Background:Online yoga offers significant potential for healthcare systems. As efforts to incorporate online yoga in healthcare settings have grown, research in this area has mostly focused on the perspectives of patients and clinicians. Although yoga teachers are crucial to the implementation and delivery of telehealth yoga (tele-yoga), their views on this topic have not yet been adequately considered. This study examined the perspectives of Veterans Health Administration (VA) yoga teachers regarding a VA Office of Rural Health-funded multi-site tele-yoga implementation study. Objectives:This qualitative study aims to explore VA yoga teachers' perspectives and experiences with regards to implementing and delivering synchronous, remote, group yoga-for-wellness classes via video-based telehealth and provide lessons learned. Methods:A qualitative study was conducted with 13 yoga teachers from 6 different VA healthcare systems included in a multi-site tele-yoga implementation study. Interviews covered experience with teaching in an online format, program implementation and delivery, and equity considerations. Interviews were conducted and recorded using Microsoft Teams. Transcripts were coded using MAXQDA 2022 and analyzed via thematic content analysis. Results:VA tele-yoga teachers identified 4 categories impacting tele-yoga implementation and delivery: (1) equipment and information technology needs; (2) physical space (particularly for teachers teaching onsite in a hospital or clinic setting); (3) accessibility and safety; and (4) administrative responsibilities and end-user support. Findings highlight key considerations and potential solutions for teachers and healthcare settings, and resources needed to provide a safe, accessible, and effective experience for participants. Conclusion:Learning from tele-yoga teachers' experiences at VA can inform best practices for teaching yoga to groups in a synchronous, remote, online format within healthcare settings. The ways in which VA tele-yoga teachers surmounted barriers and harnessed opportunities for success can inform program recommendations as tele-yoga programs expand across VA and become incorporated in other healthcare systems and facilities.

Mindful Movement approaches have been a growing part of the Veterans Health Administration (VA). Innovations in tele-health technology had been an important initiative before the public health emergency to meet the needs of rural veterans as well as challenges in getting to a physical location for care. The onset of the COVID-19 pandemic accelerated this transition to tele-delivery of many practices including mindful movement. This paper aims to share lessons learned from virtual delivery of mindful movement as part of clinical and well-being programs in VA. Benefits of virtual care discussed include the convenience and decreased travel burden; accessibility for adaptive movement options; translation to home practice; and shifting the emphasis to interoceptive skills-building supportive of self-efficacy for exploring and identifying safe movement. Important challenges are also identified such as technology related barriers; teachers trained to meet the need of offering adaptations for a heterogenous population and supporting interoceptive skill-building; and supporting both physical and psychological safety. Examples are provided of medical groups incorporating virtual mindful movement within programs for diabetes and pain care to further explore the potential benefit of these practices being integrated within the care itself, rather than as a separate practice. It is hoped that the lessons learned will provide support for Veterans and staff, and the wider health care community, in what they need to participate in virtual care that is high quality, accessible, and meets the needs for greater health and well-being.

Background:During the COVID-19 pandemic, medical professionals were obligated to adapt to virtual care. Most resident physicians had no formal telehealth training. The virtual physical examination remained underutilized.Objective:We describe a needs assessment leading to the creation of a telehealth curriculum for internal medicine (IM) and internal medicine pediatric (IM/P) residents, and report changes in residents' confidence level as well as feasibility data. We hypothesized that residents' confidence in delivering virtual care would significantly improve after implementing a telehealth curriculum.Methods:A needs-based assessment for all University of California Los Angeles (UCLA) IM and IM/P residents was conducted in July 2020. Specific competencies were identified: (1) telehealth legal guidelines; (2) virtual physical examination; (3) health equity; and (4) telehealth chronic disease management. The curriculum was presented via 3 synchronous interactive online interventions between November 2020 and March 2021. Pre- and post-intervention learner assessments were conducted.Results:Out of all 180 residents, 146 UCLA IM and IM/P residents completed pre- and post-Virtual Physical Examination curriculum surveys, which were not uniquely linked to individuals. Residents reported statistically significant increased confidence levels in performing a targeted virtual physical examination (P<.001; 95% CI 0.97-1.35), engaging patients or caregivers to assist in virtual examinations (P<.001; 95% CI 0.76-1.21), and using remote monitoring devices (P<.001; 95% CI 0.58-1.03).Conclusions:Our results demonstrate that, within our IM and IM/P residency programs, a formalized telehealth curriculum significantly improved residents' confidence in delivering virtual care.

