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1.
Curr Diab Rep ; 19(12): 158, 2019 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-31811400

RESUMO

PURPOSE OF REVIEW: To assess evidence to date for use of non-insulin agents in treatment of gestational diabetes mellitus. RECENT FINDINGS: There has been increasing interest in the use of non-insulin agents, primarily metformin and glyburide (which both cross the placenta). Metformin has been associated with less maternal weight gain; however, recent studies have shown a trend toward increased weight in offspring exposed to metformin in utero. Glyburide has been associated with increased neonatal hypoglycemia. Glycemic control during pregnancy is essential to optimize both maternal and fetal outcomes. There are a myriad of factors to consider when designing treatment programs including patient preference, phenotype, and glucose patterns. While insulin is typically recommended as first-line, some women refuse or cannot afford insulin and in those cases, non-insulin agents may be used. Further studies are needed to assess treatment in pregnancy, perinatal outcomes, and particularly long-term metabolic profiles in mothers and offspring.

2.
JBMR Plus ; 3(10): e10208, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31687644

RESUMO

Silicone/mineral oil-induced granulomas have been described as an inflammatory granulomatous response when silicone/mineral oil is injected for cosmetic purposes. These sclerosing granulomas can lead to hypercalcemia. Here we present a 33-year-old man with hypercalcemia, hypophosphatemia, progressively worsening fatigue, severe proximal muscle weakness, and depression. He had an athletic build with increased muscle bulk and several areas of indurated, nontender, firm, well-circumscribed lesions in the subcutaneous tissue of his anterior pectoralis, triceps, and biceps bilaterally because of injecting himself with silicone/mineral oil-based product into his muscles. Sclerosing granulomas were diagnosed on the MRI. He had extremely low or undetectable serum levels of 25-hydroxyvitamin D [25(OH)D], and persistently elevated serum levels of 1,25-dihydroxyvitamin D [1,25(OH)2D] and calcium. He developed hypophosphatemia associated with elevated levels of fibroblast growth factor 23 (FGF-23) and severe proximal muscle weakness. Treatment with systemic steroids, furosemide, calcitonin, ketoconazole, and denosumab resulted in a significant decrease in his serum calcium, but with minimal impact on his hypophosphatemia and fatigue.Correcting his severe vitamin D deficiency with small doses of vitamin D and raising his blood level of 25(OH)D from undetectable to 10 ng/mL without significantly affecting his serum calcium or phosphate was effective in reversing his severe proximal muscle weakness, permitting him to lift his head and to be free of his wheelchair. Although measurement of the 1,25(OH)2D level is not mandatory in all cases of hypercalcemia, it is indicated in a patient who has low serum PTH levels. Clinicians need to be aware that vitamin D deficiency can cause severe proximal muscle weakness such that the patient is unable to lift his head from his chest or ambulate. This may lead to a psychiatric disorder misdiagnosis. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

4.
Curr Diab Rep ; 19(4): 14, 2019 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-30806818

RESUMO

PURPOSE OF REVIEW: Several studies have demonstrated the benefits of glycemic control in the perioperative period and there is ongoing interest in development of systematic approaches to achieving glycemic control. This review discusses currently available data and proposes a new approach to the management of hyperglycemia in the perioperative period. RECENT FINDINGS: In a recent study, we demonstrated that early preoperative identification of patients with poorly controlled diabetes and proactive treatment through various phases of surgery improves glycemic control, lowers the risk of surgical complications, and decreases the length of hospital stay. Implementation of a perioperative diabetes program that systematically identifies and treats patients with poor glycemic control early in the preoperative period is feasible and improves clinical care of patients undergoing elective surgery.


