Bagher Larijani MD Professor of Endocrinology &Internal medicine

1. Endocrinology & Metabolism Research Institute Tehran university of Medical Sciences Bagher Larijani MD Professor of Endocrinology &Internal medicine President of Endocrinology &Metabolism Research Institute (EMRI) 2012

2. Introduction (EMRI )/Research University • Endocrinology & Metabolism Research Institute was established in 1993 as a center affiliated to Tehran University of Medical Sciences. • It was upgraded and recognized as Research Institute since 2010. • Due to vast research activities, the institute upgraded to 3 subgroup institutes and 9 research centers in 2012 by Ministry of Health and Medical Education. • The headquarter of EMRI is located in Dr. Shariati University Hospital.

3. EMRI Organizational Chart /Head Office National & International Advisors Director & Chief Scientific Officer Affiliated Professors Deputy Director-General Director of Public & International Affairs Executive Secretary Administration & Human Resource Deputy Research Deputy Information Technology Management Public & Professional Training

4. Research Divisions and Laboratories directly under supervision of director Research Divisions Research Laboratories Endocrine Modeling Bio electrochemistry Immunogenetics Bio nanotechnology Bionanotechnology Modeling & Protein Chemistry Traditional Medicine Food & Drug Research Evidence Based Medicine Sensors Medical Ethics Cellular & Molecular Innovation Hormone Islamic Fasting

5. Endocrinology and Metabolism Research Institutes / Research University Institute of Endocrine Clinical Sciences Institute of Endocrine Population Sciences Institute of Endocrine Cellular and Molecular Sciences

6. Organizational Chart of Institutes Institute of Endocrine Clinical Sciences Institute of Endocrine Cellular and Molecular Sciences Institute of Endocrine Population Sciences Endocrine Research Center NCDResearch Center Inborn Metabolic Disorder Research Center Diabetes Research Center Health Elderly Research Center Obesity & Eating Habits Research Center Osteoporosis Research Center Chronic Disease Research Center Biosensor Research Center

7. GOALS • Goal 1: Enhancement of research and knowledge production • Goal 2: Expansion of professional and graduate education • Goal 3: Promotion of translational medicine by enhancing communication between clinic and laboratory

8. The Main Objectives of the Goals are: • Goal 1 • acceleration of knowledge production • Upgrade the quality of research • Improve research productivity • Keep with the ethical and legal standards • Goal 2 • Narrow interdisciplinary gaps in the field • Focus on research based education • Goal 3 • Focus on national priorities • Become technologically self sufficient • Adapt the unifying national framework • Expand internet based research and educational resources

9. Facts and Strategy of EMRI • During past 18 years, In collaboration with MOH, EMRI as the highest ranking medical research institute in Iran, has played a key role in: • Establishing national research networks on Diabetes, Osteoporosis , Aging and Obesity • Conducting fundamental and practical researches on NCD which21centers are involved in the networks. • Other subjects of strategies includes, improving public awareness, professional education and provision of clinical services with focus on diabetes, osteoporosis, and metabolic diseases.

10. Memberships EMRI is Member of 12 international Agencies and NGOs • The Endocrine Society USA 2002 to present • Society for Endocrinology England 2002 to present • Thalassemia International Federation (TIF) 2002 to present • American Association of Clinical Endocrinology (AACE) 2003 to present • American Diabetes Association (ADA) 2003 to present • International Osteoporosis Foundation (IOF) 2003 to present • International Diabetes Foundation(IDF) 2004 to present • European Association for cancer research(EACR) 2005 to present • Asian Task Force for Organ Trafficking 2007 to present • Asian Bioethics Association (ABA) 2007 to present • International Association of Bioethics (IAB) 2008 to present • European Society for Quality Health Care 2010 to present

11. Statues of Diabetes in Iran &.. • Diabetes increasing all around the world especially in developing countries such as China, India, Pakistan and Iran. (reported by IDF, WHO) • 50% of EM people with diabetes will die of cardiovascular diseases. This means that in our region, there are pandemic trends in prevalence of diabetes and associated complications. • Globally, people with diabetes are 25 times more likely to have a leg amputated than those without the condition. • Somewhere in the world, a leg is lost due to diabetes every 30 seconds. • US Dept of Health and Human Services, National Center for Health Statistics, National Vital Statistics Reports

12. Population: 75 (2011) Total area: 1.648 million sq km • Today about 3.5 million (out of about 75million) people are suffering from diabetes and its complications in Iran. • The prevalence of Diabetes increasing in Iran like other developing countries.

