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Zilbermint M, Motevalli M, Batty K, Venner-Walcott J, Edwards A, Burley T, Jackson K, Akhtar M, Demidowich AP. Effects of the COVID-19 booster vaccine on glycemia and insulin resistance in people with type 1 diabetes: A prospective pilot study. Diabetes Res Clin Pract 2023; 204:110898. [PMID: 37678726 DOI: 10.1016/j.diabres.2023.110898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/22/2023] [Accepted: 09/03/2023] [Indexed: 09/09/2023]
Abstract
AIMS Inflammation can trigger hyperglycemia in people with type 1 diabetes (T1D). Vaccines purposefully intend to cause an acute immunogenic response, and booster vaccines may cause even more potent immunologic responses. However, the effects of vaccines on glycemic control and insulin requirements in the days immediately post-vaccination remains poorly understood. The aim of this study was to examine the changes in glycemic control and insulin usage immediately preceding and following a COVID-19 booster vaccine among adults with T1D. METHODS In this prospective cohort study of adults with T1D, participants wore blinded Dexcom G6 Pro continuous glucose monitors for 10 days. After a baseline period, participants received a COVID-19 booster vaccine, and subsequent changes in glycemic indices were evaluated. RESULTS Among the 21 enrolled participants, 38% received a Moderna and 62% Pfizer-BioNTech booster. Compared to baseline (162.9 ± 44.1 mg/dL), mean glucose was significantly increased at Day 2 (172.8 ± 47.0 mg/dL; p = 0.04) and Day 3 (173.1 ± 45.0 mg/dL; p = 0.02) post-vaccination. Insulin resistance was also increased on Day 2 (p = 0.03). There were no differences in outcome metrics between booster vaccine manufacturers. CONCLUSIONS These results suggest that adults with type 1 diabetes may experience transient mild glycemic elevations after receiving a COVID-19 booster vaccination. Studies examining the effects of other vaccines are warranted.
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Affiliation(s)
- Mihail Zilbermint
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, 6225 Smith Ave., Suite B-300, Baltimore, MD 21209, USA; Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287, USA; Suburban Hospital, Johns Hopkins Medicine, 8600 Old Georgetown Road, Bethesda, MD 20814, USA.
| | - Mahsa Motevalli
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, 6225 Smith Ave., Suite B-300, Baltimore, MD 21209, USA; Suburban Hospital, Johns Hopkins Medicine, 8600 Old Georgetown Road, Bethesda, MD 20814, USA.
| | - Kristine Batty
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, 6225 Smith Ave., Suite B-300, Baltimore, MD 21209, USA; Johns Hopkins Howard County Medical Center, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
| | - Jemila Venner-Walcott
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, 6225 Smith Ave., Suite B-300, Baltimore, MD 21209, USA; Johns Hopkins Howard County Medical Center, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
| | - Alexis Edwards
- Suburban Hospital, Johns Hopkins Medicine, 8600 Old Georgetown Road, Bethesda, MD 20814, USA; Office of Capital Region Research, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
| | - Tanya Burley
- Office of Capital Region Research, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
| | - Keith Jackson
- Office of Capital Region Research, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
| | - Mehro Akhtar
- Office of Capital Region Research, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
| | - Andrew P Demidowich
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, 6225 Smith Ave., Suite B-300, Baltimore, MD 21209, USA; Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287, USA; Johns Hopkins Howard County Medical Center, Johns Hopkins Medicine, 5755 Cedar Ln, Columbia, MD 20794, USA.
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Klonoff DC, Wang J, Rodbard D, Kohn MA, Li C, Liepmann D, Kerr D, Ahn D, Peters AL, Umpierrez GE, Seley JJ, Xu NY, Nguyen KT, Simonson G, Agus MSD, Al-Sofiani ME, Armaiz-Pena G, Bailey TS, Basu A, Battelino T, Bekele SY, Benhamou PY, Bequette BW, Blevins T, Breton MD, Castle JR, Chase JG, Chen KY, Choudhary P, Clements MA, Close KL, Cook CB, Danne T, Doyle FJ, Drincic A, Dungan KM, Edelman SV, Ejskjaer N, Espinoza JC, Fleming GA, Forlenza GP, Freckmann G, Galindo RJ, Gomez AM, Gutow HA, Heinemann L, Hirsch IB, Hoang TD, Hovorka R, Jendle JH, Ji L, Joshi SR, Joubert M, Koliwad SK, Lal RA, Lansang MC, Lee WA(A, Leelarathna L, Leiter LA, Lind M, Litchman ML, Mader JK, Mahoney KM, Mankovsky B, Masharani U, Mathioudakis NN, Mayorov A, Messler J, Miller JD, Mohan V, Nichols JH, Nørgaard K, O’Neal DN, Pasquel FJ, Philis-Tsimikas A, Pieber T, Phillip M, Polonsky WH, Pop-Busui R, Rayman G, Rhee EJ, Russell SJ, Shah VN, Sherr JL, Sode K, Spanakis EK, Wake DJ, Waki K, Wallia A, Weinberg ME, Wolpert H, Wright EE, Zilbermint M, Kovatchev B. A Glycemia Risk Index (GRI) of Hypoglycemia and Hyperglycemia for Continuous Glucose Monitoring Validated by Clinician Ratings. J Diabetes Sci Technol 2023; 17:1226-1242. [PMID: 35348391 PMCID: PMC10563532 DOI: 10.1177/19322968221085273] [Citation(s) in RCA: 59] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. METHODS We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation. RESULTS The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals. CONCLUSION The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.
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Affiliation(s)
- David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Jing Wang
- Florida State University College of Nursing, Tallahassee, FL, USA
| | - David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, MD, USA
| | - Michael A. Kohn
- University of California, San Francisco, San Francisco, CA, USA
| | - Chengdong Li
- Florida State University College of Nursing, Tallahassee, FL, USA
| | | | - David Kerr
- Sansum Diabetes Research Institute, Santa Barbara, CA, USA
| | - David Ahn
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | | | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | | | | | | | - Ananda Basu
- University of Virginia, Charlottesville, VA, USA
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | | | | | | | | | | | - Kong Y. Chen
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | | | | | | | | | - Thomas Danne
- Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany
| | | | | | | | | | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Juan C. Espinoza
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | - Thanh D. Hoang
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | - Linong Ji
- Peking University People’s Hospital, Peking University Diabetes Center, Beijing, China
| | | | | | | | | | - M. Cecilia Lansang
- Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Wei-An (Andy) Lee
- LAC + USC Medical Center, Los Angeles County Department of Health Service, Los Angeles, CA, USA
| | - Lalantha Leelarathna
- Manchester University NHS Foundation Trust and The University of Manchester, Manchester, UK
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital and University of Toronto, Toronto, ON, Canada
| | - Marcus Lind
- University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Umesh Masharani
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Viswanathan Mohan
- Dr. Mohan’s Diabetes Specialities Centre, Chennai, India
- Madras Diabetes Research Foundation, Chennai, India
| | | | | | | | | | | | | | - Moshe Phillip
- Institute for Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | | | - Gerry Rayman
- Ipswich Hospital, East Suffolk and North Essex Foundation Trust and University of East Anglia, Ipswich, UK
| | - Eun-Jung Rhee
- Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Steven J. Russell
- Massachusetts General Hospital Diabetes Research Center, Boston, MA, USA
| | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA
| | | | - Koji Sode
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- North Carolina State University, Raleigh, NC, USA
| | | | | | - Kayo Waki
- The University of Tokyo, Tokyo, Japan
| | | | | | | | | | - Mihail Zilbermint
- Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Bethesda, MD, USA
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Hensley KE, Fiechter CW, Klein A, Hussein R, Weiss HJ, Zilbermint M. Thyrotoxicosis in the Setting of Hydatidiform Mole with Subsequent Development of Takotsubo Cardiomyopathy Complicated by COVID-19. J Community Hosp Intern Med Perspect 2023; 13:83-87. [PMID: 37877062 PMCID: PMC10593158 DOI: 10.55729/2000-9666.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 10/26/2023] Open
Abstract
We present a rare case of hydatidiform molar pregnancy, which led to the development of thyroid storm, followed by a rare complication of takotsubo cardiomyopathy in the setting of a COVID-19 infection. A 21-year-old female of 22 weeks gestational age presented with heavy vaginal blood loss, brown emesis, tachycardia, and lethargy. Through clinical presentation and ultrasound confirmation, a molar pregnancy was diagnosed. Laboratory data and clinical presentation of thyrotoxicosis supported a diagnosis of thyroid storm. Test for COVID-19 was positive. The patient was treated with dilation and curettage, antithyroid medication, and blood transfusions, resulting in symptom resolution. Thereafter, echocardiography confirmed takotsubo cardiomyopathy. It is suspected that the homology in structure between the human chorionic gonadotropin (hCG) and thyroid stimulating hormone subunits resulted in thyroid storm secondary to receptor cross-reactivity. We speculate that subsequent cardiovascular stress of b-hCG-induced thyroid storm with superimposed COVID-19 infection facilitated the development of Takotsubo cardiomyopathy.
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Affiliation(s)
- Kara E. Hensley
- Lake Erie College of Osteopathic Medicine, Department of Medicine, Bradenton, FL,
USA
- Manatee Memorial Hospital, Graduate Medical Education, Bradenton, FL,
USA
| | - Christopher W. Fiechter
- Lake Erie College of Osteopathic Medicine, Department of Medicine, Bradenton, FL,
USA
- Manatee Memorial Hospital, Graduate Medical Education, Bradenton, FL,
USA
| | - Alysson Klein
- Manatee Memorial Hospital, Graduate Medical Education, Bradenton, FL,
USA
| | - Rhabia Hussein
- Manatee Memorial Hospital, Graduate Medical Education, Bradenton, FL,
USA
| | - Henry J. Weiss
- Manatee Memorial Hospital, Graduate Medical Education, Bradenton, FL,
USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD,
USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians, John Hopkins Medicine, Baltimore, MD,
USA
- Department of Medicine, Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD,
USA
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4
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Khan SA, Demidowich AP, Tschudy MM, Wedler J, Lamy W, Akpandak I, Alexander LA, Misra I, Sidhaye A, Rotello L, Zilbermint M. Increasing Frequency of Hemoglobin A1C Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma. J Diabetes Sci Technol 2023:19322968231153883. [PMID: 36788726 DOI: 10.1177/19322968231153883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND The American Diabetes Association (ADA) recommends measuring A1C in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1C measurements in hospitalized patients. METHODS We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1C in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1C, (2) more rapid turnaround of A1C results, and (3) an EHR glucose-management tab and insulin order set that included A1C. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1C measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis. RESULTS Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1C measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention. CONCLUSIONS We demonstrate a novel approach in improving A1C in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew P Demidowich
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan M Tschudy
- Division of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joyce Wedler
- Department of Information Systems, Suburban Hospital, Bethesda, MD, USA
| | - Wilson Lamy
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iniuboho Akpandak
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Lee Ann Alexander
- Department of Pharmacy, Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA
| | - Isha Misra
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leo Rotello
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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Khan SA, Zilbermint M. Centers for Medicare & Medicaid Services' Hospital Harm Measures for Severe Hypoglycemia and Hyperglycemia: Is Your Hospital Ready? Diabetes Spectr 2022; 35:391-397. [PMID: 36561656 PMCID: PMC9668722 DOI: 10.2337/dsi22-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Poor inpatient glycemic management is associated with increased lengths of stay and in-hospital morbidity and mortality. Improving inpatient glycemic outcomes can be difficult because there are no standardized benchmarks, and many hospitals lack the capacity to electronically extract and analyze glucose data. The Centers for Medicare & Medicaid Services recently proposed new electronic clinical quality measures to be incorporated into its mandatory Hospital Inpatient Quality Reporting Program. Among these measures is an assessment of hospital harm from severe hypoglycemia and severe hyperglycemia. Hospitals must be ready to collect the necessary data for these new measures by January 2023. The new measures could bring welcome attention to the need to implement guideline-based inpatient glycemic management. However, some hospitals that serve high-risk populations may be at risk for losing funding if they are unable to comply.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes, and Metabolism, University of Maryland School of Medicine, Baltimore, MD
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, University of Maryland School of Medicine, Baltimore, MD
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Baltimore, MD
- Division of Endocrinology, Diabetes and Metabolism, Suburban Hospital, Bethesda, MD
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Zilbermint M. Inpatient Diabetes Management: Preface: Inpatient Diabetes Management: Should We Make It Simpler? Diabetes Spectr 2022; 35:387-389. [PMID: 36561650 PMCID: PMC9668715 DOI: 10.2337/dsi22-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Demidowich AP, Batty K, Zilbermint M. Instituting a Successful Discharge Plan for Patients With Type 2 Diabetes: Challenges and Solutions. Diabetes Spectr 2022; 35:440-451. [PMID: 36561646 PMCID: PMC9668725 DOI: 10.2337/dsi22-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Achieving target inpatient glycemic management outcomes has been shown to influence important clinical outcomes such as hospital length of stay and readmission rates. However, arguably the most profound, lasting impact of inpatient diabetes management is achieved at the time of discharge-namely reconciling and prescribing the right medications and making referrals for follow-up. Discharge planning offers a unique opportunity to break through therapeutic inertia, offer diabetes self-management education, and institute an individualized treatment plan that prepares the patient for discharge and promotes self-care and engagement. However, the path to a successful discharge plan can be fraught with potential pitfalls for clinicians, including lack of knowledge and experience with newer diabetes medications, costs, concerns over insurance coverage, and lack of time and resources. This article presents an algorithm to assist clinicians in selecting discharge regimens that maximize benefits and reduce barriers to self-care for patients and a framework for creating an interdisciplinary hospital diabetes discharge program.
