CLINICAL CHARACTERISTICS OF PATIENTS WITH TYPE 2 DIABETES MELLITUS CONTINUED ON ORAL ANTIDIABETES MEDICATIONS IN THE HOSPITAL.

Objective: Basal/basal-bolus insulin with discontinuation of home oral antidiabetes medications (OADs) is the preferred method to achieve glycemic control in many hospitalized patients. We hypothesized that a subset of patients with type 2 diabetes mellitus (T2DM) can achieve an acceptable level of blood sugar control without cessation of their OADs when hospitalized. Methods: A retrospective chart review was conducted on patients with T2DM who were only on OADs at home, admitted to Fairview Hospital, a community hospital in the Cleveland Clinic Health System. We divided patients into those whose OADs were continued (group 1) and those whose OADs were discontinued (group 2), with or without the addition of insulin in the hospital. Blood glucose (BG) levels and patient characteristics were compared. Results: There were 175 patients, 73 in group 1 and 102 in group 2. The percentage of patients achieving all BG values within 100 to 180 mg/dL was the same between group 1 (21.9%) and group 2 (23.8%) (P = .78). Mean BG was similar between group 1 and group 2 (146.1 ± 41.4 mg/dL versus 152.1 ± 38.9 mg/dL; P = .33), with no significant difference in terms of percentage of patients with hyperglycemia or hypoglycemia. A greater proportion of patients in group 1 had an uninterrupted feeding status, nonintensive care unit admission and no contrast dye exposure, and a shorter length of stay. Conclusion: Our study shows that patients with certain characteristics could achieve an acceptable level of glycemic control without cessation of their home OADs. Abbreviations: BG = blood glucose; DPP-4 = dipeptidyl dipeptidase 4; GFR = glomerular filtration rate; HbA1c = hemoglobin A1c; ICU = intensive care unit; LOS = length of stay; NPO = nil per os; OAD = oral antidiabetes medication; POC = point of care; T2DM = type 2 diabetes mellitus.

Frequency and Risk Factors of Clostridium difficile Infection in Hospitalized Patients With Pouchitis: A Population-based Study.

BACKGROUND: Clostridium difficile infection (CDI) in patients with the ileal pouch after proctocolectomy has been increasingly recognized. We sought to evaluate the frequency and risk factors of CDI in patients with the primary or secondary discharge diagnosis of pouchitis in the United States. METHODS: We reviewed the National Inpatient Sample of the Healthcare Cost and Utilization Project and identified patients admitted for pouchitis with underlying inflammatory bowel disease (IBD) or familial adenomatous polyposis (FAP), between 2010 and 2012. Cases with CDI were identified based on a concomitant primary or secondary discharge diagnosis for CDI. The frequency of CDI was estimated in patients with underlying IBD and FAP. Multivariable analysis was conducted to study the risk factors associated with CDI in those with pouchitis with underlying IBD. RESULTS: A total of 3566 eligible patients with pouchitis were identified during the study period. Eighty-nine patients (2.5%) had CDI as a concomitant primary or secondary discharge diagnosis. CDI was identified in 2.6% (99.9% confidence interval [CI], 1.3-3.8) of pouchitis patients with underling IBD. None of the patients with pouchitis with underlying FAP were found to have CDI during the study period. Among pouchitis patients with underlying IBD, the presence of nonalcoholic fatty liver disease (odds ratio = 5.4; 95% CI, 1.5-19.9), obesity (odds ratio = 5.5; 95% CI, 1.4-21.4), or obstructive sleep apnea (odds ratio = 10.3; CI, 2.0-53.7) was associated with an increased risk of CDI. CONCLUSIONS: It seems that CDI was limited to pouchitis with underlying IBD and rare in those with underlying FAP. Patients with nonalcoholic fatty liver disease, obesity, and obstructive sleep apnea are at an increased risk of C. difficile pouchitis among patients with IBD.

Clinical significance and management of Barrett's esophagus with epithelial changes indefinite for dysplasia.

Barrett's esophagus (BE) is defined as the extension of salmon-colored mucosa into the tubular esophagus ≥ 1 cm proximal to the gastroesophageal junction with biopsy confirmation of intestinal metaplasia. Patients with BE are at increased risk of esophageal adenocarcinoma (EAC), and undergo endoscopic surveillance biopsies to detect dysplasia or early EAC. Dysplasia in BE is classified as no dysplasia, indefinite for dysplasia (IND), low grade dysplasia (LGD) or high grade dysplasia (HGD). Biopsies are diagnosed as IND when the epithelial abnormalities are not sufficient to diagnose dysplasia or the nature of the epithelial abnormalities is uncertain due to inflammation or technical issues. Specific diagnostic criteria for IND are not well established and its clinical significance and management has not been well studied. Previous studies have focused on HGD in BE and led to changes and improvement in the management of BE with HGD and early EAC. Only recently, IND and LGD in BE have become focus of intense study. This review summarizes the definition, neoplastic risk and clinical management of BE IND.

