Telemedicine and diabetes: achievements and prospects.

Health authorities currently have high expectations for telemedicine (TM), as it addresses several major challenges: to improve access to healthcare (especially for patients in underserved or remote areas); to overcome the scarcity of specialists faced with epidemic disease; and to reduce the costs of healthcare while improving quality. The aims of TM in the field of diabetes differ according to the type of diabetes. In type 1 diabetes (T1DM) associated with complex insulin regimens, the goal of TM is to help patients achieve better control of their blood glucose levels through accurate adjustment of insulin doses. In type 2 diabetes (T2DM), while therapeutic adjustments may be necessary, improvement in blood glucose control is based primarily on behavioural changes (reduced calorie and carbohydrate intakes, increased physical activity). Many TM studies focusing on management of blood glucose levels have been published, but most failed to demonstrate any superiority of TM vs traditional care. While previously published meta-analyses have shown a slight advantage at best for TM, these meta-analyses included a mix of studies of varying durations and different populations (both T1DM and T2DM patients, adults and children), and tested systems of inconsistent quality. Studies published to date on TM suggest two currently promising approaches. First, handheld communicating devices, such as smartphones, loaded with software to apply physicians' prescriptions, have been shown to improve glycaemic control. These systems provide immediate assistance to the patient (such as insulin-dose calculation and food choice optimization at meals), and all data stored in the smartphone can be transmitted to authorized caregivers, enabling remote monitoring and even teleconsultation. These systems, initially developed for T1DM, appear to offer many possibilities for T2DM, too. Second, systems combining an interactive Internet system (or a mobile phone coupled to a remote server) with a system of communication between the healthcare provider and the patient by e-mail, texting or phone calls have also shown certain benefits for glycaemic control. These systems, primarily aimed at T2DM patients, generally provide motivational support as well. Although the individual benefits of these systems for glycaemic control are fewer than with smartphones, their widespread use should be of particular value for overcoming the relative shortage of doctors and reducing the health costs associated with a disease of such epidemic proportions.

Extracorporeal photochemotherapy induces arginase 1 in patients with graft versus host disease.

The benefits of extracorporeal photochemotherapy (ECP; psoralen and UVA exposure of blood mononuclear cells) in graft-versus-host-disease (GVHD) are well-recognized, but the mechanisms of action remain elusive. As the metabolism of l-arginine in immune cells is known to play a role in immune tolerance, we investigated the effect of ECP on arginine metabolism, and the influence of extracellular l-arginine concentration on the response to ECP in cells from patients on therapy by ECP for a GVHD and healthy donors cultured before and after ECP in the presence of different concentrations of arginine (0, 50, 100, 200 and 1000 µmol/l). At baseline arginine was not metabolized through the same pathway in patients and donors. When cells were exposed to ECP, the production of ornithine but not NO° was enhanced, while mRNA of arginase 1 was up-regulated but not INOS. In GVHD patients, increasing arginine concentration resulted in down-regulation of IFNγ and TNFα mRNA expression, whereas IL10 was up-regulated especially at physiological plasma levels (between 0 and 100 µM). Overall, our study shows that ECP orients the metabolism of arginine toward the arginase pathway together with shifting the cytokine profile toward IL-10, providing new insights into the enigmatic mechanism of action of ECP.

Telemedicine: what more is needed for its integration in everyday life?

The Health Authorities have huge expectations of telemedicine (TM): improved patient access to healthcare, a solution to the shortage of doctors in the face of an exponentially expanding disease, and reduced healthcare costs with improved quality. There are a host of applications for TM in the area of diabetes. TM has been validated and has been widely used to screen for diabetic retinopathy, and a number of studies are currently underway for the follow-up of diabetic foot ulcers. However, the main indication of TM remains the follow-up and control of blood glucose. In this area, many studies have been conducted to improve glycaemic control. While most of these studies have failed to show any benefits vs. conventional care, a small number have demonstrated great efficacy of this approach with regard to glycaemia. Using these studies, we attempt to define the key qualities of a successful TM system. How can we extend the results of these experiments beyond the framework of clinical studies and integrate them in daily practice so as to improve diabetes management? This is the key challenge for TM, implementation of which will require reorganization of healthcare, given the evolution of medical demographics. This reorganization will involve healthcare providers specialized in diabetes that may intervene in assigning physicians for especially distressed patients. However, such reorganization will require medico-economic evaluation before it can be implemented on a larger scale.

Potential anti-inflammatory effects of Melaleuca alternifolia essential oil on human peripheral blood leukocytes.

The fungicidal and bactericidal actions of the essential oil (EO) of Melaleuca alternifolia seem well established, but their anti-inflammatory and antioxidative effects remain unclear. This study investigated in vitro the possible role of whole Melaleuca alternifolia EO as a modulator of the inflammatory/non-specific immune response by exploring the chemotaxis and kinetic radical oxygen species (ROS) production of leukocytes and cytokine secretion in peripheral blood mononuclear cells (PBMCs) in humans. The influence of Melaleuca alternifolia EO on the chemotaxis under agarose of isolated neutrophils (PMNs) was evaluated. The kinetics of ROS production by stimulated total circulating leukocytes was followed over 2 h by recording the fluorescence intensity of oxidized dihydrorhodamine 123. The effects of this EO on pro-(interleukin IL-2) and anti-(IL-4 and IL10) inflammatory cytokine secretions were determined by ELISA following incubation of PBMCs with the EO for 24 h. Melaleuca alternifolia EO was inefficient on the chemotaxis of PMNs. It exerted an antioxidant effect, reducing ROS production throughout the kinetic study. Melaleuca alternifolia EO inhibited PBMC proliferation, as revealed by a reduction in IL-2 secretion by stimulated lymphocytes. This EO at 0.1% directly increased the secretion of the anti-inflammatory cytokine IL-4 compared with IL-4 secretion without EO (18.5 +/- 10.0 vs 3.3 +/- 1, p < 0.05), and also increased IL-10 secretion at 0.01% (94.9 +/- 38.7 vs 44.1 +/- 18, ns). Melaleuca alternifolia EO may not only act as an anti-inflammatory mediator through its antioxidant activity but may also efficiently protect the organism by reducing the proliferation of inflammatory cells without affecting their capacity to secrete anti-inflammatory cytokines.