When thyroid labs do not add up, physicians should ask patients about biotin supplements.

A 69-year-old woman with a remote history of Graves' disease treated with radioactive iodine ablation, who was maintained on a stable dose of levothyroxine for 15 years, presented with abnormal and fluctuating thyroid function tests which were confusing. After extensive evaluation, no diagnosis could be made, and it became difficult to optimise the levothyroxine dose, until we became aware of the recently recognised biotin-induced lab interference. It was then noticed that her medication list included biotin 10 mg two times per day. After holding the biotin and repeating the thyroid function tests, the labs made more sense, and the patient was easily made euthyroid with appropriate dose adjustment. We also investigated our own laboratory, and identified the thyroid labs that are performed with biotin-containing assays and developed strategies to increase the awareness about this lab artefact in our clinics.

Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): From Guidelines to Clinical Practice.

BACKGROUND: Lipid profiles have been used for the purposes of health screening and monitoring of the effects of lipid-lowering medications, especially in patients with diabetes who are prone to hyperlipidemia. Fasting for lipid profiles has been the norm for the past decades. This long-lasting tradition poses a risk of hypoglycemia, especially in patients with diabetes. OBJECTIVE: Our aim is to review the overlooked occurrence of hypoglycemia in patients who fast for laboratory tests, especially lipid profile tests, and commute to the laboratory facility while fasting; a condition we titled "Fasting-Evoked En route Hypoglycemia in Diabetes patients" or "FEEHD". We also review its prevalence and clinical impact on patients with diabetes. METHODS: We undertook an extensive literature search using search engines such as PubMed and Google Scholar. We used the following keywords for the search: Fasting, Non-fasting; Hypoglycemia; Hypoglycemic Agents; Laboratory Tests; Glucose, Hypoglycemia, Lipid Profiles, FEEHD. RESULTS: Our literature review has shown that the prevalence of FEEHD is alarmingly high (17-21% of patients at risk). This form of hypoglycemia is under recognized in the clinical practice despite its frequent occurrence. Recent changes in various international guidelines have uniformly endorsed the utilization of non-fasting lipid profiles as the new standard for obtaining lipid profiles with the exception of certain conditions. Multiple studies showed the efficacy of non-fasting lipid tests in comparison to fasting lipid tests, in routine clinical practice. CONCLUSION: We hope to increase awareness among clinicians about this overlooked and potentially harmful form of hypoglycemia in patients with diabetes, which can be easily avoided. We also hope to call upon clinicians to consider changing the habit of ordering lipid profiles in the fasting state, which has been recently shown to be largely unnecessary in routine clinical settings, with few exceptions in selected cases.

Removing the problem: parathyroidectomy for calciphylaxis.

Calcific uremic arteriolopathy (CUA), widely known as calciphylaxis, is a rare and lethal disease that usually affects patients with end-stage renal disease. It is characterised by widespread vascular calcification leading to tissue ischaemia and necrosis and formation of characteristic skin lesions with black eschar. Treatment options include sodium thiosulfate, cinacalcet, phosphate binders and in resistant cases, parathyroidectomy. We report a case of recurrent, treatment-resistant CUA successfully treated with parathyroidectomy. Her postoperative course was complicated by hungry bone syndrome and worsening of her wounds before they completely healed. We then discuss the morbidity of CUA, including the controversy around the use of parathyroidectomy and risk of aggressive management of hungry bone syndrome.

Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): An Overlooked Form of Hypoglycemia in Clinical Practice.

OBJECTIVE: Many patients with diabetes opt to fast for lab tests, especially for lipid profiles, thus missing breakfast. In parallel, recent studies and international guidelines have indicated that routine fasting for lipid panels may not be necessary. Missing breakfast while fasting for lab tests may invoke hypoglycemia, if patients are not properly instructed about adjusting diabetes medications on the night before or on the day of the lab test. Our group described this form of hypoglycemia and introduced the term FEEHD to refer to it (fasting-evoked en route hypoglycemia in diabetes). In a recently published small study, we reported a rate of occurrence of FEEHD of 27.1%. The objective of this study was to evaluate the rate of occurrence of FEEHD in another clinic. METHODS: Patients with diabetes were asked to complete a simple, 2-page survey inquiring about hypoglycemic events while fasting for labs in the preceding 12 months. RESULTS: A total of 525 patients completed the surveys out of 572 patients invited (91.8% response rate). A total of 363 patients with complete data were analyzed, with a mean age of 60.6 (SD 12.5) years. A total of 62 (17.1%) patients reported having experienced one or more FEEHD events in the prior 12 months. Of the 269 patients who were at higher risk of FEEHD (on insulin secretagogues or on insulin), 59 (21.9%) reported having experienced FEEHD. Only 33 of FEEHD patients (53%) recalled having contacted their provider regarding the events and only 22 (35%) indicated having received some sort of FEEHD prevention instructions. CONCLUSION: Our study shows a significant rate of occurrence of FEEHD in the real world (a clinical practice). FEEHD is especially dangerous, as patients often commute (drive) to and from the laboratory facility (potential risk of traffic accidents). Given study limitations, further studies are needed to assess prevalence of FEEHD in other settings and in the general populations.

