Shivajirao Patil

Effects of fish oils on ex vivo B-cell responses of obese subjects upon BCR/TLR stimulation: a pilot study

The long-chain n-3 polyunsaturated fatty acids (LC-PUFAs) eicosapentaenoic (EPA) and docosahexaenoic acid (DHA) in fish oil have immunomodulatory properties. B cells are a poorly studied target of EPA/DHA in humans. Therefore, in this pilot study, we tested how n-3 LC-PUFAs influence B-cell responses of obese humans. Obese men and women were assigned to consume four 1-g capsules per day of olive oil (OO, n=12), fish oil (FO, n=12) concentrate or high-DHA-FO concentrate (n=10) for 12 weeks in a parallel design. Relative to baseline, FO (n=9) lowered the percentage of circulating memory and plasma B cells, whereas the other supplements had no effect. There were no postintervention differences between the three supplements. Next, ex vivo B-cell cytokines were assayed after stimulation of Toll-like receptors (TLRs) and/or the B-cell receptor (BCR) to determine if the effects of n-3 LC-PUFAs were pathway-dependent. B-cell IL-10 and TNFα secretion was respectively increased with high DHA-FO (n=10), relative to baseline, with respective TLR9 and TLR9+BCR stimulation. OO (n=12) and FO (n=12) had no influence on B-cell cytokines compared to baseline, and there were no differences in postintervention cytokine levels between treatment groups. Finally, ex vivo antibody levels were assayed with FO (n=7) after TLR9+BCR stimulation. Compared to baseline, FO lowered IgM but not IgG levels accompanied by select modifications to the plasma lipidome. Altogether, the results suggest that n-3 LC-PUFAs could modulate B-cell activity in humans, which will require further testing in a larger cohort.

The Time Is Now: Diabetes Fellowships in the United States

Purpose of ReviewDiabetes is a complex and costly chronic disease that is growing at an alarming rate. In the USA, we have a shortage of physicians who are experts in the care of patients with diabetes, traditionally endocrinologists. Therefore, the majority of patients with diabetes are managed by primary care physicians. With the rapid evolution in new diabetes medications and technologies, primary care physicians would benefit from additional focused and intensive training to manage the many aspects of this disease. Diabetes fellowships designed specifically for primary care physicians is one solution to rapidly expand a well-trained workforce in the management of patients with diabetes.Recent FindingsThere are currently two successful diabetes fellowship programs that meet this need for creating more expert diabetes clinicians and researchers outside of traditional endocrinology fellowships. We review the structure of these programs including funding and curriculum as well as the outcomes of the graduates.SummaryThe growth of the diabetes epidemic has outpaced current resources for readily accessible expert diabetes clinical care. Diabetes fellowships aimed for primary care physicians are a successful strategy to train diabetes-focused physicians. Expansion of these programs should be encouraged and support to grow the cadre of clinicians with expertise in diabetes care and improve patient access and outcomes.

Are Geriatric Medicine Fellows Prepared for the Important Skills of Hospice and Palliative Care

Many geriatricians care for terminally ill and dying patients, but it is unclear whether the current geriatric medicine fellows receive sufficient training in hospice and palliative care (H&PC). A national cross-sectional survey was conducted between March and June 2011 to determine fellows’ experience and perceived competency with H&PC. Fellows (143 of 298, 48%) and program directors (PDs; 69 of 150, 46%) answered the surveys on paper or online. Three-fourths of the fellows planned to practice H&PC; however, only 35% fellows versus 42% PDs believed that fellows were well prepared in this area. Factors associated with fellows’ self-reported better preparation included completion of an H&PC rotation, experiences with an inpatient hospice facility, inpatient palliative care consulting service, and the presence of a formal H&PC curriculum.

Interdisciplinary Diabetes Care: A New Model for Inpatient Diabetes Education

A patient-centered interdisciplinary diabetes care model was implemented at Vidant Medical Center in Greenville, N.C., a 909-bed tertiary care teaching hospital, for the purpose of providing all patients with diabetes clear and concise instructions on diabetes survival skills. Survival skills education during hospitalization is needed for safe transition to community resources for continued and expanded diabetes self-management education. This article describes the process used to develop, implement, and evaluate the model. This initiative achieved substantial cost savings, with no significant changes in length of stay (LOS) or diabetes readmission rates. This patient-centered model demonstrates how a team of interdisciplinary health care professionals can integrate services in providing care for a large population of patients with chronic disease.

Validation of a combined health literacy and numeracy instrument for patients with type 2 diabetes

OBJECTIVES This study aimed to validate a new consolidated measure of health literacy and numeracy (health literacy scale [HLS] plus the subjective numeracy scale [SNS]) in patients with type 2 diabetes (T2DM). METHODS A convenience sample (N = 102) of patients with T2DM was recruited from an academic family medicine center in the southeastern US between September-December 2017. Participants completed a questionnaire that included the composite HLS/SNS (22 questions) and a commonly used objective measure of health literacy-S-TOFHLA (40 questions). Internal reliability of the HLS/SNS was assessed using Cronbachs alpha. Criterion and construct validity was assessed against the S-TOFHLA. RESULTS The composite HLS/SNS had good internal reliability (Cronbachs alpha = 0.83). A confirmatory factor analysis revealed there were four factors in the new instrument. Model fit indices showed good model-data fit (RMSEA = 0.08). The Spearmans rank order correlation coefficient between the HLS/SNS and the S-TOFHLA was 0.45 (p < 0.01). CONCLUSIONS Our study suggests that the composite HLS/SNS is a reliable, valid instrument.

