Lifestyle Medicine in Diabetes Care: The Lifedoc Health Model.

Introduction: The relevance of lifestyle medicine in diabetes treatment is now incorporated in clinical practice guidelines but finding an exemplar for the creation of a Lifestyle Medicine Program (LMP) is a difficult task. Aim: To use Lifedoc Health (LDH) as a LMP exemplar by describing their multidisciplinary team (MDT) approach to diabetes care along with tactics to address sustainability challenges. Results: The LDH model facilitates early activation of patients with diabetes and other cardiometabolic risk factors, MDT approaches, and protocols/policies that are able to overcome barriers to equitable healthcare in the community. Specific programmatic targets are clinical outcomes, effective dissemination, economic viability, and sustainability. Infrastructure centers on patient-driven problem-based visits, shared medical appointments, telemedicine, and patient tracking. Further discussions on program conceptualization and operationalization are provided. Conclusion: Even though strategic plans for LMPs that specialize in diabetes care are well represented in the literature, implementation protocols, and performance metrics are lacking. The LDH experience provides a starting point for those healthcare professionals interested in translating ideas into action.

Impact of a Multidisciplinary Approach on Cardiometabolic Risk Reduction in a Multiracial Cohort of Adults: A 1-Year Pilot Study.

Evidence examining specific effects of a multidisciplinary team (MDT) on cardiometabolic risk factors (CMRFs) among multi-ethnic patients in real-world clinical settings is lacking. This one-year retrospective chart review (2018) analyzed 598 adults (African American 59%, Hispanic 35%, and Caucasian 6%) with mean age of 43.8 ± 14.0 years. Qualifying patients with primary inclusion criteria of having body mass indices and blood pressure (BP) measurements in the first and last quarter of the study period were treated under an MDT protocol and compared to those qualifying for MDT but treated solely by a primary care provider (PCP). MDT included endocrinologist-directed visits, lifestyle counseling, and shared medical appointments. MDT patients experienced a greater reduction (ß; 95% CI) in weight (-4.29 kg; -7.62, -0.97), BMI (-1.43 kg/m2; -2.68, -0.18), systolic BP (-2.18 mmHg; -4.09, -0.26), and diastolic BP (-1.97 mmHg; -3.34, -0.60). Additionally, MDT patients had 77%, 83%, and 59% higher odds of reducing ≥5% of initial weight, 1 BMI point, and ≥2 mmHg DBP, respectively. Improvements in hemoglobin A1C measurements were observed in the MDT group (insufficient data to compare with the PCP group). Compared to PCP only, MDT co-management improves CMRF related to adiposity and hypertension in a multiethnic adult cohort in real-world clinical settings. Patient access to best practices in cardiometabolic care is a priority, including the incorporation of culturally adapted evidence-based recommendations translated within a multi-disciplinary infrastructure, where competing co-morbidities are better managed, and associated research and education programs can promote operational sustainability.

Substrate pH Influences the Nutrient Absorption and Rhizosphere Microbiome of Huanglongbing-Affected Grapefruit Plants.

The substrate pH directly affects nutrient availability in the rhizosphere and nutrient uptake by plants. Macronutrients such as nitrogen, potassium, calcium, magnesium, and sulfur are highly available at pH 6.0-6.5, while micronutrients become less available at higher, alkaline pH (pH > 7.0). Recent research has indicated that low pHs can enhance nutrient uptake and improve sweet orange (Citrus sinensis) tree health. We designed a study to understand the influence of a wide range of substrate pH values on plant size and biomass, nutrient availability, leaf gas exchange, and rhizosphere microbiome of grapefruit (Citrus paradisi) affected by Huanglongbing (HLB). Two-year-old "Ray Ruby" grapefruit plants grafted on sour orange (Citrus aurantium) rootstock were cultivated indoors in 10-cm wide × 40-cm tall pots with peat:perlite commercial substrate (80:20 v/v). We tested two disease statuses [HLB-free or healthy (negative, HLB-) and HLB-affected (positive, HLB+)] and six substrate pH values (4, 5, 6, 7, 8, 9) in a 2 × 6 factorial arranged on a complete randomized design with four replications. The canopy volume of HLB+ plants was 20% lower than healthy plants, with pHs 7 and 9 resulting in 44% less canopy volume. The root and shoot ratio of dry weight was 25.8% lower in HLB+ than in healthy plants. Poor root growth and a decrease in fibrous roots were found, especially in pH 5 and 6 treatments in HLB+ plants (p < 0.0001). The disease status and the substrate pHs influenced the leaf nutrient concentration (p < 0.05). High substrate pH affects nutrient availability for root uptake, influencing the nutrient balance throughout the plant system. pH values did not affect plant photosynthesis, indicating that pH does not recover HLB+ plants to the photosynthetic levels of healthy plants-even though high pH positively influenced internal CO2. There were collectively over 200 rhizobacterial identified by the 16S rRNA gene sequencing in individual phylogenetic trees. Most rhizobacteria reads were identified in pH 9. Our results indicated no effect of substrate pHs on the plant disease status induced by enhanced nutrient uptake.

