Evaluation of the metformin initiation rate in veterans with newly identified type 2 diabetes

BackgroundAn estimated 35 million individuals in the United States have diabetes. The American Diabetes Association recommends metformin as first-line pharmacologic treatment. The primary objective of this study was to evaluate the metformin initiation rate in veterans with recently identified type 2 diabetes.MethodsVeterans with new onset type 2 diabetes were identified using National Veterans Health Administration Data. Retrospective information was obtained from those with a first A1C ≥ 6.5% (48 mmol/mol) between 2013 and 2018. Veterans with at least one additional A1C < 6.5% (48 mmol/mol) documented in the three years prior to the A1C diagnostic for diabetes were included in the analysis.ResultsA total of 144,180 veterans were included. Of those, 45,776 (31.7%) were started on metformin within one year of diabetes diagnosis. The median time to metformin initiation was 12 days and median time to initiation of any anti-hyperglycemic was 11 days. Approximately 16,000 veterans were referred for lifestyle interventions within 90 days.ConclusionMetformin initiation occurred in fewer patients than expected given metformin is a generic, well-tolerated medication recommended as first-line pharmacologic treatment option regardless of A1C. Further studies are needed to assess the barriers of initiating metformin at time of diabetes diagnosis.     

Differential development of relational memory and pattern separation

Researchers have taken a number of different approaches in their exploration of hippocampal function. One approach seeks to describe hippocampal function by probing the memory representations that the hippocampus supports. Another approach focuses on the role of the hippocampus in pattern separation and completion. Each of these approaches to understanding hippocampal function utilizes a distinct set of specialized tasks, and both of these task sets are known to be sensitive to changes in hippocampal function with age and disease status. But the question remains whether the tasks utilized in these two approaches tap into the same aspects of hippocampal function. We explored this question in the context of hippocampal development. Preadolescent children (N = 73) and young adults (N = 41) completed an identical battery of cognitive tasks consisting of a spatial reconstruction relational memory task, the mnemonic similarity task (MST)—an object‐based pattern separation task, and a novel hybrid task—the Object Discrimination and Distribution (ODD) Task—designed to integrate and simultaneously tax pattern separation and spatial relational memory. Children did not demonstrate impairments in lure discrimination relative to young adults on either the object‐based pattern separation task or for aspects of the ODD task that required pattern separation in the absence of relational memory demands but performed more poorly across aspects of tasks that required relational binding.     

Developing Validity Evidence for a Patient- and Family-Centered Rounds Presenter Empowerment Action Rating Tool

BackgroundTraining in patient- and family-centered care is endorsed by the American Academy of Pediatrics (AAP) and the Accreditation Council for Graduate Medical Education (ACGME) for learners. The AAP recommends patient- and family-centered rounds (PFCR) during inpatient care. The PEA-21 (21-item Presenter Empowerment Action checklist) was developed to evaluate presenter behavior during PFCR.ObjectiveTo gather validity evidence for the PEA-21 in evaluating third year medical student and intern presentations during PFCR in the domains of Data Accuracy, Communication Skills, Assessment and Plan Formation, and Family Interaction.MethodsA 24-month prospective cohort study of students and interns presenting on PFCR. Content, response process, internal structure, and relationship with other variables were assessed.ResultsData were collected from 101 rounds (758 individual patient encounters), both on pediatric subspecialty and hospital medicine teams. Presenters included third- and fourth-year medical students and interns in pediatrics, internal medicine-pediatrics, and family-medicine. Intraclass correlations between observers ranged from 0.5 to 0.72. Internal consistency showed α >0.7 for 3 of 4 domains. Interns scored higher than students across domains (P< .01), but students’ scores improved throughout their rotations (d = 0.2–0.8). Both groups performed lowest in the Family Interaction Domain.ConclusionsThe PEA-21 showed strong validity properties including content, response process, internal structure, and relationship with other variables and can be used by educators to assess learners’ skill levels and provide formative feedback to both medical students and interns. Targeted efforts are needed to improve skills within the Family Interaction Domain for both medical students and interns.     

Prevalence and risk factors of steatosis and advanced fibrosis using transient elastography in the United States' adolescent population

BACKGROUND Non-alcoholic fatty liver disease(NAFLD) is the leading cause of chronic liver disease in children and adolescents.AIM To determine the prevalence and risk factors of steatosis and advanced fibrosis using transient elastography(TE) in the United States' adolescent population.METHODS Using the National Health and Nutrition Examination Survey 2017-2018, adolescent participants aged 13 to 17 years who underwent TE and controlled attenuation parameter(CAP) were included in this study. Forty-one factors associated with liver steatosis and fibrosis were collected. Univariate and multivariate linear regression analysis were used to identify statistically significant predictors.RESULTS Seven hundred and forty participants met inclusion criteria. Steatosis(S1-S3), based on CAP, and advanced fibrosis(F3-F4), based on TE, were present in 27% and 2.84% of the study population, respectively. Independent predictors of steatosis grade included log of alanine aminotransferase, insulin resistance, waistto-height ratio, and body mass index. Independent predictors of fibrosis grade included steatosis grade, non-Hispanic black race, smoking history, and systolic blood pressure.CONCLUSION This study demonstrated a high prevalence of steatosis in the United States' adolescent population. Almost 3% of United States' adolescents had advanced fibrosis. These findings are concerning because a younger age of onset of NAFLD can lead to an earlier development of severe disease, including steatohepatitis, cirrhosis, and liver decompensation.