COMRADE: A randomized trial of an individually tailored integrated care intervention for uncontrolled type 2 diabetes with depression and/or distress in the rural southeastern US

BACKGROUND Emerging evidence suggests that people living with Type 2 diabetes mellitus (T2D) are also at greater risk for depression and distress. If left untreated, these comorbid mental health concerns can have long-lasting impacts on medical and physical health outcomes. DESIGN This prospective trial randomized rural men and women with uncontrolled T2D (HbA1c ≥ 7.0) who screened positive for co-morbid depressive (PHQ-2 > 3) or distress (DDS-2 > 3) symptoms in a primary medical care setting to receive either: 1) 16 sessions of cognitive and/or behavioral intervention tailored to symptom severity across 12 months along with routine medical care, or 2) usual primary care. Outcomes included change from baseline to 12-months in HbA1c, diabetes related distress, depressive symptoms, and diabetes self-care activities. BASELINE RESULTS 139 patients (Mean age = 52.6 ± 9.6 years) with T2D from impoverished rural communities were enrolled (almost half reporting annual income of <

Food Insecurity: It Is More Common Than You Think, Recognizing It Can Improve the Care You Give

10,000 per year). Baseline data indicated that patients were experiencing profoundly uncontrolled T2D of a long duration (Mean HbA1c = 9.61 ± 2.0; Mean BMI = 37.0 ± 9.1; Mean duration = 11.2 ± 8.9 years) along with high levels of distress (Mean DDS-17 Scale Score = 2.5 ± 1.0) and/or depressive symptoms (Mean PHQ-9 Scale Score = 9.3 ± 6.1). CONCLUSION Patients with uncontrolled T2D of long duration manifest complex co-morbidities including associated obesity, depressive symptoms and/or diabetes related distress. A behavioral intervention for T2D that concurrently targets symptoms of depression and distress may lead to more effective outcomes in this high-risk population. CLINICAL TRIAL REGISTRATION NCT02863523.

Increasing Residency Training of Goal-Oriented Treatment Options in Patients With Life-Limiting Illnesses (S712)

In this article, we present a case from our Interprofessional Diabetes Clinic to describe assessment and impact of food insecurity on a patient’s overall health and how the healthcare providers’ recognition of food insecurity changed the management of a patient with type 2 diabetes mellitus, obesity, and depression. This approach to treating patients with food insecurity may also apply to individuals with diabetes who regularly skipmeals; are inconsistent with their carbohydrate intake, for whatever reason; or routinely engage in fasting. Healthcare professionals should screen all patients for food insecurity, educate patients to use appropriate coping strategies, adjust medications to minimize adverse effects, recognize that food insecurity is cyclical for most, connect patients with community resources, and advocate for services in clinics and hospitals. Nutr Today. 2017;52(5):248Y257

Relationship of Vitamin B12 and Homocysteine Status with Nephropathy and Neuropathy in Metformin-Treated Patients with Type 2 Diabetes

Objectives 1. Describe prognostication attitudes among Internal Medicine sub-specialists, hospitalists, generalists, residents, and medical students at a tertiary academic medical center. 2. Describe prognostication barriers among Internal Medicine sub-specialists, hospitalists, generalists, residents, and medical students at a tertiary academic medical center. 3. Identify foreseeing and foretelling barriers to prognostication. Background. Prognostication is important for practicing physicians but can be viewed as stressful and difficult. Physicians generally feel poorly prepared to discuss prognosis. Research Objectives. 1) Determine if a 1 hour conference would improve confidence on prognostication among audience members. 2) Collect and compare self-perceived barriers to prognostication across education level from medical students to sub-specialists. Method. A dynamic 1 hour internal medicine grand rounds was delivered with audience realtime electronic data collection on nine questions about attitudes and barriers to prognostication. We categorized prognosis into foreseeing and foretelling components. Pre and post data on self-perceived prognostication was collected using a five point Likert scale. Participants were asked to identify ownership of prognostication in different settings, and to identify their primary foreseeing and foretelling barrier. Result. 60 audiencemembers (23 sub-specialists, 8 hospitalists, 10 general internists, 13 residents, and six medical students) participated. Self-perceived confidence in foreseeing prognostication among medical students was statistically significant (p 1⁄4 .041). The remaining categories did not show significance. All levels of training identified both sub-specialists and primary care physicians as responsible for prognostication in the ambulatory setting. In the inpatient setting, opinions on ownership varied. Sub-specialists and hospitalists identified themselves, residents identified sub-specialists, and medical students were evenly split between sub-specialists and primary team members on prognostication responsibility. Medical knowledge was the largest foreseeing barrier in all learner levels except sub-specialists, who identified ownership as their primary barrier. Lack of time was the largest foretelling barrier to all learner levels except medical students, who identified ‘‘missing a system or approach.’’ Conclusion. This intervention assessed attitudes and barriers to prognostication at an academic medical center and also improved medical student confidence in foreseeing prognostication. Primary prognostication barriers included knowledge and time. Implications for Research, Policy, or Practice. This data helps focus additional learner development needs regarding prognostication relationships, attitudes, and barriers by learning level and specialty.