Stereospecific determination and in vivo monodeiodination of thyroxine enantiomers in euthyroid man

To compare in man the absorption, serum disappearance, and peripheral monodeiodination of the thyroxine enantiomers, we studied six euthyroid subjects who, on separate occasions, orally ingested 3 mg of either dextrothyroxine (DT₄) or levothyroxine (LT₄). We measured the serum concentrations of total T₄ (TT₄), total T₃, and reverse T₃ (rT₃) by nonstereospecific radioimmunoassay and we determined serum DT₄ by stereospecific chromatography. Mean serum TT₄ levels from 4 hours were significantly greater after LT₄ administration. After DT₄ administration, stereospecific analysis of serum revealed two T₄ peaks that persisted from 2 to 48 hours. The mean serum LT₄ leved did not significantly change during the 48 hours after DT₄ administration. Increases in serum T₃ and rT₃ were seen from 2 hours after administration of either enantiomer. From 12 hours the levels of both triiodothyronines after LT₄ were significantly higher than after DT₄. In this short term study we found no evidence that in man DT₄ is converted to LT₄, nor is it preferentially deiodinated to rT₃. The greater and more persistent increases in serum T₄ and T₃ observed after LT₄ probably contribute to the known higher bioactivity of that enantiomer.     

Acute Exacerbations of COPD in the United States: Inpatient Burden and Predictors of Costs and Mortality

Abstract

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a leading cause of hospitalizations in the United States and the major cost driver of COPD. This study determined the national inpatient burden of AECOPD and assessed the association of co-morbidities and hospital characteristics with inpatient costs and mortality. Discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample for 2006 was utilized. Outcomes of costs and mortality were assessed for AECOPD hospitalizations in cases ≥40 years of age. Multivariate regression analyses using a generalized linear model framework were conducted to determine predictors of inpatient costs and mortality controlling for patient demographics, primary payer, co-morbidity index, length of stay, hospital region, mechanical ventilation, and admission period. Overall, 1,254,703 hospitalizations for AECOPD were observed with mean costs of $9545(±12,700) and total costs of $11.9 billion. In-hospital mortality was 4.3% (N = 53,748). Discharges averaged 70.6 (±11.9) years of age. The majority were female (52.8%) and of white race (83.6% of reported race). Several co-morbidities were significantly associated with both costs and mortality (p < 0.001): acute myocardial infarction; congestive heart failure; cerebrovascular disease; lung cancer; cardiac arrhythmias; pulmonary circulation disorders; and weight loss. Significantly higher costs (p < 0.001) were associated with large and urban hospitals. The importance of co-morbidities in AECOPD is indicated in their association with prognosis and inpatient costs. Future research should determine if better management of these conditions can favorably impact the COPD disease burden.     

Effects of a long-acting somatostatin analogue on postprandial hyperglycemia in insulin-dependent diabetes mellitus

To determine whether an agent such as WY-41,747, a long-acting somatostatin analogue, could be useful as an adjunct to insulin in the treatment of diabetes mellitus, postprandial plasma glucose concentrations were determined in subjects with insulin-dependent diabetes rendered euglycemic with the Biostator insulin infusion device under four conditions: (1) subcutaneous minipump infusion of insulin alone (13 +/- 1 units) over 30 minutes beginning 30 minutes before ingestion of a meal using insulin doses determined by the Biostator; (2) the same conditions as 1 but beginning immediately before meal ingestion; (3) the same conditions as 1 but with less insulin (7 +/- 1 units) accompanied by the analogue (0.01-0.05 mg/kg); (4) the same conditions as 2 but with the analogue and less insulin (11 +/- 1 units). Administration of the somatostatin analogue increased the effectiveness of insulin in controlling postprandial hyperglycemia and permitted satisfactory postprandial glycemic control when the insulin infusion was initiated immediately before meal ingestion. Administration of the analogue suppressed postprandial plasma glucagon and triglyceride concentrations and delayed xylose absorption. These results suggest that subcutaneous administration of a long-acting somatostatin analogue such as WY-41,747 along with insulin may be clinically useful in the treatment of diabetes mellitus.     

