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Emmet DK, Davis G, Pierce-Talsma S, Shubrook JH, Mehling W. Interoceptive bodily awareness in patients seeking pain relief with osteopathic manipulative treatment: an observational cohort pilot study. J Osteopath Med 2024; 0:jom-2022-0081. [PMID: 38650438 DOI: 10.1515/jom-2022-0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 02/14/2024] [Indexed: 04/25/2024]
Abstract
CONTEXT Interoceptive bodily awareness (IBA) is one's attentional focus on and relationship with comfortable and uncomfortable (e.g., pain) internal body sensations. Integrating IBA into research on osteopathic manipulative treatment (OMT) is growing, both as an outcome and predictor of treatment outcomes; however, it has yet to be studied in a clinical setting. OBJECTIVES We aimed to conduct a pilot study to measure IBA, with the Multidimensional Assessment of Interoceptive Awareness (MAIA), in patients seeking OMT for pain, and to test if OMT exposure may be associated with higher IBA as measured by the MAIA. The primary outcome was the change in MAIA scores, and the secondary outcomes were reduction in pain intensity, reduction in pain interference, and increase in participants' perception of change post-OMT. METHODS A convenience sample was recruited from individuals presenting for OMT appointments at a College of Osteopathic Medicine OMT teaching clinic. Participants were recruited into our single-arm observational cohort study (n=36), and categorized into one of two groups, OMT-naïve (n=19) or OMT-experienced (n=17), based on prior exposure to OMT. We measured MAIA scores and clinical pain-related outcomes prior to, immediately after, and at 1 and 3 weeks after a usual-care OMT session in the clinic. Covariates including experience with mind-body activities, non-OMT body work, and physical and emotional trauma were also collected to explore potential relationships. We utilized t tests to compare MAIA scores and pain outcomes between groups and across time points. Stepwise regression models were utilized to explore potential relationships with covariates. RESULTS The OMT-experienced group scored higher on the MAIA scales "Not-worrying" (p=0.002) and "Trusting" (p=0.028) at baseline. There were no significant changes in the MAIA scores before and after the single OMT session. Analysis of secondary outcomes revealed that all pain outcomes significantly decreased post-OMT (p<0.05), with the largest relative improvements in the acute pain and OMT-naïve subgroups, with diminishing effects over time. CONCLUSIONS Assessing IBA with MAIA in a clinical OMT setting is feasible. There were significant positive correlations between OMT exposure and two of the eight MAIA scales. Future studies are justified to further explore this relationship.
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Affiliation(s)
- Danielle K Emmet
- Department of Physical Medicine and Rehabilitation, New York Presbyterian 12295 , Weill Cornell Medicine and Columbia University , New York, USA
| | - Glenn Davis
- College of Osteopathic Medicine, 155229 Touro University California , Vallejo, CA, USA
| | - Stacey Pierce-Talsma
- College of Osteopathic Medicine, 115985 University of New England , Biddeford, ME, USA
| | - Jay H Shubrook
- College of Osteopathic Medicine, 155229 Touro University California , Vallejo, CA, USA
| | - Wolf Mehling
- Department of Family and Community Medicine, Osher Center for Integrative Medicine, 8785 University California San Francisco , San Francisco, CA, USA
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Allen AM, Charlton M, Cusi K, Harrison SA, Kowdley KV, Noureddin M, Shubrook JH. Guideline-based management of metabolic dysfunction-associated steatotic liver disease in the primary care setting. Postgrad Med 2024. [PMID: 38465573 DOI: 10.1080/00325481.2024.2325332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing worldwide. Primary care providers play a critical role in the screening, diagnosis, and management of MASLD and/or metabolic dysfunction-associated steatohepatitis (MASH), though they can face challenges in this setting, particularly where healthcare resources are limited and barriers to care exist. To address these challenges, several guidelines have been developed to provide evidence-based recommendations for the clinical assessment and management of patients with MASLD/MASH. AIMS To provide a unified, simple-to-understand, practical guide for MASLD screening, diagnosis, and management based on current guideline recommendations, for use by primary care providers in daily practice. METHODS Evidence-based recommendations from several international guidelines were summarized, focusing on the similarities and differences between them. RESULTS Recommendations are broadly aligned across the guidelines, but several key differences are evident. Practical guidance is provided on screening, identifying target populations for risk stratification, initial evaluation of individuals with suspected MASLD, surveillance, risk stratification and referral, as well as approaches to the management of MASLD and associated comorbidities, with specific considerations for the primary care setting. CONCLUSIONS Primary care providers are ideally placed to identify at-risk individuals, implement evidence-based interventions to prevent the development of fibrosis and cirrhosis, and effectively manage comorbidities. Equipping primary care providers with the necessary knowledge and tools to effectively manage MASLD/MASH may help to improve patient outcomes and reduce the burden of liver disease.
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Affiliation(s)
- Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael Charlton
- Transplantation institute, University of Chicago Medicine, Chicago, IL, USA
| | - Kenneth Cusi
- Division of Endocrinology, University of Florida, Gainesville, Florida, USA
| | | | - Kris V Kowdley
- Liver Institute Northwest and Elson S. Floyd College of Medicine, Washington State University, Seattle, Washington, USA
| | - Mazen Noureddin
- Houston Research Institute and Houston Liver Institute, Houston, TX, USA
| | - Jay H Shubrook
- Department of Clinical Sciences and Community Health, Touro University California, Vallejo, California, USA
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Neumiller JJ, St. Peter WL, Shubrook JH. Type 2 Diabetes and Chronic Kidney Disease: An Opportunity for Pharmacists to Improve Outcomes. J Clin Med 2024; 13:1367. [PMID: 38592214 PMCID: PMC10932148 DOI: 10.3390/jcm13051367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Chronic kidney disease (CKD) is an important contributor to end-stage kidney disease, cardiovascular disease, and death in people with type 2 diabetes (T2D), but current evidence suggests that diagnosis and treatment are often not optimized. This review examines gaps in care for patients with CKD and how pharmacist interventions can mitigate these gaps. We conducted a PubMed search for published articles reporting on real-world CKD management practice and compared the findings with current recommendations. We find that adherence to guidelines on screening for CKD in patients with T2D is poor with particularly low rates of testing for albuminuria. When CKD is diagnosed, the prescription of recommended heart-kidney protective therapies is underutilized, possibly due to issues around treatment complexity and safety concerns. Cost and access are barriers to the prescription of newer therapies and treatment is dependent on racial, ethnic, and socioeconomic factors. Rates of nephrologist referrals for difficult cases are low in part due to limitations of information and communication between specialties. We believe that pharmacists can play a vital role in improving outcomes for patients with CKD and T2D and support the cost-effective use of healthcare resources through the provision of comprehensive medication management as part of a multidisciplinary team. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across healthcare systems to ensure that comprehensive medication management can be optimally implemented.
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Affiliation(s)
- Joshua J. Neumiller
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA 99210, USA
| | - Wendy L. St. Peter
- Department of Pharmaceutical Care & Health Systems, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Jay H. Shubrook
- Department of Clinical Sciences and Community Health, Touro University California, Vallejo, CA 94592, USA;
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4
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Saha CK, Shubrook JH, Guyton Hornsby W, Yang Z, Pillay Y, Mather KJ, de Groot M. Program ACTIVE II: 6- and 12-month outcomes of a treatment approach for major depressive disorder in adults with type 2 diabetes. J Diabetes Complications 2024; 38:108666. [PMID: 38266570 PMCID: PMC10922820 DOI: 10.1016/j.jdiacomp.2023.108666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/12/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024]
Abstract
AIMS To evaluate the long-term effects of behavioral treatments on glycemic and psychological outcomes for patients with major depressive disorder (MDD) and type 2 diabetes (T2D). METHODS Program ACTIVE II was a multicenter randomized controlled comparative effectiveness trial of cognitive behavioral therapy (CBT), exercise (EXER), combination treatment (CBT + EXER) and usual care (UC) for adults with MDD and T2D. RESULTS Primary outcomes: change in A1c and depressive symptoms at 6- (N = 87) and 12-months (N = 75) from baseline. In those with a baseline A1c ≥7.0 %, CBT + EXER showed lasting A1c benefit at 6- (-1.2 %; SE: 0.6; p = 0.032) and 12-months (-1.4 %; SE: 0.6; p = 0.025) compared to UC. All groups had clinically significant improvements in depressive symptoms. At 6 months, CBT + EXER had significant improvements in diabetes-related distress regimen burden (p = 0.005); and social support (CIRS, p = 0.043) compared to UC. CONCLUSIONS The Program ACTIVE II CBT + EXER intervention demonstrated a sustained improvement in A1c for a subgroup of study participants with a baseline A1c ≥7.0 %. However, this finding should be considered preliminary because of small sample size. All 3 behavioral intervention groups demonstrated improvements in psychosocial outcomes one-year post-intervention. These findings point to the enduring benefits of community-based interventions to extend the availability of depression treatment for T2D patients.
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Affiliation(s)
- Chandan K Saha
- Indiana University School of Medicine, United States of America
| | | | - W Guyton Hornsby
- West Virginia University School of Medicine, United States of America
| | - Ziyi Yang
- Indiana University School of Medicine, United States of America
| | | | - Kieren J Mather
- Indiana University School of Medicine, United States of America
| | - Mary de Groot
- Indiana University School of Medicine, United States of America.
