Randomized trial of an integrated care intervention among Latino adults: Sustained effects on diabetes management

We examined the 12-month maintenance effects of a previously successful integrated model of diabetes care at improving glycemic management and psychological well-being among Latino adults with type 2 diabetes (T2D). A randomized controlled trial (2015-19) compared an integrated care intervention (ICI) with usual care among 456 adults with T2D. The ICI included integrated medical and behavioral care and health education over 6 months. Assessments were completed at baseline, 3, 6, 9, and 12 months. Most participants were female (63.7%) with a mean age of 55.7 years. In multilevel models, significant Group × Time (quadratic) interaction effects were found for HbA1c [Bint = 0.10, 95% confidence interval (CI) 0.02, 0.17, P < .01] and anxiety symptoms (Bint = 0.20, 95% CI 0.05, 0.35, P < .009), but not depression symptoms (Bint = 0.15, 95% CI -0.01, 0.31, P < .07). Analyses of instantaneous rate of change in the ICI group showed significant decreases at 3 and 6 months for both HbAc1 (B = -0.31 at 3 months; B = -0.12 at 6 months) and anxiety symptoms (B = -0.92 at 3 months; B = -0.46 at 6 months), and no significant instantaneous changes at 9 or 12 months, suggesting that initial improvements were largely maintained. The usual care group showed a small decrease in anxiety symptoms at 6 months (B = -0.17), but no other significant changes at any time-point for anxiety or HbA1c (all Ps > .05). This culturally tailored integrated care model shows potential in producing and sustaining positive effects on clinical and psychological outcomes above standard care.

Effectiveness of an integrated primary care intervention in improving psychosocial outcomes among Latino adults with diabetes: the LUNA-D study

OBJECTIVE

To compare the effectiveness of usual care (UC) versus a culturally tailored integrated care model in improving mental health symptoms for Latino patients with Type 2 diabetes mellitus (T2DM).

METHODS

We conducted a two-arm randomized controlled trial from 2015 to 2019 at a federally qualified health center. Participants were 456 adults ages 23-80 years who had a previous diagnosis of T2DM and were not currently using insulin. Participants were randomly assigned to Integrated Care Intervention (ICI; including behavioral/mental healthcare, medical visits, health education and care coordination) or UC; standard of care including referrals for health education and behavioral/mental health care where appropriate. Intention-to-treat, multilevel models were used to compare group × time changes in depression and anxiety symptoms (PHQ-8; GAD-7) and perceived stress (PSS-10) across 6 months.

RESULTS

Participant mean age was 55.7 years, 36.3% were male, and 63.7% were primarily Spanish speaking. Baseline sociodemographic factors and mental health symptoms across study arms were balanced. Significant group × time interaction effects were observed for anxiety and depression symptoms (p < .05). Within the ICI and UC groups, mean depression symptom changes were -0.93 and -0.39 (p < .01); anxiety symptom changes were -0.97 (p < .01) and -0.11 (p = .35); and perceived stress changes were -1.56 and -1.27 (p < .01), respectively.

CONCLUSIONS

Although both ICI and UC showed decreases over time, the ICI group evidenced larger, statistically significant changes in both depression and anxiety. Adapted integrated models of behavioral and chronic disease management appear to be effective and could be considered for usual care practices.

CLINICALTRIALS.GOV IDENTIFIER

NCT03983499.

Latinos understanding the need for adherence in diabetes (LUNA-D): a randomized controlled trial of an integrated team-based care intervention among Latinos with diabetes

We developed and tested a culturally appropriate, team-based, integrated primary care and behavioral health intervention in low income, Spanish-speaking Latinos with type 2 diabetes, at a federally qualified health center. This pragmatic randomized controlled trial included 456 Latino adults, 23-80 years, 63.7% female, with diabetes [recruitment glycosylated hemoglobin (HbA1c) ≥ 7.0%/53.01 mmol/mol)]. The Special Intervention occurred over 6 months and targeted improvement of HbA1c, blood pressure, and lipids. The intervention included: (i) four, same-day integrated medical and behavioral co-located visits; (ii) six group diabetes self-management education sessions addressing the cultural dimensions of diabetes and lifestyle messages; (iii) and care coordination. Usual Care participants received primary care provider led standard diabetes care, with referrals to health education and behavioral health as needed. HbA1c and lipids were obtained through electronic health records abstraction. Blood pressure was measured by trained research staff. Multi-level models showed a significant group by time interaction effect (B = -0.32, p < .01, 95% CI -0.49, -0.15), indicating statistically greater improvement in HbA1c level over 6 months in the Special Intervention group (ΔHbA1c = -0.35, p = <.01) versus Usual Care (ΔHbA1c = -0.02, p = .72). Marginally significant group by time interactions were also found for total cholesterol and diastolic blood pressure, with significant improvements in the Special Intervention group (p < .05). This culturally appropriate model of highly integrated care offers strategies that can assist with self-management goals and disease management for Latinos with diabetes in a federally qualified health center setting.

