Matthew F. Bouchonville

Weight loss, exercise or both and cardiometabolic risk factors in obese older adults: results of a randomized controlled trial.

Background:Obesity exacerbates the age-related decline in insulin sensitivity and is associated with risk for cardiometabolic syndrome in older adults; however, the appropriate treatment for obese older adults is controversial.Objective:To determine the independent and combined effects of weight loss and exercise on cardiometabolic risk factors in obese older adults.Design:One-hundred and seven obese (body mass index (BMI)⩾30 kg m−2) older (⩾65 years) adults with physical frailty were randomized to control group, diet group, exercise group and diet–exercise group for 1 year. Outcomes for this study included changes in insulin sensitivity index (ISI), glucose tolerance, central obesity, adipocytokines and cardiometabolic syndrome.Results:Although similar increases in ISI occurred in the diet–exercise and diet groups at 6 months, the ISI improved more in the diet–exercise than in the diet group at 12 months (2.4 vs 1.2; between-group difference, 1.2; 95% confidence interval, 0.2–2.1); no changes in ISI occurred in both exercise and control groups. The diet–exercise and diet groups had similar improvements in insulin area under the curve (AUC) (−2.9 and −2.9 × 103 mg min dl−1), glucose AUC (−1.4 and −2.2 × 103mg min dl−1), visceral fat (−787 and −561 cm3), tumor necrosis factor (−17.0 and −12.8 pg ml−1), adiponectin (5.0 and 4.0 ng ml−1), waist circumference (−8.2 and −8.4 cm), triglyceride (−30.7 and −24.3 g dl−1) and systolic/diastolic blood pressure (−15.9 and −13.1/−4.9 and −6.7 mm Hg), while no changes in these parameters occurred in both exercise and control groups. The cardiometabolic syndrome prevalence decreased by 40% in the diet–exercise and by 15% in the diet group. Body weight decreased similarly in the diet–exercise and diet groups (−8.6 and −9.7 kg) but not in the exercise and control groups.Conclusions:In frail, obese older adults, lifestyle interventions associated with weight loss improve insulin sensitivity and other cardiometabolic risk factors, but continued improvement in insulin sensitivity is only achieved when exercise training is added to weight loss.

Sarcopenic Obesity – How Do We Treat It?

Purpose of reviewThe increasing prevalence of sarcopenic obesity in older adults has heightened interest in identifying the most effective treatment. This review highlights recent progress in the management, with an emphasis on lifestyle interventions and pharmacologic therapy aimed at reversing sarcopenic obesity. Recent findingsWhereas weight loss and exercise independently reverse sarcopenic obesity, they act synergistically in combination to improve body composition and physical function, beyond which is observed with either intervention alone. Optimizing protein intake appears to have beneficial effects on net muscle protein accretion in older adults. Myostatin inhibition is associated with favorable changes in body composition in animal studies, although experience in humans is relatively limited. Testosterone and growth hormone offer improvements in body composition, but the benefits must be weighed against potential risks of therapy. GHRH-analog therapy shows promise, but further studies are needed in older adults. SummaryAt present, lifestyle interventions incorporating both diet-induced weight loss and regular exercise appear to be the optimal treatment for sarcopenic obesity. Maintenance of adequate protein intake is also advisable. Ongoing studies will determine whether pharmacologic therapy such as myostatin inhibitors or GHRH analogs have a role in the treatment of sarcopenic obesity.

The Effectiveness and Risks of Programming an Insulin Pump to Counteract the Dawn Phenomenon in Type 1 Diabetes

OBJECTIVE Continuous subcutaneous insulin infusion (CSII) programming for an early morning increase in insulin delivery is frequently recommended to counteract the rise in glucose prior to breakfast (dawn phenomenon). However, both the effectiveness and safety of this approach have not been tested in the ambulatory setting. Using continuous glucose monitoring, we investigated the safety and effectiveness of early morning CSII programming for management of the dawn phenomenon in subjects with type 1 diabetes. METHODS We conducted a controlled, observational eight-month longitudinal study of type 1 diabetic patients (n=40). Reproducibility of the dawn phenomenon was determined in subjects treated with multiple daily injections of insulin (MDI, n=12) and those on CSII who did not program an early morning increase in insulin delivery (CSII non-programmers, n=8). The effects of early morning CSII programming were determined by comparing rates of the dawn phenomenon and hypoglycemia in CSII non-programmers versus CSII-users who programmed an early morning increase in insulin delivery (CSII programmers, n=20). RESULTS The dawn phenomenon occurred in all tested subjects to a variable extent (median rate 56% of nights). CSII programming was not associated with a reduction in the occurrence of the dawn phenomenon (42%) compared to non-programmers (48%) (P=0.47) nor in the magnitude of the dawn phenomenon. Hypoglycemia occurred more frequently in the CSII programmers (37%) compared to non-programmers (18%) (P=0.001). CONCLUSION The dawn phenomenon occurs unpredictably; therefore, early morning CSII programming for a fixed increase in early morning insulin delivery is ineffective and may be hazardous to the patient.

