinical encounters about strategies to improve medication use.

Methods

We developed a clinical dashboard within an electronic health record (EHR) system that uses data from three sources: the medical record, pharmacy claims, and a patient portal. Next, we implemented the dashboard into three community health centers. Health care providers (n=15) and patients with diabetes (n=96) were enrolled in a before-after pilot to test the system’s impact on medication adherence and clinical outcomes. To measure adherence, we calculated the proportion of days covered using pharmacy claims. Demographic, laboratory, and visit data from the EHR were analyzed using pairwise t tests. Perceived barriers to adherence were self-reported by patients. Providers were surveyed about their use and perceptions of the clinical dashboard.

Results

Adherence significantly and meaningfully improved (improvements ranged from 6%-20%) consistently across diabetes as well as cardiovascular drug classes. Clinical outcomes, including HbA1c, blood pressure, lipid control, and emergency department utilization remained unchanged. Only a quarter of patients (n=24) logged into the patient portal and completed psychosocial questionnaires about their barriers to taking medications.

Conclusions

Integrated approaches using advanced EHR, clinical decision support, and patient-controlled technologies show promise for improving appropriate medication use and supporting better management of chronic conditions. Future research and development is necessary to design, implement, and integrate the myriad of EHR and clinical decision support systems as well as patient-focused information systems into routine care and patient processes that together support health and well-being.

An informatics approach to medication adherence assessment and improvement using clinical, billing, and patient-entered data

The aim of this study was to describe an integrated informatics approach to aggregating and displaying clinically relevant data that can identify problems with medication adherence and facilitate patient-provider communication about strategies to improve medication use. We developed a clinical dashboard within an electronic health record (EHR) system that uses data from three sources: the medical record, pharmacy claims, and a personal health record. The data are integrated to inform clinician-patient discussions about medication adherence. Whereas prior research on assessing patterns of medication adherence focused on a single approach using the EHR, pharmacy data, or patient-entered data, we present an approach that integrates multiple electronic data sources increasingly found in practice. Medication adherence is a complex challenge that requires patient and provider team input, necessitating an integrated approach using advanced EHR, clinical decision support, and patient-controlled technologies. Future research should focus on integrated strategies to provide patients and providers with the right combination of informatics tools to help them adequately address the challenge of adherence to complex medication therapies.

Chromium-picolinate therapy in diabetes care: individual outcomes require new guidelines and navigation by predictive diagnostics

AIMS

Nephropathy is the leading secondary complication of metabolic syndrome. Nutritional supplement by chromium-picolinate is assumed to have renoprotective effects. However, potential toxic effects reported increase the concerns about the safety of chromium-picolinate. The experimental design aimed at determining, whether the treatment with clinically relevant doses of chromium-picolinate can harm individual oucomes through DNA damage and extensive alterations in central detoxification / cell-cycle regulating pathways in treatment of diabetes.

METHODS

The study was performed in a double-blind manner. Well-acknowledged animal model of db/db-mice and clinically relevant doses of chromium- picolinate were used. As an index of DNA-damage, measurement of DNA-breaks was performed using "Comet Assay"-analysis. Individual and group-specific expression patterns of SOD-1 and P53 were evaluated to get insights into central detoxification and cell-cycle regulating pathways under the treatment conditions.

RESULTS

Experimental data revealed highly individual reaction towards the treatment conditions. The highest variability of DNA-damage was monitored under the prolonged treatment with high dosage of CrPic. Expression patterns demonstrated a correlation with the subcellular imaging and dosage-dependent suppression under the chromium-picolinate treatment. INTERPRETATION AND RECOMMENDATIONS: Population at-risk for diabetes is huge and increasing in pandemic scale. One of the reasons might be the failed attempt to prevent the disease by application of artificial supplements and drugs with hardly recognised individual risks. Consequently, a multimodal approach of integrative medicine by predictive diagnostics, targeted prevention and individually created treatment algorithms is highly desirable.

Opinion controversy to chromium picolinate therapy's safety and efficacy: ignoring 'anecdotes' of case reports or recognising individual risks and new guidelines urgency to introduce innovation by predictive diagnostics?