The traditions and risks of fasting for lipid profiles in patients with diabetes.

Fasting overnight has been traditionally recommended by clinicians when ordering laboratory tests for lipid profiles for the purposes of health screening or monitoring of the effects of lipid-lowering medications. Patients with diabetes are tested for lipid profiles at least annually. This deeply rooted tradition of fasting for lipid testing has recently been challenged. Several studies have shown little benefit obtained by testing lipids in fasting compared with postprandial states. Furthermore, recent studies have shown the importance of postprandial lipid spikes in the pathogenesis of cardiovascular disease. At the same time, recent reports have alerted the medical community to the risk of hypoglycemia in patients with diabetes on antidiabetic medications (particularly insulin and sulfonylureas) who are asked to fast for lab tests. This article reviews the literature on these emerging issues in lipid testing in patients with diabetes, and offers recommendations for lipid testing in these patients in view of these emerging discussions.

Pitfalls of insulin pump clocks: technical glitches that may potentially affect medical care in patients with diabetes.

The objective was to raise awareness about the importance of ensuring that insulin pumps internal clocks are set up correctly at all times. This is a very important safety issue because all commercially available insulin pumps are not GPS-enabled (though this is controversial), nor equipped with automatically adjusting internal clocks. Special attention is paid to how basal and bolus dose errors can be introduced by daylight savings time changes, travel across time zones, and am-pm clock errors. Correct setting of insulin pump internal clock is crucial for appropriate insulin delivery. A comprehensive literature review is provided, as are illustrative cases. Incorrect setting can potentially result in incorrect insulin delivery, with potential harmful consequences, if too much or too little insulin is delivered. Daylight saving time changes may not significantly affect basal insulin delivery, given the triviality of the time difference. However, bolus insulin doses can be dramatically affected. Such problems may occur when pump wearers have large variations in their insulin to carb ratio, especially if they forget to change their pump clock in the spring. More worrisome than daylight saving time change is the am-pm clock setting. If this setting is set up incorrectly, both basal rates and bolus doses will be affected. Appropriate insulin delivery through insulin pumps requires correct correlation between dose settings and internal clock time settings. Because insulin pumps are not GPS-enabled or automatically time-adjusting, extra caution should be practiced by patients to ensure correct time settings at all times. Clinicians and diabetes educators should verify the date/time of insulin pumps during patients' visits, and should remind their patients to always verify these settings.

Hypoglycemia in patients with diabetes who are fasting for laboratory blood tests: the Cape Girardeau Hypoglycemia En Route Prevention Program.

OBJECTIVE: Patients with diabetes are routinely asked to fast for laboratory tests. If not properly prepared, they may be at risk for hypoglycemia, which may result in traffic accidents while driving en route to and from laboratory facilities. We undertook this study to evaluate the magnitude of this overlooked problem, and to evaluate the effectiveness of a prevention program implemented in our clinic. METHODS: A retrospective study consisting of chart reviews and telephone interviews of consecutive hypoglycemic events (blood glucose level < 70 mg/dL). The study cohorts, A and B, were extracted from our central laboratory database. Cohort A (from January 2008-September 2009) consisted of patients prior to--and cohort B (from October 2009-June 2011) subsequent to--the implementation of a prevention program involving blood glucose monitoring and adjustment of antidiabetic medications. Duration of each cohort was 21 months. For the purpose of this article, we use the acronym FEEHD (fasting-evoked en-route hypoglycemia in diabetes) to describe this overlooked form of hypoglycemia. RESULTS: Of a total of 1801 blood glucose test results retrieved, cohort A included a total of 55 hypoglycemic events in 51 patients (4 patients with 2 events each). Cohort B included a total of 23 hypoglycemic events in 22 patients (with 1 patient sustaining 2 events) out of a total of 2561 blood glucose test results retrieved. In cohort A, of 35 patients on antidiabetic medications who recalled fasting or probably fasting, there were 39 hypoglycemic events (2.2% frequency), compared with 18 events (0.7% frequency) in 17 patients in cohort B. This indicates a 68% risk reduction. The frequency of critical hypoglycemia (< 50 mg/dL) was more significantly reduced, from 11 events (0.6%) to 2 events (0.07%), indicating a risk reduction of 88%. CONCLUSION: This study showed a 68% risk reduction of FEEHD with implementation of the prevention program, and an 88% reduction of severe FEEHD (blood glucose level < 50 mg/dL). Reporting on the first prevention program of its kind, this is the first study to evaluate an overlooked safety problem in diabetes management. Clinicians should consider if fasting laboratory tests are in fact necessary, and when ordered, clinicians should properly instruct their patients on adequate blood glucose monitoring and adjustment of antidiabetic medications. We present the guidelines that proved effective in our program to help patients with diabetes and their clinicians avert this potentially harmful complication.

