Implementation of a Standardized Preoperative Diabetes Medication Guideline and its Effect on Day of Procedure Blood Glucose Levels.

PURPOSE: The purpose of this project was to determine the effect of implementation of a preoperative diabetes medication management guideline on day of procedure blood glucose (BG) levels. DESIGN: This project was designed as pre- and postimplementation process improvement project based on the Iowa Model of evidence-based practice. METHODS: Anesthesia providers were surveyed for knowledge and confidence before and following education. Surgical patients with diabetes were provided instructions for all classes of prescribed diabetes medications. Day of procedure BG levels were compared prior to and following the guideline implementation. FINDINGS: Provider knowledge scores increased 4.5 points (95% confidence interval [CI] 3.2, 5.8) and confidence improved 31.3 percentage points (95% CI 20.8, 41.7). Mean BG level was 132.3 (SD 37.5) before implementation and 130.4 (SD 44.7) after implementation. CONCLUSIONS: The project resulted in significant gains in provider knowledge and confidence, but no significant difference in preoperative BG levels following implementation of the guideline.

External Iliac Artery Endofibrosis: A Discussion on Two Unique Cases.

Iliac artery endofibrosis (IAE), as the name suggests, involves subintimal fibrosis of the iliac artery. IAE is most commonly associated with competitive athletics, particularly cycling, and remains a rather underappreciated diagnosis in the clinical setting. We present two unique and distinct presentations of IAE in competitive athletes. The first case involves a 38-year-old male cyclist who initially presented with complaints of a bulge at the right groin and acute onset monoplegia and paresthesia associated with exertion of the right lower extremity. This patient was referred to vascular surgery and underwent right common iliac artery and proximal common femoral artery endarterectomy with patch angioplasty and Fogarty embolectomy. Case 2 involves a 50-year-old female triathlete who presented with left lower extremity claudication of a more chronic course, with symptoms beginning approximately four years prior. The pain radiated to her upper thigh and was associated with exertion, restricting her exercise tolerance and return to training. After a diagnosis of IAE was made, she was referred to vascular surgery for a left iliofemoral bypass.

Prognostic relevance of limb shaking in symptomatic carotid artery occlusion.

BACKGROUND: Internal carotid artery (ICA) occlusion, present in up to 15% of stroke patients, may cause low-flow transient ischemic attacks (TIAs) like limb shaking (LS) or retinal claudication (RC). Reliable data on the frequency of these phenomena and their potential prognostic relevance are still sparse. AIMS: To provide more data about the frequency of low-flow TIA and investigate their influence on outcome. MATERIAL AND METHODS: Medical records of 260 consecutive patients with symptomatic ICA occlusion were carefully reviewed (survey period: January 2000 to December 2006). Baseline stroke severity and outcome at 90 days and in the long term were assessed. All patients were specifically questioned about symptoms of LS and RC, were exposed to bright light (pupillary testing) and carefully watched during testing of posture/gait and early mobilization. RESULTS: LS, RC or both occurred in 28.6, 9.5 and 2.7%, respectively, of patients eligible for a thorough assessment of low-flow TIAs (n = 147). An adverse outcome was more likely in patients with LS than in those without at day 90 (modified Ranking Scale ≥4, 45.2 vs. 21.9%, p = 0.005) and in the long term (median, 37 months) (52.7 vs. 23.1%, p < 0.001). In a multivariable analysis, prognostic relevance was found to be independent of baseline stroke severity (National Institutes of Health Stroke Scale). There was also a tendency towards higher rates of recurrent stroke and TIA in limb shakers. RC had no prognostic relevance regarding functional outcome and recurrent events. CONCLUSION: In patients with ICA occlusion, RC and LS are more common than previously assumed. The presence of LS is associated with a worse outcome independent of initial stroke severity and patient characteristics.

Use of power-law analysis to predict abuse or diversion of prescribed medications: proof-of-concept mathematical exploration.

OBJECTIVE: To conduct a proof-of-concept study comparing Lorenz-curve analysis (LCA) with power-law (exponential function) analysis (PLA), by applying segmented regression modeling to 1-year prescription claims data for three medications-alprazolam, opioids, and gabapentin-to predict abuse and/or diversion using power-law zone (PLZ) classification. RESULTS: In 1-year baseline observation, patients classified into the top PLZ groups (PLGs) were demographically and diagnostically similar to those in Lorenz-1 (top 1% of utilizers) and Lorenz-25 (top 25%). For prediction of follow-up (6-month post-baseline) Lorenz-1 use of alprazolam and opioids (i.e., potential abuse/diversion), PLA had somewhat lower sensitivity compared with LCA (83.5-95.4% vs. 99.5-99.9%, respectively) but better specificity (98.2-98.8% vs. 75.5%) and much better positive predictive value (PPV; 34.5-45.3% vs. 4.0-4.6%). Of top-PLG alprazolam- and opioid-treated patients, respectively, 20.7 and 9.9% developed incident (new) Lorenz-1 in followup, compared with < 3% of Lorenz-25 patients. For gabapentin, neither PLA nor LCA predicted incident Lorenz-1 (PPV = 0.0-1.4%). For all three medications, PLA sensitivity for follow-up hospitalization was < 5%, but specificity was better for PLA (97.3-99.2%) than for LCA (74.3-75.4%). PLA better identified patients at risk of future controlled substance abuse/diversion than did LCA, but the technique needs refinement before widespread use.

Nutrition: ethical issues and challenges.

For nutrition and its associated disciplines, ethical considerations related to research are often complicated by factors that range from the use of experimental research designs that are overly holistic to inextricable links between nutrition research and marketing. As a consequence, there is the need for constant vigilance to assess and deal with apparent conflicts of interest. Also, there are few scientific disciplines that are defined by cultural, religious, or political codifications as is nutrition. Accordingly, examples of historical, cultural, and political events are described that have influenced ethical approaches related to nutrition research. Furthermore, nutrition research questions are often multifaceted and require dealing with complex variables. In this regard, ethical principles and perspectives that have relevance to data acquisition, the publication and translation of nutrition research, and the marketing of nutritional products and concepts are highlighted.

Kepler-16: a transiting circumbinary planet.

We report the detection of a planet whose orbit surrounds a pair of low-mass stars. Data from the Kepler spacecraft reveal transits of the planet across both stars, in addition to the mutual eclipses of the stars, giving precise constraints on the absolute dimensions of all three bodies. The planet is comparable to Saturn in mass and size and is on a nearly circular 229-day orbit around its two parent stars. The eclipsing stars are 20 and 69% as massive as the Sun and have an eccentric 41-day orbit. The motions of all three bodies are confined to within 0.5° of a single plane, suggesting that the planet formed within a circumbinary disk.