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Affiliation(s)
- Andrew P. Demidowich
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Community Physicians at Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, MD
| | - Kristine Batty
- Johns Hopkins Community Physicians at Howard County General Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Columbia, MD
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Community Physicians at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine, Bethesda, MD
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Khan SA, Demidowich AP, Tschudy MM, Wedler J, Lamy W, Sidhaye A, Alexander LA, Misra I, Zilbermint M. PSUN219 Increasing Frequency of Hemoglobin A1c (Hba1c) Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma. J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Studies have shown the predictive value of hemoglobin A1c (HbA1c) on inpatient glycemic control, and its value for discharge planning. There is little data on HbA1c testing adherence to American Diabetes Association (ADA) guidelines among inpatient providers, and anecdotal evidence suggests that most inpatient providers do not have a standardized approach to HbA1c measurement. The Lean Six Sigma method is a management system that originated in the automobile industry and has become widely used in healthcare to improve the efficiency of processes. The objective of this study was to determine the impact utilizing Lean Six Sigma methodology to increase frequency of HbA1c measurements among hospitalized patients with a known history of diabetes, in line with ADA guidelines.
Methods
This was a quality improvement study performed in a 240-bed community hospital, evaluating inpatients (≥16 years) consecutively admitted with a diagnosis of diabetes (ICD-10 code E8-E13 and O24) between January 2016-June 2021. Patients were excluded if they had a HbA1c in the health system electronic health record (EHR) in the prior 3 months. The Lean Six Sigma approach was utilized to define the problem and implement solutions. The intervention bundle delivered between November 2017 and February 2018 included 1) provider and nursing education on the utility of HbA1c in patient care, 2) change in laboratory protocols for more rapid turnaround of HbA1c, 3) modifications to the EHR including a glucose management tab and insulin order set that included HbA1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Demographic characteristics were calculated. Frequency of HbA1c lab sent while inpatient was compared pre- (Jan 2016-Nov 2017) and post-intervention (March 2018-June 2021) using chi-square analysis.
Results
17,869 patients were included (7,332 pre- and 10,537 post-intervention). Demographics did not differ between pre and post intervention periods (mean age [range]: 78.1 [16-106] years, sex: 52.3% male, race: 52.1% White, 25.1% Black). Only 53.5% of patients who met criteria had a HbA1c measured during hospitalization before intervention. This frequency increased to 70.2% postintervention. The improvement in the frequency of HbA1c measurement was sustained more than two years following the initial interventions and continued to improve over time.
Conclusion
This novel approach was successful in improving adherence to guideline-based measurement of HbA1c in hospitalized patients. This is the first quality improvement project in a community hospital utilizing the Lean Six Sigma process for this purpose and may represent a valuable methodology for community hospitals to improve inpatient diabetes care.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
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Zilbermint M, Demidowich AP. Primary adrenal insufficiency. Clin Case Rep 2022; 10:e6002. [PMID: 35765293 PMCID: PMC9207222 DOI: 10.1002/ccr3.6002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/23/2022] [Accepted: 06/13/2022] [Indexed: 11/24/2022] Open
Abstract
Primary adrenal insufficiency is a potentially life‐threatening condition. We report a case of a 49‐year‐old female patient who presented to the hospital for evaluation of dizziness, nausea, and vomiting. Darkening of the palmar creases and tongue was noted. The adrenocorticotropic hormone stimulation test confirmed the diagnosis of adrenal insufficiency.
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Affiliation(s)
- Mihail Zilbermint
- Johns Hopkins Community Physicians Johns Hopkins Medicine Baltimore Maryland USA
- Division of Endocrinology, Diabetes, and Metabolism Johns Hopkins University School of Medicine Baltimore Maryland USA
- Suburban Hospital, Johns Hopkins Medicine Bethesda Maryland USA
- Howard County General Hospital Johns Hopkins Medicine Columbia Maryland USA
| | - Andrew P. Demidowich
- Johns Hopkins Community Physicians Johns Hopkins Medicine Baltimore Maryland USA
- Division of Endocrinology, Diabetes, and Metabolism Johns Hopkins University School of Medicine Baltimore Maryland USA
- Suburban Hospital, Johns Hopkins Medicine Bethesda Maryland USA
- Howard County General Hospital Johns Hopkins Medicine Columbia Maryland USA
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Affiliation(s)
- Mihail Zilbermint
- Johns Hopkins Community Physicians at Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University Carey Business School, Baltimore, MD, USA
- Mihail Zilbermint, MD, FACE, Johns Hopkins Community Physicians at Suburban Hospital, Johns Hopkins Medicine, 8600 Old Georgetown Rd, Bethesda, MD 20814, USA.
| | - Andrew P. Demidowich
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Howard County General Hospital, Johns Hopkins Medicine, Columbia, MD, USA
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Najmi U, Haque WZ, Ansari U, Yemane E, Alexander LA, Lee C, Demidowich AP, Motevalli M, Mackay P, Tucker C, Notobartolo C, Sartippour P, Raynor J, Zilbermint M. Inpatient Insulin Pen Implementation, Waste, and Potential Cost Savings: A Community Hospital Experience. J Diabetes Sci Technol 2021; 15:741-747. [PMID: 33843291 PMCID: PMC8258519 DOI: 10.1177/19322968211002514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Insulin pen injectors ("pens") are intended to facilitate a patient's self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs. METHODS Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions. RESULTS 9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year. CONCLUSIONS In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.
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Affiliation(s)
- Urooj Najmi
- American International School of Medicine, Atlanta, GA, USA
| | - Waqas Zia Haque
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Umair Ansari
- Pharmacy Department, Suburban Hospital, Bethesda, MD, USA
| | | | | | - Christina Lee
- Pharmacy Department, Suburban Hospital, Bethesda, MD, USA
| | - Andrew P. Demidowich
- Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahsa Motevalli
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Periwinkle Mackay
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cynthia Tucker
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cindy Notobartolo
- Department of Safety, Security and Employee Health Services, Suburban Hospital, Bethesda, MD, USA
| | - Poroshat Sartippour
- Department of Management Information System, Suburban Hospital, Bethesda, MD, USA
| | | | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
- Mihail Zilbermint, MD, Johns Hopkins Community Physicians at Suburban Hospital, 8600 Old Georgetown Road, Bethesda, MD 20814, USA. ; Twitter: @Zilbermint; LinkedIn: https://www.linkedin.com/in/mishazilbermint/
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12
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Shelton C, Demidowich AP, Motevalli M, Sokolinsky S, MacKay P, Tucker C, Abundo C, Peters E, Gooding R, Hackett M, Wedler J, Alexander LA, Barry L, Flynn M, Rios P, Fulda CL, Young MF, Kahl B, Pummer E, Mathioudakis NN, Sidhaye A, Howell EE, Rotello L, Zilbermint M. Retrospective Quality Improvement Study of Insulin-Induced Hypoglycemia and Implementation of Hospital-Wide Initiatives. J Diabetes Sci Technol 2021; 15:733-740. [PMID: 33880952 PMCID: PMC8258511 DOI: 10.1177/19322968211008513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hospitalized patients who are receiving antihyperglycemic agents are at increased risk for hypoglycemia. Inpatient hypoglycemia may lead to increased risk for morbidity, mortality, prolonged hospitalization, and readmission within 30 days of discharge, which in turn may lead to increased costs. Hospital-wide initiatives targeting hypoglycemia are known to be beneficial; however, their impact on patient care and economic measures in community nonteaching hospitals are unknown. METHODS This retrospective quality improvement study examined the effects of hospital-wide hypoglycemia initiatives on the rates of insulin-induced hypoglycemia in a community hospital setting from January 1, 2016, until September 30, 2019. The potential cost of care savings has been calculated. RESULTS Among 49 315 total patient days, 2682 days had an instance of hypoglycemia (5.4%). Mean ± SD hypoglycemic patient days/month was 59.6 ± 16.0. The frequency of hypoglycemia significantly decreased from 7.5% in January 2016 to 3.9% in September 2019 (P = .001). Patients with type 2 diabetes demonstrated a significant decrease in the frequency of hypoglycemia (7.4%-3.8%; P < .0001), while among patients with type 1 diabetes the frequency trended downwards but did not reach statistical significance (18.5%-18.0%; P = 0.08). Based on the reduction of hypoglycemia rates, the hospital had an estimated cost of care savings of $98 635 during the study period. CONCLUSIONS In a community hospital setting, implementation of hospital-wide initiatives targeting hypoglycemia resulted in a significant and sustainable decrease in the rate of insulin-induced hypoglycemia. These high-leverage risk reduction strategies may be translated into considerable cost savings and could be implemented at other community hospitals.
