Gestational diabetes and risk of future diabetes in a multi-ethnic population

AIM

To investigate ethnic disparities in risk of gestational diabetes-mellitus (GDM) and future diabetes.

METHODS

A population-based retrospective cohort study of women who underwent a 100-g oral glucose-tolerance-test (oGTT) during pregnancy between 2007 and 2017 in Clalit-Health-Services of the Jerusalem district. Univariate and multivariate logistic regression analyses were used to compare the risk of GDM in Arab versus Jewish women. Further, Cox-regression analysis was used to establish the risk of future diabetes.

RESULTS

A total of 9875 women, 71 % of Jewish ethnicity and 29 % of Arab ethnicity were included. Arab women had a higher incidence of GDM compared to Jewish women (17.3 % vs. 10.6 %, p < 0.001), which persisted after adjusting for age, BMI, and metabolic profile (aOR 1.7; CI 1.48-2.0, P < 0.001). Additionally, Arab ethnicity was associated with an increased risk of future diabetes, even after adjusting for GDM status (aHR 5.9; 95 % CI 3.7-9.4, P < 0.001).

CONCLUSIONS

Women of Arab ethnicity have a higher risk for both GDM and future diabetes, a risk that is beyond the initial increased risk associated with GDM. These findings highlight the need for increased focus on preventing diabetes in women of Arab ethnicity, especially those with a history of GDM.

Thyroid dysfunction and mortality in cardiovascular hospitalized patients

Background

Thyroid dysfunction (TD) is associated with increased cardiovascular morbidity and mortality. Early detection may influence the clinical management.

Objective

To determine the prevalence, predictors, and prognostic value of TD among hospitalized cardiac patients.

Methods

A retrospective analysis of a 12-year database consisting of nonselectively adult patients admitted to a Cardiology Department and who were all screened for serum thyroid-stimulation-hormone (TSH) levels . Statistical analysis of demographic and clinical characteristics, mortality and length of hospital stay (LOS) was performed.

Results

A total of 14369 patients were included in the study; mean age was 67 years, 38.3% females. 1465 patients (10.2%) had TD. The most frequent type of TD was mildly elevated TSH (5.4%) followed by mildly reduced TSH (2.1%), markedly elevated TSH (1.5%), and markedly reduced TSH (1.2%). Female gender, history of hypothyroidism, heart failure, atrial fibrillation, renal failure and amiodarone use were significantly associated with TD. During follow-up 2975 (20.7%) patients died. There was increased mortality in the mildly reduced TSH subgroup (hazard ratio [HR] =1.44), markedly elevated TSH subgroup (HR=1.40) and mildly elevated TSH subgroup (HR=1.27). LOS was longer for patients with TD; the longest stay was observed in the markedly elevated TSH subgroup (odds ratio=1.69).

Conclusion

The prevalence of TD in hospitalized cardiac patients is 10.2%. TD is associated with an increased mortality rate and LOS. Consequently, routine screening for thyroid function in this population is advisable, particularly for selected high-risk subgroups. Future studies are needed to determine whether optimizing thyroid function can improve survival in these patients.

Future diabetes risk can be predicted by the number of abnormal oral glucose tolerance test values during pregnancy

AIM

To quantify the future risk of type 2 diabetes (T2D) in women with gestational diabetes (GD) based on baseline metabolic characteristics and the number of abnormal values during a 3-hour 100-g oral glucose tolerance test (OGTT).

MATERIALS AND METHODS

We conducted a population-based retrospective cohort study of 10 023 pregnant women who underwent testing for GD in a large health maintenance organization in Israel using a 100-g OGTT. Glucose values were obtained at four time points, 0, 60, 120 and 180 minutes.

RESULTS

We identified 9939 women who met the study criteria. Median follow-up was 3.25 (interquartile range 1.5-5.1; maximum 10.1) years. Using women without GD as reference, women with GD were at an increased risk of future T2D (hazard ratio [HR] 5.33 [95% confidence interval {CI} 3.86-7.34]). This risk increased with a greater number of abnormal OGTT values, with the highest risk seen in women with four abnormal values (HR 16.67 [95% CI 7.94-35.01]). In a multivariate model, a higher number of abnormal values, Arab ethnicity, higher body mass index, triglycerides and prepregnancy glucose were significantly associated with increased risk. Future T2D risk was also affected by the type of OGTT abnormality; an abnormal fasting value had the greatest risk, whereas an abnormal 3-hour value had the lowest risk (HR 3.61 [95% CI 2.42-5.38] vs. 1.50 [95% CI 0.93-2.43], respectively).

CONCLUSIONS

GD is a heterogenous disease, with varying degrees of glucose intolerance and subsequent T2D risk. Targeting interventions to women at the highest risk may help to improve postpartum adherence and effective long-term follow-up strategies.

