Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma.

BACKGROUND: Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations. METHODS: In this pragmatic, open-label trial, we randomly assigned Black and Latinx adults with moderate-to-severe asthma to use a patient-activated, reliever-triggered inhaled glucocorticoid strategy (beclomethasone dipropionate, 80 µg) plus usual care (intervention) or to continue usual care. Participants had one instructional visit followed by 15 monthly questionnaires. The primary end point was the annualized rate of severe asthma exacerbations. Secondary end points included monthly asthma control as measured with the Asthma Control Test (ACT; range, 5 [poor] to 25 [complete control]), quality of life as measured with the Asthma Symptom Utility Index (ASUI; range, 0 to 1, with lower scores indicating greater impairment), and participant-reported missed days of work, school, or usual activities. Safety was also assessed. RESULTS: Of 1201 adults (603 Black and 598 Latinx), 600 were assigned to the intervention group and 601 to the usual-care group. The annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P = 0.048). ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and by 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group (difference, 0.9; 95% CI, 0.5 to 1.2); ASUI scores increased by 0.12 points (95% CI, 0.11 to 0.13) and 0.08 points (95% CI, 0.07 to 0.09), respectively (difference, 0.04; 95% CI, 0.02 to 0.05). The annualized rate of missed days was 13.4 in the intervention group and 16.8 in the usual-care group (rate ratio, 0.80; 95% CI, 0.67 to 0.95). Serious adverse events occurred in 12.2% of the participants, with an even distribution between the groups. CONCLUSIONS: Among Black and Latinx adults with moderate-to-severe asthma, provision of an inhaled glucocorticoid and one-time instruction on its use, added to usual care, led to a lower rate of severe asthma exacerbations. (Funded by the Patient-Centered Outcomes Research Institute and others; PREPARE ClinicalTrials.gov number, NCT02995733.).

A patient-centredness improvement study for efficacy of behaviour change for healthy lifestyle and weight loss in a student-run free clinic.

BACKGROUND: Primary care is the ideal place to implement behaviour change interventions for weight management. However, most primary care physicians are not managing patient weight as a standard of care due to lack of knowledge, skills and reimbursement. Generating more physicians who are familiar and comfortable with providing weight management is essential in leveraging a global change. In our university free clinic, medical students provide healthy lifestyle counselling using shared decision making to each patient at every clinic visit. OBJECTIVE: Improve the efficacy of behaviour change interventions via increased patient responsiveness and adherence. METHODS: The needs assessment demonstrated a subpar patient response rate to check-ins regarding behavioural change goals. In the first and second interventions, check-in message structure and contact schedule were varied to maximize patient responsiveness and goal achievement. RESULTS: In the needs assessment, 58% of patients responded to follow-ups and 58% of patients accomplished their goal. The first intervention cycle resulted in an improvement of responsiveness to 70% and accomplishment of goals to 59%. The second intervention cycle resulted in an improvement of responsiveness to 78% and accomplishment of goals to 74%. CONCLUSIONS: Messages that were frequent, unique, succinct and delivered within 4 weeks after the clinic visit resulted in the highest response rate and goal attainment. Other primary care clinics can use these interventions to increase patient completion of implemented behaviour changes for a healthier lifestyle.

Teaching lifestyle medicine competencies in undergraduate medical education: active collaborative intervention for students at multiple locations.

The aims of this study are to 1) design feasible active collaborative educational approaches to teach and assess three of the newly described lifestyle medicine (LM) competencies to students at multiple locations; and 2) determine whether a mixed, flexible instructional delivery approach impacts students' learning and perception of confidence in LM. The educational interventions were part of the undergraduate clinical medical education curriculum and have two parts: 1) an asynchronous session [online self-learning module (SLM)], and 2) a synchronous session using case-based collaborative learning delivered either mostly face to face, as determined by the instructor (approach A) or mostly virtual, as determined by the student (approach B). Both approaches were delivered in the curriculum as planned to 27 students in approach A (26% attending virtually) and 31 students in approach B (90% attending virtually). Approach B required more planning time. Approach A students (26 of 27) agreed that the SLM was valuable as an educational tool. The performance in the summative assessment was similar (P = 0.49) in both approaches [means (SD): 33.2 points (SD 10.6) approach A vs. 33.2 points (SD 10.1) approach B]. Students reported a similar increase in confidence (P = 0.33) with setting lifestyle change goals. The two educational approaches presented here address three of the new LM competencies using active collaborative learning. Both approaches are feasible for synchronous delivery to students located at local and distant sites, either face to face or virtual. The increase in the proportion of students attending virtually did not decrease the measured outcomes of learning and perceptions of confidence.