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Affiliation(s)
- Carter Shelton
- Ambulatory Services, Medical University of South Carolina, Charleston, SC, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew P. Demidowich
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahsa Motevalli
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Sam Sokolinsky
- JHHS Quality and Clinical Analytics, Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Periwinkle MacKay
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cynthia Tucker
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cora Abundo
- Readmission Department, Suburban Hospital, Bethesda, MD, USA
| | - Eileen Peters
- Readmission Department, Suburban Hospital, Bethesda, MD, USA
| | | | | | - Joyce Wedler
- Department of Information Systems, Suburban Hospital, Bethesda, MD, USA
| | | | - Luvenia Barry
- Community Health and Wellness, Suburban Hospital, Bethesda, MD, USA
| | - Mary Flynn
- Community Health and Wellness, Suburban Hospital, Bethesda, MD, USA
| | - Patricia Rios
- Community Health and Wellness, Suburban Hospital, Bethesda, MD, USA
| | | | - Michelle F. Young
- Department of Food and Nutrition, Suburban Hospital, Bethesda, MD, USA
| | - Barbara Kahl
- Patient and Family Advisory Council, Suburban Hospital, Bethesda, MD, USA
| | - Eileen Pummer
- Department of Quality, Safety, and Performance Improvement, Suburban Hospital, Bethesda, MD, USA
| | - Nestoras N. Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Leo Rotello
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Mihail Zilbermint, MD, FACE, Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, 8600 Old Georgetown Road, 6th Floor Endocrinology Office, Bethesda, MD 20814, USA. Twitter: @Zilbermint; LinkedIn: https://www.linkedin.com/in/mishazilbermint/
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13
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Abstract
The endocrine hospitalist and inpatient diabetes management team increases access to endocrinology consultations and improves glycemic control and quality metrics such as length of stay and hospital readmission. Enhanced glycemic care is needed in both academic and community hospital settings. Endocrine fellowship programs should implement endocrine hospitalist rotations with emphasis on training endocrine fellows to deliver fast-paced inpatient endocrine care. Entrepreneurship, innovation, and a "start-up" culture within the field of Endocrinology should be encouraged and supported by healthcare systems.
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Affiliation(s)
- Mihail Zilbermint
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins University Carey Business School, Baltimore, MD, USA
- Mihail Zilbermint, MD, FACE, Johns Hopkins Community Physicians at Suburban Hospital, 8600 Old Georgetown Road, 6th Floor Endocrinology Office, Bethesda, MD 20814, USA.
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14
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Kane T, Flood C, Oluwato T, Pan Q, Zilbermint M. Expanding legal treatment options for medical marijuana in the State of Louisiana. J Community Hosp Intern Med Perspect 2021; 11:343-349. [PMID: 34234903 PMCID: PMC8118431 DOI: 10.1080/20009666.2021.1890339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The use of cannabis for ‘medical’ purposes has expanded throughout the USA. Despite the limited peer-reviewed medical research, medical marijuana therapy has been to treat chronic pain, stimulate appetite, treat nausea, and ameliorate muscle spasticity. Challenge: In the state of Louisiana, this potential treatment is strictly controlled. The ability of the individual patient to receive this therapy is limited since any prescribing provider had to be both licensed by the state medical board and registered with the board to prescribe medical marijuana. Medical cannabis could be used only for limited medical disorders. The ‘Medical Marijuana’ HB819 bill authorizes the recommendation of medical marijuana for additional conditions and allows any state-licensed physician to recommend/prescribe medical marijuana. Alternative options: The government may consider working with the state medical board to lessen its regulation allowing a collaborative effort to formalize protocols for safe prescribing of medical marijuana. A more liberal option would be to make it available to the consumer over the counter, while a state tracking mechanism is set in place to limit the amount purchased. Conclusions: Two stakeholders pertaining to this new legislation to focus on are the Louisiana State government and healthcare providers. This law probably has the biggest impact on healthcare providers and their relationship to patients. This legislation may allow providers to have more ‘freedom in medical marijuana treatment plans’. These benefits would be monitored using such criteria as cost, access to care, as well as patient and healthcare provider satisfaction.
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Affiliation(s)
- Theresa Kane
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA
| | - Christopher Flood
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Department of Quality, Suburban Hospital, Johns Hopkins Medicine, Bethesda, USA
| | - Tobi Oluwato
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Department of Quality, Suburban Hospital, Johns Hopkins Medicine, Bethesda, USA.,Department of OB Hospitalists, Sutter East Bay Medical Group, Berkeley, CA, USA
| | - Qinshi Pan
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Health Care Management MBA Program, Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, MD, USA.,Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Bedoya Reina MT, Brereton N, Zilbermint M. Haven Health is About to Disrupt the U.S. Healthcare System. J Community Hosp Intern Med Perspect 2021; 11:357-360. [PMID: 34234906 PMCID: PMC8118442 DOI: 10.1080/20009666.2021.1906832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Healthcare costs are increasing in the U.S. Healthcare market is fragmented and opaque. The Amazon, JP Morgan Chase, and Berkshire Hathaway partnered to form an independent healthcare company ‘Haven’, designed to support cost-containment in health care and to forge a better patient experience. Limited information is available in the public domain about Haven’s strategy to deliver cost-effective healthcare for their employees. Objective: To describe the impact of Haven Health of modern healthcare. Methods: We reviewed literature in Pubmed (MEDLINE database of references and abstracts on life sciences and biomedical topics from the USA National Library of Medicine at the National Institutes of Health) and the public domain. Results: Amazon’s expertise and abilities in e-commerce such as logistics, supply, and big data management will support Haven’s quest to resolve inefficiencies in health care. Haven may attempt to directly negotiate with providers, bypassing insurance companies, to establish themselves as an independent payor. Additionally, Haven to establish themselves as a provider by building new low-cost primary care clinics, focusing on chronic disease prevention. The new healthcare system may leverage machine learning, artificial intelligence and big data analysis to support its initiatives and other ‘big data’ analytics to drive it all. Conclusions: Heaven Health may use its expertise to disrupt everything from the pharmaceutical supply chain to primary care and telehealth. More research is needed to evaluate the impact of Haven Healthcare on disease outcomes and healthcare costs.
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Affiliation(s)
| | | | - Mihail Zilbermint
- Johns Hopkins University Carey Business School, Baltimore, MD, USA.,Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, MD, USA.,Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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16
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Demidowich AP, Batty K, Love T, Sokolinsky S, Grubb L, Miller C, Raymond L, Nazarian J, Ahmed MS, Rotello L, Zilbermint M. Effects of a Dedicated Inpatient Diabetes Management Service on Glycemic Control in a Community Hospital Setting. J Diabetes Sci Technol 2021; 15:546-552. [PMID: 33615858 PMCID: PMC8120056 DOI: 10.1177/1932296821993198] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Community hospitals account for over 84% of all hospitals and over 94% of hospital admissions in the United States. In academic settings, implementation of an Inpatient Diabetes Management Service (IDMS) model of care has been shown to reduce rates of hyper- and hypoglycemia, hospital length of stay (LOS), and associated hospital costs. However, few studies to date have evaluated the implementation of a dedicated IDMS in a community hospital setting. METHODS This retrospective study examined the effects of changing the model of inpatient diabetes consultations from a local, private endocrine practice to a full-time endocrine hospitalist on glycemic control, LOS, and 30-day readmission rates in a 267-bed community hospital. RESULTS Overall diabetes patient days for the hospital were similar pre- and post-intervention (20,191 vs 20,262); however, the volume of patients seen by IDMS increased significantly after changing models. Rates of hyperglycemia decreased both among patients seen by IDMS (53.8% to 42.5%, P < .0001) and those not consulted on by IDMS (33.2% to 29.9%; P < .0001). When examined over time, rates of hypoglycemia steadily decreased in the 24 months after dedicated IDMS initiation (P = .02); no such time effect was seen prior to IDMS (P = .34). LOS and 30DRR were not significantly different between IDMS models. CONCLUSIONS Implementation of an endocrine hospitalist-based IDMS at a community hospital was associated with significantly decreased hyperglycemia, while avoiding concurrent increases in hypoglycemia. Further studies are needed to investigate whether these effects are associated with improvements in clinical outcomes, patient or staff satisfaction scores, or total cost of care.
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Affiliation(s)
- Andrew P. Demidowich
- Johns Hopkins Community Physicians
at Howard County General Hospital (HCGH), Division of Hospital Medicine,
Johns Hopkins Medicine, Columbia, MD, USA
- Division of Endocrinology,
Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of
Medicine, Baltimore, MD, USA
- Andrew P. Demidowich, MD, Assistant
Professor of Medicine, Johns Hopkins Medicine, Howard County General
Hospital, 5755 Cedar Ln, Columbia, MD 21044, USA.
| | - Kristine Batty
- Johns Hopkins Community Physicians
at Howard County General Hospital (HCGH), Division of Hospital Medicine,
Johns Hopkins Medicine, Columbia, MD, USA
| | - Teresa Love
- Rehab Services, Diabetes
Management & The Center for Wound Healing, HCGH, Johns Hopkins Medicine,
Columbia, MD, USA
| | - Sam Sokolinsky
- JHHS Quality and Clinical
Analytics, Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD,
USA
| | - Lisa Grubb
- Johns Hopkins Armstrong Institute
at HCGH, Johns Hopkins Medicine, Columbia, MD, USA
| | - Catherine Miller
- Division of Nursing – Critical
Care, HCGH, Johns Hopkins Medicine, Columbia, MD, USA
| | - Larry Raymond
- Rehab Services, Diabetes
Management & The Center for Wound Healing, HCGH, Johns Hopkins Medicine,
Columbia, MD, USA
| | - Jeanette Nazarian
- Johns Hopkins Community Physicians
at Howard County General Hospital (HCGH), Division of Hospital Medicine,
Johns Hopkins Medicine, Columbia, MD, USA
| | - M. Shafeeq Ahmed
- Johns Hopkins Armstrong Institute
at HCGH, Johns Hopkins Medicine, Columbia, MD, USA
| | - Leo Rotello
- Johns Hopkins Community Physicians
at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine,
Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology,
Diabetes and Metabolism, Department of Medicine, Johns Hopkins School of
Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians
at Suburban Hospital, Division of Hospital Medicine, Johns Hopkins Medicine,
Bethesda, MD, USA
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17
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Hollister BM, Zilbermint M, Minniti CP, Buscetta AJ, Abdallah KE, You S, Soldin SJ, Meyer JS, Stratakis CA, Bonham VL. Lower hair cortisol among patients with sickle cell disease may indicate decreased adrenal reserves. Am J Blood Res 2021; 11:140-148. [PMID: 34079627 PMCID: PMC8165714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Sickle cell disease (SCD) is a chronic illness that presents with a wide range of phenotypic variation. Stress may be a contributing factor to differences that are found in this population. OBJECTIVES Our objective is to determine the relationship between hair cortisol content (HCC), a biomarker of stress, and other clinical measures in individuals with SCD. METHODS We collected hair samples and other clinical measures from 73 subjects with SCD (mean age: 39 ± 12 years, 63% female). RESULTS HCC was lower among individuals who had greater than 30% hemoglobin S, compared with those who had less than 30% hemoglobin S (W=272.5, P=0.01). Lower HCC was also associated with report of not being on a chronic transfusion program (β=48.34, SE=14.09, P=0.001) and higher ferritin levels (β=-0.006, SE=0.002, P=0.02). Furthermore, HCC was significantly correlated with serum cortisol (rs=0.26, P=0.03) and corticosterone (rs=0.29, P=0.01). We also observed a consistent pattern of low steroid values among our population. CONCLUSION Our findings suggest that individuals with higher hemoglobin S and ferritin, both markers of severe SCD, may have decreased cortisol levels. This is consistent with the relationship we observed between higher HCC among individuals who are on a chronic blood transfusion program, which typically increases quality of life. Our results suggest that hair cortisol may be an indicator in patients with SCD who could be at risk for developing adrenal insufficiency. We recommend that clinicians treating patients with SCD follow the Endocrine Society guidelines for testing for adrenal insufficiency and treat accordingly.
