Telephone Virtual Versus In-Person Pharmacotherapy-Based Obesity Care: A COVID-19-Related Experience at a Veterans Administration Facility.

Background: Most of the Veterans Administration (VA) population is either overweight or obese, which is a serious health concern. Medical weight management visits have traditionally occurred through in-person clinics. However, the COVID-19 pandemic forced care delivery to virtual platforms. Methods: We compared weight loss with in-person versus telephone-based medical weight management (lifestyle counseling coupled with pharmacotherapy) delivered by physician and nurse practitioner visits during the pandemic. We designed a program evaluation utilizing a naturalistic (pragmatic) observational study structure, including both newly enrolled and previously established participants in the Minneapolis VA MOVE! program between 2017 and 2021. A "transition" cohort (n = 74) received in-person care from March 2019 to March 2020, and then transitioned to virtual care. A "new start" virtual care cohort (n = 149) enrolled after March 2020 was compared to a separate historical group (n = 180) that received in-person care between January 2017 and December 2019. Weight loss was accessed over a 9-month period in both cohorts. Results: Mean weight loss over 9 months was -6.5 ± 18.2 and -2.5 ± 13.3 lbs in the in-person and virtual phases of the transition cohort, respectively, without significant difference between the two phases (p = 0.22). Mean weight loss over 9 months in the new start (virtual) cohort was -14.4 ± 17.0 lbs compared to -16.7 ± 21.0 lbs in the historical cohort, without significant difference between groups (p = 0.44). Conclusions: In our naturalistic study in a single-site VA clinic setting, weight loss with telephone-based medical weight management during the pandemic was comparable to in-person care. These findings are important for veterans living in rural and/or underserved areas.

Best Practices in Resident Research- A National Survey of High Functioning Internal Medicine Residency Programs in Resident Research in USA.

PURPOSE: Meaningful participation in research for both faculty and residents is generally viewed to be an essential component of residency training. To better understand best practices in residency research, the authors conducted a survey among Internal Medicine (IM) Residency Programs with experience in research. METHODS: Phone interviews were conducted with a convenience sample of Residency Program Directors (PDs). Survey responses were analyzed across the following domains: size and makeup of the residency and research programs, resources for research, role of the PD/research director (RD), profile of trainees doing research, curriculum description, scope of research, role of mentors, career choices and determinants of success. RESULTS: Fifteen programs were included in the study. Across these programs, approximately two-thirds of residents were involved in research during their training . Eighty percent of the programs required an application for residents to engage in research. Ninety-two percent of the programs had a RD but only 58% had a formal research curriculum. Clinical research projects were the most common types of research. On average, two-thirds of residents involved in research submitted abstracts to regional and/or national meetings. The factor most frequently associated with resident research success was an effective faculty research mentor. CONCLUSIONS: Research success during residency is multifactorial. The authors propose that having a robust structure for research that is led by a residency RD, and the presence of effective mentors and strong administrative support are critical for success.

Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

Background: Testosterone treatment rates in adult men have increased in the United States over the past 2 decades. Purpose: To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism. Data Sources: English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews. Study Selection: 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information. Data Extraction: Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. Data Synthesis: Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication. Limitation: Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied. Conclusion: In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown. Primary Funding Source: American College of Physicians. (PROSPERO: CRD42018096585).

Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services?

In 2016, Batalden et al proposed a coproduction model for health care services. Starting from the argument that health care services should demonstrate service-dominant rather than goods-dominant logic, they argued that health care outcomes are the result of the intricate interaction of the provider and patient in concert with the system, community, and, ultimately, society. The key notion is that the patient is as much an expert in determining outcomes as the provider, but with different expertise. Patients come to the table with expertise in their lived experiences and the context of their lives.The authors posit that education, like health care services, should follow a service-dominant logic. Like the relationship between patients and providers, the relationship between learner and teacher requires the integrated expertise of each nested in the context of their system, community, and society to optimize outcomes. The authors then argue that health professions learners cannot be educated in a traditional, paternalistic model of education and then expected to practice in a manner that prioritizes coproductive partnerships with colleagues, patients, and families. They stress the necessity of adapting the health care services coproduction model to health professions education. Instead of asking whether the coproduction model is possible in the current system, they argue that the current system is not sustainable and not producing the desired kind of clinicians.A current example from a longitudinal integrated clerkship highlights some possibilities with coproduced education. Finally, the authors offer some practical ways to begin changing from the traditional model. They thus provide a conceptual framework and ideas for practical implementation to move the educational model closer to the coproduction health care services model that many strive for and, through that alignment, to set the stage for improved health outcomes for all.

Patient Satisfaction With Medical Student Participation in a Longitudinal Integrated Clerkship: A Controlled Trial.

