I was welcomed by Christine Olimpio, Director of Investor Relations and David Walton, Vice President of Marketing and Commercial Development, who explained to me how it works. First, a special skin preparation device is used to permeate the skin before placing the sensor.
The Symphony wirelessly provides the patient’s glucose level every minute to a remote monitor. In order to reduce blood sugar, hospitals — surprise, surprise – often give these patients intravenous insulin. As noted, there are other invasive or minimally invasive continuous glucose monitoring systems currently approved for in-hospital use in the EU, though not in the US.
Additionally, getting back to potential out-patient applications, while a 1-3 day sensor is never going to compete with Medtronic and Dexcom, it could conceivably make sense if it were to be incorporated into a patch pump, like the Omnipod, which has to be switched out every three days anyway. In that case you’d only have to deal with switching out one system (and you’d have only one thing stuck to your body), rather than the current two.
In short, the Symphony system is interesting stuff – and hopefully there will be good news on the in-hospital CE Mark soon.
The Diabetes Media Foundation is a 501(c)(3) tax-exempt nonprofit media organization devoted to informing, educating, and generating community around living a healthy life with diabetes. This section looks at the development of health promotion and its contribution to public health policy.
The health and well-being of individuals and populations across all age groups is influenced by a range of factors both within and outside the individual's control. The Dahlgren and Whitehead model has been useful in providing a framework for raising questions about the size of the contribution of each of the layers to health, the feasibility of changing specific factors and the complementary action that would be required to influence linked factors in other layers. However this might only be applicable to US or another western country with similar socioeconomic, environmental conditions and a similar population. In 2003 WHO published an influential document 'The Solid Facts' on the social determinants of health, which reviewed the evidence for causal relationships between social and environmental factors and health, and outlined policy implications (Wilkinson & Marmot, Eds, 2003). The following table (1.1) summarises the key facts about each area and policy implications, but readers are highly recommended to refer to the whole document. Stressful circumstances, making people feel worried, anxious and unable to cope, are damaging to health making people susceptible to infections, diabetes, high blood pressure, heart attack, stroke, depression and aggression, and may lead to premature death.
Although a medical response to biological changes from stress may be to try to control them with drugs, attention should be focused upstream, on reducing the major causes of chronic stress. In schools, workplaces and other institutions, the quality of the social environment and material security are often as important to health as the physical environment. Governments should recognize that welfare programmes need to address both psychosocial and material needs: both are sources of anxiety and insecurity. A good start in life means supporting mothers and young children: the health impact of early development and education lasts a lifetime. All citizens should be protected by minimum income guarantees, minimum wages legislation and access to services. Interventions to reduce poverty and social exclusion are needed at both the individual and the neighbourhood levels. Legislation can help protect minority and vulnerable groups from discrimination and social exclusion.
Public health policies should remove barriers to health care, social services and affordable housing. Labour market, education and family welfare policies should aim to reduce social stratification. Appropriate involvement in decision-making is likely to benefit employees at all levels of an organization. Friendship, good social relations and strong supportive networks are known to improve health at home, at work and in the community.
Reducing social and economic inequalities and reducing social exclusion can lead to greater social cohesiveness and better standards of health.
Improving the social environment in schools, in the workplace and in the community more widely, will help people feel valued and supported in more areas of their lives and will contribute to their health, especially their mental health. Designing facilities to encourage meeting and social interaction in communities could improve mental health.
In all areas of both personal and institutional life, practices that cast some as socially inferior or less valuable should be avoided because they are socially divisive. Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is influenced by the wider social setting. Work to deal with problems of both legal and illicit drug use needs not only to support and treat people who have developed addictive patterns of use, but should also aim to address the patterns of social deprivation in which the problems are rooted.
Policies need to regulate availability through pricing and licensing, and to inform people about less harmful forms of use, to use health education to reduce recruitment of young people and to provide effective treatment services for addicts.
Healthy transport means less driving and more walking and cycling, backed up by better public transport. Roads should give precedence to cycling and walking for short journeys, especially in towns.