Due to the important physiologic function of trivalent chromium in glucose/insulin homeostasis, some commercial organisations promote Cr3+ supplements in maintaining proper carbohydrate and lipid metabolism; regulation of reducing carbohydrate carvings and appetite; prevention of insulin resistance and glucose intolerance; regulation of body composition, including reducing fat mass and increasing lean body mass; optimal body building for athletes; losing weight; treatment of atypical depression as an antidepressant; and prevention of obesity and type 2 diabetes mellitus. On one hand, case reports are commented as 'nonevidence-based anecdotes'. On the other hand, a number of independent studies warn against adverse health outcomes assigned to chromium picolinate (CrPic) dietary application. This review analyses opinion controversies, demonstrates highly individual reactions towards CrPic dietary supplements and highlights risks when the dietary supplements are used freely as therapeutic agents, without application of advanced diagnostic tools to predict individual outcomes.

Time for new guidelines in advanced healthcare: the mission of The EPMA Journal to promote an integrative view in predictive, preventive and personalized medicine

Changing long-held beliefs is never easy. As a consequence of the accumulating clinical data and knowledge about the epidemiology and pathological mechanisms of the most frequent causes of morbidity and mortality, we are currently reconsidering our view of the origins and progression of cardiovascular, oncologic and neurodegenerative diseases. Optimistic versus pessimistic prognosis for healthcare sector depends much on diagnostic, preventive and treatment approaches, which healthcare systems will preferably adopt in the near future. PPPM offers great promise for the future practice of medicine. We are pleased to announce this first open access volume of The EPMA Journal following its transfer to BioMed Central two years after publication of the first article in the journal.

Management of diabetes mellitus: could simultaneous targeting of hyperglycemia and oxidative stress be a better panacea?

The primary aim of the current management of diabetes mellitus is to achieve and/or maintain a glycated hemoglobin level of ≤6.5%. However, recent evidence indicates that intensive treatment of hyperglycemia is characterized by increased weight gain, severe hypoglycemia and higher mortality. Besides, evidence suggests that it is difficult to achieve and/or maintain optimal glycemic control in many diabetic patients; and that the benefits of intensively-treated hyperglycemia are restricted to microvascular complications only. In view of these adverse effects and limitations of intensive treatment of hyperglycemia in preventing diabetic complications, which is linked to oxidative stress, this commentary proposes a hypothesis that “simultaneous targeting of hyperglycemia and oxidative stress” could be more effective than “intensive treatment of hyperglycemia” in the management of diabetes mellitus.

Chromium-picolinate therapy in diabetes care: molecular and subcellular profiling revealed a necessity for individual outcome prediction, personalised treatment algorithms and new guidelines

AIMS

Global figures clearly demonstrate inadequacy of current diabetes care: every 10 seconds one patient dies of diabetes-related pathologies. Nephropathy is the leading secondary complication of the disease. Nutritional supplement by chromium-picolinate is assumed to have beneficial therapeutic effects. However, potential toxic effects reported increase concerns about safety of chromium-picolinate. The experimental design aimed at determining, whether the treatment with clinically relevant doses of chromium-picolinate can harm through DNA damage and extensive alterations in central detoxification / cell-cycle regulating pathways in treatment of diabetes.

METHODS

Well-acknowledged animal model of db/db-mice and clinically relevant doses of chromium-picolinate were used. As an index of DNA-damage, measurement of DNA-breaks was performed using "Comet Assay"-analysis. Individual and group-specific expression patterns of SOD-1 and P53 were evaluated to give a clue about central detoxification and cell-cycle regulating pathways under treatment conditions. The study was performed in a double-blind manner.

RESULTS

Experimental data revealed highly individual reaction under treatment conditions. However, group-specific patterns were monitored: highest amount of damaged DNA--under the longest treatment with high doses, in contrast to groups with low doses of chromium-picolinate. Comet patterns were intermediate between untreated diabetised and control animals. Expression patterns demonstrated a correlation with subcellular imaging and dosage-dependent suppression under chromium-picolinate treatment.

CONCLUSIONS

This article highlights possible risks for individual long-term effects, when chromium-picolinate is used freely as a therapeutic nutritional modality agent without application of advanced diagnostic tools to predict risks and individual outcomes. Targeted measures require a creation of new guidelines for advanced Diabetes care.

Birth asphyxia as the major complication in newborns: moving towards improved individual outcomes by prediction, targeted prevention and tailored medical care

Perinatal Asphyxia—oxygen deficit at delivery—can lead to severe hypoxic ischaemic organ damage in newborns followed by a fatal outcome or severe life-long pathologies. The severe insults often cause neurodegenerative diseases, mental retardation and epilepsies. The mild insults lead to so-called “minimal brain-damage disorders” such as attention deficits and hyperactivity, but can also be associated with the development of schizophrenia and life-long functional psychotic syndromes. Asphyxia followed by re-oxygenation can potentially lead to development of several neurodegenerative pathologies, diabetes type 2 and cancer. The task of individual prediction, targeted prevention and personalised treatments before a manifestation of the life-long chronic pathologies usually developed by newborns with asphyxic deficits, should be given the extraordinary priority in neonatology and paediatrics. Socio-economical impacts of educational measures and advanced strategies in development of robust diagnostic approaches targeted at effected molecular pathways, biomarker-candidates and potential drug-targets for tailored treatments are reviewed in the paper.

