Expanding the Lifestyle Medicine Inpatient Consultation Services at Loma Linda University Health: A Transformative Tool for Chronic Diseases Management in Tertiary Care Settings.

Lifestyle Medicine (LM) is an emerging field dedicated to the prevention, management, and reversal of chronic diseases by promoting healthy lifestyle choices. LM utilizes six pillars targeting the root causes of diseases to promote health, improve clinical outcomes and significantly enhance overall quality of life. They include plant-based nutrition, physical activity, sleep health, tobacco cessation/managing risky alcohol use, and spiritual/emotional well-being. LM holds great promise as an evidence-based solution for the rising rates of chronic diseases and healthcare costs in the United States. Loma Linda University Health (LLUH), a pioneer of LM, has successfully implemented a phased expansion of its novel LM inpatient consultation services to positively impact the trajectory of morbidity and mortality among patients with chronic conditions and/risk factors admitted to the hospital. This was achieved by boosting awareness, hiring LM-trained providers to meet growing demand, and making consultations accessible hospital-wide. The service has been very well received and saw a 50-fold increase in consultations between 2016 and 2022. It is also reimbursed by all major insurers. LLUH's experience shows that establishing and growing an inpatient LM consultation service is a viable clinical and cost-effective chronic care model that can be utilized in a tertiary care setting.

Improvements in skin quality parameters in postmenopausal participants after use of topical growth factor serum.

BACKGROUND: Photodamage can induce skin aging processes that can be particularly concerning for postmenopausal women. Growth factors from hypoxic human fibroblast-conditioned media have demonstrated improvements in skin quality parameters. AIMS: The aim of the study was to assess efficacy and tolerability of topical combination-treatment hypoxic growth factor serum (TNS A+) in postmenopausal women with moderate to severe facial photodamage. PATIENTS/METHODS: In this 12-week, open-label, single-center study, participants used TNS A+ serum twice daily. Postmenopausal women (40-65 years of age) with Fitzpatrick skin types I-VI and modified Griffiths scale scores 4-9 were eligible. Clinical and participant-reported assessments were evaluated at Weeks 6 and 12. Statistical significance was defined as p ≤ 0.05. RESULTS: There were 17 enrolled participants. TNS A+ treatment demonstrated significant improvements from baseline in fine lines and wrinkles in periocular, forehead, and cheek areas at Week 12 and the perioral area at Weeks 6 and 12. Significant improvements from baseline in coarse lines and wrinkles were observed for the perioral area at Week 12 and periocular and cheek areas at Weeks 6 and 12. Improvements in overall photodamage, skin tone evenness, and tactile roughness were significantly greater at Weeks 6 and 12 versus baseline. Most participants reported TNS A+ made their skin look and feel smooth, soft, and rejuvenated; improved skin radiance; made lines and wrinkles less apparent; and improved skin texture. No treatment-related adverse events were reported. CONCLUSIONS: The TNS A+ regimen was well tolerated and provided significant improvements in skin quality in postmenopausal women with moderate to severe facial photodamage.

Efficacy and tolerability of a hyaluronic acid-based serum and a peptide-rich cream for the face and neck in subjects with photodamaged skin.

BACKGROUND: Barrier properties of the stratum corneum inhibit delivery of topical ingredients containing large molecules to desired targets in the skin. This study evaluated the efficacy and tolerability of a skincare regimen comprised of a hyaluronic acid-based serum (InF-HA) and a peptide-rich cream (InF-PEP) containing large molecular ingredients designed to improve the appearance and overall quality of skin. METHODS: This 12-week study evaluated changes from baseline in skin tone, skin texture, and lines/wrinkles (6-point grading scale) of twice-daily application of a two-part skincare regimen to the face and neck in female subjects with mild to moderate photodamage. Subject satisfaction was assessed, and Adverse Events (AEs) were captured throughout. RESULTS: Seventeen subjects with a mean age of 52 years completed the study. Improvements from baseline in the appearance of facial skin texture (79%), lines/wrinkles (50%), and skin tone (44%) occurred at week 12. Improvements in neck appearance from baseline were demonstrated in skin texture (68%), skin tone (48%), and lines/wrinkles (36%). No AEs occurred related to the use of study products. All subjects reported an overall improvement in the appearance of their skin and that their skin looked and felt smoother; 88% reported their skin looked more radiant, and 82% reported their skin looked firmer. CONCLUSIONS: Application of a skincare regimen comprised of an HA-based serum and a peptide-rich cream led to substantial improvements in skin texture, skin tone, and lines/wrinkles on the face and neck over 12 weeks. Both products were well-tolerated with a high level of subject satisfaction.

