Thyrotoxicosis and bilateral internal carotid artery dissections.

Cervical artery dissection is a rare but important diagnosis to consider in young patients presenting with stroke. Multiple etiologies of cervical artery dissections have been previously reported, but the association with thyrotoxicosis is extremely rare. A previously healthy 43-year-old female presented to the emergency department with new symptoms related to thyrotoxicosis and bilateral internal carotid artery dissections. Her atrial fibrillation and hypertension resolved by treating the underlying hyperthyroidism with methimazole and propranolol. The bilateral internal carotid artery dissections were managed conservatively with acetylsalicylic acid. Despite an initially poor prognosis, the patient made a complete recovery with resolution of her neurological symptoms.

Acute Kidney Injury Events in Patients With Type 2 Diabetes Using SGLT2 Inhibitors Versus Other Glucose-Lowering Drugs: A Retrospective Cohort Study.

RATIONALE & OBJECTIVE: Sodium/glucose cotransporter 2 (SGLT2) inhibitors slow the progression of chronic kidney disease and prevent heart failure events. However, SGLT2 inhibitors may increase the risk for acute kidney injury (AKI). Our objective was to assess whether SGLT2 inhibitor use, compared with all other glucose-lowering drugs (oGLDs), is associated with increased rates of AKI. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults in Manitoba, Canada, with type 2 diabetes mellitus followed up from June 2014 until March 2017. EXPOSURES: Initial SGLT2 inhibitor or oGLD use ascertained through a province-wide outpatient prescription database. OUTCOME: The primary outcome was incident AKI, identified either by an increase in serum creatinine level and/or hospital discharge codes for AKI while taking glucose-lowering drugs (on-treatment approach). ANALYTICAL APPROACH: A propensity score analysis was used to assemble groups of incident users of SGLT2 inhibitors and a 1:1 matched set of oGLD users. The rate of AKI was compared across matched groups using cause-specific hazards models. Sensitivity analyses considered exposure to be constant throughout follow-up after initiation of the drug treatment (intention-to-treat approach) or incorporated recurrent exposures (new user design). RESULTS: Comparing 4,778 incident users of SGLT2 inhibitors with 4,778 incident users of oGLDs, there were no differences observed in the primary outcome (HR, 0.64; 95% CI, 0.40-1.03; P = 0.06) using an on-treatment approach. In neither set of sensitivity analyses were SGLT2 inhibitors associated with increased risk for AKI. LIMITATIONS: Drug choice may have been related to AKI risk, laboratory data were obtained from clinical care, and changes in adverse event reporting may have followed the US Food and Drug Administration warning. There were insufficient data to compare individual SGLT2 inhibitors. CONCLUSIONS: Compared with oGLDs, SGLT2 inhibitors were not observed to be associated with increased risk for AKI in a clinical population-based cohort.

Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit.

OBJECTIVE: To assess safety and efficacy compared to a historical cohort. Clinical practice guidelines recommend that patients with diabetic ketoacidosis (DKA) be treated with a standardized protocol. We created a multifaceted order set to promote best-practice management of DKA. METHODS: We performed a retrospective cohort study of admissions to internal medicine for DKA in adults during a 4.5-year period; 2.25 years before and after order-set initiation. Groups were compared using independent samples t tests and Pearson chi-square or Fisher exact test (categorical data). The Mann-Whitney U test was used for continuous data not normally distributed. RESULTS: The order-set cohort consisted of 47 admissions, 72.3% with type 1 and 27.7% with type 2 diabetes. The historical cohort consisted of 59 admissions, 69.5% with type 1 and 30.5% with type 2 diabetes. There were no significant differences in initial laboratory values between patients with type 1 and type 2 diabetes in both cohorts. The median length of hospital stay approached significance in the order-set cohort: 3.53 days (2.5 to 5.1); in the historical cohort, the median length of stay was 4.6 days (2.44 to 8.99) (p=0.102). CONCLUSION: A standardized DKA order set was as effective and safe in type 1 and type 2 diabetes as individual physician management in an academic care setting. Further study is needed to assess its value in community hospital settings with less expertise and fewer diabetes specialty services.

A Systematic Review of Clinical Practice Guidelines' Recommendations on Levothyroxine Therapy Alone versus Combination Therapy (LT4 plus LT3) for Hypothyroidism.

PURPOSE: Patients with hypothyroidism are increasingly enquiring about the benefit of using combination therapy of levothyroxine (LT4) and liothyronine (LT3) as a potential treatment for hypothyroidism. Combination therapy, however, remains controversial. The purpose of this study was to systematically review available hypothyroidism treatment recommendations from clinical practice guidelines from around the world to identify the consensus regarding combination therapy. SOURCE: Clinical practice guidelines were obtained from searches of PubMed, EMBASE, and MEDLINE, using several combinations of MeSH terms. The search was limited to clinical guidelines in English-language publications, published between January 1, 1990 and May 1, 2015. A quantitative approach was utilized for data synthesis. PRINCIPAL FINDINGS: Thirteen guidelines were identified, including three regarding pregnancy, two regarding pediatric populations and eight regarding adult populations. There were six guidelines from North America, four guidelines from Europe and three guidelines from South America. Twelve of the guidelines were published after 2010. Nine guidelines addressed combination therapy of LT4 plus LT3, and all nine concluded that LT4 therapy alone is the standard of care, with insufficient evidence to recommend widespread combination therapy. Only the 2012 ETA Guidelines and the 2015 BTA Guidelines concluded that combination therapy could be used, although only in certain circumstances and as an experimental treatment. CONCLUSION: This systematic review illustrates that clinical practice guidelines worldwide do not recommend and do not support routine use of combination LT4 and LT3 therapy to treat hypothyroidism.