Treatment of acute pulmonary embolism as outpatients or following early discharge. A systematic review.

The purpose of this systematic review is to test the hypothesis that carefully selected low-risk patients with acute pulmonary embolism (PE) can safely be treated entirely as outpatients or after early hospital discharge. Included articles were required to describe inclusion or exclusion criteria and outcome of patients treated for PE. Early hospital discharge was defined as an average hospital stay < or = 3 days. Six investigations included patients with PE who were treated entirely as outpatients; two investigations included patients with PE who were treated after early discharge. All investigations included only low-risk patients or patients with small or medium sized PE. Outcome after 3-46 months in patients treated entirely as outpatients showed recurrent PE in 0% to 6.2% of patients, major bleeding in 0% to 2.8% with one death from an intracerebral bleed. Definite death from PE did not occur, but there was one possible death from PE. Outcome in three months in patients treated after early discharge showed no instances of recurrent PE. Major bleeding occurred in 0% to 3.7% of patients. There were no deaths from PE, but there was one death from bleeding. In conclusion, outpatient therapy of acute PE is probably safe in low-risk, carefully selected compliant patients who have access to outpatient care if necessary. Such outpatient treatment would be cost-effective.

Photoplethysmography: a simplified method for the office measurement of ankle brachial index in individuals with diabetes.

OBJECTIVE: To compare the use of photoplethysmography (PPG) and Doppler techniques to measure the ankle brachial index (ABI) for the evaluation of peripheral arterial disease (PAD) in individuals with diabetes. METHODS: Consecutive patients with diabetes (n = 103) referred for PAD evaluation had ABI measured by PPG and Doppler techniques in our diabetes center. Medical records were reviewed, and the results of the Doppler and PPG testing were compared. RESULTS: Mean age was 60 years, 57% were female, and 79% had type 2 diabetes with an average duration of 17 years. PPG readings could not be obtained in 3 individuals. Of 200 limbs evaluated, 17 (8.5%) had noncompressible (NC) vessels by both techniques. In the remaining 183 limbs, the correlation coefficient comparing the two methods was 0.864. Mean ABI values were 1.11 ± 0.14 for Doppler and 1.12 ± 0.14 for PPG. The sensitivity of PPG compared to the Doppler technique for detection of an abnormal result was 88.2%, and the specificity was 99.4%. ABI results were classified as discordant if Doppler and PPG varied by more than 0.15, placing them in different diagnostic categories (abnormal low [≤0.9], borderline [0.91-0.99], normal [1.0-1.4], or abnormal high [>1.4 or NC vessels]). There were only 4 (2%) discordant results. CONCLUSIONS: We found excellent concordance between PPG and the gold standard Doppler technique for ABI measurement in individuals with diabetes. PPG requires less training and takes less time to perform, making it highly suitable for use in an office setting.

Markedly low hemoglobin A1c in a patient with an unusual presentation of beta-thalassemia minor.

OBJECTIVE: To describe very low hemoglobin A1c levels in a patient with type 2 diabetes mellitus and an unusual presentation of beta-thalassemia minor. METHODS: We present the clinical and laboratory findings of the study patient. RESULTS: A 64-year-old African American man with type 2 diabetes mellitus was referred to the endocrinology clinic with a hemoglobin A1c level of 1.6% despite elevated blood glucose concentrations. A red blood cell survival study with chromium-51 revealed that he had a reduced erythrocyte life span less than 25% of normal. He also had a markedly elevated reticulocyte count ranging from 236 to 534 x 10(3)/microL (reference range, 25-75 x 10(3)/microL). The laboratory findings, which are not characteristic of beta-thalassemia minor, could be the cause of the markedly low hemoglobin A1c in this patient. CONCLUSIONS: Although rare, when associated with marked erythrocyte turnover, beta-thalassemia minor can lead to a severe reduction in HbA1c levels. In this scenario, glycemic control is best assessed by measuring fructosamine.

Vitamin D and diabetes mellitus.

Better understanding of the physiological role of the vitamin-D system, in particular its potential effects on inflammatory and autoimmune conditions as well as on insulin secretion and possibly also on insulin resistance, increased the interest in its potential role in prevention and control of the diabetic condition, both type-1 and -2 diabetes. Both these conditions are associated with inflammation and type-1 diabetes also with an autoimmune pathology. Indeed, animal and human studies support the notion that adequate vitamin-D supplementation may decrease the incidence of type-1 and possibly also of type-2 diabetes mellitus and may improve the metabolic control in the diabetes state. However, the exact mechanisms by which vitamin-D and calcium supplementation exert their beneficial effects are not clear and need further investigation.

Venous thromboembolism in patients hospitalized with thyroid dysfunction.

The objective of this investigation is to explore a possible role of thyroid dysfunction in venous thromboembolism (VTE). The number of patients discharged from short-stay nonfederal hospitals in the United States, from 1979 to 2005, with a diagnostic code for hypothyroidism or hyperthyroidism, pulmonary embolism (PE), and deep venous thrombosis (DVT) was obtained from the National Hospital Discharge Survey (NHDS). Among 19,519,000 hospitalized patients discharged with a diagnosis of hypothyroidism from 1979 to 2005, 119,000 (0.61%) had PE. Among patients with no thyroid dysfunction, PE was diagnosed in 3,372,000 of 908,805,000 patients (0.37%; relative risk = 1.64, 95% CI 1.63-1.65). Deep venous thrombosis was diagnosed in 1.36% of hypothyroid patients and in 0.84% of patients with no thyroid dysfunction (relative risk = 1.62, 95% CI 1.61-1.62). The relative risk of PE in patients with hypothyroidism was highest in patients <40 years of age (relative risk = 3.99) and the relative risk of DVT was also highest in patients <40 years (relative risk = 2.25). Hyperthyroidism was not associated with an increased risk of VTE (relative risk = 0.98, 95% CI = 0.96-1.01). In conclusion, an increased risk of PE, DVT, and VTE was shown in patients with hypothyroidism but not hyperthyroidism. Antithrombotic prophylaxis in patients with severe hypothyroidism, however, should be viewed with caution because of a possible hyperfibrinolytic state in such patients.