Technetium-99m sestamibi imaging: are the results dependent on the reviewer?

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is dependent upon accurate preoperative parathyroid localization. We hypothesized that surgeon recognition of subtle differences in radiotracer accumulation would increase the sensitivity of technetium-99m sestamibi imaging and result in more frequent use of MIP. METHODS: Technetium-99m sestamibi scans completed at our institution for patients who underwent resection of a solitary parathyroid adenoma were reviewed by a surgeon and a radiologist who were blinded to patient identifying information, prior scan interpretation, and results of the operation. For each scan, the reviewer determined whether there was abnormal radiotracer accumulation and documented its location. Results were correlated with outcome of operation and final pathology. Blinded interpretations of the surgeon and radiologist were compared to each other and to the original radiologic interpretation. RESULTS: From 1994 to 2009, 274 patients with primary hyperparathyroidism (HPT) had sestamibi imaging prior to parathyroidectomy; 149 patients with a single adenoma underwent curative parathyroidectomy and had scans available for review. Seventeen radiologists who reviewed an average of 11 ± 14 scans (range = 1-61) completed the original interpretations of the sestamibi imaging. Sensitivity of sestamibi imaging was 86% for the blinded surgeon compared to 75% for the blinded radiologist and 69% for the original radiologists (P < 0.05). There was no difference in the false positive rates (blinded surgeon = 5%, blinded radiologist = 5%, original radiologists = 5%, P > 0.05). CONCLUSION: Radiologists were less likely to call a scan positive. Surgeon recognition of subtle anatomic asymmetry increases the sensitivity of sestamibi imaging and successful completion of MIP.

New-Onset Myasthenia Gravis Confirmed by Electrodiagnostic Studies After a Third Dose of SARS-CoV-2 mRNA-1273 Vaccine.

ABSTRACT: Coronavirus disease 2019 vaccine-related pathology is a rare occurrence with few reported cases. We report on a case of a 60-yr-old man experiencing symptoms of dysphagia, dysarthria, diplopia, and weakness with onset 6 days after receiving a third full dose of SARS-CoV-2 vaccine (mRNA-1273 vaccine) in August 2021, which he received outside of the Center for Disease Control recommended guidelines, at 4 mos after his second dose of the Moderna vaccination course in March 2021. The Food and Drug Administration Emergency Use Authorization for mRNA-1273 booster was established in October 2021.Over the next month, the patient's symptoms progressed including his inability to swallow, requiring hospitalization due to dehydration and malnutrition. Evaluation including laboratory prompted referral for electrodiagnostic studies consisting of repetitive nerve stimulation studies and needle electromyography, confirming a case of new onset bulbar myasthenia gravis.

Fenugreek Anaphylaxis in a Pediatric Patient.

Fenugreek (Trigonella foenum-graecum) is a food product that belongs to the Leguminosae family along with other legumes. It has been used in India, Greece, and Egypt for culinary and medical purposes since ancient times, and today, fenugreek is used for flavoring foods, dyes, and drugs throughout the world. Many members of the Leguminosae family have been associated with allergies including soybean, green pea, and peanut. Fenugreek is also included in this family and may result in allergic reactions. Two cases of anaphylaxis have been described in children after ingestion of curry and pastes that contain fenugreek, although the true nature of the causative agent was unclear. We report the first case of fenugreek anaphylaxis in a pediatric patient defined by skin testing, immunoglobulin E ImmunoCAP assays, and clear ingestion.

The Effectiveness of Motivational Interviewing on Glycemic Control for Adults with Type 2 Diabetes Mellitus (DM2): A Systematic Review.

