Intensification patterns and the probability of HbA1c goal attainment in Type 2 diabetes mellitus: real-world evidence for the concept of 'intensification inertia'.

AIMS: To assess the effects of 'clinical' and 'intensification inertia' by evaluating the impact of different intensification interventions on the probability of HbA1c goal attainment using real-world data. METHODS: Electronic health records (Cleveland Clinic, 2005-2016) were used to identify 7389 people with Type 2 diabetes mellitus and HbA1c ≥53 mmol/mol (≥7.0%), despite a stable regimen of two oral antihyperglycaemic drugs for ≥6 months. The participants were stratified by index HbA1c and analysed over a 6-month period for pharmacological intensification, and then for 12 additional months for HbA1c goal attainment (<53 mmol/mol). RESULTS: The probability of HbA1c goal attainment (Kaplan-Meier analysis) in the group with index HbA1c 53-63 mmol/mol (7.0-7.9%) was highest with the addition of oral antidiabetic drugs [57.3% (95% CI 52.1, 62.0)] or glucagon-like peptide-1 receptor agonists [56.7% (95% CI 40.4, 68.6)], in the 64-74 mmol/mol (8.0-8.9%) group with the addition of oral antidiabetic drugs [31.9% (95% CI 25.1, 38.1)] or insulin [30.6% (95% CI 18.3, 41.0)], and in the ≥75 mmol/mol (≥9.0%) group with the addition of glucagon-like peptide-1 receptor agonists [53.0% (95% CI 31.8, 67.6)] or insulin [43.5% (95% CI 36.4, 49.8)]. CONCLUSIONS: Numerical, but not statistically significant, differences in HbA1c goal attainment probability by type of intensification were most marked in people with the highest index HbA1c [≥75 mmol/mol (≥9.0%)]; in this group, injectable therapy showed trends toward greater glycaemic control benefits. Additional research into the phenomenon of intensification inertia is warranted.

A genotype of exceptional longevity is associated with preservation of cognitive function.

OBJECTIVE: To test whether cholesterol ester transfer protein (CETP) genotype (VV homozygosity for I405V) is associated with preservation of cognitive function in addition to its association with exceptional longevity. METHODS: We studied Ashkenazi Jews with exceptional longevity (n = 158; age 99.2 +/- 0.3 years) for the associations of CETP VV genotype and lipoprotein phenotype, using the Mini-Mental State Examination (MMSE). To confirm the role of CETP in a younger cohort, we studied subjects from the Einstein Aging Study (EAS) for associations between CETP VV and cognitive impairment. RESULTS: Subjects with MMSE > 25 were twice as likely to have the CETP VV genotype (29% vs 14%, p = 0.02), and those with the VV genotype were more likely (61% vs 30%, p = 0.02) to have MMSE > 25. Subjects with the VV genotype had lower levels of CETP (1.73 +/- 0.11 vs 2.12 +/- 0.10 mug/mL, p = 0.01), higher high-density lipoprotein (HDL) levels (p = 0.02), and larger lipoprotein particles (p = 0.03). In the EAS cohort, an approximately fivefold increase in the VV genotype (21% vs 4%, p = 0.02), higher HDL levels, and larger lipoprotein particle sizes were associated with less dementia and improved memory. CONCLUSIONS: Using two independent cohorts, we implicate the longevity CETP gene as a modulator of age-related cognitive function. A specific CETP genotype is associated with lower CETP levels and a favorable lipoprotein profile. It has not been determined whether modulation of this gene prevents age-related decline or AD.

The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old.