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5
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Shubrook JH. Improving Care for People With Type 1 Diabetes. Clin Diabetes 2024; 42:10-11. [PMID: 38230334 PMCID: PMC10788669 DOI: 10.2337/cd23-0095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Jay H. Shubrook
- Touro University California College of Osteopathic Medicine, Vallejo, CA
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6
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Jing X, Cimino JJ, Patel VL, Zhou Y, Shubrook JH, De Lacalle S, Draghi BN, Ernst MA, Weaver A, Sekar S, Liu C. Data-driven hypothesis generation among inexperienced clinical researchers: A comparison of secondary data analyses with visualization (VIADS) and other tools. J Clin Transl Sci 2024; 8:e13. [PMID: 38384898 PMCID: PMC10880005 DOI: 10.1017/cts.2023.708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 11/21/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024] Open
Abstract
Objectives To compare how clinical researchers generate data-driven hypotheses with a visual interactive analytic tool (VIADS, a visual interactive analysis tool for filtering and summarizing large datasets coded with hierarchical terminologies) or other tools. Methods We recruited clinical researchers and separated them into "experienced" and "inexperienced" groups. Participants were randomly assigned to a VIADS or control group within the groups. Each participant conducted a remote 2-hour study session for hypothesis generation with the same study facilitator on the same datasets by following a think-aloud protocol. Screen activities and audio were recorded, transcribed, coded, and analyzed. Hypotheses were evaluated by seven experts on their validity, significance, and feasibility. We conducted multilevel random effect modeling for statistical tests. Results Eighteen participants generated 227 hypotheses, of which 147 (65%) were valid. The VIADS and control groups generated a similar number of hypotheses. The VIADS group took a significantly shorter time to generate one hypothesis (e.g., among inexperienced clinical researchers, 258 s versus 379 s, p = 0.046, power = 0.437, ICC = 0.15). The VIADS group received significantly lower ratings than the control group on feasibility and the combination rating of validity, significance, and feasibility. Conclusion The role of VIADS in hypothesis generation seems inconclusive. The VIADS group took a significantly shorter time to generate each hypothesis. However, the combined validity, significance, and feasibility ratings of their hypotheses were significantly lower. Further characterization of hypotheses, including specifics on how they might be improved, could guide future tool development.
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Affiliation(s)
- Xia Jing
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - James J. Cimino
- Informatics Institute, School of Medicine, University of Alabama, Birmingham, AL, USA
| | - Vimla L. Patel
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York City, NY, USA
| | - Yuchun Zhou
- Department of Educational Studies, The Patton College of Education, Ohio University, Athens, OH, USA
| | - Jay H. Shubrook
- Department of Clinical Sciences and Community Health, College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
| | - Sonsoles De Lacalle
- Department of Health Science, California State University Channel Islands, Camarillo, CA, USA
| | - Brooke N. Draghi
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - Mytchell A. Ernst
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - Aneesa Weaver
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - Shriram Sekar
- Electrical Engineering and Computer Science, Russ College of Engineering and Technology, Ohio University, Athens, OH, USA
| | - Chang Liu
- Russ College of Engineering and Technology, Ohio University, Athens, OH, USA
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7
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Ehrhardt NM, Aroda VR, Galindo RJ, Peters AL, Shubrook JH. Use of Continuous Glucose Monitoring and Glucagon-Like Peptide 1 Receptor Agonist Therapy to Achieve Individualized Treatment Goals in Insulin-Treated People With Type 2 Diabetes: A Case Series and Expert Opinion. Clin Diabetes 2023; 42:341-350. [PMID: 38666194 PMCID: PMC11040021 DOI: 10.2337/cd23-0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Affiliation(s)
| | - Vanita R. Aroda
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rodolfo J. Galindo
- Diabetes Research Institute, University of Miami Health System, Miami, FL
| | - Anne L. Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, Los Angeles, CA
| | - Jay H. Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA
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8
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Jing X, Cimino JJ, Patel VL, Zhou Y, Shubrook JH, De Lacalle S, Draghi BN, Ernst MA, Weaver A, Sekar S, Liu C. Data-driven hypothesis generation among inexperienced clinical researchers: A comparison of secondary data analyses with visualization (VIADS) and other tools. medRxiv 2023:2023.05.30.23290719. [PMID: 37333271 PMCID: PMC10274969 DOI: 10.1101/2023.05.30.23290719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Objectives To compare how clinical researchers generate data-driven hypotheses with a visual interactive analytic tool (VIADS, a visual interactive analysis tool for filtering and summarizing large data sets coded with hierarchical terminologies) or other tools. Methods We recruited clinical researchers and separated them into "experienced" and "inexperienced" groups. Participants were randomly assigned to a VIADS or control group within the groups. Each participant conducted a remote 2-hour study session for hypothesis generation with the same study facilitator on the same datasets by following a think-aloud protocol. Screen activities and audio were recorded, transcribed, coded, and analyzed. Hypotheses were evaluated by seven experts on their validity, significance, and feasibility. We conducted multilevel random effect modeling for statistical tests. Results Eighteen participants generated 227 hypotheses, of which 147 (65%) were valid. The VIADS and control groups generated a similar number of hypotheses. The VIADS group took a significantly shorter time to generate one hypothesis (e.g., among inexperienced clinical researchers, 258 seconds versus 379 seconds, p = 0.046, power = 0.437, ICC = 0.15). The VIADS group received significantly lower ratings than the control group on feasibility and the combination rating of validity, significance, and feasibility. Conclusion The role of VIADS in hypothesis generation seems inconclusive. The VIADS group took a significantly shorter time to generate each hypothesis. However, the combined validity, significance, and feasibility ratings of their hypotheses were significantly lower. Further characterization of hypotheses, including specifics on how they might be improved, could guide future tool development.
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Affiliation(s)
- Xia Jing
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - James J Cimino
- Informatics Institute, School of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Vimla L Patel
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York City, NY
| | - Yuchun Zhou
- Patton College of Education, Ohio University, Athens, OH
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University, Vallejo, CA
| | - Sonsoles De Lacalle
- Department of Health Science, California State University Channel Islands, Camarillo, CA
| | - Brooke N Draghi
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Mytchell A Ernst
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Aneesa Weaver
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Shriram Sekar
- Schoole of Computing, Clemson University, Clemson, SC
| | - Chang Liu
- Russ College of Engineering and Technology, Ohio University, Athens, OH
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Jing X, Draghi BN, Ernst MA, Patel VL, Cimino JJ, Shubrook JH, Zhou Y, Liu C, De Lacalle S. How do clinical researchers generate data-driven scientific hypotheses? Cognitive events using think-aloud protocol. medRxiv 2023:2023.10.31.23297860. [PMID: 37961555 PMCID: PMC10635246 DOI: 10.1101/2023.10.31.23297860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Objectives This study aims to identify the cognitive events related to information use (e.g., "Analyze data", "Seek connection") during hypothesis generation among clinical researchers. Specifically, we describe hypothesis generation using cognitive event counts and compare them between groups. Methods The participants used the same datasets, followed the same scripts, used VIADS (a visual interactive analysis tool for filtering and summarizing large data sets coded with hierarchical terminologies) or other analytical tools (as control) to analyze the datasets, and came up with hypotheses while following the think-aloud protocol. Their screen activities and audio were recorded and then transcribed and coded for cognitive events. Results The VIADS group exhibited the lowest mean number of cognitive events per hypothesis and the smallest standard deviation. The experienced clinical researchers had approximately 10% more valid hypotheses than the inexperienced group. The VIADS users among the inexperienced clinical researchers exhibit a similar trend as the experienced clinical researchers in terms of the number of cognitive events and their respective percentages out of all the cognitive events. The highest percentages of cognitive events in hypothesis generation were "Using analysis results" (30%) and "Seeking connections" (23%). Conclusion VIADS helped inexperienced clinical researchers use fewer cognitive events to generate hypotheses than the control group. This suggests that VIADS may guide participants to be more structured during hypothesis generation compared with the control group. The results provide evidence to explain the shorter average time needed by the VIADS group in generating each hypothesis.
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Affiliation(s)
- Xia Jing
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Brooke N Draghi
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Mytchell A Ernst
- Department of Public Health Sciences, Clemson University, Clemson, SC
| | - Vimla L Patel
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York City, NY
| | - James J Cimino
- Informatics Institute, School of Medicine, University of Alabama, Birmingham, Birmingham, AL
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University, Vallejo, CA
| | - Yuchun Zhou
- Patton College of Education, Ohio University, Athens, OH
| | - Chang Liu
- Russ College of Engineering and Technology, Ohio University, Athens, OH
| | - Sonsoles De Lacalle
- Department of Health Science, California State University Channel Islands, Camarillo, CA
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10
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Shubrook JH, Patel M, Young CF. Community-Based Diabetes Awareness Strategy With Detection and Intervention: The Mobile Diabetes Education Center. Clin Diabetes 2023; 42:125-134. [PMID: 38230347 PMCID: PMC10788663 DOI: 10.2337/cd23-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
To prevent diabetes and increase equitable access to health care screenings, Touro University California has created and implemented a community outreach program called the Mobile Diabetes Education Center (MOBEC). This program is a joint effort that also involves Sutter Health, the California Department of Public Health, Kaiser Permanente, the Solano County Department of Public Health, and community-based organizations, focusing on advancing health equity in Solano County's at-risk populations. This article reports on the services and initial successes of MOBEC. With its strong community collaboration, MOBEC has helped to raise awareness of diabetes and ensure access to much-needed health screenings and education. This model can potentially be used as a blueprint for similar efforts nationwide to address the health care needs of medically underserved communities.
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Affiliation(s)
- Jay H. Shubrook
- Touro University California College of Osteopathic Medicine, Vallejo, CA
| | - Megha Patel
- Touro University California College of Osteopathic Medicine, Vallejo, CA
| | - Clipper F. Young
- Touro University California College of Osteopathic Medicine, Vallejo, CA
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Shubrook JH, Neumiller JJ. Optimized Management of Cardio-Renal-Metabolic (CRM) Conditions in Patients With T2D. J Fam Pract 2023; 72:S43-S48. [PMID: 37549412 DOI: 10.12788/jfp.0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
LEARNING OBJECTIVES Describe cardio-renal-metabolic (CRM) conditions and their impact on health and patient-centered outcomes. Recognize current gaps in screening, risk factor management, and utilization of guideline-directed therapies in patients with CRM conditions. Select appropriate guideline-directed therapies for patients with type 2 diabetes, atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease based on current guidelines and clinical evidence. Recognize the importance of multidisciplinary care when managing patients with CRM conditions.
