Thyroid storm, an endocrine emergency first described in 1926, remains a diagnostic and therapeutic challenge. No laboratory abnormalities are specific to thyroid storm, and the available scoring system is based on the clinical criteria. The exact mechanisms underlying the development of thyroid storm from uncomplicated hyperthyroidism are not well understood. A heightened response to thyroid hormone is often incriminated along with increased or abrupt availability of free hormones. Patients exhibit exaggerated signs and symptoms of hyperthyroidism and varying degrees of organ decompensation. Treatment should be initiated promptly targeting all steps of thyroid hormone formation, release, and action. Patients who fail medical therapy should be treated with therapeutic plasma exchange or thyroidectomy. The mortality of thyroid storm is currently reported at 10%. Patients who have survived thyroid storm should receive definite therapy for their underlying hyperthyroidism to avoid any recurrence of this potentially fatal condition.
Cardiovascular disease remains a leading cause of death in the United States and the world. In this we will paper focus on type 2 diabetes mellitus as a risk factor for coronary heart disease, review the mechanisms of atherogenesis in diabetics, the impact of hypertension and the treatment goals in diabetics, the guidelines for screening, and review the epidemiologic consequences of diabetes and heart disease on a global scale. The underlying premise to consider diabetes a cardiovascular disease equivalent will be explored as well as the recommendations for screening and cardiac testing for asymptomatic diabetic patients.
Background A literature gap exists in educating internal medicine residents about hospital readmissions and how to prevent them. Intervention The study aimed to implement a readmissions education initiative for general internal medicine inpatient resident teams in 3 general practice units at an urban, tertiary hospital. Methods Senior residents were given access to a daily list of readmissions, used a readmission assessment tool to investigate causes and to assess whether each readmission was preventable, led a monthly general practice unit team meeting to discuss each case, and presented their findings at the monthly multidisciplinary readmissions meeting for additional feedback. For program evaluation, we hypothesized that the “preventable” readmissions count tracked via the readmissions assessment tool would increase as residents became better educated on the root causes of readmissions. We also conducted a survey to assess perception of the readmissions education initiative. Results “Preventable” readmissions increased from 21% for the first 3 months of the intervention (September–November 2010) to 46% for the most recent 3 months (January–March 2011). The survey showed that 98% (41 of 42) of respondents who had attended a multidisciplinary readmissions meeting felt involved in an effort to review or improve the rate of hospital readmissions, whereas only 40% (21 of 53) of the group that never attended a session shared the same answer. Conclusions This initiative required few resources, and it appeared to help residents identify “preventable” reasons for readmissions, as well as increased their perceptions of being actively involved in reducing hospital readmissions. The intervention was not associated with a statistically significant reduction in readmissions, which may be influenced primarily by multiple factors outside residents' control.
One of the most common metabolic abnormalities found in patients with malignancy is hypercalcemia. Hypocalcemia is a rare occurrence and is often found to be associated with renal failure and patients taking bisphosphonate therapy for bone metastasis in this patient population. Here, we present two different case reports with hypocalcemia. A 66-year-old female with a recent diagnosis of tonsillar diffuse B-cell lymphoma admitted with complaints of generalized weakness after one cycle of R-CHOP, found to have neutropenia, a low calcium level, high PTH, and low 25-hydroxy Vitamin D levels. She was given calcium gluconate and supplemental 25-hydroxy Vitamin D. On day 2, the patient's symptoms and counts improved. The second patient was a 64-year-old male with recurrent metastatic laryngeal carcinoma, along with a second locally advanced primary rectal adenocarcinoma, presented with severe hypocalcemia and a low PTH level. The patient was on adjuvant chemotherapy and exhibited Chvostek’s sign, along with perioral numbness, tingling, and twitching sensations, which eventually led to dysphagia. He was treated with calcium gluconate, calcitriol, and calcium carbonate. Signs and symptoms, along with lab values, improved on day 4. These cases suggest that calcium kinetics and 25-hydroxy Vitamin D levels need to be monitored in these patient populations in a routine manner.
Recently, a focus on tight glycemic control in intensive care units (ICU) has resulted in implementation of strict insulin protocols requiring frequent glucose monitoring. The use of pointof-care (POC) capillary glucose testing is widespread, but its validity in the ICU has been questioned. Our objective is to better understand the use of POC glucose at the extremes of glycemic control through a case review at our institution. We describe the case of a 75-year-old non-diabetic female with end stage renal disease (ESRD) on hemodialysis who was admitted with apparent hypoglycemia. After extensive workup was done for a seemingly refractive hypoglycemia, a discrepancy between POC capillary glucose and central serum glucose levels was discovered, revealing actual euglycemia and false low POC glucose values. Cases of hypoglycemia can be challenging, especially in non-diabetic patients with ESRD. While glucometers assessing capillary glucose are used both in the outpatient and inpatient environment, their validity in the critically ill patient has known limitations. Cases such as this have led to the development of systemic checks and balances, as well as further investigations regarding the use of POC glucose meters in the ICU. This case serves as a reminder to evaluate for all causes for abnormal laboratory values, including technological limitations.
4969 BACKGROUND Hydroxyurea (HU) is one of the mainstay agents used to treat myeloproliferative disorders as well as sickle cell anemia. There has been lately increasing reports of secondary skin malignancies in patients receiving Hydroxyurea therapy but the literature consists essentially of case reports. Current incidence of melanoma skin cancer in the general population in the United States is 15 per 100 000 person, and of non melanoma skin cancer is 230 per 100 000 lightly pigmented individuals and 3.4 per 100 000 darkly pigmented individuals. METHODS We reviewed 292 charts of patients treated with HU in our institution. 237 patients carried a diagnosis of myeloproliferative disorder, 14 patients were treated for sickle cell anemia and 41 patients were being treated with HU for HIV as part of a regimen to decrease viral load. Charts were reviewed looking for development of skin malignancies. RESULTS Among the patients with sickle cell anemia, the incidence of skin cancer was nil. Among the patients with HIV there were 2 cases of non melanoma skin cancer. Among patients with myeloproliferative disorders, there were 16 cases of skin cancer. The pathology was non-melanoma skin cancer. Subgroup analysis based on skin phenotype revealed that the incidence was higher than the general population in both dark and light-skinned individuals: the rate was 0.9434 per 100 among the dark skinned individuals, statistically significant when compared to the established rate of 0.0034 per 100 dark-skinned individual in the general population. Similarly among light-skinned individuals, the calculated rate was 12.0968 per 100-person, which is statistically significant compared to the rates in light-skinned individuals in the general population of 0.2300 per 100 person with a p-value of 0.001. CONCLUSION Our study showed a significantly higher incidence of non-melanoma skin cancer among patients treated with HU. While HU is well known to have cutaneous side effects in terms of hyperpigmentation, skin ulcers, scaling or skin atrophy, its implication in skin cancers had only been in the form of case reports. Our study thus highlights a true risk of skin malignancies with HU. It is worth noting though that there were only non-melanoma skin cancers, which are non-aggressive, localized and treatable. Thus this heightened incidence of skin cancer does not appear to bear a mortality or morbidity burden on patients treated with HU. Disclosures No relevant conflicts of interest to declare.
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