Preoperative Computed Tomographic Angiography Can Predict Need for Branch Pulmonary Artery Intervention in Patients With Ductal-Dependent Pulmonary Blood Flow.

BACKGROUND: Neonates with ductal-dependent pulmonary blood flow (DD-PBF) are at risk for pulmonary artery (PA) stenosis. The objective of this study was to identify preoperative cardiovascular computed tomography angiography (CTA) measures that are associated with the need for branch PA intervention. METHODS: We identified neonates with DD-PBF who underwent preoperative CTA at our center and were followed for 24 months. The primary outcome was requiring intervention for branch PA stenosis at the initial or subsequent procedure. Patients were divided into three groups: 1) No PA intervention, 2) Initial PA intervention, and 3) Remote PA intervention. Measurements of the branch PAs and patent ductus arteriosus (PDA) were made prospectively. RESULTS: Forty patients were included, 7 (18%) did not receive a PA intervention, 23 (58%) were in the initial PA intervention group, and 10 (25%) were in the remote PA intervention group. The distance from PA bifurcation to the largest diameter of the PA that receives the PDA showed a difference between the no-intervention group versus the initial and remote intervention groups (0.8 mm [IQR 0.7, 2.0], 8.2 mm [IQR 1.9, 13.7], 8.5 mm [IQR 6.5, 11.1], respectively, P = .02). The receiver operating characteristic curve showed a distance >2.2 mm had a sensitivity = 91% and specificity = 86% in predicting the need for PA intervention. CONCLUSION: The distance from the PA bifurcation to the largest diameter of the branch PA that accepts the PDA on preoperative CTA is highly predictive of the need for initial or remote PA intervention in this group. Preoperative CTA should be considered for risk stratification in neonates undergoing intervention for DD-PBF.

The impact of acute illness on HbA(1c) determination of undiagnosed diabetes.

OBJECTIVE: To improve diabetes screening efforts, the American Diabetes Association now recommends haemoglobin A(1c) (HbA(1c)) as a diagnostic test, increasing access to patients found in acute care environments. However, the influence of acute illness and care on HbA(1c) levels has not been well studied. To address this, we evaluated for intra-patient differences in HbA(1c) assessed in the emergency department (ED) and after recovery from the acute illness. METHODS: Adult patients with no known history of diabetes were tested for HbA(1c) during an ED and scheduled follow-up visit. HbA(1c) differences between the two visits were compared using limits of agreement with 95% confidence intervals. The frequency of individuals who changed diagnostic categories (using ≥6.5% to classify newly diagnosed diabetes) from ED to follow-up was determined. RESULTS: A total of 589 patients were included with a mean age of 50 years, and 57/589 (9.7%) had an ED HbA(1c) ≥ 6.5% with the average follow-up visit 45 days after the ED visit. The mean ED HbA(1c) was 5.67% (±0.86), and the follow-up HbA(1c) was 5.65% (±0.89), (difference -0.0129%, 95% limits of agreement -0.740, 0.714). The ED and follow-up HbA(1c) was highly correlated (r² = 0.829). Although on follow-up almost all patients were classified in the same diagnostic category as in the ED, 17 patients had an HbA(1c) ≥ 6.5% in the ED and an HbA(1c) < 6.5%. On follow-up most patients (14/17) still fell in an abnormal range (6.0-6.5%). CONCLUSION: The HbA(1c) value is not substantially affected by acute illness and is feasible as a screening assay for diabetes in the acute care setting such as an ED.

Hemoglobin A1c as a screen for previously undiagnosed prediabetes and diabetes in an acute-care setting.

OBJECTIVE: Hemoglobin A(1c) (HbA(1c)) is recommended for identifying diabetes and prediabetes. Because HbA(1c) does not fluctuate with recent eating or acute illness, it can be measured in a variety of clinical settings. Although outpatient studies identified HbA(1c)-screening cutoff values for diabetes and prediabetes, HbA(1c)-screening thresholds have not been determined for acute-care settings. Using follow-up fasting blood glucose (FBG) and the 2-h oral glucose tolerance test (OGTT) as the criterion gold standard, we determined optimal HbA(1c)-screening cutoffs for undiagnosed dysglycemia in the emergency department setting. RESEARCH DESIGN AND METHODS: This was a prospective observational study of adults aged ≥18 years with no known history of hyperglycemia presenting to an emergency department with acute illness. Outpatient FBS and 2-h OGTT were performed after recovery from the acute illness, resulting in diagnostic categorizations of prediabetes, diabetes, and dysglycemia (prediabetes or diabetes). Optimal cutoffs were determined and performance data identified for cut points. RESULTS: A total of 618 patients were included, with a mean age of 49.7 (±14.9) years and mean HbA(1c) of 5.68% (±0.86). On the basis of an OGTT, the prevalence of previously undiagnosed prediabetes and diabetes was 31.9 and 10.5%, respectively. The optimal HbA(1c)-screening cutoff for prediabetes was 5.7% (area under the curve [AUC] = 0.659, sensitivity = 55%, and specificity = 71%), for dysglycemia 5.8% (AUC = 0.717, sensitivity = 57%, and specificity = 79%), and for diabetes 6.0% (AUC = 0.868, sensitivity = 77%, and specificity = 87%). CONCLUSIONS: We identified HbA(1c) cut points to screen for prediabetes and diabetes in an emergency department adult population. The values coincide with published outpatient study findings and suggest that an emergency department visit provides an opportunity for HbA(1c)-based dysglycemia screening.

Increased A1C among adult emergency department patients with type 2 diabetes.

STUDY OBJECTIVE: Long-term glycemic control can prevent or delay complications of diabetes. Although diabetes is a common comorbidity in emergency department (ED) patients, the adequacy of long-term control is not known. Our objectives are to determine the frequency of poorly controlled type 2 diabetes among adults presenting to an ED and to identify characteristics associated with poor control. METHODS: An A1C level was obtained for diabetic patients 18 years and older who presented to the ED for acute medical problems and had blood tests performed for usual medical care. Consecutive patients were screened for a total of 58 24-hour periods during a 10-week period. A1C values were stratified, with less than 7% defined as good control and greater than or equal to 7% poor long-term control. Logistic regression analysis was used to identify factors associated with poor control. RESULTS: Of the 500 patients with type 2 diabetes, 53.4% had inadequate long-term control. An increased ED glucose level was independently associated with an increased A1C level. If the ED glucose level was 126 to 149 mg/dL, the odds ratio (OR) for an increased A1C level relative to a glucose level less than 100 mg/dL was 2.3 (95% confidence interval [CI] 0.95, 5.68); the OR was 6.4 (95% CI 2.9, 14.1) for glucose levels 150 to 199 mg/dL, and for glucose level of 200 mg/dL or above, the OR for an increased A1C level was 21.2 (9.1, 49.3). Other factors independently associated with increased A1C level were black race, aged 40 to 59 years, and Medicaid insurance. CONCLUSION: The high frequency of A1C levels more than 7% points to the ED as a potential source for identifying patients with poorly controlled type 2 diabetes.