Variaciones anatómicas del nervio musculocutáneo en una muestra de población colombiana. Estudio en cadaver / Anatomic variations of the musculocutaneous nerve in a colombian population sample. Cadaveric study

Introducción y objetivo: El nervio musculocutáneo (NMC) inerva a los músculos bíceps, coracobraquial y braquial, que tienen como función principal contribuir con la flexión de la articulación del codo. El conocimiento de la anatomía y las variantes de sus ramas motoras permite transferencias nerviosas para recuperar la flexión del codo cuando se lesiona.El objetivo de este estudio es describir la distribución anatómica y biométrica de las principales ramas motoras y sensitivas terminales del NMC en su recorrido en el miembro superior en cadáveres de una población local de población colombiana.Material y método.Estudio descriptivo anatómico de miembros superiores en cadáveres mediante disecciones para determinar el origen de las ramas motoras y sensitivas del NMC en relación a estructuras anatómicas constantes, y su número de ramas terminales al llegar a los vientres musculares respectivos.Resultados.Disecamos 30 extremidades superiores. El NMC atraviesa el músculo coracobraquial (MCB) a 56 mm (DE 17 mm) de la apófisis coracoides; la rama motora del bíceps sale del tronco del NMC a 142 mm (DE 44); el 80% se localizan en el tercio medio, 14% en tercio proximal y 6% en tercio distal; existe 1 rama motora para el bíceps en el 57% de los casos, 2 en el 27% y 3 o más en el 16%; la longitud de las ramas es de 34 mm (DE 17). Para el músculo braquial, la rama motora sale del tronco del NMC a 181 mm (DE 28) de la apófisis coracoides; existe 1 rama motora para el braquial en el 70% de los casos, 2 en el 20% y 3 o más en el 10%; el 88% se localizan en el tercio medio y el 12% en tercio distal; la longitud es de 44 mm (DE 17); encontramos unión con el nervio mediano en el tercio medio del brazo en el 10%. (AU)

Background and objective: The musculocutaneous nerve (NMC) innervates biceps, coracobrachialis and brachialis muscle, whose main function is to flex the elbow. Knowledge of the anatomy and variations in motor branches allow to carry out nerve transfer surgery to recover the functionality of elbow flexion when the musculocutaneous nerve is injured.Our aim is to describe the anatomical and biometric distribution of the main terminal motor and sensitive branches of the MCN during its course in the upper limb in bodies of a local Colombian population.Methods.Descriptive anatomical study in corpses of upper limbs using dissections to find the origin site of the NMC motor and sensitives branches in relation to constant anatomical structures and their number of terminal branches when they reach the respective muscle bellies.Results.Dissections were performed on 30 upper extremities. MCN crosses the coracobrachialis muscle 56 mm (SD 17) from the coracoid process; the motor branch of the biceps leaves de NMC trunk at 142 mm (SD 44); 80% of the branches are located in the middle third, 14% in the proximal third and 6% in the distal third; there is 1 motor branch for biceps in 57% of cases, 2 in 27% and 3 or more in 16%; the length of the motor branches is 34 mm (SD 17). For brachialis muscle, the motor branch leaves de NMC trunk at 181 mm (SD 28) from the coracoid process; there is 1 motor branch for brachialis muscle in 70% of cases, 2 in 20% and 3 or more in 10%; 88% of the branches are located in the middle third and 12% in the distal third; the length of the motor branches of the BR is 44 mm (DS 17). Union with the median nerve was found in the middle third of the arm in 10%. (AU)

Acute cholecystitis and residual choledocholithiasis in a situs inversus patient, successful laparoscopic approach and ERCP a case report from Ecuador.