Public transport should be improved for longer journeys, with regular and frequent connections for rural areas.
Incentives need to be changed, for example, by reducing state subsidies for road building, increasing financial support for public transport, creating tax disincentives for the business use of cars and increasing the costs and penalties of parking. Changes in land use are also needed, such as converting road space into green spaces, removing car parking spaces, dedicating roads to the use of pedestrians and cyclists, increasing bus and cycle lanes, and stopping the growth of low density suburbs and out-of-town supermarkets, which increase the use of cars. Increasingly, the evidence suggests that building more roads encourages more car use, while traffic restrictions may reduce congestion.
In 2005 the WHO launched a new initiative, the Commission on Social Determinants (CSDH), to draw the attention of governments, civil society, international organisations and donors to the health effects of social determinants. Exciting recent research has explored biological markers and physiological explanations for the effects on health of social determinants especially of prolonged chronic stress. Dahlgren G & Whitehead M (1991) Policies and strategies to promote social equity in health. Commission on Social Determinants (2006) Towards a conceptual framework for analysis and action on the social determinants of health.
The changes in the structure and organisation of society, and in the knowledge of causes of disease over the last century or so, have shifted the focus of understanding and attention to different influences on health with concomitant effects on the resourcing and structure of health care. There have been three distinct phases in the public health movement, since the mid 19th century to the current time in western Europe, in relation to industrialisation and increasing access to health care and pharmaceuticals. The third discernible phase is the therapeutic era, from the 1930's to the 1970's, with the discovery of insulin and sulphonamide drugs, a time of expansion of hospital and treatment services and the sense that medicine was 'a magic bullet' that could cure all individual ills, regardless of the context of people's everyday lives.
In 1974, the Canadian Minister of Health, Marc Lalonde, published a government report on A new perspective on the health of Canadians, which focussed attention on the fact that much ill-health in Canada was preventable.
This report set the scene for a re-emergence of public health, and for health of the population being a legitimate concern and responsibility of governments. As can be seen from this brief listing, the targets are a holistic approach to health improvement, with actions in all sectors required. By 1990, national policies in all Member States should ensure that legislative, administrative, and economic mechanisms provide broad intersectoral support and resources for the promotion of healthy lifestyles and ensure effective participation at all levels of such policy-making.
The educational model is based on the view that the world consists of rational human beings and that to prevent disease and improve health you merely have to inform or educate people about the remedies and healthy lifestyles and as rational human beings they will respond accordingly. These models may influence professionals perspective on health, illness and the causes of what makes people well or ill, which may further influence the treatment.
Like all models these are simplifications of reality and as such are all incomplete, in practice health promotion is a combination of these approaches. On the other hand, health promotion may be seen as having more complex and radical roots, representing a reaction to the medically dominated, individually-focused health systems which evolved in the years following the second world war. Health promotion began to be seen as one of the key vehicles to implement the HFA 2000 strategy and healthy public policy. The Ottawa Charter for Health Promotion resulted from the first International Conference on Health Promotion that met in Ottawa in November 1986, and it has since provided an endurable vision and practical focus for the development of health promotion.
The Ottawa Charter pledges (Box 1.3) were the global commitments made to take health promotion into the future.
Since then WHO has played a leading role in health promotion throughout the world, both by sponsoring further international conferences to explore further practical experience with the major action strategies of the Ottawa Charter, and by promoting a "settings" based model for health promotion.
World Health Organization (2005) The Bangkok Charter for health promotion in a globalized world.
The Health Center will be a new ambulatory clinic containing Primary Care, Dental Care, Dialysis, Diabetes Program, Eye Care, Audiology, Diagnostic Imaging, Mental Health, Child Protection, Maternal and Child Care, Public Health Nutrition, and Health Education.
