Provider Response to Critical Action Values for Hypoglycemia in the Ambulatory Setting: a Retrospective Cohort Study

BackgroundThe blood glucose level triggering a critical action value (CAV) for hypoglycemia is not standardized, and associated outcomes are unknown.ObjectiveTo evaluate the clinical consequences of, and provider responses to, CAVs for hypoglycemia.DesignRetrospective cohort study at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between April 1, 2013, and January 31, 2017.ParticipantsPatients with an ambulatory serum glucose < 50 mg/dL. Point-of-care capillary glucose and whole blood glucose samples were excluded.Main MeasuresElectronic medical record (EMR) review for providers’ documented response to CAV, associated patient symptoms, and serious adverse events.Key ResultsWe analyzed 209 CAVs for hypoglycemia from 154 patients. The median age (IQR) was 59 years (46, 69), 89 (57.8%) were male, and 96 (62.3%) were black. Provider-to-patient contact occurred in 128 of 209 (61.2%) episodes, among which no documented etiology was observed for 81 of 128 (63.3%), no recommendations were provided in 32 of 128 (25.0%), and no patient-reported hypoglycemic symptoms were documented in 103 of 128 (80.5%). Serious adverse events were documented in 4 of 128 episodes (3.1%), two required glucagon administration, and three required an ED visit. Provider-to-patient contact was associated with the patient having malignant neoplasm (adjusted OR 3.63, p = 0.045) or a hypoglycemic disorder (adjusted OR 7.70, p = 0.018) and inversely associated with a longer time from specimen collection to EMR result (adjusted OR 0.90 per hour, p = 0.016).ConclusionsThere is inconsistent provider-to-patient contact following CAVs for hypoglycemia, and the etiology and symptoms of hypoglycemia were infrequently documented. There were few serious documented adverse events associated with hypoglycemia, although undocumented events may have occurred, and the incidence of serious adverse events in non-contacted patients remains unknown. These findings demonstrate a need to standardize provider response to CAVs for hypoglycemia. Decreasing the lag time between sample collection and laboratory result reporting may increase provider-to-patient contact.KEY WORDS: Hypoglycemia, Critical action value, Ambulatory, Glucose     

Endoscopic management of pancreatic pseudocysts and walled-off pancreatic necrosis: A two-decade experience

Aim

To determine long-term outcome of endoscopic management of pancreatic pseudocyst/walled-off pancreatic necrosis (WOPN) without necrosectomy.

Methods

One-hundred and sixty-five pancreatic pseudocysts/WOPN managed endoscopically over a period of 22 years were analyzed retrospectively for technical success, complications, and recurrence.

Results

Symptomatic 118 males and 47 females with mean age of 35.8 years were included. Alcohol was the most common etiology (41.2 %). Transmural endoscopic drainage was done in 144 patients, while 21 patients underwent transpapillary drainage. All the patients were subjected to contrast computed tomography (CT) abdomen or routine/Doppler ultrasound. Endoscopic ultrasound was done in last 11 patients. One or two double pigtail 7 Fr stents were placed when clear watery fluid came out from cyst (130 patients, 78.8 %), and nasocystic drainage (NCD) tubes were placed in addition to two 7 Fr stents when there were frank pus, thick dark fluid, or solid components inside the cyst (35 patients). All these patients settled on this treatment. Thirty-three of 35 patients of WOPN could be managed endoscopically without necrosectomy. Complications occurred in 9.2 % of pseudocysts and 40 % of WOPN. Thirty-five patients were followed up for more than 5 years (3 patients more than 10 years), and 130 patients were followed up for up to 5 years. Recurrence occurred in 8.1 % of pseudocysts and 5.7 % of WOPN.

Conclusion

Majority of pancreatic pseudocysts/WOPN can be managed with endoscopic drainage without necrosectomy with high success, low complication, and recurrence rates.