PURPOSE: Testicular microlithiasis is an imaging entity of the testicle thought to be a marker of testicular cancer. To our knowledge the prevalence of testicular microlithiasis in an asymptomatic population at risk for testicular cancer is unknown. We report an ultrasound screening study done to establish the prevalence of testicular microlithiasis in an asymptomatic population. MATERIALS AND METHODS: Healthy men 18 to 35 years old from the annual Army Reserve Officer Training Corps training camp volunteered for study. A screening genitourinary history was obtained, and physical examination and screening scrotal ultrasound were performed. We defined testicular microlithiasis as more than 5 high intensity signals on ultrasound with each signal larger than 2 mm. We categorized testicular microlithiasis into microcalcifications that were scant-5 to 25 per side, moderate-greater than 25 per side but no areas of near confluence and too numerous to count. In all subjects with testicular microlithiasis tumor markers were also measured. RESULTS: Of 1,504 evaluated men with a mean age of 22.4 years, 84 (5.6%) had testicular microlithiasis, including 45 of 1,053 white (4%), 21 of 149 black (14.1%), 6 of 71 Hispanic (8.5%), 3 of 54 Asian or Pacific Island (5.6%) men and 9 of 174 (5.2%) who claimed no race affiliation. Tumor markers were normal in all subjects with testicular microlithiasis. CONCLUSIONS: Testicular microlithiasis occurs in more than 5% of healthy young men. In contrast, testicular cancer develops in 3/100,000 to 5/100,000 men or 1,000-fold less often. The relative prevalence of testicular microlithiasis with respect to testicular cancer, increased prevalence in minorities, bilateral distribution, and inverse geographic distribution of men with testicular microlithiasis and testicular cancer represent evidence against an association of the 2 conditions. This study indicates that testicular microlithiasis is a common finding in asymptomatic men that may not be related to testicular cancer.

Thyroid palpation versus high-resolution thyroid ultrasonography in the detection of nodules.

Detection of thyroid nodules by physical examination and high-resolution ultrasonography was compared using small groups of blinded, experienced physician examiners working with a sample of 2441 persons from Estonia, most of whom were Chernobyl nuclear reactor clean-up workers. A random subsample of 113 (5%) persons was subjected to triple control examinations with both physical examination and high-resolution ultrasonography. Positive high-resolution ultrasonographic findings were considerably more reproducible among different observers than were positive physical examination findings. Agreement between methods was poor. Nodules were found in 169 (6.9%) subjects by physical examination and in 249 (10.2%) subjects by high-resolution ultrasonography. Physical examination found only 53 (21%) of the 249 nodules found by high-resolution ultrasonography. High-resolution ultrasonography did not confirm the existence of 115 (68%) of the 169 nodules found by physical examination. Only 6.4% of nodules less than 0.5 cm in diameter, as based on high-resolution ultrasonographic results, were detected by physical examination. Physical examination detection improved with increasing nodule size but was still only 48.2% for nodules larger than 2 cm. Physical examination was relatively effective in detecting nodules in the isthmus of the thyroid gland but much less so for nodules in the upper pole of the gland. Clinical evaluation and epidemiologic studies of nodular thyroid disease stand to benefit from the greater sensitivity and specificity of ultrasonographic examinations.

Congenital absence of the major salivary glands and impaired lacrimal secretion in a child: case report.

The case of a 5-year-old girl with a lifelong history of xerostomia, poor dentition and decreased lacrimal gland secretion is presented. To our knowledge, this is the youngest reported patient with such symptoms and the first case confirmed with magnetic resonance imaging.

Quantitative perfusion imaging assessing acquired discrete peripheral pulmonary artery stenosis.

We present the case an 8-yr-old boy evaluated for anastomotic stenosis of the right pulmonary artery after surgical repair of hemitruncus at 6 wk of age. Pulmonary angiography revealed only mild narrowing and a 10-mm pressure gradient across the anastomosis, but quantitative perfusion imaging demonstrated that the right lung only received 16% of pulmonary blood flow. Subsequently, balloon angioplasty of the anastomotic site was performed, resulting in complete resolution of the stenosis and gradient. Early postangioplasty perfusion imaging demonstrated increased perfusion of the right lung to 35% of total pulmonary blood flow. It is theorized that initially a chronically hyperperfused lung may develop more capacious vessels and recruit new capillaries during the years of hyperperfusion such that a "perfect" angioplasty may result in less than symmetric perfusion. The inexpensive, noninvasive quantitative perfusion study is more sensitive and accurate in evaluating acquired (postsurgical) pulmonary artery stenoses.

Efficacy of follow-up bone scans in carcinoma of the prostate.

