A retrospective review of insulin requirements in patients using U-500 insulin hospitalized to a Veterans Affairs Hospital.

AIMS: The aim of this study was to compare the changes in the total daily dose (TDD) of insulin of patients on U-500 insulin; before hospitalization, during hospitalization and six weeks after discharge. METHODS: A retrospective chart review of veterans with type 2 diabetes receiving U-500 insulin in the ambulatory setting and who were admitted between 2012 and 2015 was performed. During hospitalization, patients were transitioned to receive U-100 insulin (detemir or glargine for basal and aspart for bolus). Paired t-tests were conducted to compare TDD of insulin during hospitalization to prior to admission and at six week of follow-up. RESULTS: The average hemoglobin A1c at the time of hospital admission was 8.3±1.5% (n=20). The average TDD of insulin during hospitalization (124±67units) was significantly less than prior to admission (295±123units) and at six week follow-up (310±105units). The average glucose during hospitalization was 180±36mg/dL. Hypoglycemia was less than 0.5%. CONCLUSION: We showed that patients received significantly less total daily insulin while hospitalized compared to their insulin doses in the ambulatory setting, and we demonstrate that patients receiving U-500 insulin can be safely transitioned to U-100 insulin while hospitalized, with minimal hypoglycemia.

Nuclear Imaging in Metastatic Paraganglioma.

Paragangliomas associated with mutations of the SDHD gene can occasionally result in distant metastasis. Diagnosis can be difficult, and nuclear imaging is used to evaluate the case further. Not all tumors are alike; nuclear avidity may differ. We present a case in which metastatic paraganglioma caused by mutations of the SDHD gene was negative on 123I-metaiodobenzylguanidine scintigraphy and positive on 111In-labeled octreotide scintigraphy. This situation presents an opportunity for a novel therapeutic approach toward metastatic paraganglioma using targeted peptide receptor radionuclide therapy.

Spotlight on empagliflozin/metformin fixed-dose combination for the treatment of type 2 diabetes: a systematic review.

The dramatic rise in the prevalence of obesity and diabetes is associated with increased morbidity, mortality, and public health care costs worldwide. The need for new, effective, and long-lasting drugs is urgent. Recent research has focused on the role of the inhibitors of sodium- glucose co-transporter 2 (SGLT-2). Clinical trials have shown that SGLT-2 inhibitors have glycemic efficacy and weight-lowering potential. Dual drug therapy is a recommended therapy for patients with new-onset type 2 diabetes who need significant glycemic control. Fixed-dose combination therapy represents a particularly attractive option as it may reduce pill burden and improve adherence. The combination of metformin and empagliflozin was approved by the US Food and Drug Administration in 2014 and represents a safe and effective means to combat glycemic control and weight gain. The purpose of this systematic review is to summarize the background of the SGLT-2 inhibitors, particularly empagliflozin, and focus on the safety and efficacy of the fixed-dose combination of empagliflozin and metformin.

Adrenal oncoctyoma of uncertain malignant potential: a rare etiology of adrenal incidentaloma.

A rare cause for rapid adrenal enlargement is adrenal oncocytoma of uncertain malignant potential. A full biochemical evaluation is warranted to screen secreting adrenal adenomas as well as to evaluate adrenal cortical carcinoma. Careful pathologic evaluation is required as the diagnosis of AOC cannot be made by imaging.

Iatrogenic Subclinical Hyperthyroidism Does Not Promote Weight Loss.

OBJECTIVES: Among patients who have undergone total thyroidectomy, do those with thyroid cancer being kept iatrogenically subclinical hyperthyroid (SCH) differ from euthyroid patients in long-term weight change? METHODS: In a retrospective study, medical records identified 291 patients who had undergone a thyroidectomy for differentiated thyroid cancer or benign thyroid disease. Weight, thyroid-stimulating hormone, and levothyroxine dose were measured presurgery and 1, 2, and 3 years postsurgery. RESULTS: Of 291 patients, 147 were in the SCH group and 144 were in the euthyroid group. At all 3 years both groups gained weight from baseline, but the two groups did not differ in weight change from baseline at any time period: year 1 (SCH mean 0.4% ± 6.2% weight gain vs euthyroid group mean 2.2% ± 6.6% weight gain; P = 0.12), year 2 (SCH mean 1.1% ± 9.1% weight gain vs euthyroid mean 2.9% ± 7.8% weight gain; P = 0.22), and year 3 (SCH mean 2.6% ± 9.2% weight gain vs euthyroid mean 3.1% ± 11.1% weight gain; P = 0.49). CONCLUSIONS: Among total thyroidectomy patients, weight change did not differ between SCH patients and euthyroid patients at years 1 through 3. As such, the use of levothyroxine to induce SCH did not lead to long-term weight change when compared with euthyroid patients.

Implantable cardioverter-defibrillators: indications and unresolved issues.