Introduction: The Veterans Health Administration (VHA) is shifting care from a disease-oriented to health-creating approach that aims to provide whole person care. This Whole Health (WH) system combines person-centered care with delivery of WH services (e.g., health coaching, well-being education and skill-building classes, and evidence-based complementary and integrative health therapies), alongside conventional medical services. During the COVID-19 pandemic, WH services were modified for delivery through telehealth (teleWH). This article characterizes modifications to WH services made to maintain continuity during the transition to telehealth formats. Materials and methods: We conducted semistructured qualitative interviews with a purposive sample of 51 providers delivering teleWH services at 10 VHA medical centers. We examined WH service modifications as well as facilitators and barriers to those modifications using rapid coding and directed content analysis. Results: Modifications were driven by (1) preparing for teleWH service delivery and (2) improving teleWH service delivery. To prepare for teleWH services, modifications were prompted by access, readiness, and setting and resources. Modifications to improve the delivery of teleWH services were motivated by engagement, community-building, safety, and content for a teleWH environment. One-on-one teleWH services required the fewest modifications, while more significant modifications were needed for well-being, skill-building, and movement-based groups, and reconfiguration of manual therapies. Discussion: Findings highlighted the need for modifications to ensure that teleWH services are accessible and safe and support interpersonal relationships between patients and providers, as well as in group-based classes. Successfully delivering teleWH services requires proactive preparation that considers access, readiness, and the availability of resources to engage in teleWH services. Tailoring strategies and considering the unique needs of different teleWH services are critical. Conclusions: The COVID-19 pandemic catalyzed teleWH service implementation, utilization, and sustainment. The challenges faced and modifications made during this transition provide lessons learned for other health care systems as they attempt to implement teleWH services.

Telemedicine can be useful for the management of diabetes mellitus. Remote monitoring of glucose levels improves A1C levels in people with poor glucose control. When multiple daily injections of insulin are required, continuous glucose monitoring improves glycemic control and increases patient satisfaction. Telemedicine diabetes prevention programs can be cost-effective. Teleretinal screening allows for the remote evaluation of retinal photos obtained at the primary care office to facilitate the timely completion of annual screening. Telemedicine for patients who have diabetes requires administrative and patient preparation before the visit. The physical examination should focus on the skin and extremities, especially the feet. Patients receiving telediabetes care require at least annual in-person visits for complete foot examinations, sensory screenings, and to address issues noted during previous telemedicine visits.

Background:The Veterans Health Administration (VA) is undergoing a transformation in how healthcare is organized and provided. This transformation to a Whole Health System of Care encompasses the integration of complementary and integrative health services, education, and Whole Health coaching to develop Veterans' self-care skills. During the COVID-19 pandemic, these services were provided via telehealth (tele-WH). Objective:We sought to understand Veteran and provider perspectives on how tele-WH impacts Veteran engagement in Whole Health-aligned services and the impact on their well-being. Methods:Semi-structured interviews were conducted with 51 providers who delivered tele-WH at 10 VA Medical Centers (VAMCs) and 19 Veterans receiving tele-WH at 6 VAMCs. Participants were asked about their experiences with tele-WH, what they perceived to be the impact of tele-WH on Veterans, and their preferences moving forward. Interviews were transcribed, and a content analysis was performed using a rapid approach. Results:We identified 3 major themes that describe the perceived impact of tele-WH on Veterans. These include: (1) increased use of Whole Health-aligned services; (2) deeper engagement with Whole-Health aligned services; and (3) improvements in social, psychological, and physical well-being. Conclusion:Tele-WH is perceived to be a strong complement to in-person services and is a promising mechanism for improving engagement with Whole Health-aligned services and promoting Veteran well-being. Future research is needed to measure outcomes identified in this study and to support more equitable access to telehealth for all.