Assuntos
Diabetes Mellitus/tratamento farmacológico , Hiperglicemia/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Assistência Perioperatória/métodos , Glicemia/análise , Glicemia/efeitos dos fármacos , Protocolos Clínicos , Diabetes Mellitus/etiologia , Procedimentos Cirúrgicos Eletivos , Estudos de Viabilidade , Hemoglobina A Glicada/análise , Humanos , Hiperglicemia/etiologia , Assistência Perioperatória/normas
5.
Endocr Pract ; 24(12): 1043-1050, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30289310

RESUMO

OBJECTIVE: The patterns of emergency department (ED) visits in patients with diabetes are not well understood. The Emergency Department Diabetes Rapid-referral Program (EDRP) allows direct booking of ED patients presenting with urgent diabetes needs into a diabetes specialty clinic within 1 day of ED discharge. The objective of this secondary analysis was to examine characteristics of patients with diabetes who have frequent ED visits and determine reasons for revisits. METHODS: A single-center analysis was conducted comparing patients referred to the EDRP (n = 420) to historical unexposed controls (n = 791). The primary outcome was the proportion of patients in each frequency group of ED revisits (none, 1 to 3 [infrequent], 4 to 10 [frequent], or >10 [superfrequent]) in the year after the ED index visit. Secondary outcomes were hospitalization rates and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses at ED revisits. RESULTS: Superfrequent users, responsible for >20% of total ED visits, made up small but not significantly different proportions of EDRP and control populations, 3.6% and 5.2%, respectively. Superfrequent groups had lower hospital admission rates at ED revisits compared to frequent groups. Mental health disorders (including substance abuse) were the primary, secondary, or tertiary ICD-9 codes in 30.6% (95% confidence interval [CI], 27.7% to 33.5%) and 6.6% (95% CI, 5.1% to 8.2%) in the superfrequent and infrequent groups, respectively. CONCLUSION: Direct access to diabetes specialty care from the ED is effective in reducing ED recidivism but not amongst a small subgroup of superfrequent ED users. This group was more likely to have mental health disorders recorded at ED revisits, suggesting that more comprehensive approaches are needed for this population. ABBREVIATIONS: EDRP = Emergency Department Diabetes Rapid-referral Program; ED = emergency department; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases-Ninth Revision.


Assuntos
Diabetes Mellitus , Serviço Hospitalar de Emergência , Hospitalização , Humanos , Alta do Paciente , Encaminhamento e Consulta , Estudos Retrospectivos
6.
Endocr Pract ; 22(10): 1161-1169, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27732094

RESUMO

OBJECTIVE: Patients who present to the emergency department (ED) for diabetes without hyperglycemic crisis are at risk of unnecessary hospitalizations and poor outcomes. To address this, the ED Diabetes Rapid-referral Program (EDRP) was designed to provide ED staff with direct booking into the diabetes center. The objective of this study was to determine the effects of the EDRP on hospitalization rate, ED utilization rate, glycemic control, and expenditures. METHODS: We conducted a single-center analysis of the EDRP cohort (n = 420) and compared 1-year outcomes to historic controls (n = 791). We also compared EDRP patients who arrived (ARR) to those who did not show (NS). The primary outcome was hospitalization rate over 1 year. Secondary outcomes included ED recidivism rate, hemoglobin A1c (HbA1c), and healthcare expenditures. RESULTS: Compared with controls, the EDRP cohort was less likely to be hospitalized (27.1% vs. 41.5%, P<.001) or return to the ED (52.2% vs. 62.3%, P = .001) at the end of 1 year. Total hospitalizations were also lower in the EDRP (157 ± 19 vs. 267 ± 18 per 1,000 persons per year, P<.001). The EDRP cohort had a greater reduction in HbA1c (-2.66 vs. -2.01%, P<.001), which was more pronounced when ARR patients were compared with NS (-2.71% vs. -1.37%, P<.05). The mean per patient institutional healthcare expenditures were lower by $5,461 compared with controls. CONCLUSION: Eliminating barriers to scheduling diabetes-focused ambulatory care for ED patients was associated with significant reductions in hospitalization rate, ED recidivism rate, HbA1c, and healthcare expenditures in the subsequent year. ABBREVIATIONS: ARR = arrived ED = emergency department EDRP = emergency department diabetes rapid-referral Program HbA1c = hemoglobin A1c NS = no show.


