A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools.

OBJECTIVE: To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma. METHODS: Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care. RESULTS: We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV1% predicted and FEV1/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively). CONCLUSIONS: Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03032744.

[Proinsulin: physiology, measurement, and interest in clinical biology]. / La pro-insuline : physiologie, dosage et intérêt en biologie clinique.

The proinsulin molecule results from the cleavage of pre-pro-insulin, produced in pancreatic beta cells. Its subsequent -cleavage allows the release of insulin, the key hormone of glycemia regulation and C-peptide in equimolar proportions. During fasting trial, insulinoma diagnosis relies on inadequately high insulin and C-peptide serum levels concomitant with an hypoglycemia. In this context, proinsulin assay can be interesting in the cases of discrepancy between the two parameters. In diabetes, endoplasmic reticulum stress and beta cells inflammation, lead to the secretion of misfolded proinsulin molecules. Thus, in type 2 diabetes, proinsulin/insulin ratio increases with the degree of insulin resistance. In type 1 diabetes, proinsulin/C-peptide ratio could predict the onset of diabetes in relatives. In our practice, serum pro-insulin determined using an Elisa immunoassay (Millipore®) during fasting trial can be complementary to C-peptide and insulin assays in relation to glycemia to label an hypoglycemia. In case of glucose intolerance and diabetes, proinsulin could thus be measured.

ACTH-secreting metastatic prostate cancer with neuroendocrine differentiation.

Cushing's syndrome (CS) due to ectopic adrenocorticotropic hormone (ACTH) secretion (EAS) can result from a variety of tumours and rarely from those of prostatic origin. We present a male patient in his early 60s with ACTH-secreting metastatic prostate adenocarcinoma with neuroendocrine differentiation (ICD-O code 8574/3) years after prostatectomy and androgen-deprivation therapy, initially presenting with Cushingoid features. After open radical prostatectomy and bilateral orchiectomy for disease recurrence, the patient was found to have metastatic liver and bone lesions highly suggestive of metastatic prostatic cancer. About 10% of cells on liver biopsy expressed ACTH, a finding consistent with EAS as the cause of CS. His stay was complicated with multiple infections and ultimate death. Hence, we report a case of metastatic prostate adenocarcinoma with neuroendocrine differentiation who presented with CS. We also emphasize the importance of adequate and timely treatment.

Diagnostic Performance of FDG-PET/CT Scan as Compared to US-Guided FNA in Prediction of Axillary Lymph Node Involvement in Breast Cancer Patients.

PURPOSE: The aim of this study was to evaluate the diagnostic ability of 2-deoxy-2-[fluorine-18]fluoro-d-glucose (18F-FDG) PET/non-contrast CT compared with those of ultrasound (US)-guided fine needle aspiration (FNA) for axillary lymph node (ALN) staging in breast cancer patients. PATIENTS AND METHODS: Preoperative 18F-FDG PET/non-contrast CT was performed in 268 women with breast cancer, as well as ALN dissection or sentinel lymph node (SLN) biopsy. One hundred sixty-four patients underwent US-guided FNA in combination with 18F-FDG PET/CT. The diagnostic performance of each modality was evaluated using histopathologic assessments as the reference standard. The receiver operating characteristic (ROC) curves were compared to evaluate the diagnostic ability of several imaging modalities. RESULTS: Axillary 18F-FDG uptake was positive in 180 patients, and 125 patients had axillary metastases according to the final pathology obtained by ALN dissection and/or SLN dissection. Of the patients with positive 18F-FDG uptake in the axilla, 21% had false-positive results, whereas 79% were truly positive. Eighty-eight patients had negative 18F-FDG uptake in the axilla, among which 25% were false-negative. 18F-FDG-PET/CT had a sensitivity of 86.59% and a specificity of 63.46% in the assessment of ALN metastasis; on the other hand, US-guided FNA had a sensitivity of 91.67% and a specificity of 87.50%. The mean primary cancer size (p = 0.04) and tumor grade (p = 0.04) in combination were the only factors associated with the accuracy of 18F-FDG PET/CT for detecting metastatic ALNs. CONCLUSION: The diagnostic performance of 18F-FDG PET/CT for the detection of axillary node metastasis in breast cancer patients was not significantly different from that of US-guided FNA. Combining 18F-FDG PET/CT with US-guided FNA or SLN biopsy could improve the diagnostic performance compared to 18F-FDG PET/CT alone.

