Comparative Effectiveness of Patient-Driven versus Standardized Diabetes Shared Medical Appointments: A Pragmatic Cluster Randomized Trial.

BACKGROUND: Diabetes self-management education and support can be effectively and efficiently delivered in primary care in the form of shared medical appointments (SMAs). Comparative effectiveness of SMA delivery features such as topic choice, multi-disciplinary care teams, and peer mentor involvement is not known. OBJECTIVE: To compare effects of standardized and patient-driven models of diabetes SMAs on patient-level diabetes outcomes. DESIGN: Pragmatic cluster randomized trial. PARTICIPANTS: A total of 1060 adults with type 2 diabetes in 22 primary care practices. INTERVENTIONS: Practice personnel delivered the 6-session Targeted Training in Illness Management (TTIM) curriculum using either standardized (set content delivered by a health educator) or patient-driven SMAs (patient-selected topic order delivered by health educators, behavioral health providers [BHPs], and peer mentors). MAIN MEASURES: Outcomes included self-reported diabetes distress and diabetes self-care behaviors from baseline and follow-up surveys (assessed at 1st and final SMA session), and HbA1c, BMI, and blood pressure from electronic health records. Analyses used descriptive statistics, linear regression, and linear mixed models. KEY RESULTS: Both standardized and patient-driven SMAs effectively improved diabetes distress, self-care behaviors, BMI (- 0.29 on average), and HbA1c (- 0.45% (mmol/mol) on average, 8.3 to 7.8%). Controlling for covariates, there was a small, significant effect of condition on overall diabetes distress in favor of standardized SMAs (F(1,841) = 4.3, p = .04), attributable to significant effects of condition on emotion and regimen distress subscales. There was a small, significant effect of condition on diastolic blood pressure in favor of standardized SMAs (F(1,5199) = 4.50, p = .03). There were no other differences between conditions. CONCLUSIONS: Both SMA models using the TTIM curriculum yielded significant improvement in diabetes distress, self-care, and HbA1c. Patient-driven diabetes SMAs involving BHPs and peer mentors and topic selection did not lead to better clinical or patient-reported outcomes than standardized diabetes SMAs facilitated by a health educator following a set topic order. NIH TRIAL REGISTRY NUMBER: NCT03590041.

Terbutaline in myasthenia gravis: a pilot study.

The objective of this study was to assess the short-term efficacy and safety of terbutaline, a beta2-adrenergic agonist, in patients with myasthenia gravis (MG) in a randomized, double-blind, placebo-controlled, crossover study. The primary endpoint for efficacy was a reduction of at least 3 points in the quantitative MG score (QMGS). Secondary endpoints included changes in the functional disability scale (FDS), forced vital capacity (FVC), grip strength, anti-acetylcholine receptor (AChR) antibody levels and decremental response. During the terbutaline phase, five of eight (63%) patients had an improvement in the QMGS of 3.0 or greater, while 3/8 (38%) patients had improvement in the FDS of one grade. No improvement was seen during the placebo period. Statistical analysis using Wilcoxon signed-rank test confirmed that terbutaline treatment resulted in a significant improvement in QMGS. There was no change in FVC, grip strength or anti-AChR antibody levels, but there was an improvement in the decremental response during terbutaline phase. Terbutaline was well-tolerated in all study subjects. We conclude that terbutaline may be an effective adjunct therapy in a subset of patients with myasthenia, although confirmation with larger trials will be required.

Case report of methicillin-resistant Staphylococcus aureus (MRSA) mastitis with abscess formation in a breastfeeding woman.

An afebrile woman with persistent nonhealing nipples and low-grade intermittent breast pain was diagnosed at 9 weeks postpartum with a methicillin-resistant Staphylococcus aureus infection of the left breast with abscess formation. Unilateral weaning allowed partial lactation to continue.

Successful Breastfeeding Outcome of a Woman with a Nevus of the Nipple: A Case Study.

Unusual conditions of the nipple and breast may interfere with breastfeeding. Nevi of the nipple are rare, and breastfeeding outcomes of women with this condition have only been briefly reported in the literature. This case describes the proactive lactation management and successful breastfeeding outcome of a woman with a large, roughly textured nevus located on her right nipple and areola.

Learning to lobby for probreastfeeding legislation: the story of a Texas bill to create a breastfeeding-friendly physician designation.

Legislation can reduce institutional barriers to breastfeeding. Lobbying is the process by which legislation is influenced by a special interest group. While generally thought of as an activity available only to the rich and powerful, lobbying by lactation activists can be an effective way to change public policy. A breastfeeding coalition in central Texas has been involved with lobbying efforts since 1995. Tactical lessons learned are shared to inspire and assist others seeking to pass probreastfeeding legislation.

The milk of human kindness: the story of the Mothers Milk Bank at Austin.

Increased scientific study of human milk and awareness of the special nutritional needs of the premature infant have stimulated interest in human donor milk banking. Yet only three donor human milk banks existed in the United States in 1998. Having observed better outcomes in human milk-fed neonatal intensive care patients, two neonatologists in Austin, Texas, founded The Mothers Milk Bank at Austin (MMBA). Since opening in 1999, the MMBA has expanded rapidly as the result of careful planning, innovative procedures, fiscal stability, and widespread community support. The non-profit organizational structure, diversity and progressive vision of the board of directors and staff, and creative on-going public relations efforts have contributed to the success of the project. The MMBA demonstrates a model for 21st century milk banking.