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12
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Jing X, Zhou Y, Cimino JJ, Shubrook JH, Patel VL, De Lacalle S, Weaver A, Liu C. Development, validation, and usage of metrics to evaluate the quality of clinical research hypotheses. medRxiv 2023:2023.01.17.23284666. [PMID: 36711561 PMCID: PMC9882446 DOI: 10.1101/2023.01.17.23284666] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objectives Metrics and instruments can provide guidance for clinical researchers to assess their potential research projects at an early stage before significant investment. Furthermore, metrics can also provide structured criteria for peer reviewers to assess others' clinical research manuscripts or grant proposals. This study aimed to develop, test, validate, and use evaluation metrics and instruments to accurately, consistently, and conveniently assess the quality of scientific hypotheses for clinical research projects. Materials and Methods Metrics development went through iterative stages, including literature review, metrics and instrument development, internal and external testing and validation, and continuous revisions in each stage based on feedback. Furthermore, two experiments were conducted to determine brief and comprehensive versions of the instrument. Results The brief version of the instrument contained three dimensions: validity, significance, and feasibility. The comprehensive version of metrics included novelty, clinical relevance, potential benefits and risks, ethicality, testability, clarity, interestingness, and the three dimensions of the brief version. Each evaluation dimension included 2 to 5 subitems to evaluate the specific aspects of each dimension. For example, validity included clinical validity and scientific validity. The brief and comprehensive versions of the instruments included 12 and 39 subitems, respectively. Each subitem used a 5-point Likert scale. Conclusion The validated brief and comprehensive versions of metrics can provide standardized, consistent, and generic measurements for clinical research hypotheses, allow clinical researchers to prioritize their research ideas systematically, objectively, and consistently, and can be used as a tool for quality assessment during the peer review process.
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Affiliation(s)
- Xia Jing
- College of Behavioral, Social, and Health Sciences, Clemson University, Clemson, South Carolina, USA
| | - Yuchun Zhou
- Patton College of Education, Ohio University, Athens, Ohio, USA
| | - James J. Cimino
- Informatics Institute, School of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Jay H. Shubrook
- College of Osteopathic Medicine, Touro University, Vallejo, California, USA
| | - Vimla L. Patel
- The New York Academy of Medicine, New York, New York, USA
| | - Sonsoles De Lacalle
- College of Art and Science, California State University Channel Islands, Camarillo, California, USA
| | - Aneesa Weaver
- College of Behavioral, Social, and Health Sciences, Clemson University, Clemson, South Carolina, USA
| | - Chang Liu
- Russ College of Engineering and Technology, Ohio University, Athens, Ohio, USA
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13
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Clark JM, Cryer DRH, Morton M, Shubrook JH. Nonalcoholic fatty liver disease from a primary care perspective. Diabetes Obes Metab 2023; 25:1421-1433. [PMID: 36789676 DOI: 10.1111/dom.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/31/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) affects up to one-third of the US population. Approximately one-fifth of patients with NAFLD have nonalcoholic steatohepatitis (NASH), characterized by hepatocyte damage and inflammation with or without fibrosis. NASH leads to greater risk of liver-related complications and liver-related mortality, with the poorest outcomes seen in patients with advanced fibrosis. NASH is also associated with other metabolic comorbidities and conveys an increased risk of adverse cardiovascular outcomes and extrahepatic cancers. Despite its high prevalence, NAFLD is frequently underdiagnosed. This is a significant concern, given that early diagnosis of NAFLD is a key step in preventing progression to NASH. In this review, we describe the clinical impact of NASH from the perspective of both the clinician and the patient. In addition, we provide practical guidance on the diagnosis and management of NASH for primary care providers, who play a pivotal role in the frontline care of patients with NASH, and we use case studies to illustrate real-world scenarios encountered in the primary care setting.
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Affiliation(s)
- Jeanne M Clark
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Donna R H Cryer
- Global Liver Institute, Washington, District of Columbia, USA
| | | | - Jay H Shubrook
- Primary Care Department, Touro University California College of Osteopathic Medicine, Vallejo, California, USA
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Moverley JA, Novak L, Shubrook JH. Conquering diabetes therapeutic inertia: practical tips for primary care. J Osteopath Med 2023; 123:113-120. [PMID: 36121937 DOI: 10.1515/jom-2022-0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 08/23/2022] [Indexed: 01/27/2023]
Abstract
Diabetes is a complex condition that is largely self-managed. Decades of scientific evidence has proved that early glycemic control leads to improved microvascular and macrovascular outcomes in people with diabetes mellitus. Despite well-established management guidelines, only about half of the patients with diabetes achieve glycemic targets, and only one in five patients achieve metabolic control (blood pressure, lipid, and glucose targets), and both patients and physicians find themselves stuck in a rut called therapeutic inertia (TI). The authors present several practical strategies that can be tailored to different practice settings and facilitate reducing TI.
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Affiliation(s)
- Joy A Moverley
- Joint MSPAS/MPH Program, Touro University California, Vallejo, CA, USA
| | - Lucia Novak
- Diabetes Consulting Services, North Bethesda, MD, USA
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
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Jing X, Patel VL, Cimino JJ, Shubrook JH, Zhou Y, Draghi BN, Ernst MA, Liu C, De Lacalle S. A visual analytic tool, VIADS, to assist the hypothesis generation process in clinical research—A usability study using mixed methods (Preprint). JMIR Hum Factors 2022; 10:e44644. [PMID: 37011112 PMCID: PMC10176142 DOI: 10.2196/44644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Visualization can be a powerful tool for comprehending datasets, especially when they can be represented via hierarchical structures. Enhanced comprehension can facilitate the development of scientific hypotheses. However, the inclusion of excessive data can make a visualization overwhelming. OBJECTIVE We developed a Visual Interactive Analytic tool for filtering and summarizing large health Data Sets (VIADS) coded with hierarchical terminologies. In this study, we evaluated the usability of VIADS for visualizing data sets of patient diagnoses and procedures coded in the International Classification of Diseases, ninth revisions, clinical modification (ICD-9-CM). METHODS We used mixed methods in the study. A group of 12 clinical researchers participated in the generation of data-driven hypotheses using the same datasets and time frame (a 1-hour training session and a 2-hour study session), utilizing VIADS via the think-aloud protocol. The audio and screen activities were recorded remotely. A modified version of the System Usability Scale (SUS) survey and a brief survey with open-ended questions were administered after the study to assess the usability of VIADS and verify their intense usage experience of VIADS. RESULTS The range of SUS scores was 37.5 - 87.5. The mean SUS score for VIADS was 71.88 (out of a possible 100, standard deviation: 14.62 ), and the median SUS was 75. The participants unanimously agreed that VIADS offers new perspectives on data sets (100%), while 75% agreed that VIADS facilitates understanding, presentation, and interpretation of underlying datasets. The comments on the utility of VIADS were positive and aligned well with the design objectives of VIADS. The answers to the open-ended questions in the modified SUS provided specific suggestions regarding potential improvements in VIADS, and identified problems in usability were used to update the tool. CONCLUSIONS This usability study demonstrates that VIADS is a usable tool for analyzing secondary datasets with good average usability, SUS score, and favorable utility. Currently, VIADS accepts datasets with hierarchical codes and their corresponding frequencies. Consequently, only specific types of use cases are supported by the analytical results. Participants agreed, however, that VIADS provides new perspectives on datasets and is relatively easy to use. The functionalities mostly appreciated by participants were VIADS' ability to filter, summarize, compare, and visualize data. CLINICALTRIAL INTERNATIONAL REGISTERED REPORT RR2-10.2196/39414.
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Affiliation(s)
- Xia Jing
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, United States
| | - Vimla L Patel
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York, NY, United States
| | - James J Cimino
- Informatics Institute, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jay H Shubrook
- Primary Care Department, College of Osteopathic Medicine, Touro University, Vallejo, CA, United States
| | - Yuchun Zhou
- Department of Educational Studies, The Patton College of Education, Ohio University, Athens, OH, United States
| | - Brooke N Draghi
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, United States
| | - Mytchell A Ernst
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, United States
| | - Chang Liu
- Electrical Engineering and Computer Science, Russ College of Engineering and Technology, Ohio University, Athens, OH, United States
| | - Sonsoles De Lacalle
- Health Science Program, California State University Channel Islands, Camarillo, CA, United States
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Derricks V, Mosher J, Earl A, Jayaratne TE, Shubrook JH. Real and Perceived Discordance in Physicians and U.S. Adults' Beliefs Regarding the Causes and Controllability of Type 2 Diabetes. Health Commun 2022; 37:1264-1275. [PMID: 33622109 PMCID: PMC8380747 DOI: 10.1080/10410236.2021.1885775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Discordance between physicians and patients' health beliefs can impede health communication efforts. However, little research considers physicians' perceptions of patient beliefs, despite the importance of perceptions in shaping communication. In the current work, we examine instances of actual and perceived discordance between physicians and U.S. adults' beliefs regarding the causes and controllability of type 2 diabetes. 229 family physicians completed an online survey measuring their health beliefs and perceptions of their patients' beliefs. Physicians' responses were contrasted against beliefs from a national survey sample of 1,168 U.S. adults. T-tests assessed whether (a) physicians' beliefs diverged from the national sample's beliefs (actual discordance), (b) physicians perceived that their health beliefs diverged from their patients' beliefs (perceived discordance), and (c) physicians' perceptions of patient beliefs diverged from the national sample's beliefs (accuracy of perceived discordance). Findings revealed evidence of actual discordance; compared to the national sample, physicians were more likely to attribute type 2 diabetes to genes (versus lifestyle factors) and perceived greater control over developing diabetes. Moreover, although physicians perceived discordance between their own and their patients' beliefs, data from the national sample suggested that these gaps were less substantial than physicians expected. In particular, findings showed that physicians generally overestimated discordance, expecting that people would be less likely to (1) attribute the development of diabetes to lifestyle factors (versus genes), and (2) perceive control over developing diabetes, than was actually reported. Implications of actual and perceived discordance for effective health communication and patient education are discussed.