Variant Tyr 394Ser in the GCM2 Gene Is Rare in a Cohort of Ashkenazi Jews With Primary Hyperparathyroidism

Context

Various genes have been associated with familial and sporadic primary hyperparathyroidism (PHPT), including activating mutations of the glial cells missing transcription factor 2 (GCM2) gene.

Objective

The aim of this study was to assess the prevalence of the GCM2 p.Tyr394Ser variant in the Jerusalem Ashkenazi Jewish (AJ) population with PHPT, and to conclude whether routine genetic testing is justified.

Methods

The blood of 40 self-reported AJ patients with PHPT and 200 AJ controls was tested for the GCM2 p.Tyr394Ser variant. Demographic and medical information was extracted from the patients' charts and evaluated accordingly.

Results

Two (5%) PHPT patients and 3 (1.5%) controls were heterozygotes for the tested variant. Our patients were mostly (87.5%) sporadic cases. One of the heterozygote patients had familial PHPT; the other had 2 parathyroid adenomas, and the levels of his blood and urinary calcium were extremely high.

Conclusion

Our results suggest that in AJ patients with sporadic, single-gland PHPT, the likelihood of the tested variant is low and genetic testing should be limited to those with familial PHPT or multiglandular disease.

Bilateral Adrenal Hemorrhage in Coronavirus Disease 2019 Patient: A Case Report

CONTEXT

Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences such as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events.

CASE DESCRIPTION

A 66-year-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She also had a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). Four weeks after discharge she had no signs of COVID-19 infection and her polymerase chain reaction test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism.

CONCLUSIONS

COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening; therefore, we suggest that early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency should be carried out.

Orthopedic-Metabolic Collaborative Management for Osteoporotic Hip Fracture

OBJECTIVE

Osteoporotic hip fractures are associated with increased morbidity, mortality, and secondary fractures. Although osteoporosis treatment can reduce future fracture risk, patients often do not receive it. We report results of a coordinator-less fracture liaison service in Israel addressing hip fracture patients. The primary endpoint was attending the Metabolic Clinic. Secondary endpoints included vitamin D measurement, calcium and vitamin D recommendations, initiation of osteoporosis treatment, and mortality 1-year post-fracture.

METHODS

This prospective study included 219 hip fracture patients who were compared with historical controls. Data on hospitalized patients were collected before and after implementation of a structured protocol for hip fracture patients, led by a multidisciplinary team, without a coordinator.

RESULTS

The study included 219 and 218 patients ≥60 years old who were operated on in 2013 and 2012, respectively. Metabolic Clinic visits increased from 6.4 to 40.2% after the intervention ( P<.001). Among 14 patients who attended the Clinic in 2012, 85.7% began osteoporosis therapy; among 88 who attended in 2013, 45.5% were treated at the first visit. Vitamin D measurements and calcium and vitamin D supplementation increased postintervention (0.5-80.1%, P<.001; 30.8-84.7%, P<.001, respectively). Patients receiving osteoporosis medications had lower mortality rates than untreated patients (4.3% vs. 21.8%).

CONCLUSION

An Orthopedic-Metabolic team implemented by existing staff without a coordinator can improve osteoporosis care for hip fracture patients. Yet, gaps remain as only 40% had Metabolic Clinic follow-up postintervention, and of these, only half received specific treatment recommendations. Hospitals are encouraged to adopt secondary fracture prevention protocols and continuously improve them to close the gaps between current management and appropriate metabolic assessment and treatment.

ABBREVIATIONS

CHS = Clalit Health Services; CI = confidence interval; FLS = fracture liaison service; HMO = health maintenance organization; OR = odds ratio.

What can we learn from simulation-based training to improve skills for end-of-life care? Insights from a national project in Israel

BACKGROUND

Simulation-based training improves residents' skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families.

METHODS

Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection - including a description of our own responses and evolution of thought as well as system effects.

RESULTS

The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas.

CONCLUSIONS

Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.

Preparedness for End of Life-a Survey of Jerusalem District Nursing Homes

OBJECTIVES

To evaluate the quality of end-of-life (EOL) care in nursing homes.

DESIGN

Survey and semistructured interviews.

SETTING

Jerusalem district nursing homes.

PARTICIPANTS

Staff members of 28 long-term care and skilled nursing facilities in the Jerusalem area in Israel of various ethnic, religious, and administrative affiliations (N = 207).

MEASUREMENTS

Qualitative analysis of semistructured interviews and statistical analysis of questionnaires.

RESULTS

Most staff members reported that EOL preferences were unknown for more than 90% of residents and that fewer than 10% had a healthcare proxy. Most staff members recalled conducting fewer than five EOL conversations over the past year with residents or family members and could recall fewer than five cases in which a resident was allowed to die in the nursing home. According to staff opinions the prevalence of tube feeding was estimated at greater than 10%, initiated because of aspiration, malnutrition, and understaffing, often against family's preferences. More than 25% of staff members believed that pain management was inadequate. Knowledge about management of chronic pain was poor in half of nurses and nearly one-third of physicians. Most staff would rather not receive the treatments they administered to residents.