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Affiliation(s)
- Brittany M Hollister
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland, USA
- The University of Florida Genetics InstituteGainesville, Florida, USA
| | - Mihail Zilbermint
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesda, Maryland, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of MedicineBaltimore, Maryland, USA
- Johns Hopkins Community Physicians at Suburban HospitalBethesda, Maryland, USA
| | - Caterina P Minniti
- Division of Hematology, Department of Oncology, Montefiore Medical Center, Albert Einstein College of MedicineNew York, New York, USA
| | - Ashley J Buscetta
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland, USA
| | - Khadijah E Abdallah
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland, USA
| | - Shuo You
- Division of Hematology, Department of Oncology, Montefiore Medical Center, Albert Einstein College of MedicineNew York, New York, USA
| | - Steven J Soldin
- Department of Laboratory Medicine, Clinical Center, National Institutes of HealthBethesda, Maryland, USA
| | - Jerrold S Meyer
- Department of Psychological and Brain Sciences, University of MassachusettsAmherst, Massachusetts, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesda, Maryland, USA
| | - Vence L Bonham
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of HealthBethesda, Maryland, USA
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Abstract
CONTEXT Diabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management. OBJECTIVE To review recent literature on the financial and clinical impact of IDMS in hospital settings. METHODS We searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine. FINDINGS In addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management. CONCLUSION IDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.
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Affiliation(s)
- Waqas Zia Haque
- Johns Hopkins Bloomberg School of Public Health, 605 N Wolfe St, Baltimore, MD, 21287, USA
| | - Andrew Paul Demidowich
- Johns Hopkins Community Physicians at Howard County General Hospital, 5755 Cedar Lane, Columbia, MD, 21044, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD, 21287, USA.
- Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, 8600 Old Georgetown Road, 6th Floor Endocrinology Office, Bethesda, MD, 20814, USA.
- Johns Hopkins Carey Business School, Baltimore, MD, 21202, USA.
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19
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Mathioudakis NN, Abusamaan MS, Shakarchi AF, Sokolinsky S, Fayzullin S, McGready J, Zilbermint M, Saria S, Golden SH. Development and Validation of a Machine Learning Model to Predict Near-Term Risk of Iatrogenic Hypoglycemia in Hospitalized Patients. JAMA Netw Open 2021; 4:e2030913. [PMID: 33416883 PMCID: PMC7794667 DOI: 10.1001/jamanetworkopen.2020.30913] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/01/2020] [Indexed: 12/19/2022] Open
Abstract
Importance Accurate clinical decision support tools are needed to identify patients at risk for iatrogenic hypoglycemia, a potentially serious adverse event, throughout hospitalization. Objective To predict the risk of iatrogenic hypoglycemia within 24 hours after each blood glucose (BG) measurement during hospitalization using a machine learning model. Design, Setting, and Participants This retrospective cohort study, conducted at 5 hospitals within the Johns Hopkins Health System, included 54 978 admissions of 35 147 inpatients who had at least 4 BG measurements and received at least 1 U of insulin during hospitalization between December 1, 2014, and July 31, 2018. Data from the largest hospital were split into a 70% training set and 30% test set. A stochastic gradient boosting machine learning model was developed using the training set and validated on internal and external validation. Exposures A total of 43 clinical predictors of iatrogenic hypoglycemia were extracted from the electronic medical record, including demographic characteristics, diagnoses, procedures, laboratory data, medications, orders, anthropomorphometric data, and vital signs. Main Outcomes and Measures Iatrogenic hypoglycemia was defined as a BG measurement less than or equal to 70 mg/dL occurring within the pharmacologic duration of action of administered insulin, sulfonylurea, or meglitinide. Results This cohort study included 54 978 admissions (35 147 inpatients; median [interquartile range] age, 66.0 [56.0-75.0] years; 27 781 [50.5%] male; 30 429 [55.3%] White) from 5 hospitals. Of 1 612 425 index BG measurements, 50 354 (3.1%) were followed by iatrogenic hypoglycemia in the subsequent 24 hours. On internal validation, the model achieved a C statistic of 0.90 (95% CI, 0.89-0.90), a positive predictive value of 0.09 (95% CI, 0.08-0.09), a positive likelihood ratio of 4.67 (95% CI, 4.59-4.74), a negative predictive value of 1.00 (95% CI, 1.00-1.00), and a negative likelihood ratio of 0.22 (95% CI, 0.21-0.23). On external validation, the model achieved C statistics ranging from 0.86 to 0.88, positive predictive values ranging from 0.12 to 0.13, negative predictive values of 0.99, positive likelihood ratios ranging from 3.09 to 3.89, and negative likelihood ratios ranging from 0.23 to 0.25. Basal insulin dose, coefficient of variation of BG, and previous hypoglycemic episodes were the strongest predictors. Conclusions and Relevance These findings suggest that iatrogenic hypoglycemia can be predicted in a short-term prediction horizon after each BG measurement during hospitalization. Further studies are needed to translate this model into a real-time informatics alert and evaluate its effectiveness in reducing the incidence of inpatient iatrogenic hypoglycemia.
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Affiliation(s)
- Nestoras N. Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammed S. Abusamaan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmed F. Shakarchi
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sam Sokolinsky
- Department of Quality Improvement and Clinical Analytics, Johns Hopkins Health System, Baltimore, Maryland
| | - Shamil Fayzullin
- Department of Quality Improvement and Clinical Analytics, Johns Hopkins Health System, Baltimore, Maryland
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, Maryland
| | - Suchi Saria
- Departments of Computer Science, Applied Math and Statistics, and Health Policy, Johns Hopkins University, Baltimore, Maryland
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Wurth R, Tirosh A, Kamilaris CDC, Camacho J, Faucz FR, Maria AG, Berthon A, Papadakis GZ, Nilubol N, Hamimi A, Gharib AM, Demidowich A, Zilbermint M, Eisenhofer G, Braun L, Reincke M, Stratakis CA, Hannah-Shmouni F. Volumetric Modeling of Adrenal Gland Size in Primary Bilateral Macronodular Adrenocortical Hyperplasia. J Endocr Soc 2021; 5:bvaa162. [PMID: 33305158 PMCID: PMC7716656 DOI: 10.1210/jendso/bvaa162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 11/19/2022] Open
Abstract
CONTEXT Radiological characterization of adrenal size in primary bilateral macronodular adrenocortical hyperplasia (PBMAH) has not been previously investigated. OBJECTIVE We hypothesized that volumetric modeling of adrenal gland size may correlate with biochemical disease severity in patients with PBMAH. Secondary analysis of patients with concurrent primary aldosteronism (PA) was performed. DESIGN A retrospective cross-sectional analysis of 44 patients with PBMAH was conducted from 2000 to 2019. SETTING Tertiary care clinical research center. PATIENTS Patients were diagnosed with PBMAH based upon clinical, genetic, radiographic and biochemical characteristics. INTERVENTION Clinical, biochemical, and genetic data were obtained. Computed tomography scans were used to create volumetric models by manually contouring both adrenal glands in each slice using Vitrea Core Fx v6.3 software (Vital Images, Minnetonka, Minnesota). MAIN OUTCOME AND MEASURES 17-hydroxycorticosteroids (17-OHS), ARMC5 genetics, and aldosterone-to-renin ratio (ARR) were retrospectively obtained. Pearson test was used for correlation analysis of biochemical data with adrenal volume. RESULTS A cohort of 44 patients with PBMAH was evaluated, with a mean age (±SD) of 53 ± 11.53. Eight patients met the diagnostic criteria for PA, of whom 6 (75%) were Black. In the Black cohort, total adrenal volumes positively correlated with midnight cortisol (R = 0.76, P = 0.028), urinary free cortisol (R = 0.70, P = 0.035), and 17-OHS (R = 0.87, P = 0.0045), with a more pronounced correlation with left adrenal volume alone. 17-OHS concentration positively correlated with total, left, and right adrenal volume in patients harboring pathogenic variants in ARMC5 (R = 0.72, P = 0.018; R = 0.65, P = 0.042; and R = 0.73, P = 0.016, respectively). CONCLUSIONS Volumetric modeling of adrenal gland size may associate with biochemical severity in patients with PBMAH, with particular utility in Black patients.
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Affiliation(s)
- Rachel Wurth
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Amit Tirosh
- Neuroendocrine Tumors Service, Division of Endocrinology, Diabetes and Metabolism, The Chaim Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Crystal D C Kamilaris
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jancarlos Camacho
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fabio R Faucz
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Andrea Gutierrez Maria
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Annabel Berthon
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Georgios Z Papadakis
- Foundation for Research and Technology (FORTH), Institute of Computer Science (ICS), Computational Biomedicine Laboratory, Heraklion, Greece
- Department of Radiology, Medical School, University of Crete, Heraklion, Greece
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Ahmed Hamimi
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Ahmed M Gharib
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Andrew Demidowich
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Mihail Zilbermint
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
- Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Graeme Eisenhofer
- Institute of Clinical Chemistry and Laboratory Medicine, and Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität, Dresden, Germany
| | - Leah Braun
- Medizinische Klinik und Poliklinik IV, Division of Endocrinology, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Division of Endocrinology, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Constantine A Stratakis
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Fady Hannah-Shmouni
- Section on Endocrinology & Genetics (SEGEN), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, USA
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Abstract
Background Diabetes mellitus, a looming crisis, is approaching worldwide epidemic proportions. In 2018, 34.2 million Americans, or 10.5% of the population had diabetes. Climate change, and in particular rising global temperatures, may exacerbate various health issues, including diabetes and ultimately lead to increased mortality. Objectives To identify the impact of climate change on diabetes. Methods A systematic literature review of Pubmed (MEDLINE database of references and abstracts on life sciences and biomedical topics from the USA National Library of Medicine at the National Institutes of Health) and Scopus (Elsevier’s abstract and citation database) with the following terms: ‘diabetes’ [AND] ‘climate change’. Results The following risk factors for diabetes due to climate change were identified and discussed: extreme temperatures (heat), the risk of hospitalization, shortage of medical and food supplies and urbanization. Conclusions Diabetes and climate change are interconnected. Extreme weather events and rising temperatures may increase morbidity and mortality in patients living with diabetes, especially in those with cardiovascular complications. Failure to mitigate climate change and the diabetes epidemic threatens the lives of many people in the U.S. and beyond.
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Affiliation(s)
- Mihail Zilbermint
- Johns Hopkins Community Physicians at Suburban Hospital, Suburban Hospital, Bethesda, MD, USA.,Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins University Carey Business School, Baltimore, MD, USA
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22
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Umpierrez G, Rushakoff R, Seley JJ, Zhang JY, Shang T, Han J, Spanakis EK, Alexanian S, Drincic A, Kulasa K, Mendez CE, Tanton D, Wallia A, Zilbermint M, Klonoff DC. Hospital Diabetes Meeting 2020. J Diabetes Sci Technol 2020; 14:928-944. [PMID: 32783456 PMCID: PMC7477766 DOI: 10.1177/1932296820939626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patients with diabetes may experience adverse outcomes related to their glycemic control when hospitalized. Continuous glucose monitoring systems, insulin-dosing software, enhancements to the electronic health record, and other medical technologies are now available to improve hospital care. Because of these developments, new approaches are needed to incorporate evolving treatments into routine care. With the goal of educating healthcare professionals on the most recent practices and research for managing diabetes in the hospital, Diabetes Technology Society hosted the Virtual Hospital Diabetes Meeting on April 24-25, 2020. Because of the coronavirus disease 2019 (COVID-19) pandemic, the meeting was restructured to be held virtually during the national lockdown to ensure the safety of the participants and allow them to remain at their posts treating COVID-19 patients. The meeting focused on (1) inpatient management and perioperative care, (2) diabetic ketoacidosis and hyperglycemic hyperosmolar state, (3) computer-guided insulin dosing, (4) Coronavirus Disease 2019 and diabetes, (5) technology, (6) hypoglycemia, (7) data and cybersecurity, (8) special situations, (9) glucometrics and insulinometrics, and (10) quality and safety. This meeting report contains summaries of each of the ten sessions. A virtual poster session will be presented within two months of the meeting.