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Affiliation(s)
- Veronica Derricks
- Indiana University – Purdue University Indianapolis, Department of Psychology, Indianapolis, Indiana, USA
- University of Michigan, Department of Psychology, Ann Arbor, Michigan, USA
| | - Jeremy Mosher
- Touro University California, College of Osteopathic Medicine, Vallejo, California, USA
| | - Allison Earl
- University of Michigan, Department of Psychology, Ann Arbor, Michigan, USA
| | - Toby E. Jayaratne
- University of Michigan, School of Public Health, Ann Arbor, Michigan, USA
| | - Jay H. Shubrook
- Touro University California, College of Osteopathic Medicine, Vallejo, California, USA
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17
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Shubrook JH, Radin M, Ali SN, Chubb B, DiPietrantonio K, Collings H, Wyn R, Smith M. Preference for Type 2 Diabetes Therapies in the United States: A Discrete Choice Experiment. Adv Ther 2022; 39:4114-4130. [PMID: 35797004 PMCID: PMC9402769 DOI: 10.1007/s12325-022-02181-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/05/2022] [Indexed: 12/01/2022]
Abstract
Introduction Type 2 diabetes mellitus (T2DM) is a chronic condition associated with substantial clinical and economic burden. As multiple therapeutic options are available, patient preferences on treatment characteristics are key in T2DM therapeutic decision-making. This study aimed to determine the preferences of US patients with T2DM for therapies recommended for first pharmacologic intensification after metformin. Methods As part of a discrete choice experiment, an online survey was designed using literature review and qualitative interview findings. Eligibility was met by US patients with T2DM who were aged 18 years or older with an HbA1c ≥ 6.5%. Anonymized therapy profiles were created from six antidiabetic therapies including oral and injectable semaglutide, dulaglutide, empagliflozin, sitagliptin, and thiazolidinediones. Results Eligible patients (n = 500) had a mean HbA1c of 7.4%, and a mean BMI of 32.0 kg/m2, the majority of which (72.2%) were injectable-naïve. The treatment characteristic with greatest importance was mode and frequency of administration (35.5%), followed by body weight change (29.2%), cardiovascular event risk (19.1%), hypoglycemic event risk (9.9%), and HbA1c change (6.5%). An oral semaglutide-like profile was preferred by 91.9–70.1% of respondents depending on the comparator agent, and preference was significant in each comparison (p < 0.05); an injectable semaglutide-like profile was preferred by 89.3–55.7% of respondents in each comparison depending on the comparator agent. Conclusion Patients with T2DM in the USA are significantly more likely to prefer oral or injectable semaglutide-like profiles over those of key comparators from the glucagon-like peptide 1 receptor agonist, sodium-glucose cotransporter 2 inhibitor, dipeptidyl peptidase 4 inhibitor, and thiazolidinedione classes. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02181-7.
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Affiliation(s)
- Jay H Shubrook
- Primary Care Department, Touro University California College of Osteopathic Medicine, Vallejo, CA, USA
| | | | - Sarah N Ali
- Novo Nordisk Pharma Ltd., Plainsboro, NJ, USA
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18
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Jing X, Patel VL, Cimino JJ, Shubrook JH, Zhou Y, Liu C, De Lacalle S. The Roles of a Secondary Data Analytic Tool and Experience in Scientific Hypothesis Generation in Clinical Research: A Study Design. JMIR Res Protoc 2022; 11:e39414. [PMID: 35736798 PMCID: PMC9345027 DOI: 10.2196/39414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/18/2022] [Accepted: 06/21/2022] [Indexed: 11/20/2022] Open
Abstract
Background Scientific hypothesis generation is a critical step in scientific research that determines the direction and impact of any investigation. Despite its vital role, we have limited knowledge of the process itself, thus hindering our ability to address some critical questions. Objective This study aims to answer the following questions: To what extent can secondary data analytics tools facilitate the generation of scientific hypotheses during clinical research? Are the processes similar in developing clinical diagnoses during clinical practice and developing scientific hypotheses for clinical research projects? Furthermore, this study explores the process of scientific hypothesis generation in the context of clinical research. It was designed to compare the role of VIADS, a visual interactive analysis tool for filtering and summarizing large data sets coded with hierarchical terminologies, and the experience levels of study participants during the scientific hypothesis generation process. Methods This manuscript introduces a study design. Experienced and inexperienced clinical researchers are being recruited since July 2021 to take part in this 2×2 factorial study, in which all participants use the same data sets during scientific hypothesis–generation sessions and follow predetermined scripts. The clinical researchers are separated into experienced or inexperienced groups based on predetermined criteria and are then randomly assigned into groups that use and do not use VIADS via block randomization. The study sessions, screen activities, and audio recordings of participants are captured. Participants use the think-aloud protocol during the study sessions. After each study session, every participant is given a follow-up survey, with participants using VIADS completing an additional modified System Usability Scale survey. A panel of clinical research experts will assess the scientific hypotheses generated by participants based on predeveloped metrics. All data will be anonymized, transcribed, aggregated, and analyzed. Results Data collection for this study began in July 2021. Recruitment uses a brief online survey. The preliminary results showed that study participants can generate a few to over a dozen scientific hypotheses during a 2-hour study session, regardless of whether they used VIADS or other analytics tools. A metric to more accurately, comprehensively, and consistently assess scientific hypotheses within a clinical research context has been developed. Conclusions The scientific hypothesis–generation process is an advanced cognitive activity and a complex process. Our results so far show that clinical researchers can quickly generate initial scientific hypotheses based on data sets and prior experience. However, refining these scientific hypotheses is a much more time-consuming activity. To uncover the fundamental mechanisms underlying the generation of scientific hypotheses, we need breakthroughs that can capture thinking processes more precisely. International Registered Report Identifier (IRRID) DERR1-10.2196/39414
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Affiliation(s)
| | - Vimla L Patel
- Cognitive Studies in Medicine and Public Health, The New York Academy of Medicine, New York City, US
| | - James J Cimino
- Informatics Institute, School of Medicine, University of Alabama, Birmingham, Birmingham, US
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University, Vallejo, US
| | - Yuchun Zhou
- Patton College of Education, Ohio University, Athens, US
| | - Chang Liu
- Russ College of Engineering and Technology, Ohio University, Athens, US
| | - Sonsoles De Lacalle
- College of Art and Science, California State University Channel Islands, Camarillo, US
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19
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Kanwal F, Shubrook JH, Cusi K. Reply. Gastroenterology 2022; 162:2132-2134. [PMID: 35183548 DOI: 10.1053/j.gastro.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, Texas
| | - Jay H Shubrook
- Touro University California College of Osteopathic Medicine, Vallejo, California
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes, and Metabolism, University of Florida, Gainesville, Florida
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20
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Ha CL, Shubrook JH, Mason T. Gestational diabetes: Optimizing Dx and management in primary care. J Fam Pract 2022; 71:66-73. [PMID: 35507821 DOI: 10.12788/jfp.0360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Understanding risk factors and glucose targets for gestational diabetes can help you identify at-risk patients and improve outcomes for mother and infant.
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Affiliation(s)
- Connie L Ha
- Primary Care Department, Touro University California
| | | | - Tina Mason
- Primary Care Department, Touro University California
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21
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Shubrook JH, Neumiller JJ, Wright E. Management of chronic kidney disease in type 2 diabetes: screening, diagnosis and treatment goals, and recommendations. Postgrad Med 2021; 134:376-387. [PMID: 34817311 DOI: 10.1080/00325481.2021.2009726] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at high risk of CKD progression and cardiovascular (CV) disease. Prevalence of CKD in patients with T2D is currently around 40% and continues to grow. The increasing number of people with CKD and T2D will ultimately have a significant impact upon health resource use and costs of care for people with T2D. Management of CKD in patients with T2D aims to preserve kidney function to reduce the risk of end-stage kidney disease, CV events, and mortality. Evidence-based recommendations for the treatment of patients with CKD and T2D are provided by several international and national organizations and recommend several lifestyle and pharmacological approaches to help prevent or delay the progression of CKD in patients with T2D. Guidelines include regular screening of patients with T2D for CKD using spot urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (at least annually and at least twice a year if UACR >300 mg/g). Additionally, assessment of vascular complications, together with interventions designed to improve glycemic control and lipid levels, maintain healthy body weight, and optimize blood pressure should be performed. Medications shown to slow progression of CKD include renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and, more recently, selective, non-steroidal mineralocorticoid receptor antagonists. This review highlights the ongoing challenges facing primary care providers in the management of CKD in patients with T2D including the consideration of comorbidities, adoption of new treatment options, and implementation of individualized care. Achieving consensus for optimal treatment of this disease is critical in providing consistent and appropriate care for all patients. Strategies to improve outcomes should also include use of clear referral criteria, use of a multi-disciplinary approach, and patient education.
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Affiliation(s)
- Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
| | - Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Eugene Wright
- Performance Improvement at Charlotte Area Health Education Center, Charlotte, NC, USA
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22
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Kanwal F, Shubrook JH, Adams LA, Pfotenhauer K, Wai-Sun Wong V, Wright E, Abdelmalek MF, Harrison SA, Loomba R, Mantzoros CS, Bugianesi E, Eckel RH, Kaplan LM, El-Serag HB, Cusi K. Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology 2021; 161:1657-1669. [PMID: 34602251 PMCID: PMC8819923 DOI: 10.1053/j.gastro.2021.07.049] [Citation(s) in RCA: 214] [Impact Index Per Article: 71.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/22/2021] [Accepted: 07/31/2021] [Indexed: 02/07/2023]
Abstract
Find AGA's NASH Clinical Care Pathway App for iOS and Android mobile devices at nash.gastro.org. Scan this QR code to be taken directly to the website.Nonalcoholic fatty liver disease (NAFLD) is becoming increasingly common, currently affecting approximately 37% of US adults. NAFLD is most often managed in primary care or endocrine clinics, where clinicians must determine which patients might benefit from secondary care to address hepatic manifestations, comorbid metabolic traits, and cardiovascular risks of the disease. Because NAFLD is largely asymptomatic, and because optimal timing of treatment depends on accurate staging of fibrosis risk, screening at the primary care level is critical, together with consistent, timely, evidence-based, widely accessible, and testable management processes. To achieve these goals, the American Gastroenterological Association assembled a multidisciplinary panel of experts to develop a Clinical Care Pathway providing explicit guidance on the screening, diagnosis, and treatment of NAFLD. This article describes the NAFLD Clinical Care Pathway they developed and provides a rationale supporting proposed steps to assist clinicians in diagnosing and managing NAFLD with clinically significant fibrosis (stage F2-F4) based on the best available evidence. This Pathway is intended to be applicable in any setting where care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices.
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Affiliation(s)
- Fasiha Kanwal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jay H Shubrook
- Touro University California College of Osteopathic Medicine, Vallejo, California
| | - Leon A Adams
- University of Western Australia Medical School, Perth, Western Australia, Australia
| | - Kim Pfotenhauer
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China
| | - Eugene Wright
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Manal F Abdelmalek
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Rohit Loomba
- NAFLD Research Center, Department of Medicine, University of California San Diego, La Jolla, California
| | | | | | - Robert H Eckel
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Lee M Kaplan
- Harvard Medical School, Boston, Massachusetts; Gastroenterology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Hashem B El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Kenneth Cusi
- University of Florida, Gainesville, Florida; Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.