Osteoid osteoma: 95 cases and a review of the literature

Osteoid osteoma is a benign bone tumor occurring primarily in patients under the age of 30 yr. Bone pain at night and relief by aspirin or other nonsteroidal antiinflammatory agents is a common symptom complex. The proximal femur and spine are frequent sites of involvement, but almost any bone can be involved. If plain roentgenograms do not demonstrate the lesion, tomography or a bone scan may be helpful. Complete surgical excision is the therapy of choice with a low recurrence rate. Osteoid osteoma may present initially with symptoms suggestive of inflammatory arthritis, degenerative joint disease, neoplasm, or infection. This lesion can therefore be a difficult diagnostic problem, especially if routine roentgenograms are normal. A high index of suspicion is necessary to make the diagnosis.     

Association between treatment facility volume,therapy types and overall survival in patients with intrahepatic cholangiocarcinoma

Background

To determine the association between the number of patients with intra-hepatic cholangiocarcinoma (IHCC) treated annually at a treatment facility (volume) and overall survival (outcome).

Burden of 30-Day Readmissions Associated With Discharge Against Medical Advice Among Inpatients in the United States

BackgroundDischarges against medical advice are common among inpatients in the United States. The impact of discharge against medical advice on readmission rates and subsequent hospitalization outcomes is uncertain. We sought to ascertain the effect of discharge against medical advice on 30-day readmission rates and outcomes of readmission.MethodsWe used the 2014 Nationwide Readmissions Database to identify index hospitalizations among patients older than 18 years of age. The primary exposure variable was discharge against medical advice, and the primary outcome measure was all-cause unplanned 30-day readmission. We used multivariate hierarchical logistic regression modeling to ascertain the effect of discharge against medical advice on 30-day readmission rates.ResultsThere were an estimated 23,110,641 index hospitalizations nationwide with an overall unplanned 30-day readmission rate of 10.2%. 1.3% of index admissions resulted in a discharge against medical advice. Patients who were discharged against medical advice were younger (mean age 47.1 years vs 56.5 years, P < 0.001) with a higher proportion of males (61.1% vs 39.5%, P < 0.001) compared with patients with a routine discharge. Discharge against medical advice was associated with significantly higher odds of 30-day readmission (risk-adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] 2.03-2.09, P < 0.001). Discharge against medical advice was associated with higher odds of readmission to a different hospital (OR 2.35, 95% CI 2.22-2.49, P < 0.001) and repeat discharge against medical advice after readmission (OR 18.41, 95% CI 17.46-19.41, P < 0.001). The most common cause of readmission after discharge against medical advice was alcohol-related disorders (9%). Hospital-level rates of discharge against medical advice ranged from 0% to 12.5%.ConclusionsDischarge against medical advice is associated with over twice the odds of all-cause unplanned 30-day readmission compared with routine discharge. There is large hospital-level variation in rates of discharge against medical advice. Interventions to reduce discharges against medical advice, particularly at hospitals with high rates of such discharges, may reduce the overall readmission burden in this challenging and high-risk patient population.     

Angiographic occurrence and clinical correlates of intraluminal coronary artery thrombus: role of unstable angina

The importance of intraluminal coronary artery thrombus in acute myocardial infarction is now recognized. Coronary thrombi, however, may be important in ischemic syndromes other than infarction. The coronary angiograms of 268 consecutive patients undergoing diagnostic angiography were prospectively examined for intracoronary thrombus and form the basis of this study. Of these patients, 29 (11%) (25 men and 4 women) met the criteria for coronary artery thrombus. Of the 29 patients with thrombus, 24 (83%) had unstable angina before angiography. The five remaining patients with thrombus had had a transmural myocardial infarction 3 to 18 months before cardiac catheterization. In 21 patients, the thrombus was distal to a significant stenosis; in 8 it was proximal to or at the site of a significant stenosis. Coronary artery thrombus was identified in 24 (35%) of 67 patients with unstable angina compared with only 5 (2.5%) of 201 patients with stable angina (p less than 0.0001).     

Combined testing of anterior pituitary gland with insulin, thyrotropin-releasing hormone, and luteinizing hormone-releasing hormone

Provocative tests of hypothalamic-pituitary function were performed in 20 healthy subjects to learn whether the simultaneous testing by three agents--insulin, thyrotropin-releasing hormone, and luteinizing hormone-releasing hormone--was feasible. The responses to simultaneous testing on one day did not differ significantly from those to testing on three separate days. The time and expense of pituitary-hypothalamic testing can thus be much reduced with no impairment of reliability and with no increased risk to the patient.