Personal Health Practices and Perceptions of Lifestyle Counseling and Preventive Services Among Residents.

Background. Primary care residents are expected to provide lifestyle counseling and preventive services for patients with chronic diseases; also, physicians' personal lifestyle practice impacts patient care. The purpose of this article is to assess healthy lifestyle behaviors and attitudes to engage in lifestyle counseling and preventive services among residents and fellows in different training levels and specialty. Methods. A cross-sectional pilot study was conducted on medical residents and fellows (n = 57). Surveys collected information on lifestyle behaviors and perceptions of lifestyle counseling and preventive services. Comparisons of study measures were made across residents' specialty and training levels. Fisher's exact and analysis of variance tests were used for statistical analysis. Results. There were several significant differences in perceptions of counseling and screening by specialty and training level. There were no significant differences in personal lifestyle behaviors between all resident specialties and training levels. Conclusion. Our findings suggest that there are opportunities to improve healthy lifestyle behaviors and perceptions of lifestyle counseling and preventive services among residents in different specialties and training levels. This knowledge can inform development of training programs in lifestyle and preventive medicine practice during residency and fellowship.

Treatment of Mild to Moderate Facial Chrono- and Photodamage with a Novel Intense Liquid Trichloroacetic Acid Peel.

Background: Chemical peeling with trichloroacetic acid (TCA) is a well-established modality to improve the appearance of chrono- and photodamaged skin. Objective: We sought to evaluate the efficacy and safety of a novel formulation of TCA and hydrogen peroxide for the treatment of chrono- and photodamaged skin. Methods: Healthy subjects (N=5, 100% female) aged 49 to 72 years and Fitzpatrick Skin Types II (n=2) and III (n=3) enrolled in the Institutional Review Board-approved study. Subjects had mild to moderate facial wrinkles. Subjects were treated with a TCA-peroxide product four times at one-week intervals and applied at-home care products daily between visits. Investigator Global Assessments (IGA), investigator tolerability assessments, and subjective tolerability assessments were conducted on all subjects at each visit. The median score at each visit was calculated and compared to baseline using the Friedman test for repeated measures. Results: Among IGA attributes, differences in median scores from baseline were significant among the four visits for tone (p=0.0174), smoothness (p=0.0014), texture (p=0.0017), redness, ((p=0.0013) and overall appearance (p=0.0073), while the difference approached significance for radiance (p=0.0749). Twenty percent of subjects showed immediate improvement in radiance, tone, smoothness, and texture (Visit 1, immediately after the initial treatment) while 100 percent of subjects showed improvement by Visit 3 for smoothness, texture, and redness, and the improvements persisted to the end of the study. The treatment was well-tolerated and adverse events were not observed. Conclusion: The TCA-peroxide and at-home care products appear to provide rapid and consistent improvement of chrono- and photodamaged skin without adverse effects.

Safety and efficacy for hair removal in dark skin types III and IV with a high-powered, combined wavelength (810, 940 and 1060 nm) diode laser: A single-site pilot study.

BACKGROUND: Previous studies have demonstrated the superior efficacy of a high-power diode laser (4800 W) with a wavelength of 810 nm over others with less power and the same wavelength, while also being safe and comfortable for the patient. However, the use of this laser is limited on dark skin. OBJECTIVES: This study aims to compare the efficacy, safety, and comfort of a 4800 W diode laser (810 nm) with that of the new Blend diode laser (810 nm, 940 nm, and 1064 nm). Furthermore, the study aims to demonstrate that the Blend diode laser delivers better results on darker skin. MATERIALS AND METHODS: A 810 nm diode laser was compared with the Blend diode laser (810, 940 and 1064 nm) (Primelase, Cocoon Medical). A side-by-side comparative study was carried out over three sessions involving fourteen participants with skin types III and IV, with evaluation of the results 6 months after treatment. The study was performed at the Tennessee Clinical Research Center, Nashville, Tennessee, USA. This evaluation was based on efficacy, safety, comfort, and participant satisfaction. RESULTS: Blend diode laser treatments were performed with fluences 40% (SE = 0.04%) higher than those of the 810 nm. Besides mild-to-moderate transient discomfort during the procedure, the Blend diode laser also produced an increased pricking sensation that was 1.8 points higher on a 10-point scale (p < 0.05), due to the higher fluence used. Hair reduction was 12% higher with the Blend diode laser, with a confidence level of 70%. Moreover, participants were more satisfied with the results of the Blend diode laser than with the diode laser (50% very satisfied vs. 36%, respectively). No long-term adverse effects were observed. CONCLUSIONS: The new Blend diode laser has been shown to be more effective and satisfactory than 810 nm diode laser on dark skin types III and IV, while also being safe and comfortable for participants.