Three hundred fifteen radioisotopic bone scans ranging from initial scan only to nine scans per patient, performed on 114 patients with adenocarcinoma of the prostate between 1979 and 1984, were reviewed. Seventeen patients had positive scans, ten on initial scan and seven at follow-up. Nine patients had bone pain at the time of the first positive scan and pain developed in two patients 6 months and 2 years later, respectively. The other six patients are still asymptomatic 1 to 4 years later. False-positive scans were found in six other patients. No patient with bone pain had a negative scan. We believe that routine bone scans for prostate cancer follow-up are not cost-effective unless the patient is symptomatic. Bone scans also are indicated for initial staging and to observe disease response to protocol treatment.

Muscle necrosis in the extremities: evaluation with Tc-99m pyrophosphate scanning--a retrospective review.

A retrospective review was done of 34 extremities studied between 1981 and 1985 with technetium-99m pyrophosphate scanning; 22 were subsequently amputated. Results of detailed pathologic examination or immediate postoperative examination of the resected extremity were available in 16 cases. In these cases, scanning had allowed correct prediction of the level of amputation and of the specific areas of muscle infarction in 13 cases. In the one case in which amputation was performed for infection rather than muscle necrosis, the lack of necrosis was correctly predicted with the scan. The limited results of this study indicate that the Tc-99m pyrophosphate scan allows the location of necrotic muscle to be predicted accurately and may therefore be a useful adjunct in determining the best level for ultimate amputation. Special caution is required in those cases in which muscle necrosis is due to acute causes (e.g., traumatic thrombosis) rather than chronic vascular disease.

Effects of inversion on cardiovascular function: the bat scan.

This study was performed to measure the effect on cardiovascular functional parameters of remaining in an inverted position for a relatively short period of time. With the aid of radionuclide gated bloodpool scanning techniques, left ventricular ejection fraction (LVEF), heart rate (HR), systolic blood pressure (SBP), systolic average rate of left ventricular emptying (dV/dt), and double product (DP) measurement values were obtained from 16 normal, healthy subjects in four positions: supine, standing, half-inverted, and fully inverted. When comparing full-inversion to supine values, the HR and double product were not significantly different, the SBP was significantly higher, and the LVEF and dV/dt values were significantly lower. There were no significant differences between the partial and fully inverted positions. Comparison of standing to fully inverted positions reveals no significant change in SBP or double product. HR, LVEF, and dV/dt values were significantly lower in inverted subjects. It is suggested that these findings reflect the mechanism by which the cardiovascular system compensates for increased ventricular end-diastolic volume. Suggestions for future investigations include inverted cardiac ultrasound and right ventricular function studies.

The last surviving wall.

A total of 66 patients with advanced coronary artery disease (CAD) and 36 with dilated cardiomyopathies (DCM) with ejection fractions less than 20% were analyzed retrospectively to establish patterns of wall motion in each of four quadrants on standard left anterior oblique gated radionuclide ventriculograms. In both disease states the best preserved wall motion was found in the basal free wall quadrant of the left ventricle. The two terminal disease states could not be differentiated on the basis of wall motion patterns.

Craniotomy flap osteomyelitis: a diagnostic approach.

Nine cases of suspected craniotomy flap osteomyelitis evaluated by combined bone and gallium scanning are presented. In six cases, the clinical data were inconclusive and evaluation by radionuclide imaging provided an accurate negative diagnosis. The other three cases considered positive by this technique were proven infected at subsequent exploration and flap removal. The use of radionuclide bone and gallium imaging should be considered in cases of possible craniotomy flap osteomyelitis.

Vasospastic exercise-associated unilateral leg ischemia: evaluation with thallium-201.

Thallium 201 (Tl-201) as a marker of regional tissue perfusion is described as a diagnostic aid in a case of exercise-induced vasospastic disease affecting the lower leg of a physically active young adult male who had no evidence of atherosclerotic disease. The success and failure of various therapeutic attempts made in behalf of this patient have been monitored by repeated Tl-201 administrations. Exercise-associated ischemia in tissues other than the myocardium can be investigated with Tl-201.