Since the implantable cardioverter-defibrillator was first used clinically in 1980, several large randomized controlled trials have shown that therapy with this device can be beneficial in various patient populations. Evidence suggests that this therapy is useful in the secondary prevention of sudden cardiac death among patients who have survived arrhythmic events. Several trials have also shown the usefulness of implantable cardioverter-defibrillator therapy in the primary prevention of sudden cardiac death in patients with coronary artery disease and nonischemic cardiomyopathy. Other data support the use of this device for various infiltrative and inherited conditions. When used with cardiac resynchronization therapy, implantable cardioverter-defibrillators have improved survival rates and quality of life in patients with severe heart failure. Further research is needed to examine the potential benefits of implantable cardioverter-defibrillators in elderly, female, and hemodialysis-dependent patients, and to determine the optimal waiting period for implantation after myocardial infarction, coronary revascularization, and initial heart-failure diagnosis.

Device extraction in adults with congenital heart disease.

BACKGROUND: Device extraction is a critical component in the treatment of patients with device-related infections. Due to complex anatomic considerations, device extraction in adults with congenital heart disease presents unique challenges to the electrophysiologist. METHODS: Here, we present a series of device-extraction cases performed in patients with transposition of the great arteries status post either Mustard or Senning surgical procedures that subsequently had permanent pacemakers placed and ultimately developed device-related infections. RESULTS: All of these patients eventually underwent successful laser extractions of their infected devices resulting in complete removal of all hardware and resolution of their infections. CONCLUSIONS: These cases illustrate that endovascular device extraction has been safely and effectively performed in adult patients with congenital heart disease, though further studies are needed to determine the procedural risks and success rates of this procedure in this patient population.

Supraventricular tachycardia after orthotopic cardiac transplantation.

OBJECTIVES: The purpose of this study was to define the incidence, mechanisms, and management, including catheter ablation, of supraventricular tachycardia (SVT) in a large series of patients after orthotopic heart transplantation (OHT). BACKGROUND: Supraventricular arrhythmias are frequently encountered after OHT, but their characteristics in this population have not been well established. METHODS: We analyzed the incidence, clinical course, and management of SVTs in a cohort of 729 adult patients who underwent OHT. Furthermore, the mechanisms of arrhythmias among the patients referred for electrophysiological study (EPS) and ablation were also characterized. RESULTS: The most common arrhythmia was atrial flutter, which occurred in 9% of this cohort. Persistent or paroxysmal atrial fibrillation occurred in 7%, the majority (57%) in the perioperative period. Persistent or paroxysmal atrial fibrillation was observed in OHT patients, beyond the post-operative period, only in the presence of rejection or transplant vasculopathy. Other persistent or paroxysmal SVTs were seen in 47 stable OHT patients (7%). Of these, 24 patients (4%) underwent EPS. Accessory and dual atrioventricular nodal pathways in the donor heart caused SVT in 3 patients. Macro-reentrant atrial tachycardia was seen in 7 patients, and isthmus-dependent atrial flutter occurred in 14 patients. CONCLUSIONS: The majority of SVTs in stable OHT patients can be attributed to macro-reentrant tachycardias (flutter and scar reentry). Catheter ablation is effective in management of these SVTs. Atrial fibrillation was never encountered in stable patients in our series, and its occurrence should prompt an evaluation for acute rejection and/or vasculopathy.

Effect of solution viscosity on intramolecular electron transfer in sulfite oxidase.

Our previous studies have shown that the rate constant for intramolecular electron transfer (IET) between the heme and molybdenum centers of chicken liver sulfite oxidase varies from approximately 20 to 1400 s(-1) depending upon reaction conditions [Pacheco, A., Hazzard, J. T., Tollin, G., and Enemark, J. H. (1999) J. Biol. Inorg. Chem. 4, 390-401]. These two centers are linked by a flexible polypeptide loop, suggesting that conformational changes, which alter the Mo-Fe distance, may play an important role in the observed IET rates. In this study, we have investigated IET in sulfite oxidase using laser flash photolysis as a function of solution viscosity. The solution viscosity was varied over the range of 1.0-2.0 cP by addition of either polyethylene glycol 400 or sucrose. In the presence of either viscosogen, an appreciable decrease in the IET rate constant value is observed with an increase in the solvent viscosity. The IET rate constant exhibits a linear dependence on the negative 0.7th power of the viscosity. Steady-state kinetics and EPR experiments are consistent with the interpretation that viscosity, and not other properties of the added viscosogens, is responsible for the dependence of IET rates on the solvent composition. The results are consistent with the role of conformational changes on IET in sulfite oxidase, which helps to clarify the inconsistency between the large rate constant for IET between the Mo and Fe centers and the long distance (approximately 32 A) between these two metal centers observed in the crystal structure [Kisker, C., Schindelin, H., Pacheco, A., Wehbi, W., Garnett, R. M., Rajagopalan, K. V., Enemark, J. H., and Rees, D. C. (1997) Cell 91, 973-983].