Undergraduate Medical Education: Lifestyle Medicine Curriculum Implementation Standards.

Lifestyle medicine (LM) is an emerging specialty that is gaining momentum and support from around the world. The American Medical Association passed a resolution to support incorporating LM curricula in medical schools in 2017. Since then, the American College of Lifestyle Medicine Undergraduate Medical Education Task Force has created a framework for incorporating LM into medical school curricula. This article provides competencies for medical school LM curriculum implementation and illustrates how they relate to the Association of American Medical College's Core Entrustable Professional Activities and the LM Certification Competencies from the American Board of Lifestyle Medicine. Finally, standards are presented for how medical schools may receive certification for integrating LM into their curriculum and how medical students can work toward becoming board certified in LM through an educational pathway.

Creating a Lifestyle Medicine Specialist Fellowship: A Replicable and Sustainable Model.

As new specialties emerge in medicine, certification pathways must be defined and formalized. The Lifestyle Medicine Physician certification, including both experiential and educational pathways, have been in place for several years. Although raising competence across all specialties through the Lifestyle Medicine Physician Diplomates to a foundational level is essential, additional expertise must be attained to be a true Lifestyle Medicine Specialist as outlined by the American Board of Lifestyle Medicine. This column will describe how Loma Linda University Health (LLUH) created a Lifestyle Medicine Specialist Fellowship that meets the educational pathway requirements for the Lifestyle Medicine Specialist certification and how it can be replicated and sustained at other training sites across the nation.

Improvement of skin texture and wrinkles using radiofrequency ultra-thin electrode technology.

BACKGROUND: Application of radiofrequency (RF) energy with microneedles to facial skin shown to promote skin renewal. AIM: To evaluate the safety and efficacy of the VoluDerm technology with 100 ultra-thin electrodes gen100 tip for improvement of skin texture and wrinkles. METHODS: A prospective, open-label, intra-individual-controlled trial. Twelve subjects (mean age, 45.5; Fitzpatrick skin types II-III) with Fitzpatrick Elastosis Scale (FES) score 3-6 were treated with VoluDerm RF technology using the gen100 ultra-thin electrodes disposable tip. The participants underwent three treatments at 3-week intervals. Treatment safety was evaluated at each treatment visit and at the follow-up visits (1 and 3 months post last treatment). Efficacy of treatment evaluated at 1 and 3 months after the last treatment using the FES as well as evaluator- and subject-rated Global Aesthetic Improvement Scale (GAIS). RESULTS: Treatment was well tolerated, with no downtime or adverse events. One and three months after the last treatment session, physician-rated FES showed statistically significant improvement of 2.67 ± 1.18 and 2.33 ± 1.03, respectively (P < .0001), from baseline (4.83 ± 0.69). According to the investigator assessment of improvement using the GAIS scale, all subjects had an improvement in skin texture and pigmentation and most of the patients (91.7%) had an improvement in skin brightness, tightness, and wrinkles. CONCLUSION: This is the first study evaluating the Legend+ RF System with VoluDerm technology using the novel gen100 ultra-thin electrodes tip. This study demonstrated effective and well-tolerated treatment for improving skin texture and appearance with minimal to no downtime.

Treatment of acne scarring with a novel dual-wavelength laser.

