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Edelman EJ, Hansen NB, Cutter CJ, Danton C, Fiellin LE, O'Connor PG, Williams EC, Maisto SA, Bryant KJ, Fiellin DA. Implementation of integrated stepped care for unhealthy alcohol use in HIV clinics. Addict Sci Clin Pract 2016; 11:1. [PMID: 26763048 PMCID: PMC4711105 DOI: 10.1186/s13722-015-0048-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 12/23/2015] [Indexed: 11/19/2022] Open
Abstract
Background
Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists. Methods We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes. Results From the providers’ perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention. Conclusions Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).
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Affiliation(s)
- E Jennifer Edelman
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Nathan B Hansen
- Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA. .,College of Public Health, University of Georgia, 131 Wright Hall, Health Sciences Campus, Athens, GA, 30602, USA.
| | - Christopher J Cutter
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Cheryl Danton
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Lynn E Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
| | - Patrick G O'Connor
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA.
| | - Emily C Williams
- VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value-Driven Care, 1100 Olive Way, Suite 1400, Seattle, WA, 98101, USA. .,Department of Health Services, University of Washington, 1959 NE Pacific Street, Magnuson Health Sciences Center, Room H-664, Seattle, WA, 98195, USA.
| | - Stephen A Maisto
- Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244, USA.
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism HIV/AIDS Program, 5635 Fishers Lane, Bethesda, MD, 20892-7003, USA.
| | - David A Fiellin
- Yale University School of Medicine, 367 Cedar Street, ESH A, New Haven, CT, 06510, USA. .,Center for Interdisciplinary Research On AIDS, Yale University School of Public Health, 135 College Street, New Haven, CT, 06510, USA.
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Abstract
OBJECTIVE To assess effects of vitamin D and Calcium (Ca) on hormonal and metabolic milieu of polycystic ovary syndrome (PCOS). DESIGN Single arm open label trial. METHODS Twelve overweight and vitamin D deficient women with PCOS underwent a 2 hour oral glucose tolerance testing at baseline and following 3-month supplementation with vitamin D (daily dose of 3533 IU, increased to 8533 IU after the first five participants) and 530 mg elemental Ca daily. MAIN OUTCOME MEASURES Blood pressure (BP), plasma glucose, insulin, total testosterone (T) androstenedione (A), sex hormone binding globulin, lifestyle parameters were assessed at baseline and following 3-month intervention. Insulin resistance (IR) and area under the curve for glucose and insulin were computed; paired analyses were conducted. RESULTS Improved serum 25OHD (p < 0.001) and reductions in total T (p = 0.036) and A (p = 0.090) levels were noted following 3-month supplementation, compared to baseline. Significant lowering in BP parameters was seen in participants with baseline BP ≥ 120/80 mmHg (n = 8) and in those with baseline serum 25OHD ≤20 ng/ml (n = 9). Parameters of glucose homeostasis and IR remained unchanged (p > 0.05). CONCLUSIONS Androgen and BP profiles improved followed three month intervention, suggesting therapeutic implications of vitamin D and Ca in overweight and vitamin D deficient women with PCOS.
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Affiliation(s)
- Lubna Pal
- Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT 06520, USA.
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Atsumi T, Cho YR, Leng L, McDonald C, Yu T, Danton C, Hong EG, Mitchell RA, Metz C, Niwa H, Takeuchi J, Onodera S, Umino T, Yoshioka N, Koike T, Kim JK, Bucala R. The proinflammatory cytokine macrophage migration inhibitory factor regulates glucose metabolism during systemic inflammation. J Immunol 2007; 179:5399-406. [PMID: 17911626 DOI: 10.4049/jimmunol.179.8.5399] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Inflammation provokes significant abnormalities in host metabolism that result from the systemic release of cytokines. An early response of the host is hyperglycemia and resistance to the action of insulin, which progresses over time to increased glucose uptake in peripheral tissue. Although the cytokine TNF-alpha has been shown to exert certain catabolic effects, recent studies suggest that the metabolic actions of TNF-alpha occur by the downstream regulation of additional mediators, such as macrophage migration inhibitory factor (MIF). We investigated the glycemic responses of endotoxemic mice genetically deficient in MIF (MIF(-/-)). In contrast to wild-type mice, MIF(-/-) mice exhibit normal blood glucose and lactate responses following the administration of endotoxin, or TNF-alpha. MIF(-/-) mice also show markedly increased glucose uptake into white adipose tissue in vivo in the endotoxemic state. Treatment of adipocytes with MIF, or anti-MIF mAb, modulates insulin-mediated glucose transport and insulin receptor signal transduction; these effects include the phosphorylation of insulin receptor substrate-1, its association with the p85 regulatory subunit of PI3K, and the downstream phosphorylation of Akt. Genetic MIF deficiency also promotes adipogenesis, which is in accord with a downstream role for MIF in the action of TNF-alpha. These studies support an important role for MIF in host glucose metabolism during sepsis.