     

Magnetic resonance imaging for evaluating neurogenic dysphagia

Dysphagia due to CNS pathology usually stems from one of two patterns of disease: (1) bilateral corticobulbar tract dysfunction (“pseudobulbar palsy”) or (2) pontomedullary dysfunction (“bulbar palsy”). Computed tomography (CT) has proved to be useful for evaluating the brainstem in patients with neurogenic dysphagia. Nonetheless, artifacts are common in CT imaging of the posterior fossa. Also, direct sagittal imaging is not usually obtainable by CT in adult patients. Magnetic resonance imaging (MRI), in contrast to CT, simultaneously gathers sequential images in the same plane and can obtain direct reconstructions in any plane of interest. MRI has proven to be more sensitive than CT in demonstrating lesions of the brain, such as demyelinating (e.g., multiple sclerosis) and ischemic diseases, (Brant-Zawadzki et al. 1984, Bradley et al. 1984, Bydder et al. 1982, Sheldon et al. 1985) as well as neoplastic masses that may produce neurogenic dysphagia (Lee et al. 1985, Zimmerman et al. 1986). Five patients with dysphagia are reported for whom MRI was valuable in detecting and characterizing their lesions of the brainstem and the cerebral hemispheres.     

Concomitant parasitism: bancroftian filariasis and intestinal helminths and response to albendazole

Subjects in an disease-endemic area in Orissa, India concomitantly infected with filariasis and intestinal helminths had significantly lower intensity of filarial infection in comparison with those who were infected only with filariasis. Administration of albendazole resulted in a significant decrease in the prevalence of filarial antigenemia in subjects concomitantly infected with intestinal helminths, but produced little change in this infection measure in subjects infected only with Wuchereria bancrofti. These results indicate that intestinal helminths could play a role in the anti-filarial activity of albendazole, most probably by depressing filarial infection intensity in co-infected individuals. Confirmation of these findings in a larger cohort may yield important new insights regarding the role of using albendazole in the ongoing intervention programs for the control of lymphatic filariasis.     

Comparative analysis of Behcet's disease in the APLAR region

Aims: Behcet's disease (BD) was originally a disease of the Silk Road. Some authors think that BD from the Silk Road is different from those seen in other countries. The aim of this study was to analyze the clinical manifestations of BD in APLAR countries, where some of them are in the Silk Road (SR) and some others not (NSR). Methods: Data from Australia (NSR), Hong Kong (NSR), India (SR), Iran (SR), and Singapore (SR) were selected and analyzed under the same protocol. Prior published data from China (SR) Japan (SR) and Korea (SR) were included in the analysis. Results: The mean age at the onset of the disease was under 30 for all countries except Japan and Singapore. The male gender was more frequent except in Australia and Korea. Oral aphthosis was the most frequent manifestation (90–100%). Genital aphthosis was less frequent (57–82%). Skin manifestations were also frequent (61–87%). Ocular manifestations were reported from 21–69% of patients. The difference was mainly due to patients’ selection bias and the low number of patients in some reports. The same was true for joint (30–87%), gastrointestinal (6–38%), neurological (2.5–29%) and vascular manifestations (5–28%). Conclusion: Despite the percentage difference among some countries, the general pattern of the disease was the same, suggesting that the minor differences seen in different parts of the world were not enough to call the disease a syndrome, or to differentiate Behcet's disease of the Silk Road from those seen in Western countries.     

Ferumoxytol Is Not Retained in Kidney Allografts in Patients Undergoing Acute Rejection

Purpose

To evaluate whether ultrasmall superparamagnetic iron oxide nanoparticle (USPIO)-enhanced magnetic resonance imaging (MRI) can detect allograft rejection in pediatric kidney transplant patients.

Procedures

The USPIO ferumoxytol has a long blood half-life and is phagocytosed by macrophages. In an IRB-approved single-center prospective clinical trial, 26 pediatric patients and adolescents (age 10–26 years) with acute allograft rejection (n = 5), non-rejecting allografts (n = 13), and normal native kidneys (n = 8) underwent multi-echo T2* fast spoiled gradient-echo (FSPGR) MRI after intravenous injection (p.i.) of 5 mg Fe/kg ferumoxytol. T2* relaxation times at 4 h p.i. (perfusion phase) and more than 20 h p.i. (macrophage phase) were compared with biopsy results. The presence of rejection was assessed using the Banff criteria, and the prevalence of macrophages on CD163 immunostains was determined based on a semi-quantitative scoring system. MRI and histology data were compared among patient groups using t tests, analysis of variance, and regression analyses with a significance threshold of p < 0.05.