Using technology to increase student (and faculty satisfaction with) engagement in medical education.

Faculty dissatisfaction with diminishing levels of student engagement in lifestyle medicine sessions prompted this exploratory project that compared differences in students' substantive engagement in medical preclinical and clinical level lifestyle medicine sessions. The preclinical and clinical level sessions had the same learning objectives and learning tasks, properly aligned with that level of student learning, but were offered in different learning formats, either traditional classroom approaches or technology-enhanced approaches. At the preclinical level, we transferred a nonmandatory, face-to-face session to a nonmandatory, fully online session. At the clinical level, we introduced two novel technology tools. We utilized Zoom technologies, which afforded students the ability to access the session from anywhere, and employed Hickey's use of "promoting" student submissions as one method for increasing student-student interaction during the synchronous session. We used indicators of behavioral engagement of Henrie et al. (Henrie CR, Halverson LR, Graham CR. Comput Educ 90: 36-53, 2015) as the framework for determining applicable engagement behaviors, including attendance, assignment completion, interactions (responding/feedback/endorsements), and the quality of (and faculty satisfaction with) the face-to-face and/or online interactions. We expected to observe higher levels of engagement behaviors in the technology-enhanced approach and found that to be the case at both the preclinical and clinical levels, in both mandatory/nonmandatory and synchronous/asynchronous formats. However, it was the increase in both the level and substance of the students' interactions in the technology-enhanced sessions that provided surprising results. A review of the sessions with enhanced engagement highlight the role of student autonomy, a construct with strongly established associations to student motivation and engagement.

Wellness and Stress Management Practices Among Healthcare Professionals and Health Professional Students.

PURPOSE: Healthcare professionals experience stressors that begin during training and persist into their careers that adversely impact their well-being. This study aims to identify students' and professionals' stress levels, satisfaction with wellness domains, barriers to wellness, and stress management practices. DESIGN: This study was a cross-sectional self-reported survey study. SETTINGS AND SAMPLE: The study included students (N = 242) and professionals (N = 237) from medicine, nursing, pharmacy, physical therapy, social work, and counseling/psychology. MEASURES: The Managing Health & Wellness in Health Professions Training and Practice survey was used to capture wellness practices and barriers among participants. Results: Students reported significantly higher perceived stress compared to professionals (P < 0.001). Total wellness is significantly higher among professionals compared to students (P < 0.001). A higher stress rate is significantly related to being female, having a lower wellness score, and facing more barriers (P < 0.001). Intellectual health is the most valuable wellness domain for providers (M = 3.71, SD = 0.9) and students (M = 3.43, SD = 0.85), followed by spiritual health for providers (M = 3.4, SD = 1.1), and work/learning environment for students (M = 3.33, SD = 0.93). Professionals and students are least satisfied with their physical and financial health. Barriers include fatigue, workload/productivity in clinical practice, work hours, and burnout. CONCLUSIONS: Healthcare professionals exhibit a variety of stress management practices, encounter barriers, and prioritize different wellness domains. Healthcare systems should incorporate self-care education into their curricula and implement systemic changes to foster a thriving healthcare workforce.

Do Medical Students Appreciate Lifestyle Medicine and Are They Confident in Their Skills?

Introduction: As the prevalence of chronic diseases increases worldwide, there is a need for educating future physicians in the use of lifestyle medicine to treat and prevent diseases. Any addition to the undergraduate medical curriculum requires a strategic educational approach with consideration for efficiency. This study aims to identify priorities for lifestyle medicine interventions in the undergraduate medical curriculum. Methods: Third-year medical students (N=115) were surveyed on their beliefs about lifestyle medicine and their confidence in lifestyle medicine skills. The survey consisted of seven items to which students responded with how closely they agreed via a 5-point Likert scale. Descriptive statistics were reported. Results: Most medical students entering their clinical years understand the value of lifestyle medicine in patient care (100%) and want to learn the skills and knowledge involved (98.2%). The value of lifestyle medicine counseling skills during the limited patient-doctor time was least universally acknowledged among third-year medical students (93.9%). Third-year medical students are most confident in being able to obtain a comprehensive lifestyle history (3.6±0.8) and least confident in setting clear, personalized, lifestyle change goals (3.1±0.9). Conclusion: Future interventions to increase confidence in lifestyle medicine skills should focus on educating students on setting lifestyle change goals, personalizing prescriptions, and motivational interviewing for use in clinical care.