Because the skin has been prepared, the sensors are only microns away from the blood vessels, and are able to measure interstitial glucose . The device then removes the dead, top layer of your skin on the specific spot where the sensor will sit. Echo is currently doing a clinical trial of the Symphony system in preparation for submitting a CE Mark Technical File for approval in Europe (see press release here) and, if they get that approval, Echo believes that the Symphony system would be the first non-invasive continuous blood glucose monitoring system that would be approved for in-hospital use in the European Union. That’s because when you’re critically ill, injured, or just had a surgeon slice into you, your body starts pumping out all sorts of counterregulatory hormones, including glucagon (which makes your body release glucose into your blood), growth hormone (which stimulates the immune system but also causes insulin resistance and hyperglycemia), stress-related adrenal hormones called catecholamines (including epinephrine and norepinephrine) and a class of anti-inflammatory steroid hormones called glucocorticoids. This implies that any device that can help hospitals safely achieve tighter control without hypos could conceivably both improve patients’ health outcomes and reduce costs. In other words, bring on CGMs! It considers the contributions of individual behaviour and social, environmental and economic determinants to health.
One model, which captures the interrelationships between these factors is the Dahlgren and Whitehead (1991) 'Policy Rainbow', which describes the layers of influence on an individual's potential for health (Fig.
Places with different population structure, under different conditions, will show a very different picture. Institutions that can give people a sense of belonging, participating and being valued are likely to be healthier places than those where people feel excluded, disregarded and used. In particular, governments should support families with young children, encourage community activity, combat social isolation, reduce material and financial insecurity, and promote coping skills in education and rehabilitation. Slow growth and poor emotional support raise the lifetime risk of poor physical health and reduce physical, cognitive and emotional functioning in adulthood. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives. A virtuous circle can be established: improved conditions of work will lead to a healthier work force, which will lead to improved productivity, and hence to the opportunity to create a still healthier, more productive workplace.
Mechanisms should therefore be developed to allow people to influence the design and improvement of their work. 1.2 shows the comprehensive framework proposed by CSDH that seeks to explain and illustrate the relationships between determinants and health, their causal role in generating health inequities, and the levels for policy action. Cell aging can be measured by the length of the telomeres, the structures at the end of the chromosomes that repair cell damage, and which shorten after each cell division. A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA.
Contribution of deaths related to alcohol use of socioeconomic variation in mortality: register based follow-up study.
Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Between the 1830's and 70's in England there was recognition of the need to take action on housing and sanitation, and the provision of safe water and adequate food.
This was debunked principally by the analysis of Thomas McKeown who produced the background for a new public health based on the study of population growth and mortality.
There is also a clear prediction of the requirement of advanced technologies in terms of evidence, education and quality improvement for example. The attainment of this target could be significantly supported by strategic health planning at cabinet level, to cover broad intersectoral issues that affect lifestyle and health, the periodic assessment of existing policies in their relationship to health, and the establishment of effective machinery for public involvement in policy planning and development. For example, a professional strictly following the medical model, will determine hyperlipidaemia and hypertension as causes of heart disease, whereas a social epidemiologist may consider stress, poor living and working conditions as main contributory factors for heart disease. Health promotion can be seen as part of the natural progression and extension of health education, which has embraced the lessons of the past concerning the need to combine the actions of individuals with those of society to achieve optimal health. In this context a wider set of goals which emphasise the achievement of equity, social justice, participation and self determination are seen as being the essential elements of health promotion.
The salutogenic perspective advocates strengthening people's health potential and recognising that good health is a means for a productive and enjoyable life. Two WHO conferences which have extended our knowledge and understanding of the strategies defined in the Ottawa Charter were held in Adelaide, Australia to examine international experience in developing healthy public policy (WHO, 1988), and in Sundsvall, Sweden to explore ways and means of creating supportive environments for health (WHO, 1991). This process takes 10-20 seconds, and removal of the outer layer of skin allows the measuring of a number of physiological properties, including interstitial glucose levels. These hormones are all important in helping your body to heal, but they also cause high blood sugars (among other things, they impair insulin’s ability both to encourage glucose uptake into muscle and to prevent the liver from dumping extra glucose into the blood).