Does the "new philosophy" in predictive, preventive and personalised medicine require new ethics?

This paper maps the ethical issues that arise in the context of personalised medicine. First, it highlights the ethical problems related to increased predictive power of modern diagnostic interventions. Such problems emerge because the ability to identify individuals or groups of individuals that can potentially benefit from a particular therapeutic intervention also raises a question of personal responsibility for health-related behaviour and lifestyle. The second major area of ethical concern is related to health prevention and distributive justice. The paper discusses the ethical challenges brought by the personalised medicine in the context of the Additional Protocol to the Convention on Human Rights and Biomedicine concerning Genetic Testing for Health Purposes. Finally, it notes that the issue of consent in the context of biobanks, the need to rethink the prevalent models of research designs and to communicate relevant findings to the donors of biological materials deserve further discussion.

Degenerative valve disease and bioprostheses: risk assessment, predictive diagnosis, personalised treatments

Aortic stenosis (AS) is the most frequent valvular heart disease. Severe AS results in concentric left ventricular hypertrophy, and ultimately, the heart dilates and fails. During a long period of time patients remain asymptomatic. In this period a pathology progression should be monitored and effectively thwarted by targeted measures. A cascade of cellular and molecular events leads to chronic degeneration of aortic valves. There are some molecular attributes characteristic for the process of valvular degeneration with clear functional link between shifted cell-cycle control, calcification and tissue remodelling of aortic valves. Bioactivity of implanted bioprosthesis is assumed to result in its dysfunction. Age, gender (females), smoking, Diabetes mellitus, and high cholesterol level dramatically shorten the re-operation time. Therefore, predictive and preventive measures would be highly beneficial, in particular for young female diabetes-predisposed patients. Molecular signature of valvular degeneration is reviewed here with emphases on clinical meaning, risk-assessment, predictive diagnosis, individualised treatments.

Common origin but individual outcomes: time for new guidelines in personalized healthcare

Clinical observations clearly demonstrate that similar endogenous and exogenous risk factors cause individual reactions and pathologic characteristics; therefore, the same therapeutic approaches applied within one cohort of patients lead to individual outcomes. How could we optimize approaches used in the current healthcare systems? Individualized treatment algorithms and paradigm change from a late interventional approach to predictive diagnosis, followed by the targeted prevention of a disease before pathology manifests, presents an innovative concept for advanced healthcare that is cost effective. Predictive perinatal/postnatal diagnosis and the preselection of a particular healthy but disease-predisposed individual, followed by targeted preventive measures, represent the primary task in the overall action of personalized healthcare. Those highly effective measures can lead to a reduced prevalence of severe pathologies and better long-term outcomes for patients treated according to individual parameters and therapeutic algorithms. Furthermore, an increased portion of socially active members remaining vibrant with excellent physical and mental health can therefore, be expected in the elderly. Improving the quality of life of aging populations and reducing costs in advanced healthcare systems, is a global challenge of the 21st century. This task requires intelligent political regulations and the creation of new guidelines to advance the current healthcare systems. Targeted preventive measures should be well regulated by innovative reimbursement programs introduced by policy-makers. This is considered as the cost-effective preventive 'medicine of the future'.

Time for new guidelines in advanced diabetes care: Paradigm change from delayed interventional approach to predictive, preventive & personalized medicine

Global burden of diabetes mellitus clearly demonstrate inadequacy of current diabetes care measures: the costs of caring for patients with diabetes mellitus are the highest compared to other frequent pathologies. Nonetheless, for every 10 s one patient dies of diabetes-related consequences. Thus, there is urgent need for highly effective measures that would lead to reduced prevalence, better long-term outcomes and improved quality of life for diabetic patients reducing associated economic burden. Such targeted measures would require the creation of new guidelines for advanced diabetes care that would provide for regulation, for timely predictive diagnostics as well as an effective prevention and creation of individualized treatment algorithms. Effective communication among the research community healthcare providers, policy-makers, educators and organized patient groups (Federations of Diabetics) is of paramount importance and essential for (pre)diabetes care. The ultimate mission of the "European Association for Predictive, Preventive & Personalised Medicine" is to promote this process in Europe and across the globe.