13. Among EMR, diabetes is ranked among the leading causes of blindness, renal failure and lower limb amputation • Currently, 52% of the Region’s disease burden is due to NCD and it is expected that this burden will rise to 60% by 2020. • The modifiable risk factors smoking, unhealthy diet and physical inactivity, expressed as diabetes, obesity and high lipids, are the root causes of the global NCD epidemic .

14. The Prevalence of DM and IGT in Different Areas of Iran(WHO Criteria)

15. The prevalence of type 1DM in Iran is about 0.6 - 0.8% Azizi F. Diabetes Mellitus in the Islamic Republic of Iran, IDF Bulletin 1996

16. Diabetic Nephropathy • In diabetic patients, risk of Kidneyinvolvementis17 timesmore than normal population • After 20 - 30 years of DM onset: • risk of nephropathy in type 1 = 30 – 40 % • risk of nephropathy in type 2 = 15 – 50 % • In Iran 20 – 25 % of ESRD is due to DM* * Iranian Dialysis Center data

17. Diabetic Retinopathy in Iran • Overall prevalence of diabetic retinopathy is 32.4 %of which: • 17.3 %NPDR • 15.1 % PDR Larijani et al, Prevalence of diabetic retinopathy, MD dissertation No.17628 of TUMS, 1999

18. Burden of Diabetes Mellitus in Iran • Disproportionately expensive • DALY = 306,440 years = 4.72 years per 1000 people • YLL = 224,000 years among 1,600,000 diabetics in Iran • A real socioeconomic burden (US $98bil) Larigani et al., Iranian J of Diabetes and Lipid disorders,2005; 5:35-48

19. Diabetic foot • 15%of diabeticpatients develop foot ulcer • 15-20%of these will require amputation • Up to 50% of DFs are preventable • In one study in Iran: • Mean duration hospital admission for DF was 4 weeks • Amputation rate was 40% in 1995 and decreasedto14%in 2001 Larijani et al, Iranian Journal of Diabetes and Lipid disorders, 2002 Larijani et al, MJIRC 2006;8(3):21-24

20. Diabetes care in EM countries is not of uniform standard for a number of reasons. • Trained diabetes healthcare personnel are limited in numbers; • Diabetes education and counseling are not readily available to patients; • Health care models in the industrialized countries are not applicable due to problems of cost, organization and accessibility. • PHC structured to deal only with acute and episodic illnesses not designed to provide the optimal array of services to manage a complex, multi-system chronic illness like diabetes

21. Recent activities carried out to improve diabetes status • Establishing Diabetes clinics • Establishing Diabetic Foot clinics in most populated provinces • Educational activities at different levels

22. EMRI affiliated Clinics, Facilities & Laboratories

23. Diabetes Metabolic Disease Clinics 1 • Established March 2009 and includes:   •  Initial Visit Unit   •  Patient Education Unit   •  Diet and Nutrition Unit   •  Diabetic Foot Unit   •  Diagnostic Unit   •  Specialty Clinics Units   •  BMD Unit   •  Diagnostic Laboratory Unit   •  Researcher Unit   •  Cell Therapy Unit

24. A number of Clinic 1 facilities

25. Diabetes Metabolic Disease Clinics 2 • Established March 2011, located in Tehran Villa St and includes: • Patient screening and initial clinical examination unit. • Infection control and prevention unit • Diabetes patient Education Unit • In service training and professional education unit • Nutrition consultancy Unit • Diabetes Rehabilitation Unit • Day care clinic and home care services • Foot care Unit • Diabetes Specialty Health Services Unit • Aging Research Center • Library and Information Unit • Audiovisual unit • Research and Development Unit

26. Some of Clinic 2 facilities

27. Diabetes Virtual Clinic http://emri.tums.ac.ir/vclinic-en

28. EstablishingDiabetic Foot care Clinics Project • Improvement of 9 diabetic foot care clinics in 7 major high prevalence provinces. • These provinces have about 58% of all diabetics’ populations in Iran • These centers organize training courses to educate: patients, primary health care providers, and professionals.