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Affiliation(s)
| | | | | | | | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | | | | | | | | | - Damon Tanton
- AdventHealth Diabetes Institute, Orlando, FL, USA
| | | | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive, Room 5147, San Mateo, CA 94401, USA.
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23
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Haque W, Ahmed SR, Zilbermint M. Nivolumab-induced autoimmune diabetes mellitus and hypothyroidism in a patient with rectal neuroendocrine tumor. J Community Hosp Intern Med Perspect 2020; 10:338-339. [PMID: 32850092 PMCID: PMC7427449 DOI: 10.1080/20009666.2020.1771126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/15/2020] [Indexed: 11/24/2022] Open
Abstract
We present a rare case of autoimmune diabetes mellitus and hypothyroidism in an elderly man initiated on nivolumab two months prior to admission for treatment of a high-grade neuroendocrine rectal tumor. This patient presented to a local community hospital with one-week history of severe nausea, thirst, and bilateral leg edema. Biochemical studies confirmed the diagnosis of diabetic ketoacidosis in the setting of autoimmune diabetes mellitus and primary hypothyroidism, likely due to nivolumab use. This case illustrates an acute complication due to secondary diabetes mellitus in the setting of a novel anticancer agent. There are three key takeaways for physicians managing patients on nivolumab. First, there should be a discussion of the benefits and risks of immunomodulatory therapy. Second, patients should be tested for immunological and other markers before being started on checkpoint inhibitors. Third, oncologists must be aware of the signs and symptoms of life-threatening hyperglycemia and severe hypothyroidism. Additional studies are needed to identify those patients at highest risk for autoimmune complications.
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Affiliation(s)
- Waqas Haque
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- JThe University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Shabina R. Ahmed
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Bethesda, MD, USA
| | - Mihail Zilbermint
- Johns Hopkins Community Physicians, Bethesda, MD, USA
- Suburban Hospital, Bethesda, MD, USA
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24
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Joseph JJ, Zhou X, Zilbermint M, Stratakis CA, Faucz FR, Lodish MB, Berthon A, Wilson JG, Hsueh WA, Golden SH, Lin S. The Association of ARMC5 with the Renin-Angiotensin-Aldosterone System, Blood Pressure, and Glycemia in African Americans. J Clin Endocrinol Metab 2020; 105:5841631. [PMID: 32436940 PMCID: PMC7308077 DOI: 10.1210/clinem/dgaa290] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/18/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT Armadillo repeat containing 5 (ARMC5) on chromosome 16 is an adrenal gland tumor suppressor gene associated with primary aldosteronism, especially among African Americans (AAs). We examined the association of ARMC5 variants with aldosterone, plasma renin activity (PRA), blood pressure, glucose, and glycosylated hemoglobin A1c (HbA1c) in community-dwelling AAs. METHODS The Jackson Heart Study is a prospective cardiovascular cohort study in AAs with baseline data collection from 2000 to 2004. Kernel machine method was used to perform a single joint test to analyze for an overall association between the phenotypes of interest (aldosterone, PRA, systolic and diastolic blood pressure [SBP, DBP], glucose, and HbA1c) and the ARMC5 single nucleotide variants (SNVs) adjusted for age, sex, BMI, and medications; followed by Baysian Lasso methodology to identify sets of SNVs in terms of associated haplotypes with specific phenotypes. RESULTS Among 3223 participants (62% female; mean age 55.6 (SD ± 12.8) years), the average SBP and DBP were 127 and 76 mmHg, respectively. The average fasting plasma glucose and HbA1c were 101 mg/dL and 6.0%, respectively. ARMC5 variants were associated with all 6 phenotypes. Haplotype TCGCC (ch16:31476015-31476093) was negatively associated, whereas haplotype CCCCTTGCG (ch16:31477195-31477460) was positively associated with SBP, DBP, and glucose. Haplotypes GGACG (ch16:31477790-31478013) and ACGCG (ch16:31477834-31478113) were negatively associated with aldosterone and positively associated with HbA1c and glucose, respectively. Haplotype GCGCGAGC (ch16:31471193-ch16:31473597(rs114871627) was positively associated with PRA and negatively associated with HbA1c. CONCLUSIONS ARMC5 variants are associated with aldosterone, PRA, blood pressure, fasting glucose, and HbA1c in community-dwelling AAs, suggesting that germline mutations in ARMC5 may underlie cardiometabolic disease in AAs.
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Affiliation(s)
- Joshua J Joseph
- The Ohio State University, Columbus, Ohio
- Correspondence and Reprint Requests: Joshua J. Joseph, MD, Department of Medicine, The Ohio State University Wexner Medical Center, 566 McCampbell Hall, 1581 Dodd Drive, Columbus, OH 43210; Phone: 614-346-8878; Fax: 614-366-0345;
| | | | - Mihail Zilbermint
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, Maryland
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Fabio R Faucz
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Maya B Lodish
- Division of Pediatric Endocrinology and Diabetes, University of California, San Francisco, San Francisco, California
| | - Annabel Berthon
- Institut Cochin, Centre National de la Recherche Scientifique (CNRS), INSERM, Université Paris Descartes, Paris, France
| | - James G Wilson
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Sherita H Golden
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shili Lin
- The Ohio State University, Columbus, Ohio
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25
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Affiliation(s)
- Carter Shelton
- Johns Hopkins University Carey Business School, Baltimore, MD, USA
| | - Andrew P. Demidowich
- Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mihail Zilbermint
- Johns Hopkins University Carey Business School, Baltimore, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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26
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Abstract
Abstract
Introduction: The diagnosis and management of hypercalcemia in hospitalized patients can be challenging. Hypercalcemia is often associated with significant morbidity and end-organ damage which may delay a patient’s recovery. Case report: A 63-years-old female presented for evaluation of left hip pain and was found to have an infection of the prosthetic joint. Past medical history was significant for type 2 diabetes and atrial fibrillation. No known history of malignancy or excess calcium, vitamins A or D intake. Past surgical history was significant for multiple left hip fixation surgeries and a left hip arthroplasty 4 months prior. Patient’s serum calcium on admission was 8.4 mg/dL (corrected 9.5 mg/dL, range 9.5-10.5 mg/dL), serum creatinine 1.2 mg/dL (range, 0.5 - 1.2 mg/dL). Three days later, she underwent surgical irrigation and debridement of the left hip with placement of 30 cc STIMULAN® antibiotic beads with vancomycin. On postoperative day (POD) 5, patient was found to be confused. Laboratory workup revealed serum calcium 13 mg/dL, ionized calcium 1.91 mmol/L (range, 1.12-1.32 mmol/L), serum creatinine 1.6 mg/dL, intact PTH 10 (range, 15- 65 pg/mL), PTH-rp 15 pg/mL (range, 14-27 pg/mL), 25-OH-vitamin D 18 ng/mL (range, 30-60 ng/mL), 1,25-OH2-vitamin D <8 ng/mL (range, 18-72 ng/mL). Clinical challenge: The differential diagnosis of non-PTH mediated hypercalcemia includes malignancy, granulomatosis and/or excess calcium intake. The patient’s history and laboratory data were not consistent with these etiologies. The temporal nature of the hypercalcemia in relation to implantation of antibiotic beads suggest causality of exogenous calcium sulfate and development of the patient’s hypercalcemia. Mild renal insufficiency, as well as immobilization in the setting of surgery, were likely also contributory. Treatment and outcome: This patient was first treated with aggressive intravenous saline and calcitonin. Serum calcium rose to 13.7 mg/dL and pamidronate 30 mg was administered. Hypercalcemia resolved on POD 11 with improvement in patient functional status. Discussion: Hypercalcemia due to implanted calcium sulfate antibiotic beads is not well described outside of case reports. Kallala found hypercalcemia in less than 0.01% of patients who underwent bead implantation, with all the affected patients presenting with preoperative renal failure. Conclusion: Hypercalcemia in the setting of calcium sulfate antibiotic beads implantation may contribute to a patient’s confusion and increase length-of-stay. We recommend serum calcium and creatinine to be closely monitored during the perioperative period in patients who receive calcium sulfate antibiotic beads. Risk factors for the development of hypercalcemia require additional study, though patients with pre-existing renal insufficiency may not be good candidates for the mechanism of antibiotic administration.
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Affiliation(s)
- Mahsa Motevalli
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Kendall F Moseley
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Smita Jha
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Bethesda, MD, USA
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Demidowich AP, Camacho J, Sierra MDLL, Belyavskaya E, Lysikatos C, Kamilaris C, Suzuki M, Zilbermint M, Hannah-Shmouni F, Stratakis CA. SAT-543 Human Hair Aldosterone Measurements for Evaluation of Primary Aldosteronism. J Endocr Soc 2020. [PMCID: PMC7208665 DOI: 10.1210/jendso/bvaa046.1572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Primary Aldosteronism (PA) is the most common cause of endocrine hypertension in US. Diagnostic techniques such as a 24 hour urine collection or saline suppression test (SST) can be laborious for both patients and staff. Our group previously showed that human hair cortisol measurements correlated with urine and serum cortisol levels in patients with endogenous cortisol excess. In this study, we explored whether human hair aldosterone correlated with other measures of aldosterone production. Methods: 41 adult subjects were evaluated at the NIH Clinical Center for adrenal disorders. A pencil-width of hair near the occiput was removed, and the 1cm segment closest to the scalp was analyzed by enzyme immunoassay for aldosterone, reported as pg aldosterone/mg dry hair. Not all subjects underwent complete workup for PA. Data were transformed as necessary to maintain assumptions of normality. Student’s t-test and Pearson correlations were used for statistical analysis. Results: Of the evaluated subjects, 18 were diagnosed with PA, 22 subjects did not have PA, and 1 subject was indeterminate. The mean hair weight was 33.0±13.7mg. For hair samples weighing greater than 10mg, hair weight was not correlated with hair aldosterone concentration (p=0.40). There was no difference in measured hair aldosterone between the subjects with and without PA (2.01±1.09 vs. 2.52±2.45 pg/mg; p=0.82). Among all subjects, hair aldosterone did not correlate with serum aldosterone (p=0.92), aldosterone-to-renin ratio (ARR; p=0.94), 24 hour urine aldosterone (Ualdo; p=0.85), or the serum aldosterone at the 4 hour time point of a SST (4hrAldo; p=0.98). Serum aldosterone, ARR, Ualdo, and 4hrAldo all correlated highly amongst each other (all p’s<0.001). Conclusions: Hair aldosterone levels do not correlate with other markers of PA. Further work is needed to understand whether optimization of study conditions could improve the usefulness of hair aldosterone measurements in the evaluation of PA.