Colorectal cancer educational intervention targeting latino patients attending a community health center

OBJECTIVE

Colorectal cancer (CRC) is the third leading cause of cancer death for Latino men and women; and Latinos are more likely to be diagnosed at a later stage, which is most likely due to underutilization of CRC preventive screening. The purpose of this study was to determine whether a brief, clinic-based intervention by a community health advisor (CHA) would increase CRC knowledge compared with traditional educational methodologies (eg, use of print materials).

METHODS

Latino adults 50 years and older attending a San Diego community health center were recruited while waiting for their primary care provider routine visit and were randomly assigned to receive 1 of 3 CRC educational interventions: community health advisor (CHA) plus CRC educational brochure (CHA intervention group), CRC educational brochure (minimal intervention group), or 5-a-day nutrition brochure (usual care). CRC knowledge was assessed before and after the primary care provider visit for 130 participants.

RESULTS

Results demonstrate that the CRC educational brochure (minimal intervention group) was effective at increasing CRC screening knowledge as compared to usual care.

CONCLUSIONS

Future research is needed to explore innovative health education strategies that improve knowledge and subsequent CRC screening behaviors among low-income, low-literacy, unacculturated Latinos.

Role of calcium and erythrocyte cytoskeleton phosphorylation in the invasion of Plasmodium falciparum

The role of calcium in the invasion of the human erythrocyte by the parasite Plasmodium falciparum was studied. The intraerythrocytic and intraparasitic concentrations of Ca2+ were modified using calcium-ionophore A23187 and the chelator EGTA. The Ca2+ inside the parasite appeared to be necessary for the normal completion of invasion. We determined that in recently invaded erythrocytes (2 h), the Ca2+ concentration increased about 10 times. Merozoite invasion produced a decrease in beta-spectrin phosphorylation and an increase in the phosphorylation of a protein with band 4.1 mobility. These changes were similar to those produced by an ionophore-mediated Ca2+ influx in uninfected erythrocytes. These facts support the idea that a calcium influx into erythrocytes might precede or accompany merozoite invasion, triggering a series of molecular events, including phosphorylation and dephosphorylation of cystoskeletal proteins.

A simple technique for entrapping rifampicin and isoniazid into liposomes

A method for the preparation of liposomes loaded with rifampicin and isoniazid is described. Optimal conditions were established; the lipid suspension was mixed with the aqueous solution of the drugs and was sonicated in a bath for 30 min at 50 degrees C. The optimum composition tested was phosphatidyl choline, cholesterol and cardiolipin in a molar ratio of 7:2:1. The separation of unloaded drug was performed by centrifugation through three successive Sephadex G-25 columns. The liposomes were multilamellar vesicles with a size ranging from 100-300 nm. The drugs were trapped in concentrations from 6.5-9.5 mg/ml. This method is suitable for preparation of liposomes in small laboratories.

Effects of Ca++ depletion on the asexual cell cycle of Plasmodium falciparum

Ca++ was shown to be indispensable for the normal growth of cultures of Plasmodium falciparum. Inclusion of ethyleneglycolbis (beta-amino-ethylether) N,N'-tetra-acetic acid (EGTA) caused blocking of the asexual cell cycle of the parasite in two sites, the first blockage occurring between 20 and 26 hours after invasion of the erythrocyte. It proved to be irreversible by additions of Mg++ or Ca++, and to lead to morphologically abnormal parasites arrested in the mature trophozoite stage of the cycle. The second site of inhibition was probably one of the steps in the process of invasion of the erythrocyte by the merozoite. When 1 mM EGTA was added 24--30 hours after the culture was synchronized the cell cycle of the parasite continued without any interference in the normal maturation until the development of schizonts and release of merozoites into the medium. However, reinvasion of fresh erythrocytes by these merozoites was impeded. The inhibition of reinvasion caused by EGTA was overcome by the addition of an excess of Ca++ but not by an excess of Mg++. After the addition of Ca++ to cultures blocked just before the invasion phase as schizonts, the merozoites were again rendered fully infective and the rate of invasion was similar to that in an untreated control culture. Implications of the effects of Ca++ depletion on the asexual cell cycle and possible applications of EGTA as a reversible inhibitor of the invasion process are discussed.