2019 Endocrine Society Measures Set for Older Adults With Type 2 Diabetes Who Are at Risk for Hypoglycemia

CONTEXT

Hypoglycemia in the outpatient setting has a significant financial impact on the health care system and negative impact on a person's quality of life. Primary care physicians must address a multitude of issues in a visit with a person with type 2 diabetes mellitus (T2DM), often leaving little time to ask about hypoglycemia.

OBJECTIVE

To develop quality measures that focus on outpatient hypoglycemia episodes for patients 65 and older with T2DM, which facilitate a clinician's ability to identify opportunities to improve the quality of care and reduce hypoglycemic episodes.

PARTICIPANTS AND PROCESS

A technical expert panel established by the Endocrine Society in March 2019, which includes endocrinologists, primary care physicians, a diabetes care and education specialist/pharmacist, and a patient, developed 3 outpatient hypoglycemia quality measures. The measure set is intended to improve quality of care for patients with T2DM who are at greatest risk for hypoglycemia. The measures were available for public comment in July 2019. A fourth measure on shared decision-making was removed from the final measure set based on public feedback.

CONCLUSION

A lack of outpatient hypoglycemia measures focusing on older adults with T2DM is a barrier to improving care of people with diabetes and reducing hypoglycemic episodes. This paper provides measure specifications for 3 measures that may be used to focus quality improvement efforts on patients at greatest risk for hypoglycemia.

Stroke outcomes measures must be appropriately risk adjusted to ensure quality care of patients: a presidential advisory from the American Heart Association/American Stroke Association

Because stroke is among the leading causes of death, disability, hospitalizations, and healthcare expenditures in the United States, there is interest in reporting outcomes for patients hospitalized with acute ischemic stroke. The American Heart Association/American Stroke Association, as part of its commitment to promote high-quality, evidence-based care for cardiovascular and stroke patients, fully supports the development of properly risk-adjusted outcome measures for stroke. To accurately assess and report hospital-level outcomes, adequate risk adjustment for case mix is essential. During the development of the Centers for Medicare & Medicaid Services 30-day stroke mortality and 30-day stroke readmission measures, concerns were expressed that these measures were not adequately designed because they do not include a valid initial stroke severity measure, such as the National Institutes of Health Stroke Scale. These outcome measures, as currently constructed, may be prone to mischaracterizing the quality of stroke care being delivered by hospitals and may ultimately harm acute ischemic stroke patients. This article details (1) why the Centers for Medicare & Medicaid Services acute ischemic stroke outcome measures in their present form may not provide adequate risk adjustment, (2) why the measures as currently designed may lead to inaccurate representation of hospital performance and have the potential for serious unintended consequences, (3) what activities the American Heart Association/American Stroke Association has engaged in to highlight these concerns to the Centers for Medicare & Medicaid Services and other interested parties, and (4) alternative approaches and opportunities that should be considered for more accurately risk-adjusting 30-day outcomes measures in patients with ischemic stroke.

Crossed aphasia after right anterior temporal lobectomy. A case report

The occurrence of crossed aphasia as a complication after temporal lobe epilepsy surgery is extremely rare. We report the case of a 47-year-old right-handed patient with drug-resistant mesial temporal lobe epilepsy (MTLE) who developed a transitory aphasic syndrome after a right temporal anterior lobectomy. This syndrome was characterized by anomia, poor verbal fluency, verbal perseveration, and verbal comprehension difficulties. He also showed writing difficulties, reading substitutions, and calculation task errors. The patient was regularly assessed with language tasks, and showed a spontaneous and progressive recovery of his symptoms, with remaining naming difficulties. We discuss the role that epileptogenic zone could play in cortical reorganization of the language systems.

A study of word finding difficulties in Spanish speakers with temporal lobe epilepsy

It is well established that naming deficits can be found in temporal lobe epilepsy (TLE). The aim of this study was to determine in Spanish speakers with pharmacoresistant TLE the characteristics of subjective naming difficulties and to examine performance in a definition task and a picture task in left TLE and right TLE. We observed that almost one-third of patients report frequent and severe word finding problems during spontaneous speech. In naming tests, our patients exhibited delayed times for finding words. Even if the target word was identified and semantically activated, there was difficulty with lexical access, which improved when a phonetic cue was given. Left TLE patients derived a lower benefit from phonetic cues in accessing words, even when the word is known and recognized semantically. These findings were not related to any demographic or clinical characteristics analyzed. The fact that the only weakly lateralized variable has been a lexical access facilitation measurement could support a lexical access hypothesis for naming deficits in TLE.

