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Gunawan F, Ajaz S, Meneghini L, Gunasekaran U. Benefits of Electronic Consultations in Improving Diabetes Care Within a Safety-Net Health System. Clin Diabetes 2023; 41:292-295. [PMID: 37092146 PMCID: PMC10115762 DOI: 10.2337/cd22-0078] [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: 11/13/2022]
Abstract
Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an initiative aimed at improving access to diabetes specialty care for patients within a safety-net health system in Dallas County, TX, through the implementation of electronic consultations.
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Affiliation(s)
- Felona Gunawan
- Section of Endocrinology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Global Diabetes Program, Parkland Health, Dallas, TX
| | - Syed Ajaz
- Section of Endocrinology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Luigi Meneghini
- Section of Endocrinology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Global Diabetes Program, Parkland Health, Dallas, TX
| | - Uma Gunasekaran
- Section of Endocrinology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Global Diabetes Program, Parkland Health, Dallas, TX
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Gunawan F, Quinn A. Atypical Abdominal Lump on a Patient with Diabetes. AACE Clin Case Rep 2022; 9:55-56. [PMID: 37056415 PMCID: PMC10086592 DOI: 10.1016/j.aace.2022.12.001] [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] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/27/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
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Sanchez-Rangel E, Gunawan F, Jiang L, Savoye M, Dai F, Coppoli A, Rothman DL, Mason GF, Hwang JJ. Reversibility of brain glucose kinetics in type 2 diabetes mellitus. Diabetologia 2022; 65:895-905. [PMID: 35247067 PMCID: PMC8960594 DOI: 10.1007/s00125-022-05664-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 04/13/2021] [Accepted: 12/02/2021] [Indexed: 11/20/2022]
Abstract
AIMS/HYPOTHESIS We have previously shown that individuals with uncontrolled type 2 diabetes have a blunted rise in brain glucose levels measured by 1H magnetic resonance spectroscopy. Here, we investigate whether reductions in HbA1c normalise intracerebral glucose levels. METHODS Eight individuals (two men, six women) with poorly controlled type 2 diabetes and mean ± SD age 44.8 ± 8.3 years, BMI 31.4 ± 6.1 kg/m2 and HbA1c 84.1 ± 16.2 mmol/mol (9.8 ± 1.4%) underwent 1H MRS scanning at 4 Tesla during a hyperglycaemic clamp (~12.21 mmol/l) to measure changes in cerebral glucose at baseline and after a 12 week intervention that improved glycaemic control through the use of continuous glucose monitoring, diabetes regimen intensification and frequent visits to an endocrinologist and nutritionist. RESULTS Following the intervention, mean ± SD HbA1c decreased by 24.3 ± 15.3 mmol/mol (2.1 ± 1.5%) (p=0.006), with minimal weight changes (p=0.242). Using a linear mixed-effects regression model to compare glucose time courses during the clamp pre and post intervention, the pre-intervention brain glucose level during the hyperglycaemic clamp was significantly lower than the post-intervention brain glucose (p<0.001) despite plasma glucose levels during the hyperglycaemic clamp being similar (p=0.266). Furthermore, the increases in brain glucose were correlated with the magnitude of improvement in HbA1c (r = 0.71, p=0.048). CONCLUSION/INTERPRETATION These findings highlight the potential reversibility of cerebral glucose transport capacity and metabolism that can occur in individuals with type 2 diabetes following improvement of glycaemic control. Trial registration ClinicalTrials.gov NCT03469492.
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Affiliation(s)
- Elizabeth Sanchez-Rangel
- Department of Internal Medicine/Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Felona Gunawan
- Department of Internal Medicine/Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Lihong Jiang
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Mary Savoye
- Department of Pediatric Endocrinology and General Clinical Research Center, Yale University School of Medicine, New Haven, CT, USA
| | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Anastasia Coppoli
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Douglas L Rothman
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University School of Medicine, New Haven, CT, USA
| | - Graeme F Mason
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Janice Jin Hwang
- Department of Internal Medicine/Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA.
