Kathleen Colleran

Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care†

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team‐based interdisciplinary development. Using state‐of‐the‐art telehealth technology, best practice protocols, and case‐based learning, ECHO trains and supports primary care providers to develop knowledge and self‐efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment‐induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self‐efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self‐efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence. (HEPATOLOGY 2010)

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Thiazolidinediones: A Comparative Review of Approved Uses

Thiazolidinediones are a powerful and clinically important new class of oral antidiabetic agents that act by improving insulin sensitivity. Troglitazone is the prototype drug in this class but was withdrawn from the market in March 2000 due to its association with idiosyncratic hepatotoxicity. Currently two thiazolidinediones, rosiglitazone and pioglitazone, are U.S. Food and Drug Administration (FDA) approved for treatment of type 2 diabetes. These agents bind to and activate peroxisome proliferator-activator receptor gamma (PPAR-gamma) and work by altering the expression of genes involved in glucose uptake, glucose disposal, and lipid metabolism. The drugs differ in receptor binding and potency due to differences in their side chain moieties. These agents are rapidly absorbed from the gastrointestinal tract and are metabolized mainly in the liver. Rosiglitazone is FDA approved for monotherapy and for use in combination therapy with metformin or sulfonylureas. Pioglitazone is FDA approved for monotherapy as well as for use in combination therapy with metformin, insulin, or sulfonylureas. These drugs may also cause significant changes in plasma lipid concentrations, and improved insulin sensitivity may improve ovulatory function and fertility in women with polycystic ovary syndrome. The most serious side effect of the thiazolidinediones is hepatotoxicity. Although rosiglitazone and pioglitazone were not associated with hepatotoxicity in premarketing clinical trials, there were two recent case reports of idiosyncratic hepatotoxicity in patients treated with rosiglitazone. In addition, these agents may be associated with edema and some hematological changes. The purpose of this review is to provide an overview of the two currently approved thiazolidinediones and to suggest an approach for their safe and rational use.

Disparities in cardiovascular disease risk and treatment: demographic comparison.

Background Cardiovascular morbidity and mortality can be prevented by identification and modification of specific risk factors. Ethnic minorities have a higher incidence of cardiovascular risk factors. Additionally, ethnic minorities often reside in medically underserved areas and are subject to health care disparities. We hypothesized that ethnic minorities residing in medically underserved areas would experience greater health care disparities related to cardiovascular disease (CVD) prevention and treatment compared with those residing near an urban academic medical center. Methods We performed a retrospective chart review (N = 200) comparing an urban academic medical center with a rural community center. We evaluated the effects of ethnicity, demographics, and the absence or presence of CVD on cardiovascular risk factor prevalence, risk factor reduction, and CVD prevention and treatment. Results We found that Hispanics had more cardiovascular risk factors, including diabetes mellitus and low high-density lipoprotein cholesterol, compared with non-Hispanic whites. However, there were no ethnically based differences in risk factor prevalence by location. Additionally, ethnicity had no impact on the management of cardiovascular risk factors. However, patients with CVD residing in the rural location, regardless of ethnicity, received significantly fewer secondary prevention treatments compared with patients residing near the urban academic medical center, including aspirin or antiplatelets (p < .0001); beta-blockers or calcium channel blockers (p ≤ .0001); diuretics, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers (p = .014); and statins (p ≤ .0001). Conclusions Hispanics have more CVD risk factors than non-Hispanic whites but receive equivalent prevention initiatives. Residing in a rural, medically underserved area, regardless of ethnicity, was associated with the largest CVD treatment and health care disparity.