Time trends and predictors of hypovitaminosis D across the life course: 2009-2016.

PURPOSE: We investigated prevalence, determinants, seasonal changes, and time trends in hypovitaminosis D. We derived a desirable serum 25-hydroxy-vitamin D (25OHD) level in adults/elderly by evaluating the 25OHD-parathyroid hormone (PTH) exponential relationship. METHODS: We analyzed serum 25OHD data from a large laboratory database (N = 151,705), from a major academic medical center in Lebanon, from 2009 to 2016. We used cross calibration formulas to convert measured 25OHD levels to LC-MS/MS equivalents based on our external quality assurance protocols. RESULTS: 6% of the population were children (mean age 11 ±â€¯5 years, 56% girls), 68% were adults (44 ±â€¯13 years, 71% women), and 25% were elderly (74 ±â€¯6 years, 59% women). The prevalence of hypovitaminosis D, in the entire population, was 39%, 29% and 23% at 25OHD cutoffs of 20 ng/ml, 15 ng/ml, and 12 ng/ml, respectively, across all years. Using multivariate analysis, predictors of 25OHD levels below 12, 15 and 20 ng/ml were younger age, male sex, winter months, and inpatient status both in adults and elderly. In children, older age, female sex, winter months, and inpatient status, predicted levels below 15 ng/ml and 20 ng/ml, but only older age, female sex, and winter months predicted levels below 12 ng/ml. There was a significant steady annual increase in 25OHD levels between 2009 and 2016 of 0.9 ng/ml/year (95% CI: 0.7, 1.0) in children, 1.2 ng/ml/year (1.2, 1.3) in adults and 2.6 ng/ml/year (2.6, 2.8) in the elderly. Using best fit non-linear regression models, on a subset of adults and elderly in whom concomitant 25OHD and PTH data was available (N = 4025), PTH levels plateaued at a serum 25OHD level of 26.1 ng/ml. CONCLUSION: Secular increase in serum 25OHD levels is observed in Lebanon, but hypovitaminosis D is still prevalent. Our data provides basis for a desirable 25OHD level above 26 ng/ml in adult and elderly Lebanese individuals.

Echocardiographic assessment of mitral valve regurgitation, pattern and prevalence, expanding clinical awareness through an institutional survey with the perspective of a quality improvement project.

BACKGROUND: Mitral regurgitation (MR) is frequently reported in everyday echocardiograms; accurate assessment is essential for appropriate management and decision making. OBJECTIVE: We performed a self-audit in order to define the prevalence and pattern of MR and to evaluate methods of assessment with the perspective of developing a quality improvement project. METHODS AND SETTING: This retrospective analytical study was conducted in a university hospital. INCLUSION CRITERIA: age more than 18 years and medical records available within the facility, including a "complete" medical history. Using the picture archiving and communication system, we reviewed 961 echocardiograms performed over a 6-month period. The methods of assessment of native mitral valve regurgitation were reported, and also relevant medical data were collected using an electronic archiving system. RESULTS AND DISCUSSION: Among the 961 patients reviewed, 322 (33.50%) had MR, with variable grades. MR pattern (organic versus functional) was not specified in 49.68% of cases. "Eyeball" assessment and "color jet area" were the most frequently used methods for MR assessment (90.06% and 27.95%, respectively), while "vena contracta" and "flow convergence" methods were rarely implemented (1.55% and 2.17%, respectively). Discussion is made according to current guidelines, while showing the strengths and weaknesses of each method. CONCLUSION: The prevalence of MR was 33.50%, and in nearly half of cases, the MR pattern was not specified. Qualitative and semi-quantitative methods of assessment were mostly used; quantitative assessment should be implemented more frequently, in accordance with current guidelines. Increasing clinical awareness by creating and implementing a quality improvement project is essential in this context.