Translating Research Into Practice for Healthcare Providers

The American Heart Association’s (AHA’s) mission is “to build healthier lives, free of cardiovascular diseases and stroke.” This first article in a 2-part series will serve to present an overview of the work the AHA has undertaken to translate evidence into practice for healthcare professionals. It describes the extensive work of the AHA to support and further the delivery of evidence-based medicine, which includes the following: (1) supporting scientific discovery and the next generation of healthcare professionals and researchers; (2) disseminating scientific information; (3) developing evidence-based guidelines and statements; (4) creating and advocating for the implementation of performance indicators/measures; (5) developing clinical decision support and quality improvement tools; and (6) developing directed-cause campaigns, all of which can lead to improved patient care. This article also discusses the need for novel approaches and some of the AHA’s evolving strategies to help address gaps in care. The second article, which will be published shortly after this one, will examine the AHA’s efforts to engage and empower healthcare consumers to become more involved with their own health and health care.

Clinical-electroencephalogram patterns at seizure onset in patients with hippocampal sclerosis

OBJECTIVE

The purpose of this study is to identify specific clinical-electroencephalogram (EEG) patterns at seizure onset in patients with hippocampal sclerosis (HS).

METHODS

Sixty-six ictal video-EEG recordings corresponding to 26 patients with HS have been reviewed, focusing on the EEG features found during the first 30 ictal s. The EEG activity has been classified into the following groups: (A) according to spatial distribution: type 1: temporal electrodes on one side; type 2: temporal and adjacent frontal electrodes on one side; and type 3: non-lateralizing electrographic activity; and (B) according to morphology; subtype (a): regular 5-9 Hz rhythmic activity (RA); subtype (b): low-voltage rapid activity, followed by a 5-9 Hz RA; and subtype (c): irregular EEG sharp waves. We analyzed the clinical symptoms sequence and established the relationship with the ictal EEG patterns.

RESULTS

Considering spatial distribution and morphology, the most frequent ictal EEG patterns were type 1 (57%), type 2 (37%), and subtype (a): 62%; subtype (b): 27%; and subtype (c): 11%. The sequence of clinical symptoms observed was: aura-->behavioral arrest-->oro-alimentary automatisms-->unilateral hand automatisms. All seizures with aura and including two or more symptoms of the clinical sequence (65%) were associated with a 1a, 1b, 2a or 2b EEG pattern.

CONCLUSIONS

The identification of a specific clinical-EEG pattern provides a useful tool for the epileptogenic zone localization in non-invasive pre-surgical assessment of patients with hippocampal sclerosis.

SIGNIFICANCE

The identification of a specific clinical-EEG pattern associated to neuroimaging findings and neuropsychological testing allows indicating surgery for the treatment of epilepsy in patients with hippocampal sclerosis, without performing any further complementary studies.

Fertility of the male alpaca: effect of daily consecutive breeding

The fertility of the male alpaca under different frequencies of daily consecutive matings was evaluated. Fifteen adult male Huacaya alpacas were divided randomly into three groups of five each to breed lactating female alpacas. The schedule of daily matings was two, four and six consecutive breeding per group and for nine consecutive days. Ovulation was determined by progesterone at seven days after breeding. Pregnancy was determined by ultrasonography at 15 and 30 days after breeding. Two hundred and eighty females were bred with some males not fulfilling their schedule of breeding. There were differences (P < 0.05) in the fertility rate of males breeding two and four times daily (76%) in contrast to 59% for males breeding six times. There were also differences (P < 0.05) in the fertility of individual males. Length of copulation was affected (P < 0.05) by schedule of matings, day of breeding and male. Ovulation was independent of length of copulation. Overall, it seems the fertility of the male alpaca is affected significantly when consecutive matings are over four times a day and for nine consecutive days.

Antineutrophil cytoplasmic antibodies (ANCA) in idiopathic pulmonary hemosiderosis

Four children were diagnosed with idiopathic pulmonary hemosiderosis (IPH), over a period of 4 years. Retrospectively, antineurtrophil cytoplasmic antibodies (ANCA) were studied by indirect immunofluorescence (IIF) and ELISA in 18 sera from these patients, stored at -20 degrees C. ANCA-positive sera, from 1/20 to 1/1, 200 dilution, were found in 3/4 of the patients, by IIF. The patient with the highest titre of ANCA died 3 months later during an acute crisis, the other two patients need a minimal dose of steroids. In one case only, a patient who is still without treatment, had no ANCA. The antibodies anti-myeloperoxidase and anti-proteinase-3 were negative or at border line levels. Rheumatoid factor, antinuclear (Hep-2), anti-endomysial, anti-reticulin and antibasement membrane antibodies were negative in all sera. The surviving patients were followed-up for more than 10 years with no systemic or renal disease appearances. The presence of serum ANCA may help to classify children with pulmonary haemorrhage and may have a prognostic value.