Assuntos
Acesso à Informação , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Serviço Hospitalar de Emergência/organização & administração , Acesso aos Serviços de Saúde , Hospitalização/estatística & dados numéricos , Educação de Pacientes como Assunto/organização & administração , Adulto , Assistência Ambulatorial/economia , Assistência Ambulatorial/métodos , Assistência Ambulatorial/organização & administração , Assistência Ambulatorial/estatística & dados numéricos , Glicemia/metabolismo , Estudos de Casos e Controles , Diabetes Mellitus/sangue , Diabetes Mellitus/economia , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hemoglobina A Glicada/análise , Custos de Cuidados de Saúde , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto/estatística & dados numéricos
7.
Curr Diab Rep ; 16(3): 33, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26957107

RESUMO

Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as "stress hyperglycemia" (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.


Assuntos
Anestesia , Hiperglicemia/tratamento farmacológico , Assistência Perioperatória , Estresse Fisiológico , Glicemia , Humanos , Período Perioperatório
9.
Curr Opin Endocrinol Diabetes Obes ; 22(4): 313-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26087343

RESUMO

PURPOSE OF REVIEW: Nelson's syndrome is a rare complication that can occur during the course of management of Cushing's disease. This article summarizes the recent literature on the diagnosis, monitoring and treatment of this potentially life-threatening outcome. RECENT FINDINGS: Nelson's syndrome, with rising adrenocorticotropin hormone levels and corticotroph tumor progression on diagnostic imaging, can develop following treatment of refractory Cushing's disease with total bilateral adrenalectomy with/without radiotherapy. However, data showing that radiotherapy prevents Nelson's syndrome is inconsistent. In addition to the treatment of Nelson's syndrome with neurosurgery with/without adjuvant radiotherapy, selective somatostatin analogs and dopamine agonists, as well as other novel agents, have been used with increasing frequency in treating cases of Nelson's syndrome with limited benefit. The risk-benefit profile of each of these therapies is still not completely understood. SUMMARY: Consensus guidelines on the evaluation and management of Nelson's syndrome are lacking. This article highlights areas in the surveillance of Cushing's disease patients, and diagnostic criteria and treatment regimens for Nelson's syndrome that require further research and review by experts in the field.


Assuntos
Síndrome de Nelson , Humanos , Síndrome de Nelson/diagnóstico , Síndrome de Nelson/etiologia , Síndrome de Nelson/terapia
10.
J Pediatr Rehabil Med ; 7(2): 179-92, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25096870

RESUMO

Some of the clinically significant causes of vitamin D deficiency in children are secondary to inadequate dietary intake, limited sun exposure, disease states causing malabsorption (celiac disease, gastric and small bowel resection, pancreatic insufficiency from cystic fibrosis) and altered metabolism secondary to medications. In utero and during childhood vitamin D deficiency can have a myriad of health consequences extending beyond musculoskeletal health to acute and chronic disease. In this review, it discusses the prevalence of vitamin D deficiency, clinical spectrum of disease presentations in children with emphasis in children with disabilities, vitamin D's role in bone and nonskeletal heath as well as recommendations for prevention and treatment of vitamin D deficiency.


Assuntos
Deficiência de Vitamina D , Vitamina D/análogos & derivados , Adolescente , Criança , Pré-Escolar , Crianças com Deficiência , Feminino , Humanos , Lactente , Gravidez , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/terapia , Vitamina D/metabolismo , Vitamina D/uso terapêutico , Deficiência de Vitamina D/complicações , Deficiência de Vitamina D/epidemiologia , Deficiência de Vitamina D/metabolismo , Deficiência de Vitamina D/terapia
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