Current practices in the instruction of lifestyle medicine in medical curricula.

OBJECTIVE: A review of current practices of educational interventions for lifestyle medicine was performed to inform the design of interventions with long-term goals of improving patient outcomes. METHODS: Systematic review of PubMed, MedEdPORTAL, and Cochrane using keywords "lifestyle medicine," "education," "medical students," and "medical school" was done by 3 independent reviewers. Location, learner, curricular hours, focus, outcomes, and impact are reported. RESULTS: Of 452 identified citations, 32 met criteria. Most studies (81%) were conducted in the U.S. and designed for medical students (72%). Studies focused primarily on nutrition (78%) and exercise (59%). Curricula were delivered on average across 13.7 h. Lectures were used in 53% of papers. The outcomes most commonly studied were satisfaction (66%,), knowledge perception (66%), and reported clinical practices (34%). Intervention impact at level 2b (31%) and level 3 (34%) were most common. CONCLUSION: Medical educators looking to integrate lifestyle education curriculum should consider current resources as a starting point, especially ones with higher outcome measurements. PRACTICE IMPLICATIONS: Novel interventions should target lifestyle medicine competencies with equitable distribution among learners using active learning approaches. The authors propose initial efforts focusing on instruction of clinical educators and practicing physicians, with advocacy for increased reimbursement.

Promotion Preparation Tips for Academic Family Medicine Educators.

BACKGROUND AND OBJECTIVES: Promotion has historically valued the scholarship of discovery over the scholarship of teaching. The clinician-educator promotion pathway is an attractive option for academic family physicians engaged in significant teaching. However, clinician-educators are less often promoted than peers on other tracks. Family medicine educators face unique challenges in promotion due to clinical requirements and often less guidance on how to meet promotion criteria. Promotion recognizes achievements of faculty and is often tied to higher base salary. We aimed to identify promotion preparation tips for academic family medicine educators. METHODS: We surveyed members of the Society of Teachers of Family Medicine (STFM) Medical Student Education Collaborative electronically on promotion preparation lessons learned in (1) curriculum vitae preparation, (2) personal statement preparation, (3) selecting external reviewers, and (4) identifying measurable achievements. This qualitative study used grounded theory and constant comparison. RESULTS: Fourteen individuals from 13 medical institutions responded with tips for success in promotion preparation. The tips identified actionable steps for promotion preparation of academic family medicine educators. Several main themes emerged, including the importance of timely and thorough documentation, detailed planning, and being knowledgeable about institutional-specific criteria early. CONCLUSIONS: The tips provided in this study support family medicine educators in preparing for promotion and can be used as a tool for mentors, chairs and faculty development.

Diabetes: Device Therapy.

Insulin pumps, continuous glucose monitors (CGMs), and hybrid closed-loop insulin pumps with CGMs are available for the management of type 1 diabetes in patients of all ages and type 2 diabetes in patients treated with multiple daily injections of insulin. These devices have numerous benefits for patients, including improved diabetes control, fewer hypoglycemia and diabetic ketoacidosis events, and improved quality of life. Currently, there are seven insulin pumps on the US market, five CGMs, and four closed-loop systems. Insulin pumps can deliver insulin subcutaneously in a continuous manner. CGMs can measure and report the blood glucose level every 5 to 15 minutes. Hybrid closed-loop systems automatically discontinue basal insulin delivery if hypoglycemia is predicted, and provide alarms for hyper- or hypoglycemia and rapid changes in the blood glucose level. Some can administer correction bolus doses of insulin using a special algorithm without the input of the patient. These devices should be prescribed and managed by an interdisciplinary health care team led by a family physician or endocrinology subspecialist. Other devices include smart insulin pens and insulin inhalers. Mobile health technology for diabetes management uses mobile devices to increase patient capacity for self-management through delivery of medical information.

Diabetes: Type 1 Diabetes.

