Attitudes and Behaviors with Diabetes Technology Use in the Hospital: Multicenter Survey Study in the United States.

Objective: To assess the attitudes, behaviors, and barriers with diabetes technology use in the general medicine hospital wards. Research Design and Methods: The authors developed a nonincentivized web-based anonymous survey that captured demographic and practice data regarding continuous subcutaneous insulin infusion (CSII) and continuous glucose monitor (CGM) use in the hospital. Setting: Four large hospital systems in the United States. Results: Among 128 survey respondents, 76%, 10%, and 6% were hospitalists, advanced practice providers, and primary care physicians, respectively. The majority of respondents rated the treatment of inpatient hyperglycemia (96%) and the continuation of CSII during the hospital stay (93%) "important." While most respondents (64%) acknowledged knowing the existence of their institution's policies for CSII use, only 84% of those respondents felt somewhat to very familiar with the policy. The most common barrier to CSII use in the inpatient setting was lack of practitioner (70%) and nursing (67%) knowledge of using the device. With regard to CGM use in the hospital, a minority (28%) of respondents were aware of their institution's CGM policies. Less than half of the providers, 43.8%, stated that, when admitting a patient, they reviewed CGM data to guide insulin dosing. Conclusions: In this US multicenter survey, we found that most inpatient practitioners valued glycemic control, but many were not familiar with institutional policies, had lack of knowledge with CSII, and were not reviewing CGM data.

Intracranial hemorrhage in patients with brain metastases treated with therapeutic enoxaparin: a matched cohort study.

Venous thromboembolism occurs frequently in patients with cancer who have brain metastases, but there is limited evidence supporting the safety of therapeutic anticoagulation. To assess the risk for intracranial hemorrhage associated with the administration of therapeutic doses of low-molecular-weight heparin, we performed a matched, retrospective cohort study of 293 patients with cancer with brain metastases (104 with therapeutic enoxaparin and 189 controls). A blinded review of radiographic imaging was performed, and intracranial hemorrhages were categorized as trace, measurable, and significant. There were no differences observed in the cumulative incidence of intracranial hemorrhage at 1 year in the enoxaparin and control cohorts for measurable (19% vs 21%; Gray test, P = .97; hazard ratio, 1.02; 90% confidence interval [CI], 0.66-1.59), significant (21% vs 22%; P = .87), and total (44% vs 37%; P = .13) intracranial hemorrhages. The risk for intracranial hemorrhage was fourfold higher (adjusted hazard ratio, 3.98; 90% CI, 2.41-6.57; P < .001) in patients with melanoma or renal cell carcinoma (N = 60) than lung cancer (N = 153), but the risk was not influenced by the administration of enoxaparin. Overall survival was similar for the enoxaparin and control cohorts (8.4 vs 9.7 months; Log-rank, P = .65). We conclude that intracranial hemorrhage is frequently observed in patients with brain metastases, but that therapeutic anticoagulation does not increase the risk for intracranial hemorrhage.

A case of hypercalcemia secondary to hot tub lung.

Hypersensitivity pneumonitis (HP) is a diffuse granulomatous lung disease resulting from inhalation of an antigen to which an individual has been previously sensitized. Hot tub lung is an increasingly common form of HP associated with inhalation of water aerosols containing Mycobacterium avium complex organisms that contaminate hot tub water. Granulomatous lung disorders, most classically sarcoidosis, have been associated with unregulated 1-α-hydroxylase expression by macrophages present in the granulomas, causing conversion of 25-OH-vitamin D to the active form of vitamin D, 1,25(OH)2 vitamin D, and, thus, hypercalcemia. To our knowledge, this is the first confirmed case of hypercalcemia secondary to elevated 1,25(OH)2 vitamin D levels associated with HP.

Older women's experience with a benign breast biopsy­a mixed methods study.