PURPOSE: To determine whether longitudinal student involvement improves patient satisfaction with care. METHOD: The authors conducted a satisfaction survey of patients followed by 10 University of Minnesota Medical School students enrolled in 2016-2017 in the Veterans Affairs Longitudinal Undergraduate Medical Education (VALUE) program, a longitudinal integrated clerkship at the Minneapolis Veterans Health Care System. Students were embedded in an ambulatory practice with primary preceptors who assigned students a panel of 14 to 32 patients to follow longitudinally in inpatient and outpatient settings. Control patients, matched on disease severity, were chosen from the preceptor's panel. Two to five months after the students completed the VALUE program, the authors conducted a phone survey of the VALUE and control patients using a validated, customized questionnaire. RESULTS: Results are reported from 97 VALUE patients (63% response rate) and 72 controls (47% response rate) who had similar baseline characteristics. Compared with control patients, VALUE patients reported greater satisfaction with explanations provided by their health care provider, their provider's knowledge of their personal history, and their provider's looking out for their best interests (P < .05). Patients in the VALUE panel selected the top category more often than control patients for overall satisfaction with their health care (65% vs 43%, P < .05). CONCLUSIONS: The results of this controlled trial demonstrate that VALUE student longitudinal participation in patient care improves patient satisfaction and patient-perceived quality of health care for VALUE patients compared with controls matched by primary care provider and disease severity. These findings may have implications outside the Veterans Administration population.

Factors associated with treatment success in veterans with diabetes and hyperlipidemia: a retrospective study.

PURPOSE: The purpose of this study is to identify factors related to achieving a LDL <100 mg/dL. METHODS: Data from a recent randomized control trial of nurse case management versus usual care conducted at the Minneapolis Veterans Affairs Health Care System were analyzed. The trial consisted of 556 veterans with diabetes mellitus (DM) and at least 1 of the following: blood pressure (BP) >140/90 mmHg, and/or glycated hemoglobin (A1C) >9.0%, and/or LDL >100 mg/dL. The current analysis is focused on 275 patients in either treatment group who, at baseline, had LDL >100 mg/dL. Baseline characteristics and variables obtained during the trial of the 95 patients who reached goal LDL were compared to the 180 who did not. RESULTS: Patients who reached goal LDL had higher rates of preexisting coronary artery disease (CAD), cerebrovascular accident (CVA), congestive heart failure (CHF), and HMG-coenzyme A reductase inhibitor (statin) use. After adjustment for baseline LDL, preexisting CAD, CVA, and CHF increased the odds of patients achieving a goal LDL <100 mg/dL. This is possibly secondary to the increased prevalence of these conditions in patients with DM. These patients also likely had multiple other providers involved in their care promoting attainment of lower LDL. Baseline statin usage was not related to achieving a LDL<100 mg/dL, however, patients declining to take a statin at any time during the trial had decreased odds of reaching goal LDL. Patients with preexisting neuropathy were also less likely to reach goal LDL. CONCLUSIONS: Preexisting CAD, CVA, or CHF all increased the odds of patients achieving a goal LDL <100 mg/dL while declining statin therapy and preexisting neuropathy reduced the odds.

Providers' perspective on diabetes case management: a descriptive study.

OBJECTIVES: To address the physicians' perspective on case management (CM) for diabetes. RESEARCH DESIGN AND METHODS: A nested descriptive study in a randomized controlled trial of diabetic patients who had blood pressure >140/90 mm Hg, glycated hemoglobin >9.0%, or lowdensity lipoprotein level >100 mg/dL. Patients received CM (n = 278) versus usual care over a period of 1 year. Surveys were designed to assess physicians' comfort in working with case managers. At the end of the study physicians whose patients were randomized in the trial were mailed these surveys. RESULTS: A total of 51 of the 72 providers completed the survey (70.8% response rate). The majority of the providers felt very comfortable working with case managers (91.5 %), found treatment provided by CM to be accurate (93.3%),reported that having case managers increased the likelihood of adherence to the treatment regimens (89.4%), and reported overall improved patient satisfaction with CM (93.5%). Seventy-four percent of the providers reported that working with case managers increased the number of patients who were able to achieve therapeutic goals. Almost all providers (99.74%) reported that they will likely consult case managers for management of poorly controlled diabetes. CONCLUSIONS: Co-managing diabetes patients with nurse case managers did not undermine the providers' perceived professional role. In fact, having CM increased the rate of achieving therapeutic goals among patients with diabetes and cardiovascular risk factors.

Effect of nurse case management compared with usual care on controlling cardiovascular risk factors in patients with diabetes: a randomized controlled trial.