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Alvear Durán S, Sanchez-Del-Hierro G, Gomez-Correa D, Enriquez A, Sanchez E, Belec M, Casapulla S, Grijalva MJ, Shubrook JH. A pilot of a modified diabetes prevention program in Quito, Ecuador. J Osteopath Med 2021; 121:905-911. [PMID: 34668365 DOI: 10.1515/jom-2020-0175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 07/12/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Diabetes has become a global noninfectious pandemic with rates rapidly rising around the globe. The major drivers of this increase in type 2 diabetes are obesity, an increase in processed foods, and a decrease in physical activity. In the United States, the National Diabetes Prevention Program (NDPP) has proven to be an effective lifestyle intervention to delay or prevent new-onset type 2 diabetes. However, there is limited evidence that such a lifestyle program will work in a South American community. OBJECTIVES This pilot program aims to determine if a modified version of the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program (DPP) would be feasible in an Ecuadorian population. The goals of this pilot program were a 7% weight loss, >150 min of physical activity per week, and a reduction of fat calories to yield a reduced risk of type 2 diabetes. This program was led by family medicine physicians and was offered to people with prediabetes in Quito, Ecuador. METHODS The program was modified to include only the first half of the DPP curriculum, which included a schedule of 16 classes in the first 6 months. Further, the program was provided in Spanish and modified to be more culturally specific to this population. Participants were recruited from the faculty and staff of Pontifical Catholic University of Ecuador (Pontificia Universidad Católica del Ecuador [PUCE]) in Quito. Outcomes measured included A1c reduction, weight loss, increase in physical activity minutes, and progression to type 2 diabetes mellitus (T2DM). RESULTS The sample included 33 people with prediabetes. The mean age of the participants was 52 years (range, 41-66 years), the mean body mass index (BMI) was 27.6 kg/m2 (range, 21.0-40.3 kg/m2), and the mean HbA1C was 6.2% (range, 5.7-6.4%). The attendance was 97.8% at 6 months. The mean weight loss was 3.4 kg per participant (range, 1.5 kg weight gain to 8.3 kg weight loss); in percentage points, this was a mean weight loss of 3.6% (range, 2.3% gain to 11.8% weight loss). Three-fourths of the participants lost weight (78.3%). The majority of participants (75.8%) met the target physical activity level of 150 min per week, and all participants increased their physical activity levels from baseline. No participants progressed to type 2 diabetes during this study. CONCLUSIONS The DPP 6 month pilot was effective in this population with prediabetes in Ecuador. The largest changes were made in physical activity time. Holding the program at worksites and providing lunch were key factors in the very high retention rate in this study.
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Affiliation(s)
- Susana Alvear Durán
- Facultad de Medicina, Center for Research on Health in Latin America, Pontifical Catholic University of Ecuador, Quito, Ecuador
| | - Galo Sanchez-Del-Hierro
- Facultad de Medicina, Center for Research on Health in Latin America, Pontifical Catholic University of Ecuador, Quito, Ecuador.,Department of Primary and Interdisciplinary Care, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Diego Gomez-Correa
- Family Practice Resident, Facultad de Medicina, Hospital Vozandes Quito, Pontifical Catholic University of Ecuador, Quito, Ecuador
| | - Andrés Enriquez
- Family Practice Resident, Facultad de Medicina, Hospital Un Canto a la Vida, Pontifical Catholic University of Ecuador, Quito, Ecuador
| | - Enver Sanchez
- Family Practice Resident, Facultad de Medicina, Hospital Un Canto a la Vida, Pontifical Catholic University of Ecuador, Quito, Ecuador
| | - Melissa Belec
- Family Practice Resident, University of Minnesota - North Memorial, Minneapolis, MN, USA
| | - Sharon Casapulla
- Department of Primary Care, Office of Rural and Underserved Programs, Diabetes Institute, Infectious and Tropical Disease Institute, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - Mario J Grijalva
- Department of Biomedical Sciences, Infectious and Tropical Disease Institute, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA.,Center for Research on Health in Latin America, School of Biological Sciences, Pontifical Catholic University of Ecuador, Quito, Ecuador
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Ahmed S, Saeed S, Shubrook JH. Masqueraders: how to identify atypical diabetes in primary care. J Osteopath Med 2021; 121:899-904. [PMID: 34606708 DOI: 10.1515/jom-2021-0129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/20/2021] [Indexed: 11/15/2022]
Abstract
Diabetes mellitus is a complex set of conditions that impacts 34 million Americans. While type 1 diabetes, type 2 diabetes, and gestational diabetes are most frequently encountered, there are many other types of diabetes with which healthcare providers are less familiar. These atypical forms of diabetes make up nearly 10% of diabetes cases and can masquerade as type 1 or 2 diabetes mellitus (T1DM or T2DM), and the treatment may not be optimized if the diagnosis is not accurate. Atypical forms include monogenic diabetes (formally known as maturity-onset diabetes of the young [MODY]), latent autoimmune diabetes of the adult (LADA), ketosis-prone diabetes, and secondary diabetes. This paper will detail the defining characteristics of each atypical form and demonstrate how they can masquerade as type 1 or 2 diabetes mellitus. Gestational diabetes mellitus will not be discussed in this article.
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Affiliation(s)
- Sumera Ahmed
- Assistant Professor, Primary Care at Touro University California College of Osteopathic Medicine, Vallejo, CA, USA
| | - Sana Saeed
- Researcher, Touro University California College of Osteopathic Medicine, Vallejo, CA, USA
| | - Jay H Shubrook
- Professor, Primary Care at Touro University California College of Osteopathic Medicine, Vallejo, CA, USA
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Kanwal F, Shubrook JH, Younossi Z, Natarajan Y, Bugianesi E, Rinella ME, Harrison SA, Mantzoros C, Pfotenhauer K, Klein S, Eckel RH, Kruger D, El-Serag H, Cusi K. Preparing for the NASH epidemic: A call to action. Obesity (Silver Spring) 2021; 29:1401-1412. [PMID: 34365735 DOI: 10.1002/oby.23250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 02/06/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common conditions with a rising burden. Yet there are significant management gaps between clinical guidelines and practice in patients with NAFLD and NASH. Further, there is no single global guiding strategy for the management of NAFLD and NASH. The American Gastroenterological Association, in collaboration with 7 professional associations, convened an international conference comprising 32 experts in gastroenterology, hepatology, endocrinology, and primary care providers from the United States, Europe, Asia, and Australia. Conference content was informed by the results of a national NASH Needs Assessment Survey. The participants reviewed and discussed published literature on global burden, screening, risk stratification, diagnosis, and management of individuals with NAFLD, including those with NASH. Participants identified promising approaches for clinical practice and prepared a comprehensive, unified strategy for primary care providers and relevant specialists encompassing the full spectrum of NAFLD/NASH care. They also identified specific high-yield targets for clinical research and called for a unified, international public health response to NAFLD and NASH.
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Affiliation(s)
- Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness and Safety and Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Veterans Affairs Health Services Research and Development Service, Houston, Texas, USA
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, California, USA
| | | | | | | | | | | | | | | | - Samuel Klein
- Washington University School of Medicine, St Louis, Missouri, USA
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Kenneth Cusi
- University of Florida and Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida, USA
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Kanwal F, Shubrook JH, Younossi Z, Natarajan Y, Bugianesi E, Rinella ME, Harrison SA, Mantzoros C, Pfotenhauer K, Klein S, Eckel RH, Kruger D, El-Serag H, Cusi K. Preparing for the NASH Epidemic: A Call to Action. Diabetes Care 2021; 44:2162-2172. [PMID: 34312182 DOI: 10.2337/dci21-0020] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common conditions with a rising burden. Yet there are significant management gaps between clinical guidelines and practice in patients with NAFLD and NASH. Further, there is no single global guiding strategy for the management of NAFLD and NASH. The American Gastroenterological Association, in collaboration with 7 professional associations, convened an international conference comprising 32 experts in gastroenterology, hepatology, endocrinology, and primary care providers from the United States, Europe, Asia, and Australia. Conference content was informed by the results of a national NASH Needs Assessment Survey. The participants reviewed and discussed published literature on global burden, screening, risk stratification, diagnosis, and management of individuals with NAFLD, including those with NASH. Participants identified promising approaches for clinical practice and prepared a comprehensive, unified strategy for primary care providers and relevant specialists encompassing the full spectrum of NAFLD/NASH care. They also identified specific high-yield targets for clinical research and called for a unified, international public health response to NAFLD and NASH.
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Affiliation(s)
- Fasiha Kanwal
- Baylor College of Medicine, Veterans Affairs Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, and Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
| | - Jay H Shubrook
- Touro University California, College of Osteopathic Medicine, Vallejo, CA
| | | | | | | | | | | | | | | | - Samuel Klein
- Washington University School of Medicine, St. Louis, MO
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | - Kenneth Cusi
- University of Florida and Malcom Randall Veterans Affairs Medical Center, Gainesville, FL
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27
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Kanwal F, Shubrook JH, Younossi Z, Natarajan Y, Bugianesi E, Rinella ME, Harrison SA, Mantzoros C, Pfotenhauer K, Klein S, Eckel RH, Kruger D, El-Serag H, Cusi K. Preparing for the NASH Epidemic: A Call to Action. Gastroenterology 2021; 161:1030-1042.e8. [PMID: 34416976 DOI: 10.1053/j.gastro.2021.04.074] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common conditions with a rising burden. Yet there are significant management gaps between clinical guidelines and practice in patients with NAFLD and NASH. Further, there is no single global guiding strategy for the management of NAFLD and NASH. The American Gastroenterological Association, in collaboration with 7 professional associations, convened an international conference comprising 32 experts in gastroenterology, hepatology, endocrinology, and primary care providers from the United States, Europe, Asia, and Australia. Conference content was informed by the results of a national NASH Needs Assessment Survey. The participants reviewed and discussed published literature on global burden, screening, risk stratification, diagnosis, and management of individuals with NAFLD, including those with NASH. Participants identified promising approaches for clinical practice and prepared a comprehensive, unified strategy for primary care providers and relevant specialists encompassing the full spectrum of NAFLD/NASH care. They also identified specific high-yield targets for clinical research and called for a unified, international public health response to NAFLD and NASH.