Background At the onset of the COVID-19 pandemic, there was a rapid increase in the use of telehealth services at the US Department of Veterans Affairs (VA), which was accelerated by state and local policies mandating stay-at-home orders and restricting nonurgent in-person appointments. Even though the VA was an early adopter of telehealth in the late 1990s, the vast majority of VA outpatient care continued to be face-to-face visits through February 2020. Objective We compared telehealth service use at a VA Medical Center, Greater Los Angeles across 3 clinics (primary care [PC], cardiology, and home-based primary care [HBPC]) 12 months before and 12 months after the onset of COVID-19 (March 2020). Methods We used a parallel mixed methods approach including simultaneous quantitative and qualitative approaches. The distribution of monthly outpatient and telehealth visits, as well as telephone and VA Video Connect encounters were examined for each clinic. Semistructured telephone interviews were conducted with 34 staff involved in telehealth services within PC, cardiology, and HBPC during COVID-19. All audiotaped interviews were transcribed and analyzed by identifying key themes. Results Prior to COVID-19, telehealth use was minimal at all 3 clinics, but at the onset of COVID-19, telehealth use increased substantially at all 3 clinics. Telephone was the main modality of patient choice. Compared with PC and cardiology, video-based care had the greatest increase in HBPC. Several important barriers (multiple steps for videoconferencing, creation of new scheduling grids, and limited access to the internet and internet-connected devices) and facilitators (flexibility in using different video-capable platforms, technical support for patients, identification of staff telehealth champions, and development of workflows to help incorporate telehealth into treatment plans) were noted. Conclusions Technological issues must be addressed at the forefront of telehealth evolution to achieve access for all patient populations with different socioeconomic backgrounds, living situations and locations, and health conditions. The unprecedented expansion of telehealth during COVID-19 provides opportunities to create lasting telehealth solutions to improve access to care beyond the pandemic.

BACKGROUNDAt the onset of the COVID-19 pandemic, there was a rapid increase in the use of telehealth services at the US Department of Veterans Affairs (VA), which was accelerated by state and local policies mandating stay-at-home orders and restricting non-urgent in-person appointments. Even though, the VA was an early adopter of telehealth in the late 1990's, the vast majority of VA outpatient care continued to be face-to-face visits through February 2020.OBJECTIVEWe compare telehealth services use at one VA Medical Center, Greater Los Angeles across three clinics, primary care (PC), cardiology, and home-based primary care (HBPC), 12-months before and 12-months after onset of COVID-19 (March 2020).METHODSWe used a parallel mixed methods approach including simultaneous quantitative and qualitative approaches. The distribution of monthly outpatient and telehealth visits, as well as telephone and VA Video Connect (VVC) encounters were examined for each clinic. Semi-structured telephone interviews were conducted with 34 staff involved in telehealth services within PC, cardiology, and HBPC, during COVID-19. All audiotaped interviews were transcribed and analyzed by identifying key themes.RESULTSPrior to COVID-19, telehealth use was minimal at all three clinics, but at the onset of COVID-19, telehealth use increased substantially for all three clinics. Telephone was the main modality of patient choice. Compared to PC and cardiology, video-based care had the greatest increase in HBPC. Several important barriers (multiple steps to connect to video-conferencing, creating new scheduling grids, limited access to internet and internet-connected devices) and facilitators (flexibility in using different video-capable platforms, technical support for patients, identifying staff telehealth champions, and developing workflows to help incorporate telehealth into treatment plans) were noted.CONCLUSIONSTechnological issues must be addressed at the forefront of telehealth evolution to achieve access for all patient populations with different socioeconomic backgrounds, living situations and locations, and health conditions. The unprecedented expansion of telehealth during COVID-19 provides opportunities to create lasting telehealth solutions to improve access to care beyond the pandemic.CLINICALTRIAL

Complementary and integrative health (CIH) modalities have therapeutic value in the multidisciplinary rehabilitation of chronic pain patients. Evidence of such has been seen with the Whole Health Model at the (Veterans Affairs) VA Healthcare system. CIH therapies, including yoga, tai chi, mindfulness meditation, hypnosis, self-massage, and acupressure, are significantly effective for managing chronic pain with little to no negative effects, and can be easily incorporated into telemedicine care with great potential benefit. The future of wellness in telemedicine is evolving with great potential, and needs further attention to addressing barriers of care.

