Constructing Health State Descriptions for Low-Risk Thyroid Cancer: Stakeholder Engagement and Formative Qualitative Research.

OVERVIEW: This paper describes stakeholder involvement and formative qualitative research in the creation of health state descriptions (HSDs) or vignettes for low-risk thyroid cancer. The aim of this project was to engage stakeholders in the contribution of a novel set of HSDs, an important first step in the process of assessing value in thyroid cancer health states. METHODS: We draw upon formative, descriptive qualitative methods, following a multi-stage framework of data collection. We conducted individual semi-structured interviews, cognitive interviews, and focus groups with thyroid cancer patients, community providers, academic subspecialists, and participants with no thyroid cancer diagnosis (N = 31). The HSDs went through several iterations over the course of a year, in collaboration with a highly engaged community advisory board, laying the groundwork for HSDs that are comprehensible, comparable, and appropriate for stated-preference research. FINDINGS: Thyroid cancer survivors compared their experiences with those described in the HSDs. Feedback included concern for the emotional well-being of study participants who would be reading them. Providers were attuned to the need for clinical accuracy and made suggestions to reflect their clinical experience, including for patients with complications or disease progression. The pilot participants with no thyroid cancer were particularly valuable in promoting the need to simplify language and maximize readability. DISCUSSION: Stakeholder engagement was critical to being responsive to feedback as the iterations were refined and presented. Continuous engagement and consultation with multiple sources strengthened the HSDs. A secondary outcome from this project is that stakeholders expressed interest in adapting the HSDs into decision aids for people newly diagnosed with low-risk thyroid cancer.

Insulin Pump and Continuous Glucose Monitor Initiation in Hospitalized Patients with Type 2 Diabetes Mellitus.

BACKGROUND: Insulin pumps and continuous glucose monitoring (CGM) are commonly used by patients with diabetes mellitus in the outpatient setting. The efficacy and safety of initiating inpatient insulin pumps and CGM in the nonintensive care unit setting is unknown. MATERIALS AND METHODS: In a prospective pilot study, inpatients with type 2 diabetes were randomized to receive standard subcutaneous basal-bolus insulin and blinded CGM (group 1, n = 5), insulin pump and blinded CGM (group 2, n = 6), or insulin pump and nonblinded CGM (group 3, n = 5). Feasibility, glycemic control, and patient satisfaction were evaluated among groups. RESULTS: Group 1 had lower mean capillary glucose levels, 144.5 ± 19.5 mg/dL, compared with groups 2 and 3, 191.5 ± 52.3 and 182.7 ± 59.9 mg/dL (P1 vs. 2+3 = 0.05). CGM detected 19 hypoglycemic episodes (glucose <70 mg/dL) among all treatment groups, compared with 12 episodes detected by capillary testing, although not statistically significant. No significant differences were found for the total daily dose of insulin or percentage of time spent below target glucose range (<90 mg/dL), in target glucose range (90-180 mg/dL), or above target glucose range (>180 mg/dL). On the Diabetes Treatment Satisfaction Questionnaire-Change, group 3 reported increased hyperglycemia and decreased hypoglycemia frequency compared with the other two groups, although the differences did not reach statistical significance. CONCLUSIONS: Insulin pump and CGM initiation are feasible during hospitalization, although they are labor intensive. Although insulin pump initiation may not lead to improved glycemic control, there is a trend toward CGM detecting a greater number of hypoglycemic episodes. Larger studies are needed to determine whether use of this technology can lower inpatient morbidity and mortality.

The Effect of Continuous Glucose Monitoring in Preventing Inpatient Hypoglycemia in General Wards: The Glucose Telemetry System.

BACKGROUND: Few studies have examined the use of continuous glucose monitoring (CGM) devices in the general wards. The aim of this pilot study was to examine whether CGM readings can be successfully transmitted from the bedside to a central monitoring device in the nursing station, and whether a glucose telemetry system can prevent hypoglycemic events. METHODS: We present pilot data on 5 consecutive insulin treated general medicine patients with type 2 diabetes (T2DM) whose glucose values were observed with CGM (DEXCOM) and the results were transmitted to a central nursing station monitoring system using DEXCOM Follow and Share 2 software. CGM alarms were set-up at glucose <85 mg/dl. RESULTS: Duration of CGM observation was 4.0 ± 1.6 days (mean ± SD). During CGM, the overall time spent within blood glucose (BG) target of 70-179 mg/dl was 64.68 ± 15% (mean ± SD), on hypoglycemia (<70 mg/dl) was 0.30% ± 0.39, and time spent on hyperglycemia (≥180 mg/dl) was 35.02% ± 15.5. Two patients had 3 actions of prevention of potential hypoglycemia (CGM BG <70 mg/dl for >20 minutes) captured by alarm. No patients had CGM glucose value <54 mg/dl. CONCLUSIONS: This pilot study indicates that the use of CGM values in hospitalized patients can be successfully transmitted to a monitoring device in the nursing station, improving patient surveillance in insulin treated patients with diabetes.

Renal Transplant-Associated Thyroid Tuberculosis.

Tuberculosis is common among solid-organ transplant recipients, including renal transplants. Tuberculosis of the thyroid gland is a rare diagnosis. We report on a renal transplant recipient with subacute fever associated with a neck mass diagnosed as thyroid tuberculosis. No prior publication has reported a case of posttransplant thyroid tuberculosis. This is an important diagnostic consideration, in addition to malignant transformation, in the posttransplant setting.

Inpatient Continuous Glucose Monitoring and Glycemic Outcomes.

Continuous glucose monitoring (CGM) is commonly used in the outpatient setting to improve diabetes management. CGM can provide real-time glucose trends, detecting hyperglycemia and hypoglycemia before the onset of clinical symptoms. In 2011, at the time the Endocrine Society CGM guidelines were published, the society did not recommend inpatient CGM as its efficacy and safety were unknown. While many studies have subsequently evaluated inpatient CGM accuracy and reliability, glycemic outcome studies have not been widely published. In the non-ICU setting, investigational CGM studies have commonly blinded providers and patients to glucose data. Retrospective review of the glucose data reflects increased hypoglycemia detection with CGM. In the ICU setting, data are inconsistent whether CGM can improve glycemic outcomes. Studies have not focused on hospitalized patients with type 1 diabetes mellitus, the population most likely to benefit from inpatient CGM. This article reviews inpatient CGM glycemic outcomes in the non-ICU and ICU setting.

Potency and fate specification in CNS stem cell populations in vitro.

To realize the promise of stem cell biology, it is important to identify the precise time in the history of the cell when developmental potential is restricted. To achieve this goal, we developed a real-time imaging system that captures the transitions in fate, generating neurons, astrocytes, and oligodendrocytes from single CNS stem cells in vitro. In the presence of bFGF, tripotent cells normally produce specified progenitors through a bipotent intermediate cell type. Surprisingly, the tripotent state is reset at each passage. The cytokine CNTF is thought to instruct multipotent cells to an astrocytic fate. We demonstrate that CNTF both directs astrogliogenesis from tripotent cells, bypassing two of the three normal bipotent intermediates, and later promotes the expansion of specified astrocytic progenitors. These results show how discrete cell types emerge from a multipotent cell and provide a strong basis for future studies to determine the molecular basis of fate specification.