Building Capacity to Reduce Disparities in Diabetes: Training Community Health Workers Using an Integrated Distance Learning Model

Purpose The purpose of this study is to determine whether an innovative interactive distance training program is an effective modality to train community health workers (CHWs) to become members of the diabetes health care team. The University of New Mexico Health Sciences Center has developed a rigorous diabetes training program for CHWs involving both distance and hands-on learning as part of Project ECHO™ (Extension for Community Healthcare Outcomes). Methods Twenty-three diverse CHW participants from across New Mexico were enrolled in the first training session. Participants completed surveys at baseline and at the end of the program. They attended a 3-day hands-on training session, followed by weekly participation in tele/video conferences for 6 months. Wilcoxon signed-rank statistics were used to compare pre- and posttest results. Results Participants demonstrated significant improvements in diabetes knowledge (P = .002), diabetes attitudes (P = .04) and confidence in both clinical and nonclinical skills (P < .001 and P = .04, respectively). Additionally, during focus group discussions, participants reported numerous benefits from participation in the program. Conclusions Community health worker participation in the Project ECHO diabetes training program resulted in significant increases in knowledge, confidence, and attitudes in providing care to patients with diabetes. Studies are ongoing to determine whether the training has a positive impact on patient outcomes.

Improvement in insulin sensitivity during mifepristone treatment of cushing syndrome: Early and late effects

Increased adiposity and direct effects of glucocorticoid excess on muscle, liver, and β-cells are responsible for the high prevalence of impaired glucose tolerance (IGT) and type 2 diabetes in patients with Cushing syndrome (CS) (1,2). In the SEISMIC study, the glucocorticoid receptor antagonist mifepristone improved glucose tolerance and produced weight loss over 24 weeks in CS patients (3). Using oral glucose tolerance test data from SEISMIC, our goal was to assess whole-body insulin sensitivity (Matsuda index), β-cell function (insulinogenic index, homeostasis model assessment-β [HOMA-β]), disposition index (4,5), weight (WT), and waist circumference (WC) over time. Complete data in patients not receiving insulin were available in 19 patients, 8 with diabetes and/or IGT (C-DM) and 11 with hypertension only (C-HT). Within-group comparisons for change over time were analyzed with a mixed-effects repeated measures two-way ANOVA with cohort (C-DM and C-HT), time, and cohort by time interaction as fixed effects; unpaired Student t tests were used to assess differences between groups …

A Home-Based Educational Intervention Improves Patient Activation Measures and Diabetes Health Indicators among Zuni Indians.

Introduction One in three people will be diagnosed with diabetes by 2050, and the proportion will likely be higher among Native Americans. Diabetes control is currently suboptimal in underserved populations despite a plethora of new therapies. Patient empowerment is a key determinant of diabetes control, but such empowerment can be difficult to achieve due to resource limitation and cultural, language and health literacy barriers. We describe a home-based educational intervention using Community Health Representatives (CHRs), leading to improvement in Patient Activation Measures scores and clinical indicators of diabetes control. Methods Sixty participants with type 2 diabetes (T2D) completed a baseline evaluation including physical exam, Point of Care (POC) testing, and the Patient Activation Measure (PAM) survey. Participants then underwent a one hour group didactic session led by Community Health Representatives (CHRs) who subsequently carried out monthly home-based educational interventions to encourage healthy lifestyles, including diet, exercise, and alcohol and cigarette avoidance until follow up at 6 months, when clinical phenotyping and the PAM survey were repeated. Results PAM scores were increased by at least one level in 35 (58%) participants, while 24 participants who started at higher baseline score did not change. Six months after intervention, mean levels of A1C decreased by 0.7 ± 1.2%; fasting blood glucose decreased by 24.0 ± 38.0 mg/dl; BMI decreased by 1.5 ± 2.1 kg/m2; total cholesterol decreased by 12.0± 28.0 mg/dl; and triglycerides decreased by 52.0 ± 71.0 mg/dl. All of these changes were statistically significant (p<0.05). Conclusion This six month, CHR led and community-oriented educational intervention helps inform standards of practice for the management of diabetes, engages diabetic populations in their own care, and reduces health disparities for the underserved population of Zuni Indians. Trial Registration ClinicalTrials.gov NCT02339311

Rimonabant: a novel approach for the treatment of obesity and cardiometabolic risk by blockade of the endocannabinoid system

