Reducing adverse events associated with the glucagon stimulation test for the assessment of growth hormone deficiency in adults with a high prevalence of pituitary hormone deficiencies

DESIGN

A retrospective review of the adverse events (AEs) in 78 patients during the glucagon stimulation test (GST) for the assessment of growth hormone deficiency (GHD) before and after protocol amendments which aimed to reduce AEs in a group of patients with a high prevalence of pituitary hormone deficiencies.

PATIENTS

Based on our observations of frequent AEs during the standard GST protocol in an initial 25 patients (cohort 1), a modified protocol was introduced to include the routine administration of 20 mg of hydrocortisone pre-GST in a subsequent 53 patients (cohort 2). Post hoc analysis of the effect of glucocorticoid dosing pre-GST on AEs was examined in those receiving <20 mg hydrocortisone (group A, n = 19) vs ≥20 mg hydrocortisone (group B, n = 59).

MEASUREMENTS

AEs including hypotension, hypoglycaemia and nausea/vomiting.

RESULTS

Of the 78 patients undergoing the GST, 79% had ≥2 hormone deficiencies. Rates of AEs were 41% vs 30% for hypotension, 60% vs 28% for hypoglycaemia (p < .05) and 20% vs 13% for nausea/vomiting in cohort 1 compared with cohort 2, respectively. Post hoc analysis revealed lower rates of AEs in those receiving ≥20 mg hydrocortisone (group B) compared to those receiving <20 mg due to a reduction in hypoglycaemic events (82% vs 26%, p < .001) and hypotension (50% vs 27%, p = .05). Similar numbers of patients in group A and group B met criteria for GHD.

CONCLUSIONS

In patients with a high prevalence of pituitary deficiencies, a modified GST protocol of additional stress dose glucocorticoid attenuated the frequency of AEs without appearing to compromise the performance of the GST.

Prevalence and characteristics of adults with fetal alcohol spectrum disorder in corrections: a Canadian case ascertainment study

BACKGROUND

Individuals with fetal alcohol spectrum disorder (FASD) experience a range of cognitive, affective, and physical deficits following prenatal alcohol exposure. They are thought to be overrepresented in criminal justice settings. However, limited evidence is available to inform prevalence. We sought to estimate the prevalence of FASD in a Northern Canadian correctional population.

METHODS

Using an active case ascertainment approach we recruited a representative sample of 80 justice-involved adults (ages 18-40, 85% male) over an 18-month period from 2013 to 2015. Participants completed interdisciplinary clinical assessments comprising medical and psychological evaluations that adhered to the 2005 Canadian FASD Diagnostic Guidelines.

RESULTS

We identified a high rate of FASD (17.5, 95% CI [9.2, 25.8%]) in this sample, and this rate could have been as high as 31.2% with confirmation of prenatal alcohol exposure. Most participants in this study presented with significant neurodevelopmental and cognitive deficits in at least two domains of functioning, irrespective of diagnosis, with only five of 80 participants (6.3%) demonstrating no cognitive impairment.

CONCLUSIONS

Findings showed disproportionately high estimated FASD prevalence in this representative sample compared to general population estimates in both Canada and the U.S. (2-5%), underscoring the need for improved FASD screening and diagnosis in correctional settings, and education for clinicians working in the justice context. Strengthened health prevention and intervention efforts to support the needs of individuals with FASD outside the criminal justice context are needed.

Recognition by family members that relatives with neurodegenerative disease are likely to die within a year: a meta-ethnography

OBJECTIVE

To synthesize evidence of family members recognizing that their relative is likely to die within the year, and identifying the need for palliative care.

DESIGN

A meta-ethnography of studies of family members in multiple sclerosis (MS), Parkinson's disease (PD) and motor neuron disease (MND).

REVIEW METHODS

Systematic search in electronic databases; thematic synthesis guided by the principles of meta-ethnography, which is a method for thematic synthesis of qualitative studies.

RESULTS

Nine articles were included. The results of the synthesis identified two key themes. First, family members are intimately aware of changes in their relative's health and well-being. Sub-themes include family member awareness of different and progressive stages of the disease, noticing deterioration, noticing decline in functional abilities and recognizing that their relative will die. The second key theme is dilemmas of being involved in prognostication. Sub-themes include family member ambivalence toward hearing about prognostication, health professionals not being knowledgeable of the disease and family reluctance to receive palliative care.

CONCLUSIONS

Family members monitor and recognize changes in their relative with PD, MND and MS and in themselves. Thus, drawing on the expertise of family members may be a useful tool for prognostication.

The role of continuous glucose monitoring in clinical decision-making in diabetes in pregnancy

BACKGROUND

The continuous glucose monitoring system (CGMS) is a novel tool to assess 24-h glucose fluctuations. In pregnancies complicated by diabetes, where excellent glucose control is desired to improve maternal and fetal outcomes, CGMS may have a role in fine-tuning management.

AIMS

To assess the usefulness of CGMS in pregnant women with diabetes for medical decision-making and to evaluate patient tolerability and perception of usefulness.

METHODS

Pregnant women with diabetes at the Werribee Mercy Hospital were offered CGMS in the setting of their standard diabetes care. Treating clinicians were asked if the CGMS altered management decisions from those based on conventional glucose monitoring. The accuracy of the CGMS was assessed by comparison with the patients' finger-prick glucose readings. Patients completed a feedback questionnaire after having the CGMS and viewing their results.