CONCLUSION

Nursing homes in Jerusalem lack competency for quality EOL care, and there are multiple psychological, training, and policy challenges to improvement.

Impact of glucose level on morbidity and mortality in elderly with diabetes and pre-diabetes

The prevalence of type 2 diabetes mellitus (DM) increases with age and reaches 25% in those older than age 65 years. Pre-diabetes status is also very common in the elderly, and is present in about half of those age 75 years and older. Many physicians care for elderly patients with diabetes and pre-diabetes, dealing with the challenge of controlling glucose levels and improving health with minimal adverse events. Over the last decade, research on diabetes among the elderly population has proliferated, adding new information on this topic. This review summarizes the updated medical literature on diabetes and pre-diabetes in the elderly, including the significance of pre-diabetic conditions, new-onset DM in the elderly and long-standing DM. The role of therapeutic intervention and the level of glycemic control for this population are discussed in particular.

Effect of relative humidity on the aerosolization and total inflammatory potential of fungal particles from dust-inoculated gypsum boards

The aim of this study was to investigate the effect of relative humidity (RH) on the aerosolization and total inflammatory potential (TIP) of microbial particles released from gypsum boards inoculated with dust samples from homes. After microbial colonization, the gypsum boards were incubated at either high or low RH. The aerosolized particles (0.54-19.8 μm), culturable fungi, β-glucan and the TIP of the aerosolized particles were quantified. Despite the colonization of several fungal groups, Penicillium dominated the aerosolized fraction. Higher emission rates of particles and culturable fungi were found from low RH compared with high RH in both the inhalable and particulate matter <1 μm (PM1 ) fractions, and the TIP was accordingly higher. However, for the aerosolized fractions, the TIP or concentration β-glucan relative to the number of fungi or particles present was higher from high RH compared with low RH. Despite the low number of culturable fungi in PM1 , this fraction showed a high TIP, and the concentration of β-glucan correlated strongly with the TIP of this fraction. The individual particles of the aerosolized PM1 fraction were more inflammatory than the larger particles of the inhalable fraction, and β-glucan may be an important contributor to the inflammatory potential of the aerosolized particles.

Sustainable health information exchanges: the role of institutional factors

The transfer of patient information between the domains of community and hospital influences the quality, continuity and cost of health care. To supply the need for information flow between community and hospital, computerized Health Information Exchange (HIE) systems have evolved. This paper examines the institutional forces that shape HIE development in Israel and in the United States.

In Israel, the vertically integrated Clalit health services developed a different solution for HIE than was developed in the non-vertically integrated Maccabi and Meuhedet health funds. In the United States the fragmented nature of providers – outside of specific networks such as parts of the Kaiser Permanente and Veterans Administration system – have dictated a very different evolution of information flow between community and hospital. More broadly, we consider how institutional factors shape (and will shape) the development of HIEs in different contexts.

This paper applies institutional analysis to explain the emergence of different patterns of development of HIE systems in each of the environments. The institutional analysis in this paper can be used to anticipate the future success or failure of incentives to promote digital information sharing at transition of care.

Comparison of sampling methods for the assessment of indoor microbial exposure

Indoor microbial exposure has been related to allergy and respiratory disorders. However, the lack of standardized sampling methodology is problematic when investigating dose-response relationships between exposure and health effects. In this study, different sampling methods were compared regarding their assessment of microbial exposures, including culturable fungi and bacteria, endotoxin, as well as the total inflammatory potential (TIP) of dust samples from Danish homes. The Gesamtstaubprobenahme (GSP) filter sampler and BioSampler were used for sampling of airborne dust, whereas the dust fall collector (DFC), the electrostatic dust fall collector (EDC), and vacuum cleaner were used for sampling of settled dust. The GSP assessed significantly higher microbial levels than the BioSampler, yet measurements from both samplers correlated significantly. Considerably higher levels of fungi, endotoxin, and TIP were found in the EDC compared with the DFC, and regarding fungi, the EDC correlated more strongly and significantly with vacuumed dust than the DFC. Fungi in EDC and vacuum dust correlated most strongly with airborne dust, and in particular, the measurements from the EDC associated well with those from GSP. Settled dust from the EDC was most representative of airborne dust and may thus be considered as a surrogate for the assessment of indoor airborne microbial exposure.

PRACTICAL IMPLICATIONS

Significant discrepancies between sampling methods regarding indoor microbial exposures have been revealed. This study thus facilitates comparison between methods and may therefore be used as a frame of reference when studying the literature or when conducting further studies on indoor microbial exposure. Results also imply that the relatively simple EDC method for the collection of settled dust may be used as an alternative to otherwise tedious and time-consuming airborne dust sampling.