Type 1 diabetes is defined as a state of hyperglycemia due to insulin deficiency caused by autoimmune pancreatic beta-cell destruction. The risk among individuals in the general population has been estimated at 0.5%. A family history of diabetes and a personal history of conditions associated with type 1 diabetes (ie, autoimmune diseases) increase the risk. Currently, the American Diabetes Association (ADA) recommends screening asymptomatic patients for type 1 diabetes autoimmune markers in the context of clinical research trials. All patients with diabetes should be referred to a diabetes self-management education program and for medical nutrition therapy. Medical nutrition therapy has been shown to lower the A1c by up to 1.9% in patients with type 1 diabetes. The mainstay of management is a regimen of multiple daily injections of insulin or continuous subcutaneous insulin delivered via an insulin pump. For most patients, a regimen consisting of 50% of the total daily dose prescribed as basal insulin and 50% prescribed as bolus insulin is used. Currently, pramlintide is the only Food Drug Administration (FDA)-approved adjunct to insulin therapy for patients with type 1 diabetes. Patients with type 1 diabetes should be screened regularly for hypertension and other associated conditions and complications.

Cultural Sensitivity and Learning About Healthcare Equity for the Underserved: Experiential Learning in a Student-Run Free Clinic.

With increased diversity in the USA comes a growing need to educate medical students on how best to manage diverse patient populations. Medical students on the board of a student-run free clinic (SRFC) were surveyed to determine how such a leadership experience might alter students' cultural sensitivity as it relates to healthcare equity. Forty-six students (42.2% response) reported their experiences helped them better understand patient's needs (4.37, 0.64; mean, SD), cultural barriers (4.44, 0.55), and racial/ethnic disparities (4.27, 0.70). Thus, service on the board of a SRFC improves cultural sensitivity.

A randomized, open-label, pragmatic study to assess reliever-triggered inhaled corticosteroid in African American/Black and Hispanic/Latinx adults with asthma: Design and methods of the PREPARE trial.

BACKGROUND: Asthma prevalence, morbidity, and mortality disproportionately impact African American/Black (AA/B) and Hispanic/Latinx (H/L) communities. Adherence to daily inhaled corticosteroid (ICS), recommended by asthma guidelines in all but the mildest cases of asthma, is generally poor. As-needed ICS has shown promise as a patient-empowering asthma management strategy, but it has not been rigorously studied in AA/B or H/L patients or in a real-world setting. Design and Aim The PeRson EmPowered Asthma RElief (PREPARE) Study is a randomized, open-label, pragmatic study which aims to assess whether a patient-guided, reliever-triggered ICS strategy called PARTICS (Patient-Activated Reliever-Triggered Inhaled CorticoSteroid) can improve asthma outcomes in AA/B and H/L adult patient populations. In designing and implementing the study, the PREPARE research team has relied heavily on advice from AA/B and H/L Patient Partners and other stakeholders. Methods PREPARE is enrolling 1200 adult participants (600 AA/Bs, 600H/Ls) with asthma. Participants are randomized to PARTICS + Usual Care (intervention) versus Usual Care (control). Following a single in-person enrollment visit, participants complete monthly questionnaires for 15 months. The primary endpoint is annualized asthma exacerbation rate. Secondary endpoints include asthma control; preference-based quality of life; and days lost from work, school, or usual activities. Discussion The PREPARE study features a pragmatic design allowing for the real-world assessment of a patient-centered, reliever-triggered ICS strategy in AA/B and H/L patients. Outcomes of this study have the potential to offer powerful evidence supporting PARTICS as an effective asthma management strategy in patient populations that suffer disproportionately from asthma morbidity and mortality.

Skeletal muscle NAMPT is induced by exercise in humans.

In mammals, nicotinamide phosphoribosyltransferase (NAMPT) is responsible for the first and rate-limiting step in the conversion of nicotinamide to nicotinamide adenine dinucleotide (NAD+). NAD+ is an obligate cosubstrate for mammalian sirtuin-1 (SIRT1), a deacetylase that activates peroxisome proliferator-activated receptor-gamma coactivator-1alpha (PGC-1alpha), which in turn can activate mitochondrial biogenesis. Given that mitochondrial biogenesis is activated by exercise, we hypothesized that exercise would increase NAMPT expression, as a potential mechanism leading to increased mitochondrial content in muscle. A cross-sectional analysis of human subjects showed that athletes had about a twofold higher skeletal muscle NAMPT protein expression compared with sedentary obese, nonobese, and type 2 diabetic subjects (P < 0.05). NAMPT protein correlated with mitochondrial content as estimated by complex III protein content (R(2) = 0.28, P < 0.01), MRS-measured maximal ATP synthesis (R(2) = 0.37, P = 0.002), and Vo(2max) (R(2) = 0.63, P < 0.0001). In an exercise intervention study, NAMPT protein increased by 127% in sedentary nonobese subjects after 3 wk of exercise training (P < 0.01). Treatment of primary human myotubes with forskolin, a cAMP signaling pathway activator, resulted in an approximately 2.5-fold increase in NAMPT protein expression, whereas treatment with ionomycin had no effect. Activation of AMPK via AICAR resulted in an approximately 3.4-fold increase in NAMPT mRNA (P < 0.05) as well as modest increases in NAMPT protein (P < 0.05) and mitochondrial content (P < 0.05). These results demonstrate that exercise increases skeletal muscle NAMPT expression and that NAMPT correlates with mitochondrial content. Further studies are necessary to elucidate the pathways regulating NAMPT as well as its downstream effects.

