Diabetic patients on maintenance dialysis often are characterized by a relative parathyroid hormone (PTH) deficiency and a form of renal osteodystrophy with low bone turnover known as adynamic bone. The goal of the present study was to determine whether a reduction in the dialysate calcium concentration would increase the predialysis (basal) PTH and maximal PTH level. Thirty-three diabetic maintenance hemodialysis patients with basal PTH values less than 300 pg/ml were randomized to be dialyzed with either a regular (3.0 mEq/liter or 3.5 mEq/liter, group I) or low (2.25 mEq/liter or 2.5 mEq/liter, group II) calcium dialysate for 1 year. At baseline and after 6 months and 12 months of study, low (1 mEq/liter) and high (4 mEq/liter) calcium dialysis studies were performed to determine parathyroid function. At baseline, basal (I, 126 ؎ 20 vs. II, 108 ؎ 19 pg/ml) and maximal (I, 269 pg/ml ؎ 40 pg/ml vs. II, 342 pg/ml ؎ 65 pg/ml) PTH levels were not different. By 6 months, basal (I, 98 ؎ 18 vs. II, 200 ؎ 34 pg/ml, p ؍ 0.02) and maximal (I, 276 pg/ml ؎ 37 pg/ml vs. II, 529 pg/ml ؎ 115 pg/ml; p ؍ 0.05) PTH levels were greater in group II. Repeated measures analysis of variance (ANOVA) of the 20 patients who completed the entire 12-month study showed that only in group II patients were basal PTH (p ؍ 0.01), maximal PTH ( p ؍ 0.01), and the basal/maximal PTH ratio ( p ؍ 0.03) different; by post hoc test, each was greater ( p < 0.05) at 6 months and 12 months than at baseline. When study values at 0, 6, and 12 months in all patients were combined, an inverse correlation was present between basal calcium and both the basal/maximal PTH ratio (r ؍ ؊0.59; p < 0.001) and the basal PTH (r ؍ ؊0.60; p < 0.001). In conclusion, in diabetic hemodialysis patients with a relative PTH deficiency (1) the use of a low calcium dialysate increases basal and maximal PTH levels, (2) the increased secretory capacity (maximal PTH) during treatment with a low calcium dialysate suggests the possibility of enhanced parathyroid gland growth, and (3) the inverse correlation between basal calcium and both the basal/maximal PTH ratio and the basal PTH suggests that the steady-state PTH level is largely determined by the prevailing serum calcium concentration.
We explored perceptions, coping strategies, and levels of depression, anxiety, and stress among residents during the coronavirus disease 2019 pandemic and administered a multiple-choice online anonymous survey to assess residents’ perceptions of the virus, coping strategies, and self-reported levels of depression, anxiety, and stress. We received completed information from 59/143 (41.3%) residents in a single southern community-based graduate medical education program with academic affiliation.
Background:The combination of amylase and lipase tests for diagnosing acute pancreatitis is not better than a lipase test alone; however, both tests are commonly ordered simultaneously. Further, although no data indicate usefulness of monitoring changes in elevated amylase and lipase levels, the tests are often ordered multiple times during the same clinical encounter. Methods: We retrospectively reviewed all amylase and lipase tests performed at a university-affiliated teaching hospital during a 6-month period. We considered amylase and lipase results diagnostic if they were >3 times the upper limit of normal and borderline if they were ࣘ3 times the upper limit of normal. During a single clinical encounter, we considered amylase tests superfluous if ordered simultaneously with lipase tests or repeated after diagnostic results, questionably superfluous if repeated alone, and nonsuperfluous otherwise. Lipase tests were considered superfluous if repeated after diagnostic results, questionably superfluous if repeated after nondiagnostic results, and nonsuperfluous otherwise. Results: In this study, 3,502 patients had 8,801 tests (4,926 lipase, 3,875 amylase), 4% of which were diagnostic and 10% borderline. Of the 8,801 tests, 45% were superfluous and 9% were questionably superfluous. Nonsuperfluous testing was less frequent (P<0.0001) in the intensive care/stepdown units (22% of 748 tests) than in the emergency department (54% of 6,000 tests) or other settings (31% of 2,053 tests). Among 3,545 simultaneous amylase/lipase tests with nondiagnostic lipase results, 0.6% amylase results were diagnostic. Of the 190 lipase tests repeated after nondiagnostic lipase results, 12% were diagnostic. Conclusion: Superfluous amylase/lipase testing in one teaching hospital is substantial, suggesting significant potential for reducing healthcare costs without compromising the quality of care when evaluating patients for acute pancreatitis.
Background: The benefit of guideline directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF) is well established in the medical literature and clinical practice guidelines. The low prevalence of optimal dosing of these medications remains an obstacle in providing quality care for this patient population. Methods: An electronic medical record (EMR) triggered alert was attached to all patient charts with ICD-10 codes associated with HFrEF at a single internal medicine residency-associated outpatient primary care office. This alert urged use of a GDMT initiation and titration reference sheet based on the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction . A retrospective review of patients with corresponding ICD-10 codes and documented ejection fractions less than or equal to 40% was conducted and the intensity of GDMT dosing in these patients was recorded. A group of patients treated 3 years prior to the intervention were then compared to those treated after the intervention Results: 38 patients with a documented diagnosis of HFrEF that were evaluated between January 9, 2017 and January 9, 2020 were identified. 32 (84.2%) of these patients were on GDMT beta blockers and only 1 (3.1%) of these patients were receiving the target dose. Of the 31 (81.5%) of patients receiving ACE/ARB/ARNi therapy, 9 (41.9%) patients received target dosing. Mineralocorticoid receptor antagonist therapy (MRA) was prescribed to 11 (28.9%) patients; all of these patients received the target dose. Uptitration of medication was observed in the management of 9 (23.7%) of patients. Following the intervention, 8 patients with a documented diagnosis of HFrEF were evaluated between January 9, 2020 and March 5, 2020.GDMT beta blockers were prescribed to 7 (87.5%) of these patients; 1 (12.5%) patient received a target dose. ACE/ARB/ARNi therapy was given to all 8 patients and half of the patients were prescribed a target dose. MRA treatment was given to 2 (25%) of the8 patients; both patients were given the target dose. Uptitration of GDMT was observed in 1 (12.5%) patient following the intervention. There was no statistically significant difference between pre-intervention and post-intervention groups (P= 0.7187) regarding initiation and uptitration of GDMT. Conclusion: An EMR triggered effort to improve GDMT dosing in HFrEF patients did not show significant improvement in a small patient population over a short time period.
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