RESULTS

CGMS traces (n = 68) were obtained in 55 pregnant women - 37 with gestational diabetes, ten with type 2 and eight with type 1 diabetes. Forty-two of 68 (62%) traces were assessed as providing additional information which altered clinical management decisions. This included showing undetected postprandial hyperglycaemia and overnight hypoglycaemia. Subject feedback was generally positive, with 37 of 48 (77%) respondents reporting that the benefits of the CGMS outweighed the inconvenience.

CONCLUSION

CGMS is a well-tolerated clinically useful tool in the management of gestational diabetes and pre-existing diabetes in pregnancy.

Metformin in obstetric and gynecologic practice: a review

Metformin is a common treatment for women who have insulin resistance manifesting as type 2 diabetes or polycystic ovarian syndrome (PCOS). With an increasing number of these patients conceiving, it is expected that the use of metformin in and around the time of pregnancy will increase. This article reassesses the mechanisms, safety, and clinical experience of metformin use in obstetrics and gynecology. Metformin is an attractive therapeutic option because administration is simple, hypoglycemia rare, and weight loss promoted. There is a large volume of research supporting the use of metformin treatment in diabetes mellitus, androgenization, anovulation, infertility, and recurrent miscarriage. Although metformin is known to cross the placenta, there is, as yet, no evidence of teratogenicity. Metformin has an array of complex actions, accounting for the varied clinical roles, many of which are still to be fully evaluated. Much research is still needed.

Cytokine activity after human bone marrow transplantation. III. Defect in IL2 production by peripheral blood mononuclear cells is not corrected by stimulation with Ca++ ionophore plus phorbol ester

Previous studies have shown that interleukin 2 (IL2) production by peripheral blood mononuclear cells (PBMC) is severely impaired post allogeneic bone marrow transplantation, whereas production of interferon-gamma (IFN-gamma) is at most marginally depressed. To investigate the mechanisms behind this apparently differential inhibition of lymphokine production, we stimulated PBMC from recipients of HLA-identical sibling bone marrow transplants with phytohaemagglutinin (PHA), PHA + phorbol ester (PMA) (to bypass accessory cell requirements) or Ca++ ionophore + PMA (to bypass both accessory cell and T cell surface receptor (CD2 and/or CD3/Ti interactions). Increasing the potency of the stimulus increased the amount of IL2 and IFN produced by PBMC from both normal volunteers and from marrow transplant recipients, but for each stimulus the amount of IL2 produced by marrow transplant recipient PBMC remained 10-100-fold lower than that produced by normal PBMC, suggesting an underlying defect in IL2 production by marrow transplant recipient T cells, not due to accessory cell or CD2 defects. Selection experiments showed that CD3+ cells were the primary IL2 producers, and we were unable to demonstrate presence of suppressor cells in marrow transplant PBMC. Statistical analysis of the clinical factors possibly affecting lymphokine synthesis showed that in vivo cyclosporin A did not affect the in vitro capacity of PBMC to produce cytokines, although steroid therapy had a negative effect on IL2 production. The only variable significantly affecting IL2 and IFN production in marrow transplant recipients was increasing time post transplant. It is suggested that the defect in IL2 but not IFN production could be due to either a selective reduction in the frequency of IL2 producing cells as opposed to IFN producing cells, or to a reduction in the amount of IL2 produced per cell in marrow transplant recipients.

Mechanical tests of smooth silver-plated retention pins in amalgam

Retention and stress concentration factors can be improved if a good mechanical bond exists between smooth retention pins and an amalgam restoration. It is shown that, by silver-plating pins and by using a rubbing technique during condensation of the amalgam, a good mechanical bond is produced. Mechanical tests of this bond show that its shear strength is adequate to withstand the stresses likely to be produced by occlusal forces. The form of the tests was: (a) torsion, to demonstrate the performance of the bond in shear and (b) push-through, to provide stress distributions more closely allied to those found under clinical conditions. Plain stainless steel and plated stainless steel pins were compared for their performance and sterling silver pins were used for checking the validity of the torsion test methods. It is concluded from these tests that, with the plating and "rubbing" techniques mentioned, a good mechanical bond is produced which is likely to have value in clinical dentistry.

Microscopic study of smooth silver-plated retention pins in amalgam

A silver-plating technique was developed in an effort to produce good mechanical bonding characteristics between stainless steel pins and amalgam. Metallographic microscope and scanning electron microscope (SEM) studies were made to assess the presence, or otherwise, of such a bond between (a) the silver layer plating and the surface of the stainless steel pins, and (b) and silver plating and the amalgam. Unplated stainless steel and sterling silver pins were used as a control and as a comparison, respectively. A "rubbing" technique of condensation was devised closely adapt amalgam to the pins. It is concluded that there is strong evidence for the existence of a good bond between the plated pins and amalgam. The mechanical performance of the bond is discussed elsewhere.

Axial stiffness of retention pins in human dentin

Axial deflections of pins, anchored in specimens of human dentin by five different procedures, were measured by a specially constructed apparatus to an accuracy of 0.1 mu. Axial stiffness values calculated from these measurements were found to be significantly different for different methods of anchorage. Cemented pins displayed the lowest axial stiffness when compared with friction-locked and self-threading pins.

A photoelastic study of stress concentrations produced by retention pins in amalgam restorations

Photoelastic models of pin-amalgam restorations were constructed to simulate different pin-dentin-amalgam relationships. The stress-raising effect of a pin is influenced by the axial stiffness of the pin and its capability of bonding with the amalgam. The stress produced by a very stiff non-bonded pin could cause failure of the restoration.