Patients with Type 2 diabetes mellitus (T2DM) show cognitive and mood impairment, indicating potential for brain injury in regions that control these functions. However, brain tissue integrity in cognition, anxiety, and depression regulatory sites, and their associations with these functional deficits in T2DM subjects remain unclear. We examined gray matter (GM) changes in 34 T2DM and 88 control subjects using high-resolution T1-weighted images, collected from a 3.0-Tesla magnetic resonance imaging scanner, and assessed anxiety [Beck Anxiety Inventory], depressive symptoms [Beck Depression Inventory-II], and cognition [Montreal Cognitive Assessment]. We also investigated relationships between GM status of cognitive and mood control sites and these scores in T2DM. Significantly increased anxiety (p = 0.003) and depression (p = 0.001), and reduced cognition (p = 0.002) appeared in T2DM over controls. Decreased GM volumes appeared in several regions in T2DM patients, including the prefrontal, hippocampus, amygdala, insular, cingulate, cerebellum, caudate, basal-forebrain, and thalamus areas (p < 0.01). GM volumes were significantly associated with anxiety (r = −0.456,p = 0.009), depression (r = −0.465,p = 0.01), and cognition (r = 0.455,p = 0.009) scores in regions associated with those regulations (prefrontal cortices, hippocampus, para hippocampus, amygdala, insula, cingulate, caudate, thalamus, and cerebellum) in T2DM patients. Patients with T2DM show brain damage in regions that are involved in cognition, anxiety, and depression control, and these tissue alterations are associated with functional deficits. The findings indicate that mood and cognitive deficits in T2DM patients has brain structural basis in the condition.

Cognitive impairments are common in patients with type 2 diabetes (T2DM) and adversely impact self-care and glycemic control. However, brain injury in a site that controls cognition (prefrontal cortices; PFC) and its relationship to glycemic outcomes in T2DM remains unclear. Methods: We examined 9 T2DM patients (age 58.2 ± 4.6 years; BMI 30.3 ± 5.0 kg/m2;3 males) and 47 healthy controls (age 55.7 ± 4.2 years; BMI 26.4 ± 3.0 kg/m2; 29 males) for cognition (Montreal Cognitive Assessment [MoCA]), glycemic control (hemoglobin A1c [A1C]), and PFC status via brain magnetic resonance imaging (MRI). Two high-resolution T1-weighted images were collected using a 3.0-Tesla MRI scanner to evaluate PFC status with voxel-based morphometry (VBM) procedures. Results: No significant differences in age and gender emerged between T2DM and control subjects. However, BMI values were significantly higher in T2DM subjects over controls. MoCA scores were significantly lower in T2DM patients compared to controls (24.3 ± 2.4 vs. 26.9 ± 2.3; p = 0.004). Mean A1C was 7.6±0.8% (51-68 mmol/mol) in T2DM patients. Reduced PFC volume was observed in T2DM patients compared to controls (left 0.35±0.02 vs. 0.41±0.03, p<0.001; right 0.31±0.02 vs. 0.38±0.02, p<0.001). PFC volume was positively correlated with cognition; left PFC regions (r= 0.94, p=0.002) and right PFC regions (r= 0.89, p=0.007) with age and gender as covariates. Significant negative correlations were found between PFC volume and A1C; left PFC (r= -0.92, p=0.003) and right PFC regions (r=-0.92, p=0.004) with age and gender as covariates. Conclusions: T2DM patients have PFC brain damage which is associated with cognitive deficits and poor glycemic control. Further research is needed to identify causal relationships between A1C and brain changes in T2DM and to examine interventions to enhance brain/neurogenesis and its impact on A1C. Disclosure S.E. Choi: None. B. Roy: None. R. Kumar: None. M. Freeby: None. R.S. Mullur: None. M.A. Woo: None. Funding National Institutes of Health (R01NR017190)