Bone Health ECHO: telementoring to improve osteoporosis care.

Extension for Community Healthcare Outcomes creates knowledge networks that enable a transition from centralized specialty care at academic institutions to empowerment of primary care providers to provide more highly skilled care closer to home.

Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model

Worldwide increases in diabetes prevalence in the face of limited medical resources have prompted international interest in innovative healthcare delivery models. Project ECHO (Extension for Community Healthcare Outcomes) is a “telementoring” program which has been shown to increase capacity for complex disease management in medically underserved regions. In contrast to a traditional telemedicine model which might connect a specialist with one patient, the ECHO model allows for multiple patients to benefit simultaneously by building new expertise. We recently applied the ECHO model to improve health outcomes of patients with complex diabetes (Endo ECHO) living in rural New Mexico. We describe the design of the Endo ECHO intervention and a 4-year, prospective program evaluation assessing health outcomes, utilization patterns, and cost-effectiveness. The Endo ECHO evaluation will demonstrate whether and to what extent this intervention improves outcomes for patients with complex diabetes living in rural New Mexico, and will serve as proof-of-concept for academic medical centers wishing to replicate the model in underserved regions around the world.

Iatrogenic Cushing's syndrome after triamcinolone plus ritonavir-boosted atazanavir

OBJECTIVE To describe a case of iatrogenic Cushings syndrome (ICS) following a triamcinolone injection for subscapular bursitis in an HIV-positive patient receiving an antiretroviral regimen that included ritonavir boosted-atazanavir. SETTING University outpatient HIV clinic. CASE SUMMARY A 60-year-old HIV-positive man on a ritonavir-boosted, atazanavir-containing antiretroviral regimen was diagnosed with subscapular bursitis. The patient received two intrabursal injections with 1% lidocaine plus triamcinolone 20 mg. Four weeks after the injections, the patient experienced symptoms of Cushings syndrome with a pronounced drop in his CD4+ T-cell count, requiring treatment of oral candidiasis and prophylaxis for opportunistic infections. CONCLUSION The interaction between ritonavir and oral corticosteroids, resulting in ICS, has been established. This case adds to the literature as one of the few cases illustrating that interaction can also occur between ritonavir and intrabursal administration of corticosteroids. This case further supports concerns regarding use of corticosteroids in HIV-infected patients who are treated with ritonavir-containing antiretroviral regimens.

ENDO ECHO IMPROVES PRIMARY CARE PROVIDER AND COMMUNITY HEALTH WORKER SELF-EFFICACY IN COMPLEX DIABETES MANAGEMENT IN MEDICALLY UNDERSERVED COMMUNITIES

OBJECTIVE To determine whether participation in a multidisciplinary telementorship model of healthcare delivery improves primary care provider (PCP) and community health worker (CHW) confidence in managing patients with complex diabetes in medically underserved regions. METHODS We applied a well-established healthcare delivery model, Project ECHO (Extension for Community Healthcare Outcomes), to the management of complex diabetes (Endo ECHO) in medically underserved communities. A multidisciplinary team at Project ECHO connected with PCPs and CHWs at 10 health centers across New Mexico for weekly videoconferencing virtual clinics. Participating PCPs and CHWs presented de-identified patients and received best practice guidance and mentor-ship from Project ECHO specialists and network peers. A robust curriculum was developed around clinical practice guidelines and presented by weekly didactics over the ECHO network. After 2 years of participation in Endo ECHO, PCPs and CHWs completed self-efficacy surveys comparing confidence in complex diabetes management to baseline. RESULTS PCPs and CHWs in rural New Mexico reported significant improvement in self-efficacy in all measures of complex diabetes management, including PCP ability to serve as a local resource for other healthcare providers seeking assistance in diabetes care. Overall self-efficacy improved by 130% in CHWs ( P<.0001) and by 60% in PCPs ( P<.0001), with an overall large Cohens effect size. CONCLUSION Among PCPs and CHWS in rural, medically underserved communities, participation in Endo ECHO for 2 years significantly improved confidence in complex diabetes management. Application of the ECHO model to complex diabetes care may be useful in resource-poor communities with limited access to diabetes specialist services. ABBREVIATIONS CHW = community health worker; CME = Continuing Medical Education; ECHO = Extension for Community Healthcare Outcomes; FQHC = federally qualified health center; PCP = primary care provider.