BACKGROUND: Little is known about older women's experience with a benign breast biopsy. OBJECTIVES: To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy. DESIGN: Prospective cohort study using quantitative and qualitative methods. SETTING: Three Boston-based breast imaging centers. PARTICIPANTS: Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy. MEASUREMENTS: We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs <1 are reported at time of screening) and women responded to open-ended questions about their experience. At follow-up, participants described the quality of information received after their benign breast biopsy. We used a linear mixed effects model to examine if PCQs declined over time. We also reviewed participants' open-ended comments for themes. RESULTS: Overall, 88% (83/94) of participants were non-Hispanic white and 33% (31/94) had a high-school degree or less. At biopsy, 76% (71/94) reported negative psychological consequences from their biopsy compared to 39% (37/94) at follow-up (p < 0.01). In open-ended comments, participants noted the anxiety (29%, 27/94) and discomfort (28%, 26/94) experienced at biopsy (especially from positioning on the biopsy table). Participants requested more information to prepare for a biopsy and to interpret their negative results. Forty-four percent (39/89) reported at least a little anxiety about future mammograms. CONCLUSIONS: The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy.

Success of ultrasound-guided peripheral intravenous access with skin marking.

OBJECTIVES: The most effective technique for ultrasound-guided peripheral intravenous access (USGPIVA) is unknown. In the traditional short-axis technique (locate, align, puncture [LAP]), the target vessel is aligned in short axis with the center of the transducer. The needle is then directed toward the target under real-time ultrasound (US) guidance. Locate, align, mark, puncture (LAMP) requires the extra step of marking the skin at two points over the path of the vein and proceeding with direct visualization as in LAP. The difference in success between these two techniques was compared among variably experienced emergency physician and emergency nurse operators. METHODS: Subjects in an urban academic emergency department (ED) were randomized to obtain intravenous (IV) access using either LAP or LAMP after two failed blind attempts. Primary outcomes were success of the procedure and time to complete the procedure in variably experienced operators. RESULTS: A total of 101 patients were enrolled. There was no difference in success between LAP and LAMP, even among the least experienced operators. Of successful attempts, LAMP took longer than LAP (median 4 minutes, interquartile range [IQR] 4-10.5 vs. median 2.9 minutes, IQR 1.6-7; p = 0.004). Only the most experienced operators were associated with higher levels of success (first attempt odds ratio [OR] 6.64; 95% confidence interval [CI] = 2 to 22). Overall success with up to two attempts was 73%. Complications included a 2.8% arterial puncture rate and 12% infiltration rate. CONCLUSIONS: LAMP did not improve success of USGPIVA in variably experienced operators. Experience was associated with higher rates of success for USGPIVA.

Adverse health outcomes after Hurricane Katrina among children and adolescents with chronic conditions.

Children with chronic conditions may be at risk of increased disruptions in health care following natural disasters such as Hurricane Katrina. The objective of this cross-sectional study was to evaluate differences between children and adolescents with and without chronic conditions immediately following Katrina. Of 531 participants, there were 79.8% younger than 13 years old, 50.5% male, 42.8% African American. Participants with pre-existing conditions (39.4% of the total sample) were more likely than those without to be at the clinic for a non-chronic health condition rather than another problem (43.5 vs. 16.2%), to take asthma medication (37.4 vs. 3.9%), to have asthma worsen (16.3 vs. 1.9%), to miss a visit (49.2 vs. 39.8%), to run out of medications (33.9 vs. 7.9%), to live with flood damage (19.7 vs. 11.3%) or mold (23.6 vs. 15.8%), and to experience disruption in care (58.4 vs. 38.3%) or negative psychological consequences (ranging from 2.5% to 12.9%). While the medical differences are unsurprising, given the groups being compared, the other differences between the groups merit attention from policymakers and health care providers. Children and adolescents with chronic conditions are at increased risk of adverse outcomes following a natural disaster. Providers may be able to reduce negative effects on this population by developing condition-specific preparedness care mechanisms.