BACKGROUND: Situs inversus totalis is a rare genetic condition characterized by the transposition of organs to the opposite side of the body, consequently, clinical syndromes show an atypical clinical picture creating a challenge for the surgery team and predisposing to delays in treatment and diagnosis. Laparoscopic cholecystectomy is the gold standard for acute cholecystitis, and in patients with situs inversus, the laparoscopic technique must be modified to accommodate the patient's anatomy. CASE PRESENTATION: We present the case of a 55-year-old male patient without any past medical history, he presented to the emergency room with abdominal pain in his upper left quadrant. After a thorough examination, acute cholecystitis and situs inversus was diagnosed. He underwent a modified laparoscopic cholecystectomy without complications. In his postoperative period, residual choledocholithiasis was identified and ERCP was done. On follow-ups, the patient is doing well. CONCLUSIONS: Although rare and technically demanding, laparoscopic cholecystectomy and ERCP in a patient with situs inversus is feasible. The altered anatomy could lead to complex procedures, therefore proper planning and careful execution of intraoperative techniques are required to treat these patients safely and effectively.

Superluminal and stopped light due to mode coupling in confined hyperbolic metamaterial waveguides.

Anisotropic metamaterials with hyperbolic dispersion can be used to design waveguides with unusual properties. We show that, in contrast to planar waveguides, geometric confinement leads to coupling of ordinary (forward) and extraordinary (backward) modes and formation of hybrid waveguided modes, which near the crossing point may exhibit slow, stopped or superluminal behavior accompanied by very strong group velocity dispersion. These modes can be used for designing stopped-light nanolasers for nanophotonic applications and dispersion-facilitated signal reshaping in telecom applications.

Eliminating material constraints for nonlinearity with plasmonic metamaterials.

Nonlinear optical materials comprise the foundation of modern photonics, offering functionalities ranging from ultrafast lasers to optical switching, harmonic and soliton generation. Optical nonlinearities are typically strong near the electronic resonances of a material and thus provide limited tuneability for practical use. Here we show that in plasmonic nanorod metamaterials, the Kerr-type nonlinearity is not limited by the nonlinear properties of the constituents. Compared with gold's nonlinearity, the measured nonlinear absorption and refraction demonstrate more than two orders of magnitude enhancement over a broad spectral range that can be engineered via geometrical parameters. Depending on the metamaterial's effective plasma frequency, either a focusing or defocusing nonlinearity is observed. The ability to obtain strong and fast optical nonlinearities in a given spectral range makes these metamaterials a flexible platform for the development of low-intensity nonlinear applications.

Ultrafast all-optical modulation with hyperbolic metamaterial integrated in Si photonic circuitry.

The integration of optical metamaterials within silicon integrated photonic circuitry bears significantly potential in the design of low-power, nanoscale footprint, all-optical functionalities. We propose a novel concept and provide detailed analysis of an on-chip ultrafast all-optical modulator based on an hyperbolic metamaterial integrated in a silicon waveguide. The anisotropic metamaterial based on gold nanorods is placed on top of the silicon waveguide to form a modulator with a 300x440x600 nm(3) footprint. For the operating wavelength of 1.5 µm, the optimized geometry of the device has insertion loss of about 5 dB and a modulation depth of 35% with a sub-ps switching rate. The switching energy estimated from nonlinear transient dynamic numerical simulations is 3.7 pJ/bit when the transmission is controlled optically at a wavelength of 532 nm, resonant with the transverse plasmonic mode of the metamaterial. The switching mechanism is based on the control of the hybridization of eigenmodes in the metamaterial slab and the Si waveguide.