[Challenges and barriers in the promotion of quality in health care services]

The promotion of quality and safety in health care faces many challenges and barriers including lack of cooperation by physicians. Complexity and uncertainty in measuring quality raise methodological difficulties. Lack of sufficient awareness about these limitations, also among those who measure quality, contributes to physicians lack of interest, suspicion and mistrust. Strategic issues associated with quality assessment in the Israeli health care system derive from lack of regulation and evasiveness about the accountability of executives and governing bodies regarding the quality of the services provided to patients in hospitals and clinics. Some of these challenges relate to the intrusion of market forces into the world of medicine without needed adaptations, so that reimbursement is often conveniently linked to the quantity of services and not to their quality. Efficiency, which characterizes competitive markets, is not easily translated in the clinical world where empathy, listening skills, and capability of explaining are critical physician attributes. This clinical world values giving beyond monetary compensation, and cooperation between institutions--rather than competition--all crucial for the continuity of patient's care. The interface between economics and health care calls for creative thinking, with a novel definition for the social value of medical and nursing care according to their quality and not their quantity.

Rapid, absolute calibration of x-ray filters employed by laser-produced plasma diagnostics

The Electron Beam Ion Trap (EBIT) facility at the Lawrence Livermore National Laboratory is being used to absolutely calibrate the transmission efficiency of x-ray filters employed by diodes and spectrometers used to diagnose laser-produced plasmas. EBIT emits strong, discrete monoenergetic lines at appropriately chosen x-ray energies. X rays are detected using the high resolution EBIT Calorimeter Spectrometer (ECS), developed for LLNL at the NASA/Goddard Space Flight Center. X-ray filter transmission efficiency is determined by dividing the x-ray counts detected when the filter is in the line of sight by those detected when out of the line of sight. Verification of filter thickness can be completed in only a few hours, and absolute efficiencies can be calibrated in a single day over a broad range from about 0.1 to 15 keV. The EBIT calibration lab has been used to field diagnostics (e.g., the OZSPEC instrument) with fully calibrated x-ray filters at the OMEGA laser. Extensions to use the capability for calibrating filter transmission for the DANTE instrument on the National Ignition Facility are discussed.

Family history of stroke and severity of neurologic deficit after stroke

BACKGROUND

A family history of stroke is an independent risk factor for stroke.

OBJECTIVE

To assess whether severity of neurologic deficit after stroke is associated with a family history of stroke.

METHODS

The Ischemic Stroke Genetics Study, a five-center study of first-ever symptomatic ischemic stroke, assessed case subjects prospectively for a family history of stroke-affected first-degree relatives. Certified adjudicators used the NIH Stroke Scale (NIHSS) to determine the severity of neurologic deficit.

RESULTS

A total of 505 case subjects were enrolled (median age, 65 years; 55% male), with 81% enrolled within 1 week of onset of symptoms. A sibling history of stroke was associated with more severe stroke. The odds of an NIHSS score of 5 or higher were 2.0 times greater for cases with a sibling history of stroke compared with cases with no sibling history (95% CI, 1.0 to 3.9). An association of family history of stroke in parents or children with stroke severity was not detected.

CONCLUSIONS

A sibling history of stroke increased the likelihood of a more severe stroke in the case subjects, independent of age, sex, and other potential confounding factors. Other family history characteristics were not associated with stroke severity.

Multiple activation loop conformations and their regulatory properties in the insulin receptor's kinase domain

Low catalytic efficiency of protein kinases often results from intrasteric inhibition caused by the activation loop blocking the active site. In the insulin receptor's kinase domain, Asp-1161 and Tyr-1162 in the peptide substrate-like sequence of the unphosphorylated activation loop can interact with four invariant residues in the active site: Lys-1085, Asp-1132, Arg-1136, and Gln-1208. Contributions of these six residues to intrasteric inhibition were tested by mutagenesis, and the unphosphorylated kinase domains were characterized. The mutations Q1208S, K1085N, and Y1162F each relieved intrasteric inhibition, increasing catalytic efficiency but without changing the rate-limiting step of the reaction. The mutants R1136Q and D1132N were virtually inactive. Steric accessibility of the active site was ranked by relative changes in iodide quenching of intrinsic fluorescence, and A-loop conformation was ranked by limited tryptic cleavage. Together these ranked the openness of the active site cleft as R1136Q approximately D1132N > or = D1161A > Y1162F approximately K1085N > Q1208S > or = wild-type. These findings demonstrate the importance of specific invariant residues for intrasteric inhibition and show that diverse activation loop conformations can produce similar steady-state kinetic properties. This suggests a broader range of regulatory properties for the activation loop than expected from a simple off-versus-on switch for kinase activation.