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Affiliation(s)
- Fasiha Kanwal
- Baylor College of Medicine, Veterans Affairs Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Jay H Shubrook
- Touro University California, College of Osteopathic Medicine, Vallejo, California
| | | | | | | | | | | | | | | | - Samuel Klein
- Washington University School of Medicine, St Louis, Missouri
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | - Kenneth Cusi
- University of Florida and Malcom Randall Veterans Affairs Medical Center, Gainesville, Florida.
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28
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Kanwal F, Shubrook JH, Younossi Z, Natarajan Y, Bugianesi E, Rinella ME, Harrison SA, Mantzoros C, Pfotenhauer K, Klein S, Eckel RH, Kruger D, El-Serag H, Cusi K. Preparing for the NASH epidemic: A call to action. Metabolism 2021; 122:154822. [PMID: 34289945 DOI: 10.1016/j.metabol.2021.154822] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/20/2021] [Indexed: 02/07/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are common conditions with a rising burden. Yet there are significant management gaps between clinical guidelines and practice in patients with NAFLD and NASH. Further, there is no single global guiding strategy for the management of NAFLD and NASH. The American Gastroenterological Association, in collaboration with 7 professional associations, convened an international conference comprising 32 experts in gastroenterology, hepatology, endocrinology, and primary care providers from the United States, Europe, Asia, and Australia. Conference content was informed by the results of a national NASH Needs Assessment Survey. The participants reviewed and discussed published literature on global burden, screening, risk stratification, diagnosis, and management of individuals with NAFLD, including those with NASH. Participants identified promising approaches for clinical practice and prepared a comprehensive, unified strategy for primary care providers and relevant specialists encompassing the full spectrum of NAFLD/NASH care. They also identified specific high-yield targets for clinical research and called for a unified, international public health response to NAFLD and NASH.
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Affiliation(s)
- Fasiha Kanwal
- Baylor College of Medicine, Veterans Affairs Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Jay H Shubrook
- Touro University California, College of Osteopathic Medicine, Vallejo, CA, United States of America
| | - Zobair Younossi
- Inova Health System, Falls Church, VA, United States of America
| | - Yamini Natarajan
- Baylor College of Medicine, Houston, TX, United States of America
| | | | - Mary E Rinella
- Northwestern University, Chicago, IL, United States of America
| | | | | | - Kim Pfotenhauer
- Michigan State University, East Lansing, MI, United States of America
| | - Samuel Klein
- Washington University School of Medicine, St Louis, MO, United States of America
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Davida Kruger
- Henry Ford Health System, Detroit, MI, United States of America
| | - Hashem El-Serag
- Baylor College of Medicine, Houston, TX, United States of America
| | - Kenneth Cusi
- University of Florida and Malcom Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America.
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Affiliation(s)
| | | | - Tina Mason
- Touro University California, Vallejo, CA
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30
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Neumiller JJ, Shubrook JH, Manley T, Alicic RZ, Tuttle KR. Optimizing use of SGLT2 inhibitors and other evidence-based therapies to improve outcomes in patients with type 2 diabetes and chronic kidney disease: An opportunity for pharmacists. Am J Health Syst Pharm 2021; 79:e65-e70. [PMID: 34185826 DOI: 10.1093/ajhp/zxab271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joshua J Neumiller
- College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA
| | - Jay H Shubrook
- Primary Care Department, Touro University, Vallejo, CA, USA
| | - Tom Manley
- National Kidney Foundation, New York, NY, USA
| | - Radica Z Alicic
- Providence Medical Research Center, Providence Health Care, Spokane, WA, and Division of Medicine, University of Washington, Spokane and Seattle, WA, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, WA, and Division of Nephrology, Kidney Research Institute, and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, WA, USA
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31
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Healy AM, Uhrig JL, Shubrook JH, Aung NL, Sadhu AR. Resident opinions of diabetes management in training: a survey. J Osteopath Med 2021; 121:755-762. [PMID: 34192834 DOI: 10.1515/jom-2021-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Primary care physicians need a strong foundation in diabetes management, as they are the first line of care for patients with this complex disease, which is increasing in frequency in the United States. This foundational training begins in medical school, but its applications become more important during residency. OBJECTIVES To quantify osteopathic and allopathic family medicine residents' amount of exposure to diabetes in residency training, investigate referral patterns related to diabetes management, and assess comfort levels with various diabetes treatment modalities. METHODS An 18-item cross sectional survey was sent via email using Qualtrics to program directors and chief residents of 16 different training programs located in seven different health systems and four different states; the programs were focused on family medicine, internal medicine, pediatrics, and combined internal medicine/pediatrics programs. The link was also posted on Twitter using specific "handles" to "tag" professional associations and groups related to primary care. Emails and tweets were initiated on October 15, 2018 and responses were collected through April 15, 2019. Data collection was reinitiated via email only from May 1, 2020 through July 31, 2020 due to low initial response rate. The study, which included multiple choice and Likert scale questions with some skip logic, was designed by study investigators. Data was exported from Qualtrics to an Excel spreadsheet and analyzed using descriptive statistics, which are reported as percentages. RESULTS A total of 61 residents responded to the survey, with most (52; 85.2%) enrolled in family medicine or internal medicine programs. Residents were mostly located in rural (28; 45.9%) and suburban (25; 41.0%) areas. Respondents reported being extremely comfortable with metformin (45; 73.8%), basal insulin (24; 39.3%), and healthy lifestyle education (32; 52.5%) for the treatment of diabetes. They reported being least comfortable with diabetes technology, with 51 (83.6%) uncomfortable or extremely uncomfortable with insulin pumps and 43 (70.5%) uncomfortable with continuous glucose monitoring systems for diabetes treatment. Referral rates to endocrinologists were low, with 47 (77%) reporting referral of diabetes patients 10-15% of the time. Residents reported interest in workshops and online continuing medical education for further training opportunities, but interest in additional formal training was low (3; 4.9%). CONCLUSIONS Residents in this study reported confidence in diabetes management and referral rates among this group were low. However, reported comfort levels with treatment modalities beyond metformin and lifestyle changes were not strong. Referral rates may have been low due to the low number of endocrinologists in rural areas and therapeutic inertia. Diabetes fellowships could increase resource availability for patient referral. Utilization of diabetologists in primary care programs may also add benefit and improve skills among trainees including more familiarity with diabetes technology and use of newer medications used in diabetes management.
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Affiliation(s)
- Amber M Healy
- Ohio University Heritage College of Osteopathic Medicine Diabetes Institute and Department of Specialty Medicine in Athens, OH; Ohio Health Physician Group Heritage College Diabetes and Endocrinology in Athens, OH; and Ohio University Heritage College of Osteopathic Medicine Department of Specialty Medicine, Athens, OH, USA
| | - Jarrod L Uhrig
- Carilion Clinic Endocrinology and Virginia Tech Carilion School of Medicine in Roanoke, Roanoke, VA, USA
| | - Jay H Shubrook
- Primary Care Department, Director of Clinical Research and Diabetes Services Touro University California College of Osteopathic Medicine in Vallejo, Vallejo, CA, USA
| | - Nay Linn Aung
- St Elizabeth Family Medicine Residency Program at Mohawk Valley Health System (MVHS), Department of Hospitalist and Glucose Management Team at Mohawk Valley Health System (MVHS) in Utica, Utica, NY, USA
| | - Archana R Sadhu
- System Director, Diabetes Program and Director, Transplant Endocrinology at Houston Methodist in Houson, TX; Assistant Clinical Professor, Weill Cornell Medical College in New York, NY; and Adjunct Assistant Professor, Texas A&M Health Sciences in Bryan, Bryan, TX, USA
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Draznin B, Sadhu A, Schutta M, Ramirez BF, Polsky S, Shubrook JH, Low Wang CC. Authors' Reply: Improved Access to Quality Diabetes Care in the United States: Where Do We Go From Here? Endocr Pract 2021; 27:760-761. [PMID: 33940181 DOI: 10.1016/j.eprac.2021.04.883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Boris Draznin
- Anschutz Medical Campus School of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Aurora, Colorado
| | - Archana Sadhu
- Weil Cornell Medical College, Texas A&M Heath Sciences, Houston Methodist, Houston, Texas
| | - Mark Schutta
- University of Pennsylvania Penn Rodebaugh Diabetes Center, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Beatriz Francesca Ramirez
- Division of Endocrinology, Department of Internal Medicine, East Carolina University, Greenville, North Carolina
| | - Sarit Polsky
- Anschutz Medical Campus School of Medicine, Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, California
| | - Cecilia C Low Wang
- Anschutz Medical Campus School of Medicine, Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Aurora, Colorado
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Affiliation(s)
| | - Jay H Shubrook
- Touro University College of Osteopathic Medicine, Fairfield, CA
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Kuo S, Ye W, de Groot M, Saha C, Shubrook JH, Hornsby WG, Pillay Y, Mather KJ, Herman WH. Cost-effectiveness of Community-Based Depression Interventions for Rural and Urban Adults With Type 2 Diabetes: Projections From Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II. Diabetes Care 2021; 44:874-882. [PMID: 33608260 PMCID: PMC7985429 DOI: 10.2337/dc20-1639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/17/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We estimated the cost-effectiveness of the Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II community-based exercise (EXER), cognitive behavioral therapy (CBT), and EXER+CBT interventions in adults with type 2 diabetes and depression relative to usual care (UC) and each other. RESEARCH DESIGN AND METHODS Data were integrated into the Michigan Model for Diabetes to estimate cost and health outcomes over a 10-year simulation time horizon from the health care sector and societal perspectives, discounting costs and benefits at 3% annually. Primary outcome was cost per quality-adjusted life-year (QALY) gained. RESULTS From the health care sector perspective, the EXER intervention strategy saved $313 (USD) per patient and produced 0.38 more QALY (cost saving), the CBT intervention strategy cost $596 more and gained 0.29 more QALY ($2,058/QALY), and the EXER+CBT intervention strategy cost $403 more and gained 0.69 more QALY ($585/QALY) compared with UC. Both EXER and EXER+CBT interventions dominated the CBT intervention. Compared with EXER, the EXER+CBT intervention strategy cost $716 more and gained 0.31 more QALY ($2,323/QALY). From the societal perspective, compared with UC, the EXER intervention strategy saved $126 (cost saving), the CBT intervention strategy cost $2,838/QALY, and the EXER+CBT intervention strategy cost $1,167/QALY. Both EXER and EXER+CBT interventions still dominated the CBT intervention. In comparison with EXER, the EXER+CBT intervention strategy cost $3,021/QALY. Results were robust in sensitivity analyses. CONCLUSIONS All three Program ACTIVE II interventions represented a good value for money compared with UC. The EXER+CBT intervention was highly cost-effective or cost saving compared with the CBT or EXER interventions.
