Retrospective review of postoperative glycemic control in patients after distal pancreatectomy.

BACKGROUND: Distal pancreatectomy (DP) is carried out for resection of lesions in the body and tail of the pancreas. DP may lead to both insulin and glucagon deficiency, which may worsen diabetes mellitus and render patients more vulnerable to severe hypoglycemia. Maintaining glycemic control can be challenging after DP, and no guidelines have been established for clinicians. The objective of this study was to investigate postoperative glycemic control and insulin dose among patients after DP. METHODS: The medical records from 82 eligible adult patients after DP between 2013 and 2014 were reviewed retrospectively. RESULTS: Twenty-one (25.6%) patients had pre-existing diabetes. The average length of stay was 5.8 ± 2.6 days. The average resected volume was 193 ± 313 cm3. Of 2124 blood glucose (BG) values, only 0.3% were <70 mg/dL (3.9 mmol/L); 45% were 140-180 mg/dL (7.8-10.0 mmol/L); and 14% were >180 mg/dL. Postoperatively, insulin was the most common agent prescribed for glycemic control. Among those who received insulin, 86.8% used rapid-acting correction insulin, 4.4% prandial insulin, and 8.8% long-acting insulin. On postoperative day 1 through 6 and on the day before hospital discharge, <30% of patients received insulin, and a total daily dose (TDD) of <0.10 units/kg was frequently needed for glycemic control. At discharge, 35.3% of patients with pre-existing diabetes improved; 23.2% required diabetic medications, of whom 50% took insulin. Only 2 patients without pre-existing diabetes required medications. CONCLUSION: Postoperative BG levels were relatively well controlled. The majority of BG levels were in the optimal range, and the incidence of hypoglycemia or clinically significant hypoglycemia was minimal with our current regimen. Postoperative patients required small TDD of insulin for glycemic control. Our data suggested that 0.05-0.20 units/kg was an appropriate dose range for postoperative glycemic control among the vulnerable population. Our findings provide guidance for clinicians to dose insulin safely for postoperative patients with DP in a hospital setting.

Detecting and Managing Diabetes Mellitus and Prediabetes in Patients With Acute Stroke.

PURPOSE: The purpose of the study was to determine the prevalence of undiagnosed diabetes mellitus (DM) and prediabetes (pre-DM) in acute stroke patients, to evaluate recommendations of diabetes treatment and follow-up care in a hospital setting, and to examine 1-year readmission rates based on admission A1C measure. METHODS: This retrospective study comprised 200 patients randomly selected from 1095 patients admitted with an acute stroke and an A1C measurement during admission. DM and pre-DM prevalence levels were determined per A1C level. Recommendations for diabetes treatment during and after hospitalization were assessed; charts were reviewed for readmission. RESULTS: Among 200 patients, 43% had known DM, and 0.5% had pre-DM. Among 113 patients without history of DM or pre-DM, 61.9% had A1C 5.7% to 6.4% (39-46 mmol/mol), and 8.8% had A1C ≥6.5% (48 mmol/mol). None of the newly diagnosed pre-DM and 60% of newly diagnosed DM were documented. Only 7 of newly diagnosed DM or pre-DM patients received diabetes education. For patients with known DM and A1C ≥7.0% (53 mmol/mol), 40.5% registered no change of diabetic regimen. Few patients were recommended for diabetes follow-up care. Patients with A1C ≥6.5% or <5.7% were more likely to be readmitted for any reason within 1 year (33.3% and 31.6%, respectively) than patients with A1C levels of 5.7% to 6.4% (16.5%). CONCLUSIONS: The majority of acutely admitted stroke patients without known DM or pre-DM had A1C ≥5.7%. Newly diagnosed DM or pre-DM patients received inadequate diabetes education and follow-up care. These findings provide significant opportunities for improving acute stroke management.

Evaluation and therapy of hypercalcemia.

Hypercalcemia is a common but challenging disorder. It results from PTH-dependent or independent increased bone resorption, increased vitamin D-dependent absorption, or as a result of various drugs and substances. Outpatient hypercalcemia is most commonly caused by primary hyperparathyroidism while malignancy accounts for most inpatient disease. Treatment includes adequate hydration, intravenous bisphosphonates, and occasionally calcitonin as a temporizing measure. Treating the underlying cause, such as employing chemotherapy for malignancy or parathyroidectomy for hyperparathyroidism, is also essential.

Hürthle cell carcinoma in a patient with Graves' Disease.

Hürthle cell, a rare form of thyroid carcinoma, has been reported only five times in patients with Grave's Disease. We present a case report and comprehensive review of the literature. Surgery should be considered in patients with both Graves' Disease and an expanding goiter. Initial high-dose radioiodine should be administered post-operatively in patients with Hürthle cell carcinoma. Serum thyroglobulin and 18-FDG total body PET imaging may be valuable in discovering residual or recurrent disease.