A low-carbohydrate, ketogenic diet to treat type 2 diabetes.

BACKGROUND: The low-carbohydrate, ketogenic diet (LCKD) may be effective for improving glycemia and reducing medications in patients with type 2 diabetes. METHODS: From an outpatient clinic, we recruited 28 overweight participants with type 2 diabetes for a 16-week single-arm pilot diet intervention trial. We provided LCKD counseling, with an initial goal of <20 g carbohydrate/day, while reducing diabetes medication dosages at diet initiation. Participants returned every other week for measurements, counseling, and further medication adjustment. The primary outcome was hemoglobin A1c. RESULTS: Twenty-one of the 28 participants who were enrolled completed the study. Twenty participants were men; 13 were White, 8 were African-American. The mean [+/- SD] age was 56.0 +/- 7.9 years and BMI was 42.2 +/- 5.8 kg/m2. Hemoglobin A1c decreased by 16% from 7.5 +/- 1.4% to 6.3 +/- 1.0% (p < 0.001) from baseline to week 16. Diabetes medications were discontinued in 7 participants, reduced in 10 participants, and unchanged in 4 participants. The mean body weight decreased by 6.6% from 131.4 +/- 18.3 kg to 122.7 +/- 18.9 kg (p < 0.001). In linear regression analyses, weight change at 16 weeks did not predict change in hemoglobin A1c. Fasting serum triglyceride decreased 42% from 2.69 +/- 2.87 mmol/L to 1.57 +/- 1.38 mmol/L (p = 0.001) while other serum lipid measurements did not change significantly. CONCLUSION: The LCKD improved glycemic control in patients with type 2 diabetes such that diabetes medications were discontinued or reduced in most participants. Because the LCKD can be very effective at lowering blood glucose, patients on diabetes medication who use this diet should be under close medical supervision or capable of adjusting their medication.

Patient and clinician satisfaction with a store-and-forward teledermatology consult system.

The aim of this study was to assess satisfaction with and acceptance of a store and forward teledermatology consult system among patients, referring primary-care clinicians, and consultant dermatologists. As part of a randomized clinical trial that compared the clinical and economic outcomes of store and forward teledermatology to a conventional referral process, we conducted satisfaction assessments among participating patients, referring primary-care clinicians, and consultant dermatologists. Survey questions included issues related to the timeliness of each consult process, the confidence participants displayed in each consult modality, and assessments of overall satisfaction and preferences. A majority of referring clinicians (92%) and dermatologist consultants (75%) reported overall satisfaction with the teledermatology consult process. Ninety-five percent of referring clinicians reported that teledermatology resulted in more timely referrals for their patients. This finding was validated by the observation that teledermatology patients reached a point of initial intervention significantly sooner than did patients in usual care (41 days versus 127 days, p = 0.0001). Teledermatology patients reported satisfaction with the outcome of their teledermatology consultation 82% of the time. However, patients did not express a clear preference for a consult method. A total of 41.5% of patients preferred teledermatology, 36.5% preferred usual care, and 22% were neutral. Our study showed a high level of satisfaction among all users of a store-and-forward teledermatology consult system, and, in some cases, our survey results could be validated with observed clinical outcomes.

An economic analysis of a store and forward teledermatology consult system.

Our objective was to assess the economic impact of store-and-forward teledermatology in a United States Department of Veterans Affairs (VA) health care setting. Patients being referred to the Dermatology Consult Service from the Primary Care Clinics at the Durham, North Carolina VA Medical Center were randomized either to usual care or to a teledermatology consultation. Fixed and variable costs for both consult modalities were identified using a microcosting approach. The observed clinical outcomes from the randomized trial generated probability and effectiveness measures that were inserted into a decision model. A cost analysis and a cost-effectiveness analysis that compared the two consult modalities was performed. Teledermatology was not cost saving when compared to usual care using observed costs and outcomes. Sensitivity analyses indicated that teledermatology has the potential to be cost saving if clinic visit costs, travel costs, or averted clinic visits were higher than observed in the study. Teledermatology was cost-effective for decreasing the time required for patients to reach a point of initial definitive care. Cost-effectiveness ratios ranged from $0.12-0.17 (U.S.) per patient per day of time to initial intervention.

Teledermatology's impact on time to intervention among referrals to a dermatology consult service.

The aim of this study was to determine if a teledermatology consult system, using store-and-forward digital imaging technology, results in patients achieving a shorter time from referral date to date of initial definitive intervention when compared to a traditional referral process. Patients being referred to the dermatology consult service from the primary care clinics at the Durham VA Medical Center were randomized to either a teledermatology consultation or usual care. A usual care consultation consisted of a text-based electronic consult request. A teledermatology consultation included digital images and a standardized history, in addition to the text-based electronic consult. Time to initial definitive intervention was defined as the time between referral date and the date the patient was scheduled for a clinic visit for those patients that the consultant requested a clinic-based evaluation, or the time between referral date and the date the consult was answered by the consultant if a clinic visit was not required. Patients in the teledermatology arm of the study reached a time to initial definitive intervention significantly sooner than did those patients randomized to usual care (median 41 days versus 127 days, p = 0.0001, log-rank test). Additionally, 18.5% of patients in the teledermatology arm avoided the need for a dermatology clinic-based visit compared to zero patients avoiding a dermatology clinic visit in the usual care arm of the study (p < 0.001, z-test). Teledermatology consult systems can result in significantly shorter times to initial definitive intervention for patients compared to traditional consult modalities, and, in some cases, the need for a clinic-based visit can be avoided.