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Affiliation(s)
| | - Wen Ye
- University of Michigan, Ann Arbor, MI
| | - Mary de Groot
- Indiana University School of Medicine, Indianapolis, IN
| | - Chandan Saha
- Indiana University School of Medicine, Indianapolis, IN
| | - Jay H Shubrook
- Touro University College of Osteopathic Medicine in California, Vallejo, CA.,Heritage College of Osteopathic Medicine, Ohio University, Athens, OH
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Lingvay I, Kirk AR, Lophaven S, Wolden ML, Shubrook JH. Outcomes in GLP-1 RA-Experienced Patients Switching to Once-Weekly Semaglutide in a Real-World Setting: The Retrospective, Observational EXPERT Study. Diabetes Ther 2021; 12:879-896. [PMID: 33594582 PMCID: PMC7947062 DOI: 10.1007/s13300-021-01010-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/23/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are highly effective for glycaemic control and weight loss in patients with type 2 diabetes (T2D). In this retrospective, observational study, we analysed glycated haemoglobin (HbA1c) and weight following switching to semaglutide from any other GLP-1 RA, using US electronic health records and prescription data. METHODS Adults (≥ 18 years old) with T2D required at least one prescription for injectable semaglutide at index date (treatment switch), at least one prescription for any other GLP-1 RA in the previous 365 days, a baseline HbA1c and/or weight measurement in the 90 days pre-index and a follow-up measurement at 180 and 365 days post-index. HbA1c and weight cohorts were analysed separately using an ANCOVA model. Sensitivity analyses were conducted in patients with at least two prescriptions for pre-switch GLP-1 RA. A secondary analysis compared subgroups receiving different GLP-1 RAs pre-switch. RESULTS Patients with HbA1c (n = 710) and weight (n = 921) data had similar baseline characteristics. Significant reductions in HbA1c at 6 months (0.7%; 95% confidence interval [CI] - 0.8, - 0.6) were sustained at 12 months. Weight reductions were significant at 6 months (- 2.1 kg; 95% CI - 2.6, - 1.6) and greater at 12 months (- 2.8 kg; 95% CI - 3.9, - 1.8). These patterns were consistent with the two-prescription sensitivity analysis and independent of the pre-switch GLP-1 RA. CONCLUSION Switching to injectable semaglutide from any other GLP-1 RA was associated with significant improvements in glycaemic control and weight. Our findings support decision-making in clinical practice in patients with an indication to switch between GLP-1 RAs.
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Affiliation(s)
- Ildiko Lingvay
- Department of Internal Medicine/Endocrinology and Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | | | | | | | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
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36
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Molinari AM, Shubrook JH. Treatment options and current guidelines of care for pediatric type 2 diabetes patients: a narrative review. J Osteopath Med 2021; 121:431-440. [PMID: 33694353 DOI: 10.1515/jom-2020-0172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 11/03/2020] [Indexed: 11/15/2022]
Abstract
CONTEXT Type 2 diabetes (T2D) mellitus, which was once considered a disease affecting adults, is a growing problem among youths. Research now shows that T2D in youths is more progressive and associated with earlier onset of complications than adult-onset T2D. OBJECTIVES To update practicing clinical physicians on what is currently known about pediatric T2D and share current guidelines to care for these patients. METHODS The authors conducted a literature review through the MEDLINE/PubMed, Google Scholar, and clinicaltrials.gov databases in July 2019 using the following search phrases: "youth-onset type 2 diabetes," "pediatric type 2 diabetes," "diabetes in youth," and "FDA-approved pediatric diabetes medications." Items published between 2010 and 2019 and written in English were included. RESULTS A total of 65 items were included after database review, including 44 articles, 10 FDA product inserts, six clinicaltrials.gov listings, three position statements/guideline documents, one website, and one FDA announcement. CONCLUSIONS There are very limited treatment options available to manage pediatric T2D. Prevention of pediatric T2D is paramount, which requires a high index of suspicion, routine screening of children and adolescents, and willingness to engage in family-based interventions for those at risk for prediabetes and T2D. Osteopathic physicians have a unique opportunity to help by applying the osteopathic principles to the whole person - including environmental, societal, and lifestyle factors - to help patients achieve their health and wellness goals.
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Affiliation(s)
- Antonia M Molinari
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
| | - Jay H Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA, USA
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37
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Shubrook JH, Ramirez BF, Healy AM, Salzberg L, Ahmed S, Feinberg H, Schutta M, Schwartz FL, Low Wang CC. Primary Care Diabetes Fellowship Programs: Developing National Standards. Clin Diabetes 2021; 39:88-96. [PMID: 33551558 PMCID: PMC7839610 DOI: 10.2337/cd20-0055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The rapid and constant increase in the number of people living with diabetes has outstripped the capacity of specialists to fully address this chronic disease alone. Furthermore, although most people with diabetes are treated in the primary care setting, most primary care providers feel under-prepared and under-resourced to fully address the needs of their patients with diabetes. Addressing this care gap will require a multifaceted approach centering on primary care training in diabetes and its complications. One-year diabetology fellowship programs are well situated to provide this training. Previous research has shown that the higher the diabetes-specific volume of patients seeing a primary care physician was, the better the quality outcomes were across six quality indicators (eye examinations, LDL cholesterol testing, A1C testing, prescriptions for ACE inhibitors or angiotensin receptor blockers, prescriptions for statins, and emergency department visits for hypoglycemia or hyperglycemia). Primary care diabetes fellowships have existed for many years, but the number of fellowships and fellowship positions has recently grown dramatically. This article proposes a standardized curriculum for such programs and makes the case for increasing their number in the United States.
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Affiliation(s)
- Jay H. Shubrook
- Touro University California College of Osteopathic Medicine, Vallejo, CA
| | | | - Amber M. Healy
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH
- Ohio Health Physician Group Heritage College Diabetes and Endocrinology, Athens, OH
| | - Lenard Salzberg
- Duke Southern Regional Area Health Education Center, Fayetteville, NC
| | - Sumera Ahmed
- Touro University California College of Osteopathic Medicine, Vallejo, CA
| | - Howard Feinberg
- Touro University California College of Osteopathic Medicine, Vallejo, CA
| | | | - Frank L. Schwartz
- West Virginia University/Camden Clark Medical Center, Parkersburg, WV
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38
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Doyle-Delgado K, Chamberlain JJ, Shubrook JH, Skolnik N, Trujillo J. Pharmacologic Approaches to Glycemic Treatment of Type 2 Diabetes: Synopsis of the 2020 American Diabetes Association's Standards of Medical Care in Diabetes Clinical Guideline. Ann Intern Med 2020; 173:813-821. [PMID: 32866414 DOI: 10.7326/m20-2470] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The American Diabetes Association (ADA) updates the Standards of Medical Care in Diabetes annually to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of diabetes. METHODS To develop the 2020 Standards, the ADA Professional Practice Committee, comprising physicians, adult and pediatric endocrinologists, diabetes educators, registered dietitians, epidemiologists, pharmacists, and public health experts, continuously searched MEDLINE (English language only) from 15 October 2018 through August-September 2019 for pertinent studies, including high-quality trials that addressed pharmacologic management of type 2 diabetes. The committee selected and reviewed the studies, developed the recommendations, and solicited feedback from the larger clinical community. RECOMMENDATIONS This synopsis focuses on guidance relating to the pharmacologic treatment of adults with type 2 diabetes. Recommendations address oral and noninsulin injectable therapies, insulin treatment, and combination injectable therapies. Results of recent large trials with cardiovascular and renal outcomes are emphasized.
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Affiliation(s)
- Kacie Doyle-Delgado
- St. Mark's Hospital and St. Mark's Diabetes Center, Salt Lake City, Utah (K.D., J.J.C.)
| | - James J Chamberlain
- St. Mark's Hospital and St. Mark's Diabetes Center, Salt Lake City, Utah (K.D., J.J.C.)
| | - Jay H Shubrook
- Touro University California, College of Osteopathic Medicine, Vallejo, California (J.H.S.)
| | - Neil Skolnik
- Abington Family Medicine, Jenkintown, Pennsylvania (N.S.)
| | - Jennifer Trujillo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado (J.T.)
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Young CF, Moussa M, Shubrook JH. Erratum. Diabetic Gastroparesis: A Review. Diabetes Spectrum 2020;33:290-297 (https://doi.org/10.2337/ds19-0062). Diabetes Spectr 2020; 33:358. [PMID: 33223775 PMCID: PMC7666604 DOI: 10.2337/ds20-er04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
[This corrects the article on p. 290 in vol. 33, PMID: 32848351.].
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Young CF, Shubrook JH, Valencerina E, Wong S, Henry Lo SN, Dugan JA. Associations Between Social Support and Diabetes-Related Distress in People With Type 2 Diabetes Mellitus. J Osteopath Med 2020; 120:721-731. [PMID: 33033833 DOI: 10.7556/jaoa.2020.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Context Diabetes is a complex, chronic condition and managing it can have psychosocial implications for patients, including an impact on relationships with their loved ones and physical wellness. The necessary modifications to daily behaviors can be very overwhelming, thus leading to diabetes-related distress. Objective To investigate the association between diabetes-related distress and perceived social support among people with type 2 diabetes. Methods This cross-sectional study surveyed a population with a lower socioeconomic status (Medi-Cal recipients, which are only given to low-income individuals) in Solano County, California. Patients who had type 2 diabetes mellitus, who were between 40 and 80 years old, and who had a medical appointment in the clinic(s) at least once between December 2015 and December 2016 were included. Patients who could not understand or speak English and patients whose primary care clinicians declined their participation in the study were excluded from the study. Each study participant was recruited at the end of their medical appointment, and the survey instrument in paper form was administered. The Problem Areas in Diabetes (PAID) scale, which indicates diabetes-related distress, and Multidimensional Scale of Perceived Social Support (MSPSS) with 3 subscales (family, friends, and significant others) were used in this study. Multiple linear regression models were used to analyze the associations between PAID and MSPSS surveys. Results For the 101 participants included in our study, multiple linear regression models showed statistically significant association between total MSPSS scores and total PAID scores (β = -.318; 95% CI, .577, -.0581; P=.017) as well as between MSPSS family subscale scores and total PAID scores (β= -.761; 95% CI, -1.35, -.168; P=.012). Among the 3 MSPSS subscales, higher perceived support from family members was found to be significantly associated with lower total PAID scores (β= -.761; 95% CI, -1.35, -.168; P=.012). Conclusion Our findings suggest that a higher level of perceived social support experienced was associated with lower diabetes-related distress among patients with type 2 diabetes. Osteopathic physicians have a central role in providing comprehensive, patient-centered, holistic care, and the attention to social support in chronic disease management can help remove barriers in providing optimal care.