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Affiliation(s)
- Toshiya Atsumi
- Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Park SY, Cho YR, Kim HJ, Higashimori T, Danton C, Lee MK, Dey A, Rothermel B, Kim YB, Kalinowski A, Russell KS, Kim JK. Unraveling the temporal pattern of diet-induced insulin resistance in individual organs and cardiac dysfunction in C57BL/6 mice. Diabetes 2005; 54:3530-40. [PMID: 16306372 DOI: 10.2337/diabetes.54.12.3530] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Type 2 diabetes is a heterogeneous disease characterized by insulin resistance and altered glucose and lipid metabolism in multiple organs. To understand the complex series of events that occur during the development of obesity-associated diabetes, we examined the temporal pattern of changes in insulin action and glucose metabolism in individual organs during chronic high-fat feeding in C57BL/6 mice. Insulin-stimulated cardiac glucose metabolism was significantly reduced after 1.5 weeks of high-fat feeding, and cardiac insulin resistance was associated with blunted Akt-mediated insulin signaling and GLUT4 levels. Insulin resistance in skeletal muscle, adipose tissue, and liver developed in parallel after 3 weeks of high-fat feeding. Diet-induced whole-body insulin resistance was associated with increased circulating levels of resistin and leptin but unaltered adiponectin levels. High-fat feeding caused insulin resistance in skeletal muscle that was associated with significantly elevated intramuscular fat content. In contrast, diet-induced hepatic insulin resistance developed before a marked increase in intrahepatic triglyceride levels. Cardiac function gradually declined over the course of high-fat feeding, and after 20 weeks of high-fat diet, cardiac dysfunction was associated with mild hyperglycemia, hyperleptinemia, and reduced circulating adiponectin levels. Our findings demonstrate that cardiac insulin resistance is an early adaptive event in response to obesity and develops before changes in whole-body glucose homeostasis. This suggests that obesity-associated defects in cardiac function may not be due to insulin resistance per se but may be attributable to chronic alteration in cardiac glucose and lipid metabolism and circulating adipokines.
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Affiliation(s)
- So-Young Park
- Department of Internal Medicine, Section of Endocrinology and Metabolism, Yale University School of Medicine, New Haven ,Connecticut, USA
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Park SY, Cho YR, Finck BN, Kim HJ, Higashimori T, Hong EG, Lee MK, Danton C, Deshmukh S, Cline GW, Wu JJ, Bennett AM, Rothermel B, Kalinowski A, Russell KS, Kim YB, Kelly DP, Kim JK. Cardiac-specific overexpression of peroxisome proliferator-activated receptor-alpha causes insulin resistance in heart and liver. Diabetes 2005; 54:2514-24. [PMID: 16123338 DOI: 10.2337/diabetes.54.9.2514] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Diabetic heart failure may be causally associated with alterations in cardiac energy metabolism and insulin resistance. Mice with heart-specific overexpression of peroxisome proliferator-activated receptor (PPAR)alpha showed a metabolic and cardiomyopathic phenotype similar to the diabetic heart, and we determined tissue-specific glucose metabolism and insulin action in vivo during hyperinsulinemic-euglycemic clamps in awake myosin heavy chain (MHC)-PPARalpha mice (12-14 weeks of age). Basal and insulin-stimulated glucose uptake in heart was significantly reduced in the MHC-PPARalpha mice, and cardiac insulin resistance was mostly attributed to defects in insulin-stimulated activities of insulin receptor substrate (IRS)-1-associated phosphatidylinositol (PI) 3-kinase, Akt, and tyrosine phosphorylation of signal transducer and activator of transcription 3 (STAT3). Interestingly, MHC-PPARalpha mice developed hepatic insulin resistance associated with defects in insulin-mediated IRS-2-associated PI 3-kinase activity, increased hepatic triglyceride, and circulating interleukin-6 levels. To determine the underlying mechanism, insulin clamps were conducted in 8-week-old MHC-PPARalpha mice. Insulin-stimulated cardiac glucose uptake was similarly reduced in 8-week-old MHC-PPARalpha mice without changes in cardiac function and hepatic insulin action compared with the age-matched wild-type littermates. Overall, these findings indicate that increased activity of PPARalpha, as occurs in the diabetic heart, leads to cardiac insulin resistance associated with defects in insulin signaling and STAT3 activity, subsequently leading to reduced cardiac function. Additionally, age-associated hepatic insulin resistance develops in MHC-PPARalpha mice that may be due to altered cardiac metabolism, functions, and/or inflammatory cytokines.
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Affiliation(s)
- So-Young Park
- Yale University School of Medicine, Department of Internal Medicine, Section of Endocrinology and Metabolism, The Anlyan Center, S269C, P.O. Box 208020, 300 Cedar St., New Haven, CT 06520-8020, USA.
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