Anti-immunoglobulin antibodies in children with Schönlein-Henoch syndrome. Absence of serum anti-IgA antibodies

Circulating immune complexes (CIC) that simultaneously contain IgG and IgA are frequently found in IgA nephropathy (IgA-N) and the Schönlein-Henoch syndrome (SHS). The presence of anti-immunoglobulin antibodies (IgA anti-IgG and IgG anti-IgA) was studied by ELISA in the serum of 39 children with SHS and compared to 30 normal children. The mean level of IgG anti-IgA antibodies (240 +/- 104 u/ml) in SHS patients was similar to control values (251 +/- 85 u/ml); the IgA anti-IgG antibodies were increased, although only the antibodies against Fc fraction of IgG were elevated (185 +/- 71 u/ml in patients vs 127 +/- 24 mu/ml in controls, P < 0.0001) without a significant increase of IgA anti-IgGFab antibodies (141 +/- 54 mu/ml vs. 137 +/- 25 u/ml); 16/39 (41%) of the patients had increased levels of IgA anti-IgGFc and 6 of these had also high IgA anti-IgGFab. None of these patients had high IgA anti-IgGFab antibodies without simultaneous augmentation of IgA anti-IgGFc. Only 3/39 (7.7%) of SHS patients showed high levels of IgG anti-IgA antibodies. The correlation of IgA anti-IgGFc antibodies with IgA anti-IgGFab was very strong (P < 0.0001) but lower with IgG anti-IgA antibodies (P < 0.002). In addition, 8/39 children had renal involvement, nevertheless in these patients the findings were quite similar, with a non-significant elevation of IgA anti-IgGF ab antibodies. These results show that the IgA anti-IgG antibodies are more frequently increased than IgG anti-IgA antibodies in the SHS; moreover they are mainly directed against Fc fraction and are IgA-FR isotype. Our findings suggest that the CIC in SHS are likely formed by the reaction of IgA anti-bodies against IgG and not vice versa.

New Lignan Glucosides from Stemmadenia minima*

Reinvestigation of the polar fractions from the stem bark of STEMMADENIA MINIMA A. Gentry (Apocynaceae) afforded two known and four new lignan glucosides. Their structures were deduced by spectroscopic and chemical methods.

Transient phenytoin induced IgA deficiency and permanent IgE increase

This is a report of a 9-year-old epileptic boy, who was studied over a period of 7 years. The seizures started when he was 2 months old. He was treated with phenytoin from the age of 2 years and 7 months. Serum and salivary IgA were absent with high IgE serum total. The routine immunologic studies were normal. The IgA was normalized after phenytoin withdrawal, but IgE determination increased progressively without any atopic symptoms. The T4 (helper)/T8 (suppressor) ratio decreased (1.0 and 1.2) on two different days, although above the normal limit. The phenytoin only modified the IgA levels. These data suggest that a primary immunoregulatory abnormality may be present in drug induced IgA deficiency.

[Cardiotonically Active Principles from Spigelia anthelmia1.]

From the upper parts of SPIGELIA ANTHELMIA L. besides some widely distributed phenolcarboxylic acids and flavonoids two volatile alkaloids have been isolated and identified as isoquinoline and an iridoid compound of the actinidine type. In the water extract choline, benzoylcholine and 3,3-dimethyl-acryloylcholine could be identified. Preliminary pharmacological investigations revealed that the alkaloids are involved in the cardiotonic activity of the plant.

[Incidence of circulating immune complexes in pediatric diseases. Comparative study with adults]

Circulating immune complexes were studied using 3.5% polyethyleneglycol precipitation in 312 children with various diseases whose ages ranged from 1 month to 14 years. One hundred and one patients (32.6%) were positive and the groups with the highest percentage were those with viral hepatitis (90%), sepsis (80.7%), collagen diseases (76.4%) and Schonlein-Henoch purpura (57.1%). We found immune complexes less frequently in idiopathic thrombocytopenic purpura than in published series of adult cases, possibly due to the fact that the diseases in children is due to a different pathogenetic mechanism. The composition of the immune complexes was tested by 1% agarose immunodiffusion against a panel of antisera. IgG and IgM were found most frequently, and IgA was very uncommon except in some cases of hepatitis. C4 was the most frequently found complement component, followed by C3. Important differences between the various diseases studied were noted. Our results are very similar to those previously published by other authors. Whereas serum autoantibodies and autoimmune diseases are less common in children than in adults, circulating immune complexes seem to have a similar frequency in children to that already reported for adults. It is difficult to assess the significance of circulating immune complexes. They might be (a) a mere "marker" of no pathogenic significance (b) a mechanism of tissue damage by intravascular deposition, or (c) they might interfere with the cell membrane receptors of macrophages, producing a defect in phagocytosis. However, we were unable to demonstrate an increased number of infections in these patients.