REVIEW QUESTION/OBJECTIVE: The objective of this systematic review is to synthesize the best available evidence on the effects of motivational interviewing (MI) interventions (including adaptions of motivational interviewing [AMIs]) on the improvement of glycemic control in adults with type 2 diabetes. BACKGROUND: Worldwide, 346 million people have diabetes. With the growing prevalence of diabetes, controlling modifiable risk factors is essential to preventing complications and disease progression. The prevalence of type 2 diabetes is estimated to be double the present rate and by the year 2034 nearly 44 million Americans will have this preventable disease. In the United States (US), nearly 13 percent of adults aged 20 years and older have diabetes; this includes 25.8 million people, adults and children . Type 2 diabetes is more common in ethnic groups inclusive of African Americans, Latinos, Native Americans, and Asian Americans, Native Hawaiians and other Pacific Islanders. Diabetes is especially common in the elderly, 10.9 million or 26.9% of those aged 65 years and older have the disease. The US Centers for Disease Control and Prevention (CDC) estimates that 26% of US adults have impaired fasting glucose (IFG) of 100-125mg/dl and that 34% of adults meet the criteria for metabolic syndrome. An additional 35 % of adults have pre-diabetes, a condition marked by elevated blood sugar that is not yet in the diabetic range.Type 2 diabetes occurs when people have insulin resistance and insulin cannot be appropriately utilized for blood sugar regulation. Type 2 diabetes is characterised by impaired glucose tolerance. It can be defined by the criteria derived from the World Health Organization [WHO] that uses a single fasting glucose value of ≥ 126mg/dl or a single two hour glucose value of ≥ 200mg/dl. A laboratory blood test examining levels of glycosylated haemoglobin (HgbA1c) provides an estimated average blood glucose level over the past two-three months. An HbA1C level of 6.5% or higher can indicate diabetes.Serious complications and premature death can ensue if type 2 diabetes is not treated. Collaboratively, the health care team and people with type 2 diabetes aim to manage this disease process, and lessen the risk of complications to the heart, blood vessels, nerves, eyes and kidneys. Comprehensive support, knowledge, multidisciplinary therapy and treatment modalities will enhance health outcomes and slow disease progression.The Healthy People 2020 initiative outlines several objectives to achieve these changes and cover a comprehensive assortment of disease specific management accountabilities including regular medical care and self-management education/training. Many behaviour change techniques and strategies are known to be successful, yet are seldom implemented in today's health care arena. Dieticians, diabetes educators, and nurse practitioners are in an excellent position to serve as change agents to assist patients with diabetes in making necessary lifestyle changes.Motivational interviewing (MI) is a well-known, scientifically tested method of counseling clients first described by Miller and further developed by Miller and Rollnick. Motivational interviewing is a useful intervention strategy in the treatment of lifestyle problems and diseases such as diabetes . MI is a client-oriented, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The four guiding principles of MI are: express empathy, develop discrepancies, roll with resistance, and support self-efficacy. Adaptation of motivational interviewing (AMI) utilises the basic elements of motivational interviewing and also includes a feedback component. In clinical research, most empirical studies have dealt with the efficacy of AMIs and no studies have addressed the efficacy of MI in its relatively pure form.In clinical practice, health care providers utilise AMIs solely or in combination with other approaches such as the transtheoretical model (TTM) to promote behavioural change. These techniques are often used in brief sessions to maximise time, cost and efficiency.Motivational interviewing has been shown to be effective in counseling patients towards behaviour change in smoking cessation , increasing exercise, and reducing alcohol consumption. While combined effect estimates including body mass index (BMI) show a significant effect for MI, combined effect estimates for cigarettes per day and glycosylated haemoglobin (HA1c) were not significant . Isolated effects of MI on BMI and/or HbA1c have not been identified. Strong clinical evidence suggests that patients with diabetes should achieve certain clinical goals such as lowering HbA1c to reduce morbidity and mortality. Motivational interviewing is a technique that is effective in behaviour change and could potentially be effective with achieving these goals. MI may lead to improved quality of life, health status and clinical outcomes for persons with type 2 diabetes through empowerment and supporting informed decision-making, self-care behaviors, and problem-solving, with active participation and collaboration with the interdisciplinary health care team.A search of the MEDLINE, DARE, CINHAHL, PROSPERO, Joanna Briggs and Cochrane Libraries of Systematic Reviews failed to locate a review conducted on this topic.

Telehealth in adult patients with congestive heart failure in long term home health care: a systematic review.

BACKGROUND: Congestive heart failure results in clinical signs of edema, shortness of breath, and decreased quality of life. The effective management of patients with congestive heart failure in long term home care settings is important in reducing rehospitalization, emergency department visits and improving quality of life. Telehealth interventions following hospital discharge in various settings have been reported in the published literature as having an impact on decreasing emergency department visits, rehospitalization and quality of life. The data on its effectiveness with patients in a long term home health agency program however, is limited. OBJECTIVE: The purpose of this systematic review was to find and report on the best available evidence related to the effectiveness of telehealth interventions on specific outcomes in adult patients with congestive heart failure in a long term home health care setting. SEARCH STRATEGY: The search strategy identified both published and unpublished literature in the English language from 1995 to 2010. A range of electronic databases were searched including CINAHL, MEDLINE, EMBASE and COCHRANE. INCLUSION CRITERIA: Adult patients 18 years and older with a diagnosis of congestive heart failure receiving long term care from a home health care agency were considered in this review. Interventions of interest were telemonitoring and telephone follow-up calls with usual care as the comparator. Outcome measures were rehospitalizations rates, emergency department visit rates, and patients' perceived quality of life. Randomized controlled trials and quasi-experimental studies addressing the interventions of interest were selected. DATA COLLECTION AND ANALYSIS: The included studies were evaluated independently by two reviewers for methodological quality using The Joanna Briggs institute appraisal and extraction tools. MAIN RESULTS: Three randomized controlled trials and two quasi-experimental studies with a total of 612 patients were included in the review. Two randomized controlled trials and one quasi-experimental study evaluated telemonitoring. One quasi-experimental study evaluated structured nursing and telephone visits and the other randomized control trial evaluated in-home visits supplemented by telephone calls. Among the telemonitoring studies only one had a statistically significant reduction in ED 12(26.1%) P =<0.001 and hospital admission rates 13(28.3%) P= <0.001. Two quasi-experimental trials showed improvement in quality of life but in one there was no comparison with the control group. The randomized controlled trial did not evaluate quality of life as an outcome. CONCLUSIONS: The results of this review were equivocal. Only one randomized control trial demonstrated statistically significant results in reducing emergency department visits and hospital readmissions, and the sample size for this study was small. IMPLICATIONS FOR PRACTICE: The key to improving quality of life and reducing emergency department and rehospitalization rates is to develop interventions that will be effective when implemented into practice. IMPLICATIONS FOR RESEARCH: Research evaluating the role of telehealth in the management of congestive heart failure patients in long term home care agency is in its infancy. There needs to be well designed randomized control trials with larger sample sizes, of longer duration, and appropriately powered to evaluate different interventions.