Background: Healthy rate of weight loss (RWL) is defined as 1-2 lb of body weight loss per week. Objective: The objective of this study is to investigate changes in adherence to remote monitoring devices and RWL per week in response to a fully online, 12-week, medically monitored, weight management program incorporating weekly video-based health coaching (intervention group [INT]) versus self-guided (control group [CON]). Methods: Twenty-five obese participants (12 males, 13 females) were randomly assigned to either an INT (n = 13, 106.8 ± 25.46 kg, body mass index [BMI] = 35.19 ± 3.91 kg/m2) or CON group (n = 12, 99.8 ± 19.14 kg, BMI = 34.86 ± 4.43 kg/m2). Program related content was derived from inHealth Medical Services, Inc., Telehealth Enabled Approach to Multidisciplinary care (TEAM™) curriculum. All participants were given two wireless devices (Activity Pop and Body Scale; Withings®, Cambridge, MA) that connected them directly with the research team. The INT group connected via telehealth videoconferencing weekly for health coaching with the registered dietitian and monthly for medical monitoring with the physician, while the CON group did not. Both groups connected with the physician and registered dietitian at baseline to establish clinical goals and at the end to review progress. To analyze the data, independent samples t-tests and χ2 tests were performed via SPSS v24 with data displayed as average ± SD; significance set to p < 0.05. Results: The INT group had increased device adherence when compared with CON (92% ± 10% vs. 75% ± 15% scale [p < 0.05]) and (80% ± 14% vs. 49% ± 15% tracker [p < 0.05]). Furthermore, RWL per week was greater in the INT when compared with CON; -0.74 ± 1.8 kg versus 0.18 ± 1.8 kg per week, respectively (p < 0.05). Conclusions: Weekly health coaching via telehealth can be an effective tool to increase remote device adherence and may help to induce a healthy RWL.

The term, dietary supplement, refers to a broad category of products, including herbal or plant-based extracts, micronutrients, and food-based nutraceuticals. The use of supplements in clinical rehabilitation requires clear communication from patients and health care providers to understand the types of products used and their effects on health. Providers should distinguish between using micronutrient supplementation for therapeutic purposes and treatment of nutritional deficiency in patients with malnutrition syndromes. Evidence supports micronutrient and nutraceutical supplementation use to improve pain, functional status, and inflammation. There is little evidence on the use of herbal or plant-based extracts in therapeutic rehabilitation; larger studies are warranted.

BACKGROUND:Complementary, alternative, and integrative medicine (CAIM) are considered important in shifting toward whole person care. Residents remain limited in their understanding of CAIM approaches, preventing effective utilization.OBJECTIVE:We created modules to expose residents to available CAIM approaches in a Veterans Administration setting, using conceptual frameworks for experience-based learning.METHODS:In June 2016, 38 internal medicine residents at the VA Greater Los Angeles Healthcare System were randomized to 45-minute small group sessions. One cohort received an experiential module incorporating 10-minute practices of yoga, biofeedback, and acupressure. The other cohort received a standard lecture focused on CAIM use and outcomes. Participants completed a 6-question quiz to measure their understanding of CAIM use and an 8-question survey to assess their satisfaction of teaching, exposure to CAIM, and anticipated practice change. Referrals to CAIM modalities before and after the learning modules were counted to assess practice change.RESULTS:All 38 residents completed the study, with 25 residents completing the experiential learning modules and 13 completing the standard lectures. Initial postquiz scores were similar. Five months postintervention, residents who participated in experiential modules were more likely to refer patients to CAIM modalities than those who received standard lectures (3.4 per month versus 0.6 per month, P = .018).CONCLUSIONS:This study highlights the advantages of experiential learning of CAIM approaches for residents. It reinforces existing literature suggesting that physicians who experience CAIM are more likely to incorporate these approaches into practice.

No chief complaint unites endocrinologists in quite the same way as adrenal fatigue. The term itself, coined in the late 1990s by chiropractor James Wilson ( 1. Wilson J.L. Adrenal Fatigue: The 21st Century Stress Syndrome. Us Smart Publications, 2002 Google Scholar ), has often been loosely defined as a “weakening or burnout” of the adrenal glands in response to chronic stress. Unfortunately, this improper characterization of the physiology of the hypothalamic-pituitary-adrenal (HPA) axis immediately places this syndrome at odds with traditional endocrinologists. We have all experienced patients presenting to our offices with vague complaints of fatigue, weight changes, difficulty with sleep, and changes in mood, wondering if their symptoms are the result of an undiagnosed hormonal abnormality. Unlike the well-recognized disorders of either adrenal insufficiency or Cushing syndrome, adrenal fatigue appears to exist as a hybrid condition. Patients are told that they are suffering from the negative impacts of excess cortisol while also being told that their adrenal glands are unable to effectively produce enough of this hormone. These patients, under the illusion that their adrenal glands have “burned out,” are often incorrectly advised by nonphysicians to use glandular extracts as treatment.