Serum 25-Hydroxyvitamin D Levels and the Risk of Dysplasia and Esophageal Adenocarcinoma in Patients with Barrett's Esophagus.

BACKGROUND: To date, there are no studies reporting an association between vitamin D and Barrett's esophagus (BE), the precursor for esophageal adenocarcinoma (EAC). AIMS: Our aim was to study the association between serum 25-hydroxyvitamin D (25(OH)D) levels and prevalence and incidence of dysplasia/EAC in BE. METHODS: Patients from our BE Registry cohort seen between 2000 and 2012 who had serum 25(OH)D levels measured were included. Age, gender, race, BE length, hiatal hernia size, and histological findings were recorded. Patients without high-grade dysplasia (HGD)/EAC at or within 1 year of index biopsy and who had follow-up endoscopies and 25(OH)D levels were studied for incidence of dysplasia/EAC. RESULTS: Among 429 patients with BE, the mean 25(OH)D level was 72 ± 31.2 nmol/L. Hundred and one (23.6 %) patients had deficiency (<50 nmol/L), 149 (34.7 %) had insufficiency (50-74.9 nmol/L), and 179 (41.7 %) had normal levels of 25(OH)D. There was no association between serum 25(OH)D levels and dysplasia (p = 0.90). In the incidence cohort of 246 patients with median follow-up of 46 months, there were 34 cases of low-grade dysplasia, 12 of HGD, and 5 of EAC. Change in 25(OH)D levels did not impact progression to dysplasia/EAC (every 5 nmol/L increase from baseline, hazard ratio 0.98; p = 0.62). CONCLUSIONS: Serum 25(OH)D levels were low in 58.3 % of our BE cohort. There was no association between 25(OH)D levels and prevalence or incidence of HGD/EAC in patients with BE. Further long-term studies are needed to study the association between vitamin D status and progression of dysplasia in BE.

Life-threatening hypoglycemia resulting from a nonislet cell tumor.

Nonislet cell tumor-induced hypoglycemia (NICTH), also known as Doege-Potter syndrome, is a rare paraneoplastic syndrome seen in association with various nonpancreatic tumors, benign and malignant, and comprising mesenchymal, vascular, or epithelial cell types. We report a case of recurrent life-threatening hypoglycemia from a large pelvic solitary fibrous tumor.

Prolonged zoledronic acid-induced hypocalcemia in hypercalcemia of malignancy.

Zoledronic acid is a parenteral long-acting bisphosphonate that has been shown to be more effective than other bisphosphonates in treating hypercalcemia of malignancy. It is important to be aware of its ability to induce prolonged and severe hypocalcemia (hypoCa) following administration, which can be difficult to control despite aggressive calcium replacement. We report on a patient with metastatic breast cancer who presented with severe symptomatic hypoCa after receiving zoledronic acid for hypercalcemia of malignancy.

Teriparatide induced delayed persistent hypercalcemia.

Teriparatide, a recombinant PTH, is an anabolic treatment for osteoporosis that increases bone density. Transient hypercalcemia is a reported side effect of teriparatide that is seen few hours following administration of teriparatide and resolves usually within 16 hours of drug administration. Persistent hypercalcemia, although not observed in clinical trials, is rarely reported. The current case describes a rare complication of teriparatide induced delayed persistent hypercalcemia.

Immune thrombocytopenia.

Immune thrombocytopenia (ITP) is a common hematologic disorder characterized by isolated thrombocytopenia. ITP presents as a primary or a secondary form. ITP may affect individuals of all ages, with peaks during childhood and in the elderly, in whom the age-specific incidence of ITP is greatest. Bleeding is the most common clinical manifestation of ITP. The pathogenesis of ITP is complex, involving alterations in humoral and cellular immunity. Corticosteroids remain the most common first line therapy for ITP. This article summarizes the classification and diagnosis of primary and secondary ITP, as well as the pathogenesis and options for treatment.

A clinical review of small-cell carcinoma of the urinary bladder.

Small-cell carcinoma of the urinary bladder is a rare and aggressive type of bladder cancer that has a poor prognosis. The incidence has been gradually increasing because of the aging population. Owing to its rarity there are no available treatment guidelines. Several retrospective studies and 1 prospective study have provided some insight into therapy for this disease. A multimodal approach that includes chemotherapy, local radiation therapy, and definitive surgery in resectable cases appears to be an optimal management approach.

Immune thrombocytopenia in adults: an update.

Immune thrombocytopenia (ITP) in adults is a chronic disease resulting from increased platelet destruction and impaired platelet production. Splenectomy remains the most effective and durable treatment in cases that are refractory to first-line therapy, but its use has declined because of the availability of alternate medical therapy, the associated risk of infection, and concern for surgery-related complications. Rituximab (Rituxan) may be an effective alternative but carries the risk of immunosuppression.