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Affiliation(s)
- Andrew Paul Demidowich
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | - Mari Suzuki
- National Institutes of Health, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ahmed SR, Bellamkonda S, Zilbermint M, Wang J, Kalyani RR. Effects of the low carbohydrate, high fat diet on glycemic control and body weight in patients with type 2 diabetes: experience from a community-based cohort. BMJ Open Diabetes Res Care 2020; 8:8/1/e000980. [PMID: 32193200 PMCID: PMC7103851 DOI: 10.1136/bmjdrc-2019-000980] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/11/2019] [Accepted: 01/28/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The optimal diet to improve glycemia in patients with type 2 diabetes remains unclear. Low carbohydrate, high fat (LCHF) diets can improve glycemic control, but have not been investigated in real-world settings. RESEARCH DESIGN AND METHODS We investigated effects of the LCHF diet compared with usual care in a community-based cohort of patients with type 2 diabetes by performing a retrospective study of 49 patients who followed the LCHF diet for ≥3 months, and compared glycemic outcomes with age-matched and body mass index (BMI)-matched controls who received usual care (n=75). The primary outcome was change in A1C from baseline to the end of follow-up. RESULTS Compared with the usual care group, the LCHF group showed a significantly greater reduction in A1C (-1.29% (95% CI -1.75 to -0.82; p<0.001)) and body weight (-12.8 kg (95% CI -14.7 to -10.8; p<0.001) at the end of follow-up after adjusting for age, sex, baseline A1C, BMI, baseline insulin dose. Of the patients initially taking insulin therapy in the LCHF group, 100% discontinued it or had a reduction in dose, compared with 23.1% in the usual care group (p<0.001). The LCHF group also had significantly greater reduction in fasting plasma glucose (-43.5 vs -8.5 mg/mL; p=0.03) compared with usual care. CONCLUSIONS In a community-based cohort of type 2 diabetes, the LCHF diet was associated with superior A1C reduction, greater weight loss and significantly more patients discontinuing or reducing antihyperglycemic therapies suggesting that the LCHF diet may be a metabolically favorable option in the dietary management of type 2 diabetes.
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Affiliation(s)
- Shabina Roohi Ahmed
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Endocrinology, Johns Hopkins Community Physicians, Bethesda, Maryland, USA
| | - Sridevi Bellamkonda
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Internal Medicine, Johns Hopkins Community Physicians, Germantown, Maryland, USA
| | - Mihail Zilbermint
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians Suburban Hospital, Suburban Hospital, Bethesda, Maryland, USA
| | - Jiangxia Wang
- Biostatistics Consulting Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rita Rastogi Kalyani
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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29
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Maria AG, Suzuki M, Berthon A, Kamilaris C, Demidowich A, Lack J, Zilbermint M, Hannah-Shmouni F, Faucz FR, Stratakis CA. Mosaicism for KCNJ5 Causing Early-Onset Primary Aldosteronism due to Bilateral Adrenocortical Hyperplasia. Am J Hypertens 2020; 33:124-130. [PMID: 31637427 DOI: 10.1093/ajh/hpz172] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/19/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Somatic variants in KCNJ5 are the most common cause of primary aldosteronism (PA). There are few patients with PA in whom the disease is caused by germline variants in the KCNJ5 potassium channel gene (familial hyperaldosteronism type III-FH-III). METHODS A 5-year-old patient who developed hypertension due to bilateral adrenocortical hyperplasia (BAH) causing PA had negative peripheral DNA testing for any known genetic causes of PA. He was treated medically with adequate control of his PA but by the third decade of his life, due to worsening renal function, he underwent bilateral adrenalectomy. RESULTS Focused exome sequencing in multiple nodules of his BAH uncovered a "hot-spot" pathogenic KCNJ5 variant, while repeated Sanger sequencing showed no detectable DNA defects in peripheral blood and other tissues. However, whole exome, "deep" sequencing revealed that 0.23% of copies of germline DNA did in fact carry the same KCNJ5 variant that was present in the adrenocortical nodules, suggesting low level germline mosaicism for this PA-causing KCNJ5 defect. CONCLUSIONS Thus, this patient represents a unique case of BAH due to a mosaic KCNJ5 defect. Undoubtedly, his milder PA compared with other known cases of FH-III, was due to his mosaicism. This case has a number of implications for the prognosis, treatment, and counseling of the many patients with PA due to BAH that are seen in hypertension clinics.
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Affiliation(s)
- Andrea G Maria
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Mari Suzuki
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
- National Institute of Diabetes and Digestive and Kidney Disorders, Bethesda, Maryland, USA
| | - Annabel Berthon
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Crystal Kamilaris
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Andrew Demidowich
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Justin Lack
- NIAID Collaborative Bioinformatics Resource (NCBR), National Institute of Allergy and Infectious Disease, Frederick, Maryland, USA
- Advanced Biomedical Computational Science, Frederick National Laboratory for Cancer Research, Frederick, Maryland, USA
| | - Mihail Zilbermint
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, Maryland, USA
| | - Fady Hannah-Shmouni
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Fabio R Faucz
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Constantine A Stratakis
- Section on Genetics & Endocrinology, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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Sidhaye AR, Mathioudakis N, Bashura H, Sarkar S, Zilbermint M, Golden SH. BUILDING A BUSINESS CASE FOR INPATIENT DIABETES MANAGEMENT TEAMS: LESSONS FROM OUR CENTER. Endocr Pract 2019; 25:612-615. [PMID: 31242127 DOI: 10.4158/ep-2018-0471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Zilbermint M, Gaye A, Berthon A, Hannah-Shmouni F, Faucz FR, Lodish MB, Davis AR, Gibbons GH, Stratakis CA. ARMC 5 Variants and Risk of Hypertension in Blacks: MH- GRID Study. J Am Heart Assoc 2019; 8:e012508. [PMID: 31266387 PMCID: PMC6662143 DOI: 10.1161/jaha.119.012508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background We recently found that ARMC5 variants may be associated with primary aldosteronism in blacks. We investigated a cohort from the MH‐GRID (Minority Health Genomics and Translational Research Bio‐Repository Database) and tested the association between ARMC5 variants and blood pressure in blacks. Methods and Results Whole exome sequencing data of 1377 blacks were analyzed. Target single‐variant and gene‐based association analyses of hypertension were performed for ARMC5, and replicated in a subset of 3015 individuals of African descent from the UK Biobank cohort. Sixteen rare variants were significantly associated with hypertension (P=0.0402) in the gene‐based (optimized sequenced kernel association test) analysis; the 16 and one other, rs116201073, together, showed a strong association (P=0.0003) with blood pressure in this data set. The presence of the rs116201073 variant was associated with lower blood pressure. We then used human embryonic kidney 293 and adrenocortical H295R cells transfected with an ARMC5 construct containing rs116201073 (c.*920T>C). The latter was common in both the discovery (MH‐GRID) and replication (UK Biobank) data and reached statistical significance (P=0.044 [odds ratio, 0.7] and P=0.007 [odds ratio, 0.76], respectively). The allele carrying rs116201073 increased levels of ARMC5 mRNA, consistent with its protective effect in the epidemiological data. Conclusions ARMC5 shows an association with hypertension in blacks when rare variants within the gene are considered. We also identified a protective variant of the ARMC5 gene with an effect on ARMC5 expression confirmed in vitro. These results extend our previous report of ARMC5’s possible involvement in the determination of blood pressure in blacks.
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Affiliation(s)
- Mihail Zilbermint
- 1 Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD.,2 Division of Endocrinology, Diabetes, and Metabolism Johns Hopkins University School of Medicine Baltimore MD.,3 Johns Hopkins Community Physicians at Suburban Hospital Bethesda MD.,4 Johns Hopkins University Carey Business School Baltimore MD
| | - Amadou Gaye
- 5 Genomics of Metabolic, Cardiovascular and Inflammatory Disease Branch, Cardiovascular Section National Human Genome Research Institute Bethesda MD
| | - Annabel Berthon
- 1 Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD
| | - Fady Hannah-Shmouni
- 1 Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD
| | - Fabio R Faucz
- 1 Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD
| | - Maya B Lodish
- 1 Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD
| | - Adam R Davis
- 6 Technological Research and Innovation Uniformed Services University Bethesda MD
| | - Gary H Gibbons
- 5 Genomics of Metabolic, Cardiovascular and Inflammatory Disease Branch, Cardiovascular Section National Human Genome Research Institute Bethesda MD.,7 National Heart, Lung, and Blood Institute Bethesda MD
| | - Constantine A Stratakis
- 1 Section on Endocrinology and Genetics Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda MD
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Mandel SR, Langan S, Mathioudakis NN, Sidhaye AR, Bashura H, Bie JY, Mackay P, Tucker C, Demidowich AP, Simonds WF, Jha S, Ebenuwa I, Kantsiper M, Howell EE, Wachter P, Golden SH, Zilbermint M. Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital. J Community Hosp Intern Med Perspect 2019; 9:64-73. [PMID: 31044034 PMCID: PMC6484466 DOI: 10.1080/20009666.2019.1593782] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/07/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown. Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR). Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models. Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048). Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.
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Affiliation(s)
| | - Susan Langan
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Nicolas Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aniket R Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Holly Bashura
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jun Y Bie
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Periwinkle Mackay
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cynthia Tucker
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Andrew P Demidowich
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA.,Department of Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
| | - William F Simonds
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Smita Jha
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Ifechukwude Ebenuwa
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Melinda Kantsiper
- Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Eric E Howell
- Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Patricia Wachter
- Hospitalist Division, Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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Zilbermint M, Hannah-Shmouni F, Stratakis CA. Genetics of Hypertension in African Americans and Others of African Descent. Int J Mol Sci 2019; 20:ijms20051081. [PMID: 30832344 PMCID: PMC6429313 DOI: 10.3390/ijms20051081] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 02/07/2023] Open
Abstract
Hypertension is the leading cause of cardiovascular disease in the United States, affecting up to one-third of adults. When compared to other ethnic or racial groups in the United States, African Americans and other people of African descent show a higher incidence of hypertension and its related comorbidities; however, the genetics of hypertension in these populations has not been studied adequately. Several genes have been identified to play a role in the genetics of hypertension. They include genes regulating the renin-aldosterone-angiotensin system (RAAS), such as Sodium Channel Epithelial 1 Beta Subunit (SCNN1B), Armadillo Repeat Containing 5 (ARMC5), G Protein-Coupled Receptor Kinase 4 (GRK4), and Calcium Voltage-Gated Channel Subunit Alpha1 D (CACNA1D). In this review, we focus on recent genetic findings available in the public domain for potential differences between African Americans and other populations. We also cover some recent and relevant discoveries in the field of low-renin hypertension from our laboratory at the National Institutes of Health. Understanding the different genetics of hypertension among various groups is essential for effective precision-guided medical therapy of high blood pressure.
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Affiliation(s)
- Mihail Zilbermint
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, BG 31 RM 2A46, 31 Center Dr, Bethesda, MD 20892, USA.
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD 20814, USA.
- Johns Hopkins University Carey Business School, Baltimore, MD 21202, USA.
| | - Fady Hannah-Shmouni
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, BG 31 RM 2A46, 31 Center Dr, Bethesda, MD 20892, USA.
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, BG 31 RM 2A46, 31 Center Dr, Bethesda, MD 20892, USA.
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Zilbermint M, Schiavone L. To Give or Not to Give: The Challenge of Pharmaceutical Coupons. The Journal of Clinical Ethics 2018. [DOI: 10.1086/jce2018294319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
INTRODUCTION The diagnosis of endogenous Cushing syndrome is often challenging and requires multiple repeated blood, urine, and saliva tests to detect elevated cortisol levels. Hair cortisol concentration has been described as a marker of long-term exposure to systemic cortisol in patients with Cushing syndrome. Like hemoglobin A1c is used to detect serum glucose exposure over months, segmental hair cortisol can help identify patients with milder forms of and/or periodic or cyclical Cushing syndrome, which may reduce time and costs associated with collection of urine, salivary, and serum cortisol. AREAS COVERED Success of hair cortisol in detection of Cushing syndrome will be discussed in context of current literature, including differences between total or segmental hair cortisol in accurately determining timeline of cortisol exposure. Optimal methods of hair collection, storage, processing, and analysis and efforts toward standardization will be a major focus. EXPERT COMMENTARY Recent evidence suggests increased sensitivity and specificity of hair cortisol in detecting Cushing syndrome. Future guidelines should consider this test as a routine part of the repertoire of screening tests for Cushing syndrome. Possible confounders to explain discrepant results in the literature will be discussed.