Patients with diabetes have higher prevalence of depression and diabetes-related distress that negatively impacts care. Mindfulness-based approaches have shown to improve depression, diabetes-related distress, and in small studies also improve glycemic outcomes. We created a 90-minute, shared medical appointment; led by an endocrinologist, teaching patients integrative approaches to manage diabetes- related distress. We included patients with type 2 diabetes referred by a primary care provider or an endocrinologist, and assessed Diabetes Distress Scale (DDS), Patient Health Questionnaire-9 (PHQ-9) as well as Hemoglobin A1C (HbA1C), weight, blood pressure (BP), heart rate (HR) before the group visit. Thirty-four patients attended group sessions, with mean age of 63.9 years, mean baseline HbA1C 7.7% and mean BMI 33.3. The mean DDS was 36.2, and mean PHQ-9 was 7.8. Twenty-four patients followed up in clinic 3 months after initial appointment and showed mean reduction in HbA1C by 0.18% (p=0.35). Subgroup analysis of patients with baseline HbA1C ≥ 7.5% (n=11) showed mean reduction in HbA1C by 0.8% (p=0.005). No statistically significant changes in BP, HR or weight were seen, while a subgroup of patients with baseline A1C ≥7.5% had non-statistically significant mean weight loss of 1.3kg. This retrospective study of a mindfulness-based approach suggests positive clinical impact and need for a larger, randomized trial. Table 1. Baseline characteristics, change in parameters 3 months after interventionBaseline characteristicsTotal patients who attended (N=34)Patients with 3 months follow up (n=24)Subgroup with baseline HbA1C ≥7.5 (n=11)Mean age in years (SD)63.9 (10.2)65.2 (9.7)64.6 (10.9)% Women67.60%66.70%72.70%Mean body weight, kg (SD)94.3 (22.8)90.2 (16.6)91.7 (17.5)Mean BMI (SD)33.3 (7.2)31.9 (5.54)31.8 (6.0)Mean HgbA1C, % (SD)7.7 (1.3)7.5 (1.2)8.5 (0.9)Mean DDS (SD)36.2 (13.7)35.7 (14.3)35.9 (15.8)Mean PHQ-9 (SD)7.8 (5.2)7.4 (5.8)7.1 (6.7)Change in HbA1C from baseline to 3 months- 0.15 % (p=0.35)- 0.8 % (p=0.005)Change in weight from baseline to 3 months- 0.4 kg (p=0.48)- 1.3kg (p=0.17) Disclosure J. Ku: None. M. Freeby: None. R.S. Mullur: None.

Introduction Clinically significant weight loss is defined as a ≥5% of initial body weight loss within a 6-month period. The purpose of this study was to assess body weight change from a 12-week telehealth-based weight loss program that integrated health coaching via video conferencing. Methods A total of 25 obese participants (12 males, 13 females) were recruited for this fully online 12-week weight loss program. Participants were randomly assigned to either an intervention group or control group (n = 13 intervention, body mass index (BMI) = 34.7 ± 4.5 kg/m2; n = 12 control, BMI = 34.4 ± 4.43 kg/m2). All participants were given access to a secure platform for data tracking and video conferencing with the research team. The intervention group met with the medical doctor once per month and with a registered dietitian, weekly. Control participants met with the research team at baseline and at 12 weeks. Independent samples t-tests and Chi-square tests were used via SPSS version 24 with significance set to p < 0.05. Results There was a significant difference between the intervention and control groups for body weight loss (7.3 ± 5.2 versus 1.2 ± 3.9 kg, respectively, p < 0.05) as well as for percent body weight loss (7.16 ± 4.4 versus 1.5 ± 4.1%, respectively, p < 0.05). Clinically significant weight loss was achieved in 9 out of 13 (69.2%) in the intervention group versus 1 out of 12 (8%) in the control group. Discussion Mobile phone-based health coaching may promote weight loss. Weekly video conferencing with education may be an applicable tool for inducing significant body weight loss in obese individuals.