This would be a big improvement over the current non-CGM-based techniques to measure blood glucose in an in-patient setting, which usually occur only once every several hours and involve taking arterial blood samples (from IV lines that are already in place), which are either tested on an in-room Accu-chek glucometer, or sent to a lab.
But the fact that the Symphony is completely non-invasive could make it stand out from the crowd: particularly in a germ-filled hospital setting amongst immune-compromised patients, the fewer puncture wounds you have, the better. The determinants of health are explained using the 'Policy Rainbow' model, the WHO publication 'The Solid Facts' and the WHO Commission for Social Determinants. As an example, in a country where a civil was breaks out, people's health can deteriorate quite rapidly due to the general socio-economic and environmental conditions; because suddenly factors like availability of food, shelter and drinking water will become dominant in determining health as compared with other factors. Poverty and social exclusion increase the risks of divorce and separation, disability, illness, addiction and social isolation and vice versa, forming vicious cycles that deepen the predicament people face. This blames the victim, rather than addressing the complexities of the social circumstances that generate drug use. Social and environmental factors are at the root of much inequality relating to both communicable and non-communicable disease. Psychological stress, both perceived and objectively measured stress levels, has been shown in women to be significantly associated with higher oxidative stress and shorter telomere length. These environmental responses to preventing infectious disease and improving health were evident in the National Public Health Acts in 1846 and 1875 showing government taking responsibility through legislation for preventing disease in communities living in poverty. Its principles emphasised the importance of the development of primary health care, the need for real community participation, and the imperative of intersectoral collaboration between sectors and agencies. The focus is on taking the best combination of actions to achieve the best possible health outcomes for the community and the individual. In the latter case WHO supported the development of the Healthy Cities Project, a network of Health Promoting Schools, and action to support the development of health promoting worksites and health promoting hospitals. Second, as it stands now, the transmitter that sits on your skin is pretty large and unattractive (not that my G4 is winning any beauty contests).
Throw in the fact that many patients in the ICU are receiving intravenous nutritional infusions (often glucose-based), and you’ve got a recipe for hyperglycemia. Additionally, Echo is hoping to be able to price their sensors lower than those currently on the market. The development of the public health movement and the role that health promotion has played in conceptualising this is described, considering the Lalonde 'Health Field concept' and WHO Health for All by the Year 2000. Whitehead (1995) described these factors as those that are fixed (core non modifiable factors), such as age, sex and genetic and a set of potentially modifiable factors expressed as a series of layers of influence including: personal lifestyle, the physical and social environment and wider socio-economic, cultural and environment conditions. Effective drug policy must therefore be supported by the broad framework of social and economic policy.
1.3 shows the model from the UK used to implement policy to tackle health inequalities, demonstrating the interrelationships between the themes and principles. Epel et al (2004) show that women with the highest levels of perceived stress have telomeres shorter on average by the equivalent of at least one decade of additional aging compared to low stress women. This was followed by an era of growing understanding of the transmission of disease - the germ theory - which increased the focus on individual approaches to prevention; including the introduction of immunisation and vaccination, and community and school health services to support mothers and children.
The main objectives were the promotion of lifestyles conducive to health, the prevention of preventable conditions and provision of rehabilitation and health services. Identifying scientifically sound solutions to measurable health problems is the base on which such action is built. And third, considering how painless the Dexcom is once inserted, I don’t consider the non-invasive angle as a huge improvement.
Ideological models of health promotion and the Ottawa Charter are also described in this section. These findings have opened up a new area of interdisciplinary research that attempts to explain the causative factors and opportunities for intervening, across the 'interdisciplinary canyon' from cell biology to social and psychological studies (Sapolsky, 2004), which is fundamental to future public health action on health inequalities. The emphasis in these initiatives was more on providing information and some practical support to enable individuals to take responsibility for taking the actions necessary to keep themselves healthy. This was further developed for the European Region in its HFA strategy (WHO, 1981) and clearly operationalized in the Targets for Health for All published in 1985 (WHO, 1985).
I mean, yes, if it could deliver the accuracy of the G4 and could be worn for a week, I might prefer skin abrasion over constant new puncture wounds.
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