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Shubrook JH. Recognition and Management of Hypoglycemia. J Fam Pract 2020; 69:S45-S50. [PMID: 33104110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Abstract
In this highly digitalized era, sleep disorders are becoming more common and are associated with an increased burden of chronic disease. Shift workers are at an increased risk for both sleep disorders and metabolic syndrome. In this article, the authors outline the connection between circadian discordance, hormonal imbalance, and the development of metabolic syndrome in shift workers. Based on a literature review of animal model studies, observational studies, and clinical trials conducted between August and October of 2018, the authors offer several clinical interventions, including work schedules, light therapy, medications, and dietary habits to improve the circadian synchronicity of shift workers and reduce their risk of morbidity and mortality. It is important for physicians to be familiar with the consequences of shift work and ways to mitigate the risks for this patient population.
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Lustig E, Shubrook JH, Pfotenhauer KM. Time-Restricted Feeding and Potential for Type 2 Diabetes Mellitus: A Narrative Review. J Osteopath Med 2020; 120:2765220. [PMID: 32776136 DOI: 10.7556/jaoa.2020.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Intermittent fasting (IF) is an increasingly popular strategy for weight loss and improved metabolic health. IF regimes involve deliberate implementation of fasting windows ranging from 12 to 72 hours. During these fasting windows, individuals reduce their caloric intake by 75% to 100%. Such strategies show promise and are increasingly socially popular, but many effects are not completely understood. Specifically, the effects of time-restricted feeding (TRF), a specific form of IF in which participants undergo daily fasting periods lasting about 16 hours, is among the most popular yet under-studied regimens. This review finds that TRF may produce mild weight loss and improved function of insulin. TRF also likely produces cardiovascular effects, such as decreased blood pressure and fasting blood triglycerides. TRF, like other forms of IF, may encourage fat loss specifically when combined with exercise. The manuscripts identified in this narrative literature review were analyzed for the potential benefit for patients with type 2 diabetes mellitus, and limitations of summarized content were noted. While these studies support some suspected benefits of TRF, they also legitimize the need for future TRF studies, since conclusions are greatly limited by a paucity of evidence.
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Affiliation(s)
- Clipper F. Young
- Primary Care Department, Touro University California College of Osteopathic Medicine, Vallejo, CA
| | - Marianne Moussa
- Graduate, Touro University California College of Pharmacy, Vallejo, CA
| | - Jay H. Shubrook
- Primary Care Department, Touro University California College of Osteopathic Medicine, Vallejo, CA
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Abstract
As the cornerstone of type 2 diabetes (T2D) management within the community, primary care providers are now faced with the challenge of not only managing diabetes itself, but also preventing hypoglycemia and weight gain associated with intensive disease management, and reducing cardiovascular risk. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are well established as efficacious treatments for T2D, and the safety/tolerability profile of this drug class is well defined. However, despite their beneficial effects, GLP-1RAs are under-utilized, highlighting the need for novel approaches to increase their use in primary care. Oral semaglutide is the first oral GLP-1RA approved for the treatment of T2D, offering glucose lowering and body weight loss, a low risk of hypoglycemia, and no increase in cardiovascular risk. Oral semaglutide represents an additional treatment option for patients not achieving their glycemic goal despite treatment with metformin, either alone or with other hypoglycemic agents. Oral semaglutide has the potential to increase usage of GLP-1RAs in the primary care setting by addressing clinician and patient concerns about injections, and may facilitate earlier initiation of GLP-1RA therapy in T2D. Due to the formulation of oral semaglutide, clinicians need to be aware of specific considerations in order to ensure optimal use. Such considerations include dosing conditions and use of concomitant medications. This article provides practical guidance on the use of oral semaglutide in the primary care setting, based on evidence from clinical studies, including the phase 3a PIONEER program, and the authors' clinical experience.
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Affiliation(s)
- Javier Morales
- Department of Medicine, Donald and Barbara Zucker School of Medicine, Hofstra/Northwell University , New York, NY, USA
| | - Jay H Shubrook
- Primary Care Department, College of Osteopathic Medicine, Touro University California , Vallejo, CA, USA
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Edelman SV, Wood R, Roberts M, Shubrook JH. Patients With Type 2 Diabetes Are Willing to Do More to Overcome Therapeutic Inertia: Results From a Double-Blind Survey. Clin Diabetes 2020; 38:222-229. [PMID: 32699470 PMCID: PMC7364461 DOI: 10.2337/cd19-0067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We performed a survey of 305 patients with type 2 diabetes receiving basal insulin and 240 physicians to measure key contrasts and similarities in patients' preferences and providers' beliefs and perceptions regarding insulin use. Many patients reported being more frustrated with their lack of treatment progress than physicians were aware of. Patients were also more likely to say they would do more than their physicians believed they would to better manage their diabetes. Identifying priorities and setting clear goals and timelines for achieving glycemic control could provide an opportunity to address these differences and reduce patients' frustration.
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Affiliation(s)
- Steven V. Edelman
- University of California San Diego Veterans Affairs Medical Center, San Diego, CA
| | | | | | - Jay H. Shubrook
- College of Osteopathic Medicine, Touro University California, Vallejo, CA
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Abstract
Debate is ongoing regarding the relationship between type 2 diabetes and cancer, and the pathways linking the two are incompletely understood. Some posit that the relationship hinges on a common predisposing factor such as obesity, insulin resistance, or chronic inflammation that increases the risk of cancer independently. Others speculate that diabetes acts as an independent risk factor for cancer because of other molecular pathways and interactions. Additionally, antidiabetic medications have been associated with changes in cancer risk. This review presents a summary of the latest studies and data concerning the relationships among type 2 diabetes, antidiabetic medications, cancer risk, and cancer prognosis.
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Chilton RJ, Dungan KM, Shubrook JH, Umpierrez GE. Cardiovascular risk and the implications for clinical practice of cardiovascular outcome trials in type 2 diabetes. Prim Care Diabetes 2020; 14:193-212. [PMID: 31704161 DOI: 10.1016/j.pcd.2019.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 09/18/2019] [Accepted: 09/30/2019] [Indexed: 12/25/2022]
Abstract
Cardiovascular disease (CVD) is the primary cause of morbidity and mortality in patients with type 2 diabetes (T2D). This review examines the impact of cardiovascular outcome trials (CVOTs) on clinical practice. To date, all CVOTs have shown non-inferiority versus placebo (both added to standard of care) against a primary endpoint of 3- or 4-point major adverse cardiovascular event (MACE), confirming CV safety of these treatments. Additionally, some CVOTs have shown superiority to placebo against the same MACE endpoint, suggesting a cardioprotective action for these treatments. This is reflected in guideline updates, which primary care physicians should consider when personalizing treatments.
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Affiliation(s)
- Robert J Chilton
- Division of Cardiology, University of Texas Health Science Center, San Antonio, TX, USA.
| | - Kathleen M Dungan
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA
| | - Jay H Shubrook
- Touro University California College of Osteopathic Medicine, Primary Care Department, Vallejo, CA, USA
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Wu CA, Simon AJ, Modrich MA, Stacey MW, Matyas BT, Shubrook JH. Adapting the Social-Ecological Framework for Chronic Pain Management and Successful Opioid Tapering. J Osteopath Med 2019; 119:793-801. [PMID: 31790125 DOI: 10.7556/jaoa.2019.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Context In 2015, Solano County's Medi-Cal insurer implemented a new policy to taper patients using high-dose opioids (≥120-mg morphine equivalent dose) to a safer level to follow best practices to address the opioid epidemic. Objective To evaluate the effect of the 2015 Solano County Medi-Cal prescribing policy, gain insight into the patient experience of undergoing opioid tapering, and generate hypotheses for further study. Methods Using a case series approach, researchers completed medical record reviews of affiliated clinical records, Solano County Vital Statistics, and California's prescription monitoring program in 2018. After exclusions, eligible patients were asked to participate in a comprehensive qualitative interview. Results Medical record reviews of 38 patients found the majority were not using opioids using them at a morphine equivalent dose of 90 mg or less. The reviews also found that mental illness and obesity prevalence were higher than Solano county baseline levels. Furthermore, naloxone was not prescribed to any of the 38 patients. Researchers reached 15 of the 38 patients by phone, and ultimately 6 completed the interview process. Themes and emergent concepts from interviews identified a lack of empathetic connection with health care professionals, poor understanding of overdose risks, persistent pain, and confirmed naloxone underuse. Conclusion Safer prescribing policies may take multiple years to fully implement and need to be employed across the jurisdiction to minimize doctor-shopping and adverse effects on patients with chronic pain. Approaching pain management through the social-ecological model can address potential root causes of addiction and establish a framework for doctors to provide compassionate care, community leadership, and advocacy for these patients.
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Abstract
Type 2 diabetes mellitus (T2DM) is a common chronic metabolic condition. Before receiving this diagnosis, persons typically have a long period of prediabetes. There is good evidence that T2DM can often be prevented or delayed by means of lifestyle interventions (39%-71%), medications (28%-79%), or metabolic surgery (75%). However, despite consistent data demonstrating their efficacy, these tools are underused, and knowledge about them among primary care physicians is limited. In an effort to engage physicians in addressing this public health crisis more effectively, the authors reviewed the evidence that T2DM can be prevented or delayed in persons at risk.
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