Evaluating the Emergency Department Observation Unit for the management of hyperglycemia in adults.

OBJECTIVE: To determine whether hyperglycemic patients can be successfully managed in the Emergency Department Observation Unit (EDOU), as determined by the frequency of inpatient admission following their EDOU stay. METHODS: This was a retrospective chart review of patients≥18years presenting to an academic tertiary care ED between May 1, 2014 and May 31, 2016, found to have a glucose≥300mg/dL, and selected for EDOU admission. Patient demographic information, lab results including an HbA1c, disposition, and hospital revisits within 30days of discharge were recorded. RESULTS: There were 124 EDOU patients meeting criteria. A total of 98/124 (79.0%) had a history of type 1 or 2 diabetes, and 26/124 (21.0%) were newly diagnosed with diabetes in the EDOU. The mean initial ED serum glucose was 467±126mg/dL. Of the 119 patients with HbA1c analyzed, the mean value was 12.1±2.2% (109±24mmol/mol) and in 112/119 (94.1%) the level was ≥9.0% (75mmol/mol). Overall, 104/124 (83.9%) were discharged from the EDOU, 18/124 (14.5%) were admitted to the inpatient service, and 2/124 (1.6%) left the EDOU against medical advice. A total of 7/124 (5.6%) patients returned to the ED within 30days of discharge with hypoglycemia, hyperglycemia, or diabetic ketoacidosis, 6/7 (85.7%) of whom had been discharged from the EDOU. CONCLUSIONS: Results suggest hyperglycemic patients selected by ED physicians can be managed in the EDOU setting. Nearly all patients managed in the EDOU for hyperglycemia had an HbA1c≥9.0%, suggesting unrecognized or poorly controlled chronic diabetes as the basis for hyperglycemia.

Hypoestrogenism does not mediate social suppression of cortisol in subordinate female marmosets.

Behaviorally subordinate female marmosets undergo social suppression of ovulation and hypoestrogenism, as well as chronic reductions in circulating basal cortisol concentrations. Because estrogen elevates hypothalamic-pituitary-adrenal axis activity and circulating glucocorticoid levels in other species, we tested the hypothesis that socially induced hypoestrogenism contributes to cortisol reductions in subordinate female marmosets. We characterized morning basal plasma cortisol levels, as well as cortisol responses to exogenous adrenocorticotropic hormone (ACTH; 0, 1, or 10 microg/kg), in seven anovulatory subordinate females and six ovariectomized, non-subordinate females under two conditions: during long-term treatment with estradiol (E2) and control. Circulating E2 and cortisol levels were compared to those of six dominant females undergoing ovulatory cycles. Basal cortisol concentrations in the control condition were significantly lower in subordinates than in both dominant and ovariectomized females. E2 treatment elevated circulating E2 levels of subordinate and ovariectomized females into the range seen in dominant females but did not increase either mean basal or ACTH-stimulated cortisol levels. To the contrary, E2 treatment caused a decline in basal cortisol levels over time, especially in ovariectomized animals. These results indicate that treatment with exogenous estrogen does not elevate circulating cortisol levels in previously hypoestrogenemic female marmosets and, correspondingly that socially induced hypoestrogenism does not diminish cortisol levels in subordinate females.

Male marmoset monkeys express an adrenal fetal zone at birth, but not a zona reticularis in adulthood.

Neonatal human males produce high levels of dehydroepiandrosterone (DHEA) and its sulfo-conjugated form (DS) that decline within a few months of birth, due to regression of the adrenal fetal zone (FZ). Adult male humans and rhesus monkeys produce C19 steroids in abundance from the adrenal zona reticularis (ZR). Male marmoset monkeys produce DS at birth, but unlike humans and rhesus monkeys, do not produce comparable amounts of DHEA and DS in adulthood. To determine whether male marmosets express a functional ZR in adulthood, we examined adult and neonatal male marmosets for the presence of a ZR and FZ, respectively. Exogenous ACTH failed to stimulate DHEA or DS in adults, and dexamethasone treatment failed to suppress DHEA and DS, although cortisol levels changed as expected. In steroidogenic tissues, the key proteins necessary to synthesize C19 steroids from pregnenolone are P450c17, 3beta-hydroxysteroid dehydrogenase (3beta-HSD), nicotinamide adenine dinucleotide phosphate (reduced) oxido-reductase cytochrome P450 (reductase), and cytochromeb5 (cytb5). Adult adrenal cross sections showed P450c17 and reductase protein expression throughout the cortex but showed no expected decrease in 3beta-HSD and increase in cytb5 in the innermost region. Western analysis confirmed these data, demonstrating comparable P450c17 expression to rhesus monkeys, but not cytb5. HPLC analysis revealed similar 17alpha-hydroxylase action on pregnenolone for adult marmoset and rhesus adrenal microsomes but greatly diminished 17,20-lyase activity in marmosets. Neonatal marmoset adrenals exhibited staining indicative of a putative FZ (with P450c17, reduced 3beta-HSD and increased cytb5). We conclude that neonatal marmosets exhibit a C19 steroid-secreting FZ similar to humans, but adult males fail to acquire a functional ZR.