29. EMRI is the project manager and analyzing data gathered from 8 other partners. • Ministry of Health and Medical Education in collaboration with EMRO/ WHO, succeeded to Integrate NCD in PHC and; • Ministry of Health and Medical education allocated budget for establishing / improving existing diabetic clinics in provinces and also for salary of involved personnel. • WDF supported to increase public, patients & professional’s awareness by providing necessary materials and will support with agreed budget in its time line.(grant obtained from WDF)

30. Ministry of Health & Medical Education (MOHME) Tehran University of Medical Sciences (TUMS) Endocrinology &Metabolism Research Institute (EMRI) Tehran Tabriz Boushehr13.6% Isfahan 7.76% Mashhad Tehran (Three centers) rural population over 30 years 7.6 % Urban population is about 7.2% Shiraz Yazd 16.3%

31. EMRI educational activities • Public Education • Professional Education

32. Public Education • Preparing 110 books, brochures, pamphlets & CDs distributing all over the country • Celebration of World Days • World Diabetes Day (WDD) • Public Awareness Campaigns • Weekly Diabetes Education for patients and their families

33. Professional Education • 70Books &Booklets for Healthcare Providers • Preparing National Guidelines; • Diabetes Guideline • Diabetic Foot Guideline

34. This journal since 2008 is available in English as e journal with open –access available full-text. • IJDLD is a peer reviewed journal, provides a forum for scientific inquiry in the fields of Diabetes , Lipid and Metabolic disorders and Cardiovascular • Information is available in: http://www.jdmdonline.com/

35. Workshops & Seminars • Since establishment, EMRI organized 15 international seminars,workshops and 160 national workshops and seminars. • Details in three centers of EMRI As a sample

36. International Interprofessional Wound Care Course (IIWC) April &NOV 2007 • International Training course on Wound care with special Focus on Foot care with collaboration of University of Toronto Canada was organized. • 100 professionals ,Nurses and Nurse educators,GPs,Vascular surgeons , Dermatologists and Endocrinologists from Iran and Region participated as trainees.

37. International Interprofessional Wound Care Course (IIWC) April &NOV 2007 • International Training course on Wound care with special Focus on Foot care with collaboration of University of Toronto Canada was organized. • 100 professionals ,Nurses and Nurse educators,GPs,Vascular surgeons , Dermatologists and Endocrinologists from Iran and Region participated as trainees.

38. The 4th International Diabetes Updates Congress 29 Feb to 2 March 2012

39. EMRI Innovations • Producing biosensors for monitoring of low level different ingredients, • Cell transplantation • ANGIPARSA New Phytotherapeutic Drug for Wound Healing

40. Invention of a Device for Detection of Sulfonylurea in the Urine • Sulfonylurea derivatives are a class of antidiabetic drugs used in the management of type 2 diabetes mellitus. • The first generation of these drugs caused significant and potentially fatal hypoglycemia • Although new generation of sulfonylurea drugs such as Glipizide, Glimepiride, and Glibenclamide (Glyburide) are currently used as antidiabetic agents, they may also cause severe hypoglycemia.

41. Necessity for Invention of the Device • Patients with hypoglycemia can be brought to the emergency ward in an unconscious state • Currently, there exists no means of detecting sulfonylurea in the urine • The condition can remain undiagnosed • Therefore, the Endocrinology and Metabolism Research University planned a project for invention of a device for detection of Sulfonylurea in the urine

42. The Device for Detection of Sulfonylurea in the Urine

43. Biosensors in the process of development • Pioglitazone • Terazocin • Prazocin • Donpezile • Memantine • Naltroxone • Floxetine • Flurazepam • Metformine • Granisetron • Tramadol • Verapamil

44. Novel Approach In Treatment Of DM • Oral Insulin • Gene Therapy • Immunomodulators • replacement of functional insulin-producing pancreaticcells, with pancreas , islet-cell transplants or stem cell

45. Stem cell Differentiate Self-renewal Stem cell Specialized cell (e.g., white blood cell) Stem Cell Stem cell is a special kind of cell that has unique capacity • to renew itself • Differentiate to specialized cell

46. Kinds of Stem Cell: • Embryonicstem cell • Fetalstem cell • Extra embryonic stem cell (umbilical cord stem cell) • Adultstemcell • Induced pluripotent stem cells (iPS) 

47. Trials Underway In The World And Iran • Cardiac disease • Diabetes • Multiple Sclerosis • Muscular Dystrophy • Parkinson’s disease • Spinal cord injury • Stroke

48. Stem Cell TherapyOur Research

49. Adult Stem Cells Adult Tissues • Adiposetissue (adipose stem cell, ASC) • Bonemarrow(hematopoietic stem cell, HSC) • Bone marrow (mesenchymal stem cell, MSC) • Liver(hepatic stem cell) • Nervous tissue (neural stem cell, NSC) • Pancreas

50. Islet Cell Transplantation in Iran • The first phase of the project accomplished • Islet lab equipped and ready to operate Islets successfully isolated and purified • Recipients selected, evaluated, and in waiting list for transplantation • Next phases carried out with collaboration of UBC experts