Interventions for Increasing the Quality of Preventive Care at a Free Clinic.

A quality improvement committee targeted six clinically meaningful measures in order to determine which interventions improved preventative care in a free clinic as well as to qualify for certification as a Patient-Centered Medical Home. Four quality improvement interventions were designed and implemented. The outcomes of these interventions were compared with the national average performance and the Center for Disease Control's Healthy People 2020 goals. All outcomes measured exceeded the national averages, and five out of six outcomes were above the Healthy People 2020 goals. The approach outlined may be used by other free clinics aiming to provide quality preventive care for their patient population and to help obtain Patient-Centered Medical Home certifications.

Adipogenic human adenovirus Ad-36 induces commitment, differentiation, and lipid accumulation in human adipose-derived stem cells.

Human adenovirus Ad-36 is causatively and correlatively linked with animal and human obesity, respectively. Ad-36 enhances differentiation of rodent preadipocytes, but its effect on adipogenesis in humans is unknown. To indirectly assess the role of Ad-36-induced adipogenesis in human obesity, the effect of the virus on commitment, differentiation, and lipid accumulation was investigated in vitro in primary human adipose-derived stem/stromal cells (hASC). Ad-36 infected hASC in a time- and dose-dependent manner. Even in the presence of osteogenic media, Ad-36-infected hASC showed significantly greater lipid accumulation, suggestive of their commitment to the adipocyte lineage. Even in the absence of adipogenic inducers, Ad-36 significantly increased hASC differentiation, as indicated by a time-dependent expression of genes within the adipogenic cascade-CCAAT/Enhancer binding protein-beta, peroxisome proliferator-activated receptor-gamma, and fatty acid-binding protein-and consequentially increased lipid accumulation in a time- and viral dose-dependent manner. Induction of hASC to the adipocyte state by Ad-36 was further supported by increased expression of lipoprotein lipase and the accumulation of its extracellular fraction. hASC from subjects harboring Ad-36 DNA in their adipose tissue due to natural infection had significantly greater ability to differentiate compared with Ad-36 DNA-negative counterparts, which offers a proof of concept. Thus, Ad-36 has the potential to induce adipogenesis in hASC, which may contribute to adiposity induced by the virus.

A Case of the Forgotten Thyroid: The Sequelae of Chronic Untreated Hypothyroidism.

Hypothyroidism is a common endocrine disorder frequently caused by iodine deficiency, autoimmune disease, or as a result of certain medical treatments such as radioactive iodine. We report a 57-year-old woman 21 years pos-radioiodine ablation therapy for Graves' disease. She presented to the clinic after more than two decades without medical care with a variety of symptoms, including a left-sided lower facial droop and gait instability, and was found to have bradycardia, hyperlipidemia, and mild depression. After evaluation for vitamin deficiencies, anemia, thyroid dysfunction, and stroke, her symptoms were attributed to iatrogenic hypothyroidism. She was started on appropriate thyroid replacement therapy with subsequent symptom resolution. Patients receiving thyroid destructive therapy require education and close follow-up to prevent the development of severe hypothyroidism and its associated sequelae, which can be easily improved with simple, cost-effective thyroid replacement therapy.

Lifestyle Medicine Education: Finding Learning Outcomes in Unexpected Places.

We present here an unexpected finding of our educational lifestyle medicine program. The impact of educational interventions not yet modeled by practitioners (including counseling on lifestyle changes) may not present where expected. Medical educators need to identify and interpret evidence of impact across a broader array of student curricular activities.