Concomitant dysregulation of androgen secretion and dysfunction of adipose tissue induced insulin resistance

Hyperandrogenism and hyperinsulinemia have resulted from dysfunction of the theca cell of the ovary and adipose tissue and each one potentiates the other in patients with androgen excess disorders e.g., polycystic ovary disease and idiopathic hirsutism. Possible external and/or internal triggers can produce such cellular dysfunction. There is evidence that sodium valproate acts as a trigger of cellular dysfunction and produces both hyperinsulinemia and hyperandrogenism. Therefore, the elimination of these triggers can help the patients to recover from hyperinsulinemia, insulin resistance and hyperandrogenism.     

Hematopoietic growth factors for graft failure after bone marrow transplantation: a randomized trial of granulocyte-macrophage colony- stimulating factor (GM-CSF) versus sequential GM-CSF plus granulocyte- CSF

Delay in hematologic recovery after bone marrow transplantation (BMT) can extend and amplify the risks of infection and hemorrhage, compromise patients' survival, and increase the duration and cost of hospitalization. Because current studies suggest that granulocyte- macrophage (GM) colony-stimulating factor (CSF) may potentiate the sensitivity of hematopoietic progenitor cells to G-CSF, we performed a prospective, randomized trial comparing GM-CSF (250 micrograms/m2/d x 14 days) versus sequential GM-CSF x 7 days followed by G-CSF (5 micrograms/kg/d x 7 days) as treatment for primary or secondary graft failure after BMT. Eligibility criteria included failure to achieve a white blood cell (WBC) count > or = 100/microL by day +21 or > or = 300/microL by day +28, no absolute neutrophil count (ANC) > or = 200/microL by day +28, or secondary sustained neutropenia after initial engraftment. Forty-seven patients were enrolled: 23 received GM-CSF (10 unrelated, 8 related allogeneic, and 5 autologous), and 24 received GM- CSF followed by G-CSF (12 unrelated, 7 related allogeneic, and 5 autologous). For patients receiving GM-CSF alone, neutrophil recovery (ANC > or = 500/microL) occurred between 2 and 61 days (median, 8 days) after therapy, while those receiving GM-CSF+G-CSF recovered at a similar rate of 1 to 36 days (median, 6 days; P = .39). Recovery to red blood cell (RBC) transfusion independence was slow, occurring 6 to 250 days (median, 35 days) after enrollment with no significant difference between the two treatment groups (GM-CSF: median, 30 days; GM-CSF+G- CSF; median, 42 days; P = .24). Similarly, platelet transfusion independence was delayed until 4 to 249 days (median, 32 days) after enrollment, with no difference between the two treatment groups (GM- CSF: median, 28 days; GM-CSF+G-CSF: median, 42 days; P = .38). Recovery times were not different between patients with unrelated donors and those with related donors or autologous transplant recipients. Survival at 100 days after enrollment was superior after treatment with GM-CSF alone. Only 1 of 23 patients treated with GM-CSF died versus 7 of 24 treated with GM-CSF+G-CSF who died 16 to 84 days (median, 38 days) after enrollment, yielding Kaplan-Meier 100-day survival estimates of 96% +/- 8% for GM-CSF versus 71% +/- 18% for GM-CSF+G-CSF (P = .026). These data suggest that sequential growth factor therapy with GM-CSF followed by G-CSF offers no advantage over GM-CSF alone in accelerating trilineage hematopoiesis or preventing lethal complications in patients with poor graft function after BMT.(ABSTRACT TRUNCATED AT 400 WORDS)     

Traumatic near amputation secondary to hippopotamus attack: lessons for surgeons

A 34-y-old man presented to Naivasha District Hospital (NDH) in Naivasha Town, Kenya, with near-complete below-knee amputation and hemorrhage after a hippopotamus attack. Residents from the University of Washington (UW), Departments of Surgery, Anesthesia, and Medicine, were rotating at NDH with the Clinical Education Partnership Initiative, a joint venture of UW and University of Nairobi. These providers met the patient in the operating theater. The leg was mangled with severely traumatized soft tissues and tibia–fibula fractures. The visiting UW Surgery resident (R3) and an NDH medical officer (second-year house officer) performed emergency below-knee completion amputation—the first time either had performed this operation. The three major vessel groups were identified and ligated. Sufficient gastrocnemius and soleus were preserved for future stump construction. The wound was washed out, packed with betadine-soaked gauze, and wrapped in an elasticized bandage. Broad-spectrum antibiotics were initiated. Unfortunately, the patient suffered infection and was revised above the knee. After a prolonged course, the patient recovered well and was discharged home. NDH house officers and UW trainees collaborated successfully in an emergency and conducted the postoperative care of a patient with a serious and challenging injury. Their experience highlights the importance of preparedness, command of surgical basics, humility, learning from mistakes, the expertise of others, a digitally connected surgical community, and the role of surgery in global health. These lessons will be increasingly pertinent as surgical training programs create opportunities for their residents to work in developing countries; many of these lessons are equally applicable to surgical practice in the developed world.     