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Affiliation(s)
- Aaron Hodes
- a Albert Einstein College of Medicine, Department of Radiology , Jacobi Medical Center , Bronx , NY , USA
| | - Jerrold Meyer
- b Department of Psychological and Brain Sciences , University of Massachusetts , Amherst , MA , USA
| | - Maya B Lodish
- c Section on Endocrinology and Genetics , Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD , USA
| | - Constantine A Stratakis
- c Section on Endocrinology and Genetics , Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD , USA
| | - Mihail Zilbermint
- c Section on Endocrinology and Genetics , Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD , USA
- d Division of Endocrinology, Diabetes, and Metabolism , Johns Hopkins University School of Medicine , Baltimore , MD , USA
- e Division of Endocrinology, Diabetes and Metabolism, Department of Medicine , Johns Hopkins Community Physicians at Suburban Hospital , Bethesda , MD , USA
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Zilbermint M, Schiavone L. To Give or Not to Give: The Challenge of Pharmaceutical Coupons. J Clin Ethics 2018; 29:319-322. [PMID: 30605442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Diabetes is epidemic and many people cannot afford insulin, a lifesaving medication, as its price has increased by almost 160 percent in the past five years.1 To help subsidize the cost of insulin, one of the staff members at my hospital would like to give patients copayment coupons provided to her by pharmaceutical companies. I advised my colleague to stop distributing these branded coupons, as they promote particular pharmaceutical companies. This practice is not consistent with the policy on interaction with industry established by the Johns Hopkins Health System. Yet at the same time, I want my patients to be able to afford their insulin so they can treat their diabetes. I truly believe in utilitarianism. Would temporarily subsidizing patients' insulin make me and my staff better healthcare providers? Would this minimize my patients' financial burden? Would giving away medications coupons help pharmaceutical companies influence me as a prescriber? This challenge created a personal internal debate and profound moral distress.
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Affiliation(s)
- Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine in Baltimore, Maryland USA; Endocrinology, Diabetes, and Metabolism, Suburban Hospital, Bethesda, Maryland USA; Endocrinology, Diabetes, and Metabolism, Johns Hopkins Community Physicians, Suburban Hospital, Bethesda, Maryland USA; Johns Hopkins Carey Business School, Baltimore, Maryland USA. mzilber3@ jhmi.edu
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Golden SH, Maruthur N, Mathioudakis N, Spanakis E, Rubin D, Zilbermint M, Hill-Briggs F. The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes. Curr Diab Rep 2017; 17:51. [PMID: 28567711 PMCID: PMC5553206 DOI: 10.1007/s11892-017-0875-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes. RECENT FINDINGS Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.
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Affiliation(s)
- Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA.
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nisa Maruthur
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
| | - Elias Spanakis
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland Medical System, Baltimore, MD, USA
| | - Daniel Rubin
- Division of Endocrinology and Metabolism, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Felicia Hill-Briggs
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Tirosh A, Hannah-Shmouni F, Lyssikatos C, Belyavskaya E, Zilbermint M, Abraham SB, Lodish MB, Stratakis CA. Obesity and the diagnostic accuracy for primary aldosteronism. J Clin Hypertens (Greenwich) 2017; 19:790-797. [PMID: 28612447 DOI: 10.1111/jch.13041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/17/2017] [Accepted: 03/26/2017] [Indexed: 12/11/2022]
Abstract
The effects of body mass index on the diagnostic accuracy of primary aldosteronism (PA) are inconsistent and yet important considering the high prevalence and frequent co-occurrence of obesity and hypertension. The current study included 59 adult patients who underwent a stepwise evaluation for PA, using aldosterone to renin ratio for case detection and plasma aldosterone concentration after saline suppression test and/or 24-hour urinary aldosterone after oral sodium loading for case confirmation. Body mass index had a quadratic (U-shaped) correlation with plasma aldosterone concentration, plasma renin activity, aldosterone to renin ratio, and plasma aldosterone concentration after saline suppression test. Among patients with a body mass index ≥30 kg/m2 , the aldosterone to renin ratio yielded lower case detection accuracy of PA. We conclude that obesity results in a nonlinear correlation with plasma aldosterone concentration, plasma renin activity, and aldosterone to renin ratio, which affects the accuracy of case detection for PA. Patients with a body mass index ≥30 kg/m2 are less accurately identified as having PA when saline suppression and/or oral salt loading tests are used for case confirmation.
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Affiliation(s)
- Amit Tirosh
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fady Hannah-Shmouni
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Elena Belyavskaya
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Suburban Hospital, Bethesda, MD, USA
| | - Smita B Abraham
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Maya B Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Hodes A, Lodish MB, Tirosh A, Meyer J, Belyavskaya E, Lyssikatos C, Rosenberg K, Demidowich A, Swan J, Jonas N, Stratakis CA, Zilbermint M. Hair cortisol in the evaluation of Cushing syndrome. Endocrine 2017; 56:164-174. [PMID: 28194652 PMCID: PMC5437744 DOI: 10.1007/s12020-017-1231-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/06/2017] [Indexed: 01/13/2023]
Abstract
PURPOSE Hair cortisol evaluation has been used to help detect patients with suspected Cushing syndrome. Our goal was to correlate segmental hair cortisol with biochemical testing in patients with Cushing syndrome and controls. This study was a prospective analysis of hair cortisol in confirmed Cushing syndrome cases over 16 months. METHODS Thirty-six subjects (26.5 ± 18.9 years, 75% female, and 75% Caucasian) were analyzed by diurnal serum cortisol, 24 h urinary free cortisol corrected for body surface area (UFC/BSA), and 24 h urinary 17-hydroxysteroids corrected for creatinine (17OHS/Cr). Thirty patients were diagnosed with Cushing syndrome, and six were defined as controls. 3-cm hair samples nearest to the scalp, cut into 1-cm segments (proximal, medial, and distal), were analyzed for cortisol by enzyme immunoassay and measured as pmol cortisol/g dry hair. Hair cortisol levels were compared with laboratory testing done within previous 2 months of the evaluation. RESULTS Proximal hair cortisol was higher in Cushing syndrome patients (266.6 ± 738.4 pmol/g) than control patients (38.9 ± 25.3 pmol/g) (p = 0.003). Proximal hair cortisol was highest of all segments in 25/36 (69%) patients. Among all subjects, proximal hair cortisol was strongly correlated with UFC/BSA (r = 0.5, p = 0.005), midnight serum cortisol (r = 0.4, p = 0.03), and 17OHS/Cr, which trended towards significance (r = 0.3, p = 0.06). CONCLUSIONS Among the three examined hair segments, proximal hair contained the highest cortisol levels and correlated the most with the initial biochemical tests for Cushing syndrome in our study. Further studies are needed to validate proximal hair cortisol in the diagnostic workup for Cushing syndrome.
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Affiliation(s)
- Aaron Hodes
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
- Albert Einstein College of Medicine, Department of Radiology, Jacobi Medical Center, Bronx, NY, 10461, USA
| | - Maya B Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Amit Tirosh
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6997801, Israel
| | - Jerrold Meyer
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, MA, 01003, USA
| | - Elena Belyavskaya
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Kendra Rosenberg
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst, MA, 01003, USA
| | - Andrew Demidowich
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Jeremy Swan
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Nichole Jonas
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Mihail Zilbermint
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 20892, USA.
- Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Baltimore, MD, 21287, USA.
- Suburban Hospital, Bethesda, MD, 20814, USA.
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Nobel YR, Lodish MB, Raygada M, Rivero JD, Faucz FR, Abraham SB, Lyssikatos C, Belyavskaya E, Stratakis CA, Zilbermint M. Pseudohypoaldosteronism type 1 due to novel variants of SCNN1B gene. Endocrinol Diabetes Metab Case Rep 2016; 2016:150104. [PMID: 26807262 PMCID: PMC4722246 DOI: 10.1530/edm-15-0104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/07/2016] [Indexed: 11/22/2022] Open
Abstract
Autosomal recessive pseudohypoaldosteronism type 1 (PHA1) is a rare disorder characterized by sodium wasting, failure to thrive, hyperkalemia, hypovolemia and metabolic acidosis. It is due to mutations in the amiloride-sensitive epithelial sodium channel (ENaC) and is characterized by diminished response to aldosterone. Patients may present with life-threatening hyperkalemia, which must be recognized and appropriately treated. A 32-year-old female was referred to the National Institutes of Health (NIH) for evaluation of hyperkalemia and muscle pain. Her condition started in the second week of life, when she was brought to an outside hospital lethargic and unresponsive. At that time, she was hypovolemic, hyperkalemic and acidotic, and was eventually treated with sodium bicarbonate and potassium chelation. At the time of the presentation to the NIH, her laboratory evaluation revealed serum potassium 5.1 mmol/l (reference range: 3.4–5.1 mmol/l), aldosterone 2800 ng/dl (reference range: ≤21 ng/dl) and plasma renin activity 90 ng/ml/h (reference range: 0.6–4.3 ng/ml per h). Diagnosis of PHA1 was suspected. Sequencing of the SCNN1B gene, which codes for ENaC, revealed that the patient is a compound heterozygote for two novel variants (c.1288delC and c.1466+1 G>A), confirming the suspected diagnosis of PHA1. In conclusion, we report a patient with novel variants of the SCNN1B gene causing PHA1 with persistent, symptomatic hyperkalemia.
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Affiliation(s)
- Yael R Nobel
- Department of Medicine, Columbia University Medical Center , New York, New York, 10032 , USA
| | - Maya B Lodish
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Margarita Raygada
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Jaydira Del Rivero
- Medical Oncology Branch, National Cancer Institute, National Institutes of Health , 10 Center Drive, Building 10, Room 12N-226, Bethesda, Maryland, 20892 , USA
| | - Fabio R Faucz
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Smita B Abraham
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Elena Belyavskaya
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814 , USA
| | - Mihail Zilbermint
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, BG 10-CRC, Room 1-3216, 10 Center Drive, Bethesda, Maryland, 20814, USA; Johns Hopkins University School of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Baltimore, Maryland, 21287, USA; Suburban Hospital, Bethesda, Maryland, 20814, USA
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Abstract
Benign adrenocortical tumours (ACT) are relatively frequent lesions; on the contrary, adrenocortical carcinoma (ACC) is a rare and aggressive malignancy with unfavourable prognosis. Recent advances in the molecular understanding of adrenal cancer offer promise for better therapies in the future. Many of these advances stem from the molecular elucidation of genetic conditions predisposing to the development of ACC. Six main clinical syndromes have been described to be associated with hereditary adrenal cancer. In these conditions, genetic counselling plays an important role for the early detection and follow-up of the patients and the affected family members.
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Affiliation(s)
- Anna Angelousi
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
| | - Mihail Zilbermint
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Annabel Berthon
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Stéphanie Espiard
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.
