Impact of a Hyperkalemia Protocol Tailored to Glucose Concentration and Renal Function on Insulin-Induced Hypoglycemia in Patients with Low Pretreatment Glucose.

BACKGROUND: Hyperkalemia is a common electrolyte abnormality that requires urgent treatment. Insulin is an effective treatment for hyperkalemia, but risk factors for developing insulin-induced hypoglycemia exist (e.g., low pretreatment glucose or renal impairment). OBJECTIVE: This study evaluated the impact of a hyperkalemia protocol tailored to glucose concentration and renal function on insulin-induced hypoglycemia. METHODS: This was a retrospective cohort study of emergency department patients with glucose ≤ 100 mg/dL treated with insulin for hyperkalemia. The primary outcome was incidence of hypoglycemia in patients treated prior to (July 1, 2018-June 30, 2019) vs. after (January 1, 2020-December 31, 2020) the protocol update, which individualized insulin and dextrose doses by glucose concentration and renal function. Secondary outcomes included change in potassium and protocol safety. We assessed factors associated with hypoglycemia using multiple logistic regression. RESULTS: We included 202 total patients (preimplementation: 114, postimplementation: 88). Initial insulin dose was lower in the postimplementation group (p < 0.001). We found a nonsignificant reduction in hypoglycemia in the postimplementation group (42.1% vs. 30.7%, p = 0.10). Degree of potassium reduction was similar in patients who received insulin 5 units vs. 10 units (p = 0.72). Higher pretreatment glucose (log odds ratio [OR] -0.05, 95% confidence interval [CI] -0.08 to -0.02) and additional insulin administration (log OR -1.55, 95% CI -3.01 to -0.25) were associated with reduced risk of developing hypoglycemia. CONCLUSION: A hyperkalemia protocol update was not associated with a significant reduction in hypoglycemia, and the incidence of hypoglycemia remained higher than anticipated. Future studies attempting to optimize treatment in this high-risk population are warranted.

Uniparental disomy of multiple chromosomes in two cases with a complex phenotype.

Uniparental disomy (UPD) is the inheritance of both chromosomal homologs from one parent. Depending on the chromosome involved and the parental origin, UPD may result in phenotypic abnormalities due to aberrant methylation patterns or unmasking recessive conditions in isodisomic regions. UPD primarily originates from somatic rescue of a single meiotically-derived aneuploidy, most commonly a trisomy. Double UPD is exceedingly rare and triple UPD has not been previously described. Here, we report two unrelated clinical cases with UPD of multiple chromosomes; an 8-month-old male with maternal isodisomy of chromosome 7 and paternal isodisomy of chromosome 9, and a 4-week-old female with mixed paternal UPD for chromosomes 4, 10, and 14. These cases also demonstrate that although extremely rare, the detection of AOH on two or more chromosomes may warrant additional clinical and laboratory investigation such as methylation and STR marker analysis, especially when involving chromosomes known to be associated with imprinting disorders.

Mohs Micrographic Surgery for the Treatment of Merkel Cell Carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare, aggressive malignant neoplasm. Traditionally, wide local excision has been used for local control. However, the tissue-sparing capability of Mohs micrographic surgery (MMS) and the greater certainty of complete tumor removal offer a potential advantage over wide local excision if MMS offers acceptable cure rates. OBJECTIVE: This study aims to help elucidate management of MCC and includes one of the largest groups of patients from a single institution. MATERIALS AND METHODS: This study is a retrospective chart review of 22 patients with cutaneous MCC treated with MMS at our practice over 20 years. Clinical characteristics and outcomes were examined. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in the approval by our institution's human research review committee. RESULTS: The overall local recurrence rate was 5% (1/22). The overall rate of biopsy-proven metastasis to regional lymph nodes was 14% (3/22). No cases of distant metastases were documented. CONCLUSION: To our knowledge, this is the largest group of patients with MCC treated with MMS from a single institution and indicates that MMS may be a useful treatment modality for this rare aggressive disease.

Perceptions of near-peer teaching in a pharmacy skills-based laboratory.

OBJECTIVE: To assess the perception of students, faculty, and previous lab coaches on a near-peer teaching model integrated into a skills-based laboratory. METHODS: As part of a longitudinal near-peer teaching experience, third professional year students are utilized as lab coaches in a skills-based laboratory course. Lab coaches deliver lectures, provide feedback, facilitate activities, and assist with class preparation spanning 2 semesters for first and second professional year students. Students enrolled in the courses received an anonymous 12-question survey to assess the comfort and helpfulness of feedback when working with a lab coach and faculty during the 2021-2022 academic year. Statistical analysis was conducted using descriptive and inferential statistics for survey questions, and thematic analysis for open-ended responses. Semi-structured interviews with previous lab coaches and faculty were conducted, and thematic analysis was utilized for the responses. RESULTS: The student survey had an 81.4% response rate (n = 114). Students were significantly more comfortable working with and asking questions to a lab coach than a faculty instructor (mean [SD] of 4.78 [0.66] vs 4.44 [0.75]). Nine (75%) previous lab coaches and 6 (43%) faculty members were also interviewed. A total of 6 themes regarding perceptions of the lab coach position emerged: positive impact on personal and professional development; relationship building; rewarding experience recommended to others; robust teaching experience; struggles and challenges faced by both faculty and lab coaches; appreciation of the position by faculty. CONCLUSION: Implementing near-peer teachers into a pharmacy skills-based laboratory was very well received by students, previous lab coaches, and faculty.