Leveraging Scarce Resources With Bone Health TeleECHO to Improve the Care of Osteoporosis

Osteoporosis is a common condition with serious consequences because of fractures. Despite availability of treatments to reduce fracture risk, there is a large osteoporosis treatment gap that has reached crisis proportions. There are too few specialists to provide services for patients who need them. Bone Health Extension for Community Health Care Outcomes (TeleECHO) is a strategy using real-time ongoing videoconferencing technology to mentor health care professionals in rural and underserved communities to achieve an advanced level of knowledge for the care of patients with skeletal diseases. Over the first 21 months of weekly Bone Health TeleECHO programs, there were 263 registered health care professionals in the United States and several other countries, with 221 attending at least 1 online clinic and typically 35 to 40 attendees at each session at the end of the reported period. Assessment of self-confidence in 20 domains of osteoporosis care showed substantial improvement with the ECHO intervention (P = 0.005). Bone Health TeleECHO can contribute to mitigating the crisis in osteoporosis care by leveraging scarce resources, providing motivated practitioners with skills to provide better skeletal health care, closer to home, with greater convenience, and lower cost than referral to a specialty center. Bone Health TeleECHO can be replicated in any location worldwide to reach anyone with Internet access, allowing access in local time zones and languages. The ECHO model of learning can be applied to other aspects of bone care, including the education of fracture liaison service coordinators, residents and fellows, and physicians with an interest in rare bone diseases.

Characterization of Cortisol Secretion Rate in Secondary Adrenal Insufficiency

Context: In secondary adrenal insufficiency (SAI), chronic deficiency of adrenocorticotropin (ACTH) is believed to result in secondary changes in adrenocortical function, causing an altered dose-response relationship between ACTH concentration and cortisol secretion rate (CSR). Objective: We sought to characterize maximal cortisol secretion rate (CSRmax) and free cortisol half-life in patients with SAI, compare results with those of age-matched healthy controls, and examine the influence of predictor variables on ACTH-stimulated cortisol concentrations. Design: CSRmax was estimated from ACTH1-24 (250 μg)–stimulated cortisol time-concentration data. Estimates for CSRmax and free cortisol half-life were obtained for both dexamethasone (DEX) and placebo pretreatment conditions for all subjects. Setting: Single academic medical center. Patients: Patients with SAI (n = 10) compared with age-matched healthy controls (n = 21). Interventions: The order of DEX vs placebo pretreatment was randomized and double-blind. Cortisol concentrations were obtained at baseline and at intervals for 120 minutes after ACTH1-24. Main Outcome Measures: CSRmax and free cortisol half-life were obtained by numerical modeling analysis. Predictors of stimulated cortisol concentrations were evaluated using a multivariate model. Results: CSRmax was significantly (P < 0.001) reduced in patients with SAI compared with controls for both placebo (0.17 ± 0.09 vs 0.46 ± 0.14 nM/s) and DEX (0.18 ± 0.13 vs 0.43 ± 0.13 nM/s) conditions. Significant predictors of ACTH1-24–stimulated total cortisol concentrations included CSRmax, free cortisol half-life, and baseline total cortisol, corticosteroid-binding globulin, and albumin concentrations (all P < 0.05). Conclusions: Our finding of significantly decreased CSRmax confirms that SAI is associated with alterations in the CSR-ACTH dose-response curve. Decreased CSRmax contributes importantly to the laboratory diagnosis of SAI.

Are diabetes guidelines truly evidence based

The global epidemic of obesity and diabetes underscores the urgency to develop strategies to prevent cardiovascular (CV) disease in this vulnerable population. Clinical guidelines are intended to help the clinician manage these patients, but guidelines are often discordant among professional organizations and not always evidence based. Clinicians must rely upon the best available evidence, and therefore we critically reviewed the evidence behind the American Diabetes Association (ADA) 2016 guidelines on the prevention of CV disease in diabetes. We believe the most robust evidence comes from randomized controlled trials specifically designed for diabetes with hard clinical endpoints such as mortality and CV events. Our analysis supports the ADA recommendations regarding a Mediterranean diet, glycemic control, and BP control, but we believe the evidence to support aspirin and statin therapy in diabetes is inconclusive. This discordance may be multi-factorial including the exclusion of some relevant studies and an over-reliance upon subgroup and meta-analysis. Given the lack of mortality benefit and inconsistent clinical benefits of aspirin and statins, it is essential that clinicians individualize treatment decisions while carefully weighing the risks and harms of any intervention.