A new purpose for tattoos: medical alert tattoos.

Tattooing has gained a tremendous popularity for the past twenty years. The motivations that drive an individual to acquire a tattoo are plentiful. Tattooing has also found its way in the field of medicine (corneal tattooing, gastrointestinal tattooing during endoscopy, permanent make-up tattooing, scar camouflage or radiotherapy field marking...). An emerging application of tattooing is for the purpose of medical identification for conditions requiring special attention during emergency situations, such as patients with diabetes who may be found unconscious due to hypoglycaemia or with allergy to specific medication. This new phenomenon, (practiced by patients on their own without medical consultation) can be found on the Internet. We review here this practice, which is seemingly underreported in the medical literature with its advantages and potential drawbacks.

Tattooing: medical uses and problems.

Decorative tattooing is a custom thousands of years old and is growing in popularity today. Medical professionals may be less familiar with its medical applications-medical alert tattooing, reconstructive and cosmetic applications, endoscopic tattooing, corneal tattooing, tattooing in radiation oncology, and uses in forensic medicine. We review current medically related tattooing applications and discuss their potential risks and benefits.

Update on diabetes diagnosis: a historical review of the dilemma of the diagnostic utility of glycohemoglobin A1c and a proposal for a combined glucose-A1c diagnostic method.

The role of glycohemoglobin A1c (A1c) for the diagnosis of diabetes has been debated for over three decades. Recently, the American Diabetes Association (ADA) has recommended adding A1c as an additional criterion for diabetes diagnosis. In view of the continued debate about the diagnostic utility of A1c, and in view of the unabated burden of undiagnosed diabetes, the search for alternative diagnostic methods is discussed. A historical literature review is provided, in view of the new ADA diagnostic guidelines, and a proposal is provided for combining A1c and a glucose measurement as a diagnostic alternative/adjunct to the use of a single criterion. This proposal is based on the non-overlapping of the advantages and disadvantages of these individual tests. The cost-effectiveness of this method remains to be tested.

Role of ultrasonography in the differential diagnosis of thyrotoxicosis: a noninvasive, cost-effective, and widely available but underutilized diagnostic tool.

OBJECTIVE: To explore the use of ultrasonography as a diagnostic alternative to the traditional "gold standard" imaging study of nuclear scintigraphy in the evaluation of thyrotoxicosis. METHODS: We review the relevant literature and share our own experience to highlight the promising role of ultrasonography in thyrotoxicosis. In addition, we present a diagnostic algorithm suggesting liberal use of ultrasonography in the evaluation of thyrotoxicosis. RESULTS: Ultrasonography has proved effective not only in the differentiation of Graves disease from other types and causes of thyrotoxicosis but also in the detection of subtle thyroid nodules. The latter role is emphasized in light of the recent observation of an increased risk of occurrence of papillary thyroid carcinoma in patients with Graves disease. CONCLUSION: Ultrasonography is a cost-effective, noninvasive, portable, and safe imaging modality in the evaluation of thyrotoxicosis, both for physiologic assessment and for detection of nonpalpable thyroid cancers that may elude identification on physical examination and nuclear imaging studies. Although thyroid scintigraphy remains a standard radiologic study, thyroid ultrasonography can be a practical alternative in many cases and the primary imaging modality in some situations such as during pregnancy and lactation and for evaluation and management of amiodarone-induced thyrotoxicosis.