Obesity, the metabolic syndrome, diabetes and cardiometabolic risk are increasing at epidemic rates worldwide. Without interventions, the healthcare ramifications and costs of this epidemic will be astronomical. Current available treatment modalities have demonstrated limited effectiveness to deal with this metabolic epidemic. A novel metabolic pathway, the endocannabinoid system, plays a significant and direct role in appetite regulation, glucose homeostasis and lipid metabolism. Activation of the endocannabinoid system increases hunger and decreases satiety, and promotes insulin resistance and lipogenesis. Studies indicate that the endocannabinoid system is chronically activated in abdominal obesity and Type 2 diabetes. Additionally, blockade of the endocannabiniod receptor type-1 improves multiple cardiometabolic parameters and may represent a potential mechanism to combat obesity, metabolic syndrome, diabetes and other cardiometabolic risks. Rimonabant, a novel agent, blocks the endocannabinoid-receptor type 1, and results in weight loss, decreases in abdominal adiposity, improvement in glucose and lipid homeostasis and decreases components of the metabolic syndrome. It is the first therapeutic agent that inhibits the endocannabiniod system and improves multiple cardiometabolic parameters.

114 A PILOT STUDY INVESTIGATING THE ASSOCIATION BETWEEN MINDFUL EATING AND LIVING (MEAL), WEIGHT LOSS, AND BIOLOGIC MARKERS OF INFLAMMATION AND METABOLISM IN OBESE SUBJECTS.

Background and Objective In obese subjects, the effects of mindfulness, a type of meditation and life attitude, on weight loss and biologic markers of inflammation and metabolism have not been previously assessed. Current pharmacologic treatment has not proven to be effective in sustaining weight loss. We thus sought to investigate a method of behavioral change that might demonstrate a permanent solution to both achieving and maintaining weight loss. The goal of this pilot study was to identify potential relationships between a mindfulness-based eating curriculum entitled Mindful Eating and Living (MEAL) and anthropometric and biologic measures. Methods Ten obese subjects with a body mass index (BMI) of 36.9 ± 6.2 kg/m 2 underwent a 6-week mindfulness training course via a mindfulness curriculum adapted to address eating. Anthropometric and laboratory evaluation at baseline, 6 weeks, and 12 weeks were obtained. Results Ten subjects completed the 6-week training course. An analysis including all subjects, with the last observation carried forward for one who did not complete the final BMI and laboratory evaluation, demonstrated a decrease in body weight at 6 weeks (mean [± SD], −3.0 ± 1.9 kg; p = .0009) and 12 weeks (mean [± SD], −3.3 ± 1.8 kg; p = .0004) and a decrease in BMI at 6 weeks (−1.1 ± 0.7 kg/m 2 ; p = .0008) and 12 weeks (−1.2 ± 0.6 kg/m 2 ; p = .0003). Also seen was a decrease in hsCRP at 12 weeks (−0.08 ± 0.08 mg/dL; p = .04) and a decrease in PAI-1 at 6 weeks (−19.4 ± 13.3 IU/mL; p = .01). No statistically significant changes were seen in fasting lipids, glucose, insulin, interleukin-6, tumor necrosis factor α, adiponectin, or waist-hip ratio. Conclusions A brief mindfulness-based training course specifically addressing eating resulted in statistically significant decreases in body weight, hsCRP, and PAI-1. Study limitations include the small number of subjects, the absence of a control group, and a short follow-up period. A controlled study including 40 subjects, more rigorous physiologic and biologic measures, and a longer follow-up period is currently under way.

Hypothalamic Obesity Complicated by Adipsic Central Diabetes Insipidus Following Surgical Resection of a Craniopharyngioma

The hypothalamus plays a key role in appetite regulation, utilizing both hormonal and neural signaling pathways. Hypothalamic injury is increasingly recognized as a cause of obesity secondary to loss of satiety signals. The hypothalamus also plays a central role in the maintenance of osmotic balance through regulation of both antidiuretic hormone (ADH) and the thirst center. In the following case presentation, we report a patient who developed hyperphagia and aggressive food seeking behavior in addition to severe hyperosmolality following resection of a craniopharyngioma.