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Athonvarangkul D, Gunawan F, Nagel K, Bak L, Herold KC, Hwang JJ, Jastreboff AM, Kibbey R, Shulman GI, Vatner D, Alausa J, Subair L, Inzucchi SE. A Single Virtual Consult Reduces Severe Hyperglycemia in Patients Admitted with COVID19 Infection. J Endocr Soc 2021. [PMCID: PMC8089507 DOI: 10.1210/jendso/bvab048.683] [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: 11/22/2022] Open
Abstract
Diabetes and hyperglycemia are risk factors for morbidity and mortality in hospitalized patients with COVID19. Subspecialty consultative resources to help front-line clinicians treat these conditions is often limited. We implemented a “Virtual Hyperglycemia Surveillance Service (VHSS)” to guide glucose management in COVID19 patients admitted to our 1541-bed academic medical center. From April 22 to June 9, 2020, hospitalized adult patients with COVID19 and 2 or more blood glucose (BG) values greater than 250 mg/dl over 24-h were identified using a daily BG report. The VHSS reviewed BGs and treatment plans, then made recommendations for future glycemic management via a one-time note, visible to all providers. Some patients with re-admission or persistently elevated BG after 1 week received a second VHSS note. We compared BGs from 24-h pre- and 72-h post-intervention starting at 6AM on the day following VHSS review. We also evaluated for hypoglycemia, insulin infusion use and use of formal diabetes consults. A subgroup analysis was performed on patients in the intensive care unit (ICU). At the end of the intervention, we identified a retrospective control cohort admitted to the same hospital from March 21 to April 21, 2020 who met the inclusion criteria for a VHSS assessment. The VHSS group consisted of 100 patients with 126 individual VHSS encounters, and the control group comprised 50 patients. Baseline characteristics in the VHSS and control groups, respectively, were: mean age 62.5 vs 62.1 years, % male 58 vs 56, mean weight 91.4 vs 93.4 kg, BMI 31.8 vs 33.0 kg/m2, and HbA1c 9.1 vs 8.8 %. There were fewer patients in the ICU in the VHSS than control group (44% vs 66%). In the VHSS group, mean BG pre- vs. post-intervention was 260.3 ±21.7 and 227.4 ±25.3 mg/dl (p<0.001). In the control group, mean BG pre-and post- the day they met assessment criteria was 264.8 ± 6.5 mg/dl and 250.6 ± 8.6 mg/dl (p=0.18). There was no difference in the use of insulin infusions or diabetes consults between the two groups. More hypoglycemia (BG<70 mg/dl) occurred in the VHSS than control group (8.3% vs 0%, p=0.04). Within the VHSS group, the average change in BG was significantly greater in ICU than non-ICU patients (-51.8 ±8.7 vs -19.6 ±5.0 mg/dl, p<0.01) and the reduction in the % of BG over 250 mg/dl was also significantly greater in the ICU (-32.2% vs -16.8%, p=0.02). Implementation of a single virtual consult for severely hyperglycemic hospitalized COVID19 patients was associated with rapidly reduced BG concentrations, especially in the ICU. The mean reduction in BG with VHSS intervention was more than 2-fold greater than that observed in our control group. Glucose control remained suboptimal, however, suggesting the need for subsequent input from this specialty service.