National Patterns of Risk-Standardized Mortality and Readmission After Hospitalization for Acute Myocardial Infarction,Heart Failure,and Pneumonia: Update on Publicly Reported Outcomes Measures Based on the 2013 Release

BACKGROUND

The Centers for Medicare & Medicaid Services publicly reports risk-standardized mortality rates (RSMRs) within 30-days of admission and, in 2013, risk-standardized unplanned readmission rates (RSRRs) within 30-days of discharge for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Current publicly reported data do not focus on variation in national results or annual changes.

OBJECTIVE

Describe U.S. hospital performance on AMI, HF, and pneumonia mortality and updated readmission measures to provide perspective on national performance variation.

DESIGN

To identify recent changes and variation in national hospital-level mortality and readmission for AMI, HF, and pneumonia, we performed cross-sectional panel analyses of national hospital performance on publicly reported measures.

PARTICIPANTS

Fee-for-service Medicare and Veterans Health Administration beneficiaries, 65 years or older, hospitalized with principal discharge diagnoses of AMI, HF, or pneumonia between July 2009 and June 2012. RSMRs/RSRRs were calculated using hierarchical logistic models risk-adjusted for age, sex, comorbidities, and patients’ clustering among hospitals.

Results

Median (range) RSMRs for AMI, HF, and pneumonia were 15.1% (9.4–21.0%), 11.3% (6.4–17.9%), and 11.4% (6.5–24.5%), respectively. Median (range) RSRRs for AMI, HF, and pneumonia were 18.2% (14.4–24.3%), 22.9% (17.1–30.7%), and 17.5% (13.6–24.0%), respectively. Median RSMRs declined for AMI (15.5% in 2009–2010, 15.4% in 2010–2011, 14.7% in 2011–2012) and remained similar for HF (11.5% in 2009–2010, 11.9% in 2010–2011, 11.7% in 2011–2012) and pneumonia (11.8% in 2009–2010, 11.9% in 2010–2011, 11.6% in 2011–2012). Median hospital-level RSRRs declined: AMI (18.5% in 2009–2010, 18.5% in 2010–2011, 17.7% in 2011–2012), HF (23.3% in 2009–2010, 23.1% in 2010–2011, 22.5% in 2011–2012), and pneumonia (17.7% in 2009–2010, 17.6% in 2010–2011, 17.3% in 2011–2012).

Conclusions

We report the first national unplanned readmission results demonstrating declining rates for all three conditions between 2009–2012. Simultaneously, AMI mortality continued to decline, pneumonia mortality was stable, and HF mortality experienced a small increase.     

Hypertension Awareness and Control Among Young Adults in the National Longitudinal Study of Adolescent Health

BACKGROUND

Young adults are less likely than older adults to be aware they have hypertension or to be treated for hypertension.

OBJECTIVE

To describe rates of hypertension awareness and control in a cohort of young adults and understand the impact of health insurance, utilization of preventive care, and self-perception of health on rates of hypertension awareness and control in this age group.

DESIGN AND PARTICIPANTS

Cross-sectional study of 13,512 young adults participating in Wave IV of the National Longitudinal Study of Adolescent Health in 2007–2008.

MAIN MEASURES

We defined hypertension as an average of two measured systolic blood pressures (SBP) ≥ 140 mmHg, diastolic blood pressures (DBP) ≥ 90 mmHg, or self-report of hypertension. We defined hypertension awareness as reporting having been told by a health care provider that one had high blood pressure, and assessed awareness among those with uncontrolled hypertension. We considered those aware of having hypertension controlled if their average measured SBP was < 140 mmHg and DBP was < 90 mmHg.

KEY RESULTS

Of the 3,303 young adults with hypertension, 2,531 (76 %) were uncontrolled, and 1,893 (75 %) of those with uncontrolled hypertension were unaware they had hypertension. After adjustment for age, sex, race/ethnicity, weight status, income, education, alcohol and tobacco use, young adults with uncontrolled hypertension who had (vs. didn’t have) routine preventive care in the past 2 years were 2.4 times more likely (95 % confidence interval [CI] 1.68–3.55) to be aware, but young adults who believed they were in excellent (vs. less than excellent) health were 64 % less likely to be aware they had hypertension (OR 0.36, 95 % CI 0.23–0.57). Neither preventive care utilization nor self-rated health was associated with blood pressure control.

CONCLUSIONS

In this nationally representative group of young adults, rates of hypertension awareness and control were low. Efforts to increase detection of hypertension must address young adults’ access to preventive care and perception of their need for care.