Results

At 4 h p.i., mean T2* values were 6.6 ± 1.5 ms for native kidneys and 3.9 ms for one allograft undergoing acute immune rejection. Surprisingly, at 20–24 h p.i., one rejecting allograft showed significantly prolonged T2* relaxation times (37.0 ms) compared to native kidneys (6.3 ± 1.7 ms) and non-rejecting allografts (7.6 ± 0.1 ms). Likewise, three additional rejecting allografts showed significantly prolonged T2* relaxation times compared to non-rejecting allografts at later post-contrast time points, 25–97 h p.i. (p = 0.008). Histological analysis revealed edema and compressed microvessels in biopsies of rejecting allografts. Allografts with and without rejection showed insignificant differences in macrophage content on histopathology (p = 0.44).

Conclusion

After ferumoxytol administration, renal allografts undergoing acute rejection show prolonged T2* values compared to non-rejecting allografts. Since histology revealed no significant differences in macrophage content, the increasing T2* value is likely due to the combined effect of reduced perfusion and increased edema in rejecting allografts.

     

Design and Implementation of a Laboratory-Based Drug Design and Synthesis Advanced Pharmacy Practice Experience

Objective. To provide students with an opportunity to participate in medicinal chemistry research within the doctor of pharmacy (PharmD) curriculum.Design. We designed and implemented a 3-course sequence in drug design or drug synthesis for pharmacy students consisting of a 1-month advanced elective followed by two 1-month research advanced pharmacy practice experiences (APPEs). To maximize student involvement, this 3-course sequence was offered to third-year and fourth-year students twice per calendar year.Assessment. Students were evaluated based on their commitment to the project’s success, productivity, and professionalism. Students also evaluated the course sequence using a 14-item course evaluation rubric. Student feedback was overwhelmingly positive. Students found the experience to be a valuable component of their pharmacy curriculum.Conclusion. We successfully designed and implemented a 3-course research sequence that allows PharmD students in the traditional 4-year program to participate in drug design and synthesis research. Students report the sequence enhanced their critical-thinking and problem-solving skills and helped them develop as independent learners. Based on the success achieved with this sequence, efforts are underway to develop research APPEs in other areas of the pharmaceutical sciences.     

Extremely low HDL and residual cardiovascular risk—a case report

International Journal of Diabetes in Developing Countries - Extremely low high-density lipoprotein cholesterol (HDL-C) is defined as levels below 20 mg/dL. Association between extremely low HDL-C...     

Factors influencing the basal and recombinant human thyrotropin-stimulated serum thyroglobulin in patients with metastatic thyroid carcinoma

The serum thyroglobulin (Tg) level is the most sensitive marker for detecting residual thyroid carcinoma. We hypothesized that the basal and TSH-stimulated Tg levels in patients with metastatic thyroid carcinoma would reflect tumor volume, histological subtype, and location of metastatic lesions. A retrospective review of 417 thyroid cancer survivors undergoing evaluation for residual disease with the assistance of recombinant human TSH (rhTSH) was performed. In 169 patients with metastatic disease, we found that the basal Tg level directly correlated with the number of lesions, and that it was highest in patients with follicular and lowest in those with papillary thyroid carcinoma. The basal Tg level was highest in patients with bone metastases and lowest in those with cervical metastases. The fold increase in the serum Tg after rhTSH treatment was highest in papillary thyroid carcinoma and lowest in Hurthle cell carcinoma. The fold increase in Tg was not influenced by tumor volume or by the site of metastatic lesions. Multivariate analysis showed multiple interactions between factors, but did not identify one factor that significantly influenced basal Tg or fold increase. We conclude that the location and volume of metastases influence basal Tg, but not its responsiveness to rhTSH, whereas the histological type of carcinoma influences both basal Tg and responsiveness to rhTSH.