| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
|
|
|
|||||||
|
|||||||||
TRACK to:
|
|
Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Bedside biophysical-semeiotic PPARs evaluation in glucose-lipid metabosism monitoring.
The Chronic Care Model and Outcomes of Care for Diabetes: Implications for Translational Research in the Primary Care Setting
|
|
|||
|
Sergio Stagnaro, Riva Trigoso (Genova) Italy Biophysical Semeiotics Research Laboratory
Send response to journal:
|
Sirs: accordingly low caloric diet and regular physical exercise induced significant improvement in blood pressure, body mass index, waist-to-hip- circumference,without any change on drug prescription, but it brings about other paramount benifits (1). Let us consider, for instance, that one of the most active areas of metabolic research into potential treatments surrounds the role of nuclear receptors as a treatment target for both glucose and lipid metabolism. In addition, agonists of the peroxisome proliferator-activated receptor (PPAR) offer unique potential in several respects (See www.semeioticabiofisica.it; Practical Applications: PPARS). PPAR agonists (such as fibrates, thiazolidinediones, coniugated-melatonin, according to Di Bella-Ferrari) have been shown to lower triglyceride and increase HDL-c, with a variable effect upon LDL-c blood levels. PPARs agonists have variable effects on the lipid profile, in addition to improving insulin sensitivity and blood glucose levels in patients with type 2 diabetes. Pre-clinical studies suggest that both PPARs and PPARs agonists have direct anti-atherogenic effects (1). Therefore, single agents that promote both PPARs and PPARs agonism could theoretically offer significant benefits in improving dyslipidaemia and reducing hyperglycaemia, and thus reduce these cardiovascular risk factors associated with type 2 diabetes and metabolic syndrome. Interestingly, PPAR physiological functioning proved to be useful and reliable to indicate clinically a normal glyco-lipidaemic metabolism, in agreement with other authors (2). Among a lot of biophysical-semeiotic methods (See above-mentioned website; Practical Applications), different in technical difficulty, but similarly reliable and useful in assessing peroxisome proliferator-activated receptors (PPARs) (3), I suggest two methods, based on melatonin and thyroide hormone secretion, which allow doctor to bed-side evaluate the activity of such nuclear receptors in individuals with Pre-Metabolic Syndrome (3-6). In a few words, PPARs are members of the nuclear receptor family that regulates the expression of genes that control fatty acid synthesis, storage, catabolism, as well as glucose homeostasis and insulin sensitivity, e.g., in the liver. PPARs bind as heterodimers with another member of the nuclear receptor family, the retinoid X receptor (RXR- ROR), stimulated also by melatonin (3-6), to peroxisome proliferator response elements (PPREs) in the P450 4A1 and 4A6 genes. In addition, recent data suggest that PPAR alpha and gamma activation decreases atherosclerosis progression not only by correcting metabolic disorders, but also through direct effects on the vascular wall (ibidem). PPARs modulate the recruitment of leukocytes to endothelial cells, control the inflammatory response and lipid homeostasis of monocytes/macrophages and regulate inflammatory cytokine production by smooth muscle cells. In conclusion, Biophysical-Semeiotic Evaluating PPARs activity, described for the first time from clinical view-point, represents a paramount event in Preventive Medicine. REFERENCES 1) Camejo G, Rosengren B, Hallberg C, Wallin B. PPAR agonists vascular effects contributing to their apparent anti-atherogenic action. Presented at the 2nd International Symposium on PPARs: from basic science to clinical applications. March, 2003. 2) Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. 3) Stagnaro Sergio. Bed-Side Biophysical-Semeiotic Evaluation of PPARs Activity. http://www.semeioticabiofisica.it/semeioticabiofisica/Documenti/Eng/PPARs%20 BS 20Evaluation 4) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico". Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 5) Stagnaro S., Stagnaro-Neri M., La Melatonina nella Terapia del Terreno Oncologico e del "Reale Rischio" Oncologico. Ediz. Travel Factory, Roma, 2004. 6) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico-Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ediz. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm Competing interests: None declared |
|||
|
|
|||
|
Michael L. Parchman, San Antonio, Texas Associate Professor, Department of Family & Community Medicine, UT Health Science Center
Send response to journal:
|
Paul Nutting and colleagues are to be congratulated for their study on the relationship between the Chronic Care Model and outcomes of care for patients with type 2 diabetes. Not only did they demonstrate a linkage between process measures of quality and the CCM, they also found that patients seen in clinics where the CCM has been better implemented have better control of risk factors for complications due to their diabetes: A1c and lipid control. This study provides more evidence of a link between how primary care clinics organize the care they deliver and important patient outcomes. What are the implications of these findings for T2, bedside to community, translational research? The temptation would be to question which specific elements are most important and then try to design interventions focused on those elements. Unfortunately, this approach would be doomed to failure. Why? Because there is now a convincing body of literature that describes primary care clinics as a complex adaptive system.(CAS) These systems have properties such as non-linear dynamics, diversity, sensitivity to initial conditions and co-evolution among agents in the system. These properties will doom to failure any “one-size-fits-all” approach to implementing specific elements of the chronic care model. What is needed is an approach that takes into account these inherent properties such that agents in these systems are allowed to develop and adapt strategies to implement the CCM within their local internal and external environment in a way that will allow quality and outcomes to be emergent properties of these systems. Although there are numerous studies that demonstrate the difficulty of implementing sustainable change in primary care clinics, the qualitative study by Mary Hroscikoski and colleagues published in the July/August edition of the Annals of Family Medicine is an excellent story of the many challenges that we face. She noted that “…every clinic went about change differently.” We need new models and new methods for this line of research. The stakes are high when one considers the potential to reduce morbidity and mortality in our patients with type 2 diabetes by improving control of risk factors as documented by Nutting and colleagues. What is needed are innovative and effective methods to promote sustainable change in primary care practice settings. Crabtree BF. Primary care practice: uncertainty and surprise. In: McDaniel RR, Driebe DJ (eds) Uncertainty and surprise in complex systems. Springer, New York. 2005. Miller WL, McDaniel RRJ, Crabtree BF, Stange KC. Practice jazz: understanding variation in family practices using complexity science. J Fam Pract 2001 Oct;50(10):872-8. Competing interests: None declared |
|||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH |
TRACK: