Hypothyroidism is a commonly encountered clinical condition with variable prevalence. It has profound effects on cardiac function that can impact cardiac contractility, vascular resistance, blood pressure, and heart rhythm. With this review, we aim to describe the effects of hypothyroidism and subclinical hypothyroidism on the heart. Additionally, we attempt to briefly describe how hypothyroid treatment affects cardiovascular parameters. Thyroid hormone activation of THR-β induces angiogenesis by initiating the mitogen-activated protein kinase pathway. 4 Severe hypothyroidism can also cause pericardial effusion. Though the mechanism is unclear, increased capillary permeability and reduced lymphatic drainage from the pericardial space have been suggested. 4 Hypothyroidism can also be associated with a decrease in insulin sensitivity due to downregulation of glucose transporters and direct effects on insulin secretion and clearance. 6Heart Failure and HypothyroidismAs described earlier, hypothyroidism can affect cardiac contractility, which is often diastolic in nature, and impair cardiac muscle relaxation. Associated diastolic hypertension and sometimes-coexistent coronary artery disease further affect myocardial diastolic function.7 Cardiac echocardiography has demonstrated impaired relaxation in patients with overt and subclinical hypothyroidism. In addition, early impaired relaxation has been demonstrated by prolongation of the isovolumetric relaxation time and reduction in the E/A ratio in subclinical hypothyroidism.8 The E/A ratio is a ratio of early to late ventricular filling velocities, and a reduced E/A ratio signifies diastolic dysfunction from impaired relaxation. Consequently, it results in a state of low cardiac output with decreased heart rate and stroke volume. It is well known that protein-rich pericardial and/or pleural effusion often occurs in hypothyroidism as a result of increased vascular permeability. In advanced heart failure and shortly after myocardial infarction, the conversion of T4 to T3 decreases. Since T3 is the main regulator of gene expression in myocardial muscle, this decrease has been thought to affect myocardial contractility and remodeling.7 Low free T3 levels also have been associated with increased mortality in patients with heart disease. Arrhythmia and HypothyroidismIt is well known that hyperthyroidism is associated with atrial fibrillation (AF). Similarly, hypothyroidism is associated with increased cardiovascular risk factors as well as subclinical and diagnosed cardiovascular disease, both of which are thought to predispose one to AF. However, the relationship between hypothyroidism and AF was evaluated in the Framingham Heart Study and was not found to be statistically significant. 10 The QT interval is often prolonged in hypothyroidism due to prolonged ventricular action potential.11 This is indicative of increased ventricular irritability and in turn can lead to acquired Torsades de pointes. Varying degrees of atrioventricular block and low QRS complexes a...

Background: Amidst the coronavirus disease 2019 (COVID-19) pandemic, continuous glucose monitoring (CGM) has emerged as an alternative for inpatient point-of-care blood glucose (POC-BG) monitoring. We performed a feasibility pilot study using CGM in critically ill patients with COVID-19 in the intensive care unit (ICU). Methods: Single-center, retrospective study of glucose monitoring in critically ill patients with COVID-19 on insulin therapy using Medtronic Guardian Connect and Dexcom G6 CGM systems. Primary outcomes were feasibility and accuracy for trending POC-BG. Secondary outcomes included reliability and nurse acceptance. Sensor glucose (SG) was used for trends between POC-BG with nursing guidance to reduce POC-BG frequency from one to two hours to four hours when the SG was in the target range. Mean absolute relative difference (MARD), Clarke error grids analysis (EGA), and Bland-Altman (B&A) plots were calculated for accuracy of paired SG and POC-BG measurements. Results: CGM devices were placed on 11 patients: Medtronic ( n = 6) and Dexcom G6 ( n = 5). Both systems were feasible and reliable with good nurse acceptance. To determine accuracy, 437 paired SG and POC-BG readings were analyzed. For Medtronic, the MARD was 13.1% with 100% of readings in zones A and B on Clarke EGA. For Dexcom, MARD was 11.1% with 98% of readings in zones A and B. B&A plots had a mean bias of −17.76 mg/dL (Medtronic) and −1.94 mg/dL (Dexcom), with wide 95% limits of agreement. Conclusions: During the COVID-19 pandemic, CGM is feasible in critically ill patients and has acceptable accuracy to identify trends and guide intermittent blood glucose monitoring with insulin therapy.

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Obesity, classified by the American Medical Association in 2013 as a disease, is an epidemic that is drawing serious global attention. It is the most common preventable disease and the most common modifiable risk factor for several chronic diseases. It is an independent cause of increased morbidity and mortality. Obesity is spreading across most countries, socio-economic strata, age groups, gender groups, and races, albeit to variable degrees. It is concerning that both adults and children are increasingly afflicted by obesity. Both incidence and prevalence of the disease are on the rise. The direct and indirect costs attributable to obesity have reached billions of US dollars. Obesity management involves a multi-disciplinary approach that includes the patient and his or her family, the primary care provider, a dietician or nutrition specialist and physical trainer. It may also require specialist care in the use of pharmacological and surgical interventions. Currently available anti-obesity drugs are indicated for those who are obese (BMI of 30 kg/m(2)) or overweight (BMI of 27 kg/m(2)) with at least one weight-related comorbid condition. This article focuses on the FDA-approved antiobesity drugs, their mechanisms of action, chemical structures, efficacy, safety profiles and known side effects.

Context Guidelines recommend scheduled long acting basal and short acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world”, insulin therapy is complicated, with limited data on comparative effectiveness of different insulin strategies. Objective Evaluate the association of different insulin strategies with glucose control and hospital outcomes, after adjustment for patient and physician factors that influence choice of therapy. Design Retrospective, observational. Setting Academic hospital. Patients Non-critically ill hospitalized medical/surgical patients (n=4,558) receiving subcutaneous insulin ≥75% of the admission. Interventions Insulin therapy was grouped into 3 strategies within the first 48 hours: basal-bolus (BB: scheduled long and short/rapid n=2,358), sliding scale (SS: short/rapid acting n=1,855), or basal only (BO: long only: n=345). Main Outcome Measure(s) Glucose control: hypo-, hyper-, euglycemic days, mean glucose. Hospitalization: mortality, length of stay (LOS), readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40 (CI:2.04,2.82) (P< 0.001)) and fewer euglycemic days (0.90 (CI:0.85,0.97) (P=0.003)) than SS, whereas BO was associated with fewer hyperglycemic days ((0.70 (0.62,0.79) (P<0.001)), lower mean glucose (-18.03 (CI:-22.46, -12.61) (P< 0.001)) and more euglycemic days (1.22 (CI:1.09,1.37), (P< 0.001)) compared to SS. No difference in mortality, LOS and readmissions was found. However, decreased LOS was observed in the subgroup with a medical DRG (0.93 (CI:0.89,0.97) (P<0.001)). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.

Introduction Cadaveric dissection is an integral part of many medical schools and provides an opportunity for students to visualize anatomical structures through active learning and critical thinking. Often during dissection, several pathological features and medical interventions can be identified, but are not regularly explored due to time or knowledge constraints. To encourage horizontal integration of content, a self‐directed learning (SDL) activity was implemented across four concurrent courses, gross anatomy (MGA), Foundations of Medicine which includes histology and physiology (FOM), Practice of Medicine that includes physical examination (POM) and Engineering Innovation (ENG). The goal of this longitudinal experience was to foster integration of basic science with clinical science thereby increasing metacognitive and lifelong learning skills. Methods 49 students enrolled in the Engineering‐Medicine dual degree program at Texas A&M College of Medicine were divided into 7 groups, based on the cadaveric dissection assignments in MGA. Over the 16‐week MGA course, students documented the medical interventions and pathology found during dissection. During most dissection labs, a surgeon related to the field was present to answer questions. In addition, at three time points in the semester an anatomical pathologist performed a modified autopsy on the cadavers based on students request. This self‐directed, problem‐based learning (PBL) activity culminated in a forensic clinical summary, reconstructed comprehensive patient encounter 1 year prior to death, and 15‐minute oral presentation of their findings of their assigned cadaver. To assess potential changes in learning behavior, students completed a 46‐question, 8 subcategory modified Motivated Strategies for Learning Questionnaire (MSLQ) related to the activity. In addition, student’s provided verbal and written feedback on their perceptions of the project. Results 47 out of 49 students successfully completed all aspects of the project. The was a positive trend and strong correlation in 7 out of 8 MSLQ categories, including intrinsic motivation, metacognition, task value, critical thinking, self‐efficacy, peer learning and help seeking. A paired t‐test showed a decrease in student's extrinsic motivation (t(46) = 1.831, p = 0.037) as related to the project. Students reported an overall high satisfaction with the project. The student presentations demonstrated high level of integration of basic science with clinical medicine. Conclusion/Implication This innovative multi‐disciplinary activity increased the value of cadaveric dissection, integration of content across courses, and promoted self‐directed learning of integrated clinicopathology material.

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Insulin remains the mainstay of treatment for inpatient hyperglycemia in the United States and Canada. However, some other countries commonly use noninsulin agents such as metformin and sulfonylureas, and several trials have demonstrated the efficacy and safety of incretin-based agents in patients with type 2 diabetes who are admitted to noncritical care medicine and surgery services. There is a high degree of interest in alternative glucose-lowering strategies to achieve favorable glycemic outcomes with lower risks of hypoglycemia. In this case series, we highlight the challenges of inpatient glycemic management and the need for alternatives to the traditional basal-bolus insulin regimen. Additional investigation will be imperative to validate the safety and efficacy of appropriate insulin and noninsulin treatments and to further develop guidelines that are applicable in real-world hospital settings.