BACKGROUND: Facial acne scarring is a prevalent disease with both physical and psychosocial sequelae. AIMS: This study aims to evaluate an innovative solid state dual wavelength 1,319 and 589 nm laser, which does not require consumable dye, for the treatment of acne scars. PATIENTS/METHODS: A total of 12 patients (11 female, 1 man - Fitzpatrick skin phototypes II & III) with acne scar for more than one year, were treated with 1319 nm and subsequently by 589 nm, all having four-sessions, one every other week. A full face was covered in approximately 30 minutes. Acne scars were scored by one physician evaluator using the ECCA grading scale before, 2 weeks after each treatment and 1 month and 6 months after the 4th treatment. Safety was measured by recording subject discomfort scores and adverse effects. RESULTS: 12 subjects were enrolled into the study, 10 completed all 4 treatments and 2 were lost to follow up. Fluence used was 28 J/cm² ± 2.4 J/cm² at 1,319 nm and 16 ± 2.9 J/cm² at 589 nm. At baseline, mean ECCA score was 98 ± 23. This score was reduced to 88 ± 30 (p<0.02), after one session, to 68 ± 21 (p<0.01) after 2 sessions, to 58 ± 17 (p<0.01) after 3 sessions to reach 58 ± 15 (p<0.01) 1 month after the 4th and finally 66 ± 11 (p<0.01) at 6 month follow up. This observation corresponds respectively to 14%, 33%, 42%, 40% and 30% reduction of the ECCA score. Only one patient (ECCA score: 120) did not improve after 3 sessions. Slight to moderate erythema was sometimes observed without dryness or bruising. No or minimal burning or stinging was reported. No crust was observed. CONCLUSION: Improvement in scarring was noted in almost all patients with minimal discomfort and minimal downtime. Combining both minimal side effects with effective acne scar reduction, this laser appears to be highly effective. Long-term evaluation remains necessary to confirm the efficacy of this new laser.

Do medical students studying in the United Kingdom have an adequate factual knowledge of basic life support?

BACKGROUND: Healthcare professionals have a duty to maintain basic life support (BLS) skills. This study aims to evaluate medical students' factual knowledge of BLS and the training they receive. METHODS: A cross-sectional, closed-response questionnaire was distributed to the first- and fourth-year students studying at institutions in the United Kingdom. The paper questionnaire sought to quantify respondent's previous BLS training, factual knowledge of the BLS algorithm using five multiple choice questions (MCQs), and valuate their desire for further BLS training. Students received 1 point for each correctly identified answer to the 5 MCQ's. RESULTS: A total of 3,732 complete responses were received from 21 medical schools. Eighty percent (n=2,999) of students completed a BLS course as part of their undergraduate medical studies. There was a significant difference (P<0.001) in the percentage of the fourth-year students selecting the correct answer in all the MCQ's compared to the first-year students except in identifying the correct depth of compressions required during CPR (P=0.095). Overall 10.3% (95% CI 9.9% to 10.7%) of respondents correctly identified the answer to 5 MCQ's on BLS 9% of the first-year students (n=194) and 12% of the fourth-year students (n=190). On an institutional level the proportion of students answering all MCQ's correctly ranged from 2% to 54% at different universities. Eighty-one percent of students (n=3,031) wished for more BLS training in their curriculum. CONCLUSION: Factual knowledge of BLS is poor among medical students in the UK. There is a disparity in standards of knowledge across institutions and respondents indicating that they would like more training.

Randomized, side-by-side comparison of a topical photo-enhancer gel for hair removal: an efficacy and safety study.

Background: Novel protocols are evolving to enhance hair follicle damage while preserving safety and improving efficacy. Objectives: The safety and tolerability of a 755-nm diode laser was compared to a combined laser with topical photo-enhancer gel ("combined") versus laser alone ("solo"). Methods: Twenty women (age 23-33 years old), Fitzpatrick skin type I-V, were randomized to side-by-side comparisons with a laser hair removal protocol. The combined side received reduced laser energy compared to the solo side. The laser used in-motion super hair removal technology. Subjects received up to four treatments. Subjects were assessed at baseline and at 1 and 6 months after the last treatment. Results: At the 1-month follow-up, there were no statistical differences in percent hair reduction between the combined (81 ± 16%) versus the solo (77 ± 15%) protocols (p > 0.05). Similarly, at 6-month follow-up, there are no statistical differences between the combined (71 ± 24%) versus the solo (70 ± 23%) treatment protocols (p > 0.05). The average accumulative laser energy in the combined side was half of the solo side (4.2 ± 1.6 vs. 7.6 ± 2.7 kJ, respectively). Pain during the procedure was significantly higher in the solo (5.5 ± 1.8) versus the combined (3.8 ± 1.7) protocol (p < 0.001). Conclusion: A laser hair removal paradigm that combines a 755-nm diode laser with a photo-enhancer gel (reduced kJ protocol) is clinically effective as a solo treatment protocol.