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Affiliation(s)
| | | | | | - Leigh Bak
- Yale New Haven Hospital, New Haven, CT, USA
| | - Kevan C Herold
- Yale University, Section of Endocrinology, New Haven, CT, USA
| | | | | | - Richard Kibbey
- Yale University, Section of Endocrinology, New Haven, CT, USA
| | | | - Daniel Vatner
- Yale University, Section of Endocrinology, New Haven, CT, USA
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Gunawan F, Holt E. ATYPICAL RECURRENCE OF PARATHYROID CARCINOMA FOLLOWING INFLIXIMAB THERAPY IN A PATIENT WITH ULCERATIVE COLITIS. AACE Clin Case Rep 2020; 6:e113-e116. [PMID: 32524023 DOI: 10.4158/accr-2019-0519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/02/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Parathyroid carcinoma (PTC) has a high rate of recurrence, which typically occurs within 5 years of diagnosis involving locoregional sites. Immunosuppressive therapies pose a theoretical increased risk of malignancy. We report an atypical case of PTC recurrence in a patient receiving infliximab therapy for ulcerative colitis (UC). Methods Main diagnostic tests performed included calcium and parathyroid hormone (PTH) levels, computed tomography, and a venous sampling study. Results A patient with PTC, who was "cured" by parathyroidectomy, presented with recurrent hypercalcemia 21 years after his initial diagnosis. He had recently been diagnosed with UC and was started on infliximab. His serum PTH level was elevated. After negative routine neck imaging studies and sestamibi scan, he underwent selective venous sampling with PTH measurements, which localized the source lesion to the thoracic wall. Subsequent imaging showed multiple left lung and pleural nodules, which were surgically resected. Hypercalcemia abated after surgery, but quickly returned and was recalcitrant to treatment with cinacalcet and zoledronic acid. Further imaging demonstrated recurrent lung metastases, some along the left diaphragm. He underwent 2 additional surgical resections, after which PTH and calcium levels normalized. Infliximab was replaced with vedolizumab for treatment of UC. Conclusion Atypical presentation of PTC may occur in the context of immunosuppressive therapy. Venous sampling with PTH measurements can aid in localization of atypical metastatic PTC. Additional surveillance for PTC recurrence may be prudent following the initiation of immunosuppressive therapy in patients with a history of PTC.
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Gunawan F, Partridge C, Kosiborod M, Inzucchi S. SUN-149 Cardiologist vs. Endocrinologist Encounters in Patients with T2D and CVD: Potential Implications for Glucose-Lowering Therapy Use and Education. J Endocr Soc 2019. [PMCID: PMC6553036 DOI: 10.1210/js.2019-sun-149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/19/2022] Open
Abstract
Background: A large proportion of patients with type 2 diabetes (T2D) have established cardiovascular (CV) disease (D). Recent large CV outcome trials demonstrated clear CV benefits of 2 novel classes of glucose-lowering agents (GLA), SGLT2 inhibitors and GLP-1 receptor agonists. Guidelines now stipulate that these should be favored in patients with T2D and overt CVD. Not surprisingly, endocrinologists prescribe these GLAs more frequently than cardiologists. Some, however, have proposed that cardiologists should take a more active role in prescribing these GLAs for CV risk reduction. We therefore endeavored to compare prescribing opportunities for these GLAs, by assessing the likelihood that a patient with T2D and CVD had an outpatient encounter with a cardiologist vs. an endocrinologist over a 1-year period in a large academic healthcare system in New England. Methods: We reviewed electronic health records of adult patients (age ≥18) with T2D who had outpatient encounters within the Yale New Haven Hospital System (YNHHS) during 2017. We analyzed demographic information, CVD diagnostic categories (coronary artery disease [CAD], congestive heart failure [CHF], cerebrovascular disease [CBD], peripheral vascular disease [PVD]), number of cardiology and endocrinology encounters, provider types, and visit diagnoses. Results: Of 78,878 T2D patients (mean age 66.7 ±14.4 years; 51% female), 31,639 (40.1%) had established CVD. The ratio of cardiologist:endocrinologist outpatient encounters was 2.6 (51,954 vs. 20,337 encounters) for all T2D patients and 5.3 (43,482 vs. 8,264 encounters) for those with T2D and CVD. Of the 4 CVD diagnostic categories, patients with CHF had the highest cardiologist:endocrinologist encounter ratio at 8.4 (24,477 vs. 2,931 encounters), followed by patients with CAD at 6.0 (33,722 vs 5,579 encounters). Conclusion: In our health system, over the course of a single year, a patient with T2D was nearly 3 times more likely to have an outpatient encounter with a cardiologist than an endocrinologist. With coexisting CVD, the likelihood increased to greater than 5-fold. In order to capitalize on the CV benefits of the newer GLAs, prescriptions by cardiologists are apt to hasten adherence to the latest guidelines and improve patient outcomes. Educational programs pertaining to these emerging treatment paradigms should target cardiologists in addition to endocrinologists (and primary care physicians).