OBJECTIVE: To determine whether nurse case management with a therapeutic algorithm could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia compared with usual care among veterans with diabetes. RESEARCH DESIGN AND METHODS: A randomized controlled trial of diabetic patients that had blood pressure (BP) >140/90 mmHg, hemoglobin A(1c) (HbA(1c)) >9.0%, or LDL >100 mg/dL. Intervention patients received case management (n = 278) versus usual care (n = 278) over a 1-year period. The primary outcome was the percentage of patients achieving simultaneous control of all three parameters (defined by BP <130/80 mmHg, HbA(1c) <8.0%, and LDL <100 mg/dL) at 1 year. Secondary outcomes included improvements within each individual component of the composite primary outcome. Differences between groups were analyzed using t tests, Pearson χ(2) tests, and linear and logistic regression. RESULTS: A greater number of individuals assigned to case management achieved the primary study outcome of having all three outcome measures under control (61 [21.9%] compared with 28 [10.1%] in the usual care group [P < 0.01]). In addition, a greater number of individuals assigned to the intervention group achieved the individual treatment goals of HbA(1c) <8.0% (73.7 vs. 65.8%, P = 0.04) and BP <130/80 mmHg (45.0 vs. 25.4%, P < 0.01), but not for LDL <100 mg/dL (57.6 vs. 55.4%, P = 0.61), compared with those in the usual care group. CONCLUSIONS: In patients with diabetes, nurse case managers using a treatment algorithm can effectively improve the number of individuals with control of multiple cardiovascular risk factors at 1 year.

Type I allergy to insulin: case report and review of localized and systemic reactions to insulin.

Allergic reactions to insulin preparations are not uncommon. Although patients often present with skin symptoms, most articles on insulin allergy are published in endocrinology and allergy journals. The purpose of this report is to describe a case of localized type I allergy to insulin as well as provide a review of the classification of insulin allergy, methods of evaluation, and management options.

Endogenous effectors of human liver glycogen phosphorylase modulate effects of indole-site inhibitors.

Phosphorylase is regulated by a number of small-molecular-weight effectors that bind to three sites on the enzyme. Recently, a fourth site referred to as the indole-inhibitor site has been identified. Synthetic compounds bind to the site and inhibit activity. However, the effects of these compounds in the presence of other endogenous effectors are unknown. We have determined the effects of four indole derivative glycogen phosphorylase inhibitors (GPI) on recombinant human liver glycogen phosphorylase a activity. The GPIs tested were all potent inhibitors. However, the endogenous inhibitors (glucose, ADP, ATP, fructose 1-phosphate, glucose 6-phosphate, UDP-glucose) and the activator (AMP) markedly reduced the inhibitory effect of GPIs. Consistent with these in vitro findings, the IC50 for the inhibition of glycogenolysis in cells and the liver drug concentration associated with glucose-lowering activity in diabetic ob/ob mice in vivo were also significantly higher than those determined in in vitro enzyme assays. The inhibitory effect of indole-site effectors is modulated by endogenous small-molecular-weight effectors of phosphorylase a activity. However, at higher concentrations (10-30 microM), the GPI effect was dominant and resulted in inhibition of phosphorylase a activity irrespective of the presence or absence of the other modulators of the enzyme.

Integrated effects of multiple modulators on human liver glycogen phosphorylase a.

Hepatic glucose production is increased in people with type 2 diabetes. Glucose released from storage in liver glycogen by phosphorylase accounts for approximately 50% of the glucose produced after an overnight fast. Therefore, understanding how glycogenolysis in the liver is regulated is of great importance. Toward this goal, we have determined the kinetic characteristics of recombinant human liver glycogen phosphorylase a (HLGPa) (active form) and compared them with those of the purified rat enzyme (RLGPa). The Michaelis-Menten constant (K(m)) of HLGPa for P(i), 5 mM, was about fivefold greater than the K(m) of RLGPa. Two P(i) (substrate) concentrations were used (1 and 5 mM) to cover the physiological range for P(i). Other effectors were added at estimated intracellular concentrations. When added individually, AMP stimulated, whereas ADP, ATP and glucose inhibited, activity. These results were similar to those of the RLGPa. However, glucose inhibition was about twofold more potent with the human enzyme. UDP-glucose, glucose 6-phosphate, and fructose 1-phosphate were only minor inhibitors of both enzymes. We reported previously that when all known effectors were present in combination at physiological concentrations, the net effect was no change in RLGPa activity. However, the same combination reduced HLGPa activity, and the inhibition was glucose dependent. We conclude that a combination of the known effectors of phosphorylase a activity, when present at estimated intracellular concentrations, is inhibitory. Of these effectors, only glucose changes greatly in vivo. Thus it may be the major regulator of HLGPa activity.