Informed Consent: Is It Accompanied by Full Disclosure?

Informed consent assumes full disclosure has been discussed in its entirety. However, is full disclosure ever really achieved? This column discusses how lifestyle medicine, both philosophically and ethically, must be a standard component of informed consent. Yet despite unequivocal evidence regarding the efficacy of lifestyle medicine, few physicians even consider lifestyle medicine as a viable option in the informed consent process. Reasons for the lack of lifestyle medicine considerations are postulated and a potential solution through education of trainees is suggested. How one medical school is addressing the need for lifestyle medicine education through several initiatives is discussed. Last, we expect that trainees educated in lifestyle medicine will push the momentum forward toward the "tipping point" where lifestyle medicine will be a viable option in the informed consent process-only then will full disclosure truly be achieved.

Lifestyle Medicine Inpatient Consultation Services at Loma Linda University Health: A Novel Approach in a Tertiary Care Center.

As a nation facing primary care provider shortages, an expanding chronic disease burden, and rising health care costs, lifestyle medicine interventions have become critical for patient care and management. The current fee-for-service health care system in the United States is designed for delivering acute care but has made it challenging to deliver and be reimbursed sufficiently for lifestyle interventions that can help prevent and treat chronic disease. Loma Linda University Health began to address these concerns through the creation of an inpatient consultation service for the neurology rehabilitation stroke team. Initiation of the consultation service took 2 years of planning, testing, and resource development. Currently, the consultation service operates one half-day per week in the rehabilitation hospital utilizing 1 attending physician and 2 residents. Visiting residents and medical students are also permitted to rotate with the new service. In coordination with billing experts, a standard number of 21.2 to 25.4 RVUs (relative value units) has been established for the half-day service. As the service continues to expand, future considerations include adding consultation availability to other departments and increasing the consultation workforce.

Accuracy and Efficiency of Recording Pediatric Early Warning Scores Using an Electronic Physiological Surveillance System Compared With Traditional Paper-Based Documentation.

Pediatric Early Warning Scores are advocated to assist health professionals to identify early signs of serious illness or deterioration in hospitalized children. Scores are derived from the weighting applied to recorded vital signs and clinical observations reflecting deviation from a predetermined "norm." Higher aggregate scores trigger an escalation in care aimed at preventing critical deterioration. Process errors made while recording these data, including plotting or calculation errors, have the potential to impede the reliability of the score. To test this hypothesis, we conducted a controlled study of documentation using five clinical vignettes. We measured the accuracy of vital sign recording, score calculation, and time taken to complete documentation using a handheld electronic physiological surveillance system, VitalPAC Pediatric, compared with traditional paper-based charts. We explored the user acceptability of both methods using a Web-based survey. Twenty-three staff participated in the controlled study. The electronic physiological surveillance system improved the accuracy of vital sign recording, 98.5% versus 85.6%, P < .02, Pediatric Early Warning Score calculation, 94.6% versus 55.7%, P < .02, and saved time, 68 versus 98 seconds, compared with paper-based documentation, P < .002. Twenty-nine staff completed the Web-based survey. They perceived that the electronic physiological surveillance system offered safety benefits by reducing human error while providing instant visibility of recorded data to the entire clinical team.

Transitioning adolescents and young adults with spina bifida to adult healthcare: initial findings from a model program.

PURPOSE: The Spina Bifida Transition Project (SBTP) was developed by partners from pediatric and adult health care settings using existing best practice information in an effort to transition adolescents to adult health care providers. The purpose of this manuscript is to present the results of an initial evaluation of the SBTP from the adolescent/young adult (AYA) and family perspective. DESIGN AND METHODS: Qualitative evaluation data were obtained from telephone interviews with 40 individuals (24 AYA and 16 parents representing 28 families) two-three weeks after initial adult clinic visits using a semi-structured interview guide. FINDINGS: Interview analysis yielded six overall themes: Positive experience, Developing Trust, Unexpected Benefits, Communication, Potential Worries, and Suggestions for Improvement. The study supported both the effectiveness of the SBTP as well as patient desire for earlier initiation of transition activities CONCLUSION AND CLINICAL RELEVANCE: SBTP is well-received by participants and their parents and may be useful model for other chronic health conditions.