Objective: To review the currently available data on the use of ketamine in the treatment of depression among older adults from randomized controlled studies. Design: Randomized controlled trials. Setting: Variable. Participants: 60 years and older with depression. Intervention: Ketamine. Measurements: Change in Montgomery–Asberg Depression Rating Scale (MADRS) scores. Results: Two studies met the inclusion criteria. The first study showed a significant reduction in depression symptoms with use of repeated subcutaneous ketamine administration among older adults with depression. The second study failed to achieve significance on its primary outcome measure but did show a decrease in MADRS scores with intranasal ketamine along with a higher response and remission rates in esketamine group compared with the placebo group. The adverse effects from ketamine generally lasted only a few hours and abated spontaneously. No cognitive adverse effects were noted in either trial from the use of ketamine. Conclusions: The current evidence for use of ketamine among older adults with depression indicates some benefits with one positive and one negative trial. Although one of the trials did not achieve significance on the primary outcome measure, it still showed benefit of ketamine in reducing depressive symptoms. Ketamine was well tolerated in both studies with adverse effects being mild and transient.
Background The American Diabetes Association's guidelines for treatment of diabetic ketoacidosis (DKA) have explicit guidelines on the use of a weight-based insulin infusion to rapidly correct a patient's blood glucose and acidosis. Despite close monitoring, insulin infusion requires close monitoring and carries a risk of hypoglycemia, leading to adverse outcomes. While weight-based insulin infusions are designed to infuse a steady rate of insulin based on the patient's weight, constant-based insulin infusions are designed to infuse insulin based on a "constant" which represents the patient's sensitivity to insulin. Although constant-based insulin infusions are used at many institutions, there are no recommendations from any professional organization on when to use a constant-based insulin infusion. The goal of this quality improvement study was to evaluate our clinical use of weight-based and constant-based insulin infusions on the quality of care for patients admitted with diabetic ketoacidosis. Methods A retrospective review of non-ICU patients admitted with diabetic ketoacidosis over a one-year period was performed. Patients were divided into four groups for analysis based upon their insulin infusion protocol. Group 1 (n = 150) received weight-based insulin infusions throughout the study; Group 2 (n = 31) received constant-based insulin infusions throughout the study; Group 3 (n = 114) was started on weight-based insulin infusions and then switched to constant-based insulin infusions; and Group 4 (n = 6) was started on constant-based insulin infusions and then switched to weight-based insulin infusions. The primary outcome variables were hypoglycemic events and severe hypoglycemic events occurring during the initial infusion protocol and after a change from the initial infusion protocol to another protocol (if applicable). Hypoglycemia was defined as glucose levels between 41-70mg/dl and severe hypoglycemia as glucose level <=40 mg/dl. Results Both hypoglycemic events and severe hypoglycemic events during the initial insulin infusion were not significantly associated with the insulin infusion protocol (P = .391 and P = 1. 0, respectively). Moreover, hypoglycemic events were not significantly associated with a change in insulin infusion protocol; (P = .145) and no case of severe hypoglycemia was reported on infusion change. Type of diabetes (type I versus type II) was not significantly associated with the insulin infusion protocol groups (P = .784). Patients initially treated with a weight-based insulin infusion were found to have a statistically significant shorter duration of infusion (p<0. 001). This difference persisted on pairwise comparison with each group. Conclusion Our study does not provide convincing evidence that constant-based insulin infusions will improve treatment of our patients with diabetic ketoacidosis by reducing hypoglycemic events or reducing the duration of treatment when compared with the standard of care, a weight-based insulin infusion. In fact, weight-based insulin resulted in shorter duration of treatment, which may affect the length of stay. Presentation: No date and time listed
Introduction Sarcoidosis is a disorder characterized by noncaseating granulomas, most commonly in the lungs, lymph nodes, and skin. Patients often present with cough, skin or eye changes, enlarged lymph nodes, fatigue, or are found to have incidental findings on chest imaging. While any organ can be involved, thyroid involvement is rare, reportedly seen postmortem in 4.2 to 4.6% of sarcoidosis cases. We describe the case of a young adult male with thyroid sarcoidosis in addition to neurosarcoidosis. Case Presentation A 37-year old African American male was found to have a goiter on routine examination. Work up revealed an elevated TSH level of 11.1 uIU/mL (0.4-4. 0) with a free T4 of 0.91 ng/dL (0.7-1.9). Thyroid ultrasound demonstrated a dominant right-sided thyroid mass measuring 5.5×3.1×4.1 cm. Fine needle aspiration cytology reported polymorphic lymphocytes, few lymphohistiocytic aggregates, scant hurthle cells, and multinucleated giant cells. Thyroidectomy was recommended; intra-operatively the right thyroid lobe contained a 5-cm firm, hard, whitish mass in the mid inferior portion which could not be excised due to extensive fibrosis. Incisional biopsy was performed demonstrating fibrotic lymphocytic thyroiditis and non-caseating granulomas with no evidence of malignancy. He presented to the ER six weeks later with confusion, headaches, retro-orbital pain, and periodic involuntary movements in all extremities. MRI of the brain showed dural-based lesion in the right lateral and inferior temporal fossa. He underwent craniotomy and excisional biopsy of the lesion, which showed granulomatous inflammation, favoring a diagnosis of neurosarcoidosis. In a future admission, he was found to have dural venous sinus occlusion and new granulomas on brain MRI. It was then noted that previous thyroid biopsy revealed granulomatous disease, which was then linked to his sarcoidosis. He was discharged on prednisone and methotrexate with eventual further neurological complications. Discussion Thyroid sarcoidosis is very rare and because of this, it is frequently misdiagnosed initially and fine needle aspiration of the thyroid is frequently nondiagnostic. Histopathology is usually necessary to rule out malignancy and identify non-caseating granulomas. In some reported cases, thyroid sarcoidosis shared clinical, ultrasonographic, and even cytologic features with papillary thyroid cancer. Our case was unique for several reasons. Firstly, although not immediately noted, incisional thyroid biopsy was the first diagnostic clue of sarcoidosis. More commonly, patients are already diagnosed with systemic sarcoidosis. Additionally, typical findings such as mediastinal hilar adenopathy, hypercalcemia, and elevated angiotensin converting enzyme levels were absent. Although sarcoidosis of the thyroid is rare and often benign, it is important to consider this differential diagnosis while ruling out more likely causes as early detection can lead to early treatment and prevent adverse outcomes. The ideal treatment remains unclear, regarding whether to treat pharmacologically or concurrently with surgical intervention. Presentation: No date and time listed
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