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Affiliation(s)
- Felona Gunawan
- Section of Endocrinology, Yale School of Medicine and Yale-New Haven Hospital, New Haven, CT, United States
| | - Caitlin Partridge
- Yale Joint Data Analytics Team, Yale New Haven Hospital, New Haven, CT, United States
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Silvio Inzucchi
- Section of Endocrinology, Yale School of Medicine and Yale-New Haven Hospital, New Haven, CT, United States
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Jo J, Im SH, Babcock DT, Iyer SC, Gunawan F, Cox DN, Galko MJ. Drosophila caspase activity is required independently of apoptosis to produce active TNF/Eiger during nociceptive sensitization. Cell Death Dis 2017; 8:e2786. [PMID: 28492538 PMCID: PMC5520682 DOI: 10.1038/cddis.2016.474] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 12/03/2016] [Accepted: 12/06/2016] [Indexed: 01/12/2023]
Abstract
Tumor necrosis factor (TNF) signaling is required for inflammatory nociceptive (pain) sensitization in Drosophila and vertebrates. Nociceptive sensitization in Drosophila larvae following UV-induced tissue damage is accompanied by epidermal apoptosis and requires epidermal-derived TNF/Eiger and the initiator caspase, Dronc. Major gaps remain regarding TNF function in sensitization, including the relationship between apoptosis/tissue damage and TNF production, the downstream signaling in this context, and the target genes that modulate nociceptive behaviors. Here, apoptotic cell death and thermal nociceptive sensitization are genetically and procedurally separable in a Drosophila model of UV-induced nociceptive sensitization. Activation of epidermal Dronc induces TNF-dependent but effector caspase-independent nociceptive sensitization in the absence of UV. In addition, knockdown of Dronc attenuated nociceptive sensitization induced by full-length TNF/Eiger but not by a constitutively soluble form. UV irradiation induced TNF production in both in vitro and in vivo, but TNF secretion into hemolymph was not sufficient to induce thermal nociceptive sensitization. Downstream mediators of TNF-induced sensitization included two TNF receptor-associated factors, a p38 kinase, and the transcription factor nuclear factor kappa B. Finally, sensory neuron-specific microarray analysis revealed downstream TNF target genes induced during thermal nociceptive sensitization. One of these, enhancer of zeste (E(z)), functions downstream of TNF during thermal nociceptive sensitization. Our findings suggest that an initiator caspase is involved in TNF processing/secretion during nociceptive sensitization, and that TNF activation leads to a specific downstream signaling cascade and gene transcription required for sensitization. These findings have implications for both the evolution of inflammatory caspase function following tissue damage signals and the action of TNF during sensitization in vertebrates.
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Affiliation(s)
- Juyeon Jo
- Department of Genetics, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Genes and Development Graduate Program, Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Seol Hee Im
- Department of Genetics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel T Babcock
- Neuroscience Graduate Program, Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srividya C Iyer
- Neuroscience Institute, Georgia State University, Atlanta, GA, USA
| | - Felona Gunawan
- Department of Biochemistry and Cell Biology, Rice University, Houston, TX, USA
| | - Daniel N Cox
- Neuroscience Institute, Georgia State University, Atlanta, GA, USA
| | - Michael J Galko
- Department of Genetics, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Genes and Development Graduate Program, Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Neuroscience Graduate Program, Graduate School of Biomedical Sciences, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Mohareb A, Brown B, Gunawan F, Datta R, Annamalai A, Barakat L. Latent Tuberculosis Infection in a Cohort of Refugee Patients Resettling in New England. Open Forum Infect Dis 2017. [DOI: 10.1093/ofid/ofx163.1938] [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] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sydow K, Tanaka M, Gunawan F, Jacobi J, Tsao PS, Cooke JP, Robbins RC. Lowering Asymmetric Dimethylarginine (ADMA) concentrations suppresses graft coronary artery disease in a murine heterotopic heart transplantation model. Thorac Cardiovasc Surg 2007. [DOI: 10.1055/s-2007-967309] [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] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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