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Zilbermint M, Xekouki P, Faucz FR, Berthon A, Gkourogianni A, Schernthaner-Reiter MH, Batsis M, Sinaii N, Quezado MM, Merino M, Hodes A, Abraham SB, Libé R, Assié G, Espiard S, Drougat L, Ragazzon B, Davis A, Gebreab SY, Neff R, Kebebew E, Bertherat J, Lodish MB, Stratakis CA. Primary Aldosteronism and ARMC5 Variants. J Clin Endocrinol Metab 2015; 100:E900-9. [PMID: 25822102 PMCID: PMC4454793 DOI: 10.1210/jc.2014-4167] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Primary aldosteronism is one of the leading causes of secondary hypertension, causing significant morbidity and mortality. A number of genetic defects have recently been identified in primary aldosteronism, whereas we identified mutations in ARMC5, a tumor-suppressor gene, in cortisol-producing primary macronodular adrenal hyperplasia. OBJECTIVE We investigated a cohort of 56 patients who were referred to the National Institutes of Health for evaluation of primary aldosteronism for ARMC5 defects. METHODS Patients underwent step-wise diagnosis, with measurement of serum aldosterone and plasma renin activity followed by imaging, saline suppression and/or oral salt loading tests, plus adrenal venous sampling. Cortisol secretion was also evaluated; unilateral or bilateral adrenalectomy was performed, if indicated. DNA, protein, and transfection studies in H295R cells were conducted by standard methods. RESULTS We identified 12 germline ARMC5 genetic alterations in 20 unrelated and two related individuals in our cohort (39.3%). ARMC5 sequence changes in 6 patients (10.7%) were predicted to be damaging by in silico analysis. All affected patients carrying a variant predicted to be damaging were African Americans (P = .0023). CONCLUSIONS Germline ARMC5 variants may be associated with primary aldosteronism. Additional cohorts of patients with primary aldosteronism and metabolic syndrome, particularly African Americans, should be screened for ARMC5 sequence variants because these may underlie part of the known increased predisposition of African Americans to low renin hypertension.
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Abstract
PURPOSE OF REVIEW Cushing syndrome caused by cortisol-producing adrenal adenomas is a rare condition, associated with high morbidity due to weight gain, diabetes mellitus, osteoporosis, hypertension, muscle weakness, mood disturbance and others. The first gene to be identified as causative of Cushing syndrome was PRKAR1A. We present an update on protein kinase A (PKA) defects and Cushing syndrome. RECENT FINDINGS The cyclic AMP-dependent PKA catalytic subunit alpha (PRKACA) hotspot point mutation (c.617A > C [p.Leu206Arg]), leading to an increase of basal PKA activity, and formation of cortisol-producing adenoma has been frequently shown to cause the most common form of adrenocorticotropic hormone-independent Cushing syndrome. SUMMARY Somatic PRKACA mutations have been found in up to 50% of patients with adrenal adenomas. Germline PRKACA amplification was also seen in bilateral adrenal hyperplasias. PRKACA activation was associated with higher cortisol levels, smaller tumor size and overt Cushing syndrome. This breakthrough is expected to improve our understanding of how PKA defects lead to Cushing syndrome and may spearhead the development of new, molecularly designed therapies.
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Affiliation(s)
- Mihail Zilbermint
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
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Gkourogianni A, Lodish MB, Zilbermint M, Lyssikatos C, Belyavskaya E, Keil MF, Stratakis CA. Death in pediatric Cushing syndrome is uncommon but still occurs. Eur J Pediatr 2015; 174:501-7. [PMID: 25241829 PMCID: PMC4370787 DOI: 10.1007/s00431-014-2427-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 09/11/2014] [Accepted: 09/15/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Cushing syndrome (CS) in children is rare. Delayed diagnosis and treatment of CS may be associated with increased morbidity and, unfortunately, mortality. We performed a retrospective review of all patients with CS under the age of 18 years referred to the National Institutes of Health (NIH) from 1998 to 2013 in order to describe deceased patients among cases of pediatric CS referred to the National Institutes of Health (NIH). The deaths of four children (three females and one male), aged 7.5-15.5 years (mean age 11.2 years) with length of disease 2-4 years, were recorded among 160 (2.5 %) children seen at or referred to the NIH over the last 15 years. All died at different institutions, prior to coming to the NIH (two) or after leaving NIH (two). Presenting symptoms included increasing weight and decreasing height gain, facial plethora, dorsocervical fat pad (webbed neck), striae, headache, vision disturbances, and depression and other mood or behavior changes; there were no differences between how these patients presented and the others in our cohort. The causes of CS in the deceased patients were also not different, in fact, they spanned the entire spectrum of CS: pituitary disease (one), ectopic corticotropin production (one), and primary adrenal hyperplasia (one). In one patient, the cause of CS could not be verified. Three died of sepsis and one due to residual disease and complications of the primary tumor. CONCLUSIONS Despite the advances in early diagnosis and treatment of pediatric CS, a 2.5 % mortality rate was identified in a large cohort of patients with this condition referred to an experienced, tertiary care referral center (although these deaths occurred elsewhere). Pediatricians need to recognize the possibility of death, primarily due to sepsis, in a patient with pediatric CS and treat accordingly.
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Affiliation(s)
- Alexandra Gkourogianni
- Section on Endocrinology and Genetics and Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health Clinical Research Center, 10 Center Drive, Building 10, Room 1-3330, MSC1103, Bethesda, MD, 20892, USA,
| | - Maya B. Lodish
- Corresponding author: Maya B. Lodish, MD, Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health Clinical Research Center, 10 Center Drive, Building 10, Room 1-3330, MSC1103, Bethesda, Maryland 20892, USA; Tel 001-301-451-7175; FAX 001-301-480-0378;
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Monticone S, Bandulik S, Stindl J, Zilbermint M, Dedov I, Mulatero P, Allgaeuer M, Lee CCR, Stratakis CA, Williams TA, Tiulpakov A. A case of severe hyperaldosteronism caused by a de novo mutation affecting a critical salt bridge Kir3.4 residue. J Clin Endocrinol Metab 2015; 100:E114-8. [PMID: 25322277 PMCID: PMC4283020 DOI: 10.1210/jc.2014-3636] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Familial hyperaldosteronism type III (FH-III) is a rare and clinically heterogeneous condition, that can display mild as well as severe phenotypes. Point mutations in the KCNJ5 gene, affecting the ion selectivity of the inward rectifier K(+) channel 4 (Kir3.4), underlie the molecular basis of FH-III. OBJECTIVE The objective of the study was to investigate the effects of a de novo germline KCNJ5 mutation. PATIENTS AND METHODS We describe the case of a girl who came to medical attention at the age of 2 years because of polydipsia, polyuria, and failure to thrive. The patient, affected by hypertension and hypokalemia, was diagnosed with primary aldosteronism on the basis of extremely high aldosterone levels and suppressed plasma renin activity. Genomic DNA was isolated and KCNJ5 sequenced. Human adrenocortical cells were used as an in vitro model for the functional characterization of the mutant channel. RESULTS KCNJ5 sequencing in the index case and her parents revealed a de novo p.Glu145Gln germline mutation. The substitution resulted in Na(+)-dependent depolarization of adrenal cells and increased intracellular calcium concentration, which activated the transcription of NR4A2 and, in turn, CYP11B2. Pharmacological studies revealed that the mutant channel was insensitive to tertiapin-Q and calcium-channel blocker verapamil. CONCLUSIONS Herein we report the identification of a novel KCNJ5 germline mutation responsible for severe hyperaldosteronism that presented in infancy with symptoms of diabetes insipidus. The findings of this study further elucidate the etiology of FH-III and expand our knowledge of this rare condition.
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Faucz FR, Zilbermint M, Lodish MB, Szarek E, Trivellin G, Sinaii N, Berthon A, Libé R, Assié G, Espiard S, Drougat L, Ragazzon B, Bertherat J, Stratakis CA. Macronodular adrenal hyperplasia due to mutations in an armadillo repeat containing 5 (ARMC5) gene: a clinical and genetic investigation. J Clin Endocrinol Metab 2014; 99:E1113-9. [PMID: 24601692 PMCID: PMC4037724 DOI: 10.1210/jc.2013-4280] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Inactivating germline mutations of the probable tumor suppressor gene, armadillo repeat containing 5 (ARMC5), have recently been identified as a genetic cause of macronodular adrenal hyperplasia (MAH). OBJECTIVE We searched for ARMC5 mutations in a large cohort of patients with MAH. The clinical phenotype of patients with and without ARMC5 mutations was compared. METHODS Blood DNA from 34 MAH patients was genotyped using Sanger sequencing. Diurnal serum cortisol measurements, plasma ACTH levels, urinary steroids, 6-day Liddle's test, adrenal computed tomography, and weight of adrenal glands at adrenalectomy were assessed. RESULTS Germline ARMC5 mutations were found in 15 of 34 patients (44.1%). In silico analysis of the mutations indicated that seven (20.6%) predicted major implications for gene function. Late-night cortisol levels were higher in patients with ARMC5-damaging mutations compared with those without and/or with nonpathogenic mutations (14.5 ± 5.6 vs 6.7 ± 4.3, P < .001). All patients carrying a pathogenic ARMC5 mutation had clinical Cushing's syndrome (seven of seven, 100%) compared with 14 of 27 (52%) of those without or with mutations that were predicted to be benign (P = .029). Repeated-measures analysis showed overall higher urinary 17-hydroxycorticosteroids and free cortisol values in the patients with ARMC5-damaging mutations during the 6-day Liddle's test (P = .0002). CONCLUSIONS ARMC5 mutations are implicated in clinically severe Cushing's syndrome associated with MAH. Knowledge of a patient's ARMC5 status has important clinical implications for the diagnosis of Cushing's syndrome and genetic counseling of patients and their families.
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Zilbermint M, Ramnitz MS, Lodish MB, Kanaka-Gantenbein C, Kattamis A, Lyssikatos C, Patronas NJ, Quezado MM, Stratakis CA. Pituitary stalk lesion in a 13-year-old female. J Pediatr Endocrinol Metab 2014; 27:359-62. [PMID: 24129100 PMCID: PMC4727445 DOI: 10.1515/jpem-2013-0274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/14/2013] [Indexed: 11/15/2022]
Abstract
Germinomas presenting with a pituitary stalk lesion and panhypopituitarism are rare in children, and their definite diagnosis is challenging. An invasive diagnostic approach, such as a transsphenoidal biopsy, is often required prior to establishing a treatment regimen. A 13-year-old female presented with 1 year of secondary amenorrhea, fatigue, and progressive thirst with polyuria. Laboratory work-up revealed panhypopituitarism (central hypothyroidism, hypogonadotropic hypogonadism, adrenal insufficiency and central diabetes insipidus). α-Fetoprotein and β-human chorionic gonadotropin were not elevated in serum nor in cerebrospinal fluid. The magnetic resonance imaging (MRI) of the pituitary region showed an enhancing infundibular lesion, extending into the hypothalamus, and infiltrating the pituitary gland. A transsphenoidal biopsy of the infundibular lesion confirmed the diagnosis of germinoma (germ-cell tumor). After appropriate hormone replacement therapy, chemotherapy and low-dose radiation therapy, the patient achieved complete resolution of the pituitary stalk lesion on the MRI.
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Affiliation(s)
- Mihail Zilbermint
- Program on Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Mary S. Ramnitz
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Maya B. Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Christina Kanaka-Gantenbein
- First Department of Pediatrics, Athens University Medical School, “Aghia Sophia” Children’s Hospital, Athens, Greece
| | - Antonis Kattamis
- First Department of Pediatrics, Athens University Medical School, “Aghia Sophia” Children’s Hospital, Athens, Greece
| | - Charalampos Lyssikatos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Nicholas J. Patronas
- Department of Diagnostic Radiology, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Martha M. Quezado
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Constantine A. Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Building 10/CRC 1-3330, 10 Center Drive, Bethesda, MD 20892, USA, Phone: +1 (301) 594-5984, Fax: +1 (301) 480-6480
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