The Impact of Standardizing Preoperative Diabetic Medication Instruction and Glucose Optimization on Postoperative Patient Outcomes

Purpose:  The purpose of this project was to evaluate the effectiveness of a standardized preoperative diabetic medication instruction program in patients with diabetes undergoing elective noncardiac surgical procedures. In particular, we measured postoperative blood glucose levels and surgical complication rates to assess the success of the program. Methods: A retrospective review was performed on adult patients who were on oral hypoglycemic or insulin medication for diabetes mellitus type I and II, were undergoing elective non-cardiac surgery, and had been evaluated by the anesthesia preoperative clinic before and after standardization of medication instruction. Analysis was performed for the primary outcomes of postoperative glucose levels on post-op day 0 and secondary outcomes of surgical complications. Results: There were 167 patients in the pre-standardization protocol, and 183 patients in the post-standardization protocol, for a total of 350 patients. There was no significant difference between pre- and post-standardization protocols for postoperative glucose levels (158.5 ±63.22 vs. 154.3 ±56.32, P=0.52) nor secondary outcomes such as time to discharge in days (4.79 ±0.95 vs. 4.55 ±0.94, P=0.73), postoperative surgical site infection (odds ratio [OR], 13.77; 95% confidence interval [CI], [0.40, 471.1]), postoperative infection (OR=0.62; 95% CI [0.22, 1.73]), diabetes complications such as diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome (OR=1.29; 95% CI [0.04, 43.08]), readmission to the hospital within 30-days (OR=1.15; 95% CI [0.40, 43.08]), and return to the operating room (OR=0.61; 95% CI [0.21, 1.73]). Conclusion: There is no statistically significant difference in the measured perioperative outcomes before and after the standardization of preoperative diabetic medication instruction. This is most likely due to a low observation of surgical complications. Future studies may include larger populations to further evaluate the efficacy of a standardized preoperative diabetic medication instruction program

There’s Something in the Water: An Unusual Case of Hypophosphatasia

Learning Objectives 1. Explain the mechanism of TNSALP in the pathogenesisof hypophosphatasia and the role of ALPL mutations inthe severity of disease presentation. 2. Describe the clinical manifestations and diagnosticcriteria of hypophosphatasia, as well as the rationale forutilizing enzyme-replacement therapy in the treatmentof disease. 3. Explain the role of minerals in the enzymatic activityof ALP and understand why a mineral deficiencyassociated with drinking exclusively tap water couldcontribute to symptom severity in patients withhypophosphatasia

Associated Outcomes of Tranexamic Acid Use in Non-surgical Chronic Subdural Hematomas

Purpose: Tranexamic acid (TXA) is a compound used to treat many bleeding conditions by inhibiting plasmin activity via binding to plasminogen and reducing fibrinolysis and inflammation. The role of TXA in the non-surgical management of chronic subdural hematomas (cSDH) has been studied previously, but data has been controversial. Mixed reports show TXA can reduce hematoma volume or result in complete resolution, while others show no benefit in reducing cSDH recurrence. Therefore, examined the impact of TXA in patients with cSDH who do not undergo burrhole drainage or middle meningeal artery embolization, and determine whether outcomes are associated with other complications. Methods: We performed a retrospective case-control analysis using a multi-institutional database (TriNetX). We reviewed non-acute subdural hematoma patients who did not undergo surgical treatment and were treated with or without TXA. The primary endpoint was mortality at 6 months. Secondary endpoints included ventilator dependence, seizure, venous thromboembolism, myocardial infarction (MI), cerebral infarction, and percutaneous endoscopic gastrostomy (PEG). Cohorts were propensity score-matched for confounding variables. Results: 470 patients were identified from TXA (cohort 1) and non-TXA (cohort 2) populations. The mean age at cSDH was 57.5 vs. 59.3 years. Mortality was seen in 93 patients (19.79%) in cohort 1 vs 73 (15.53%) in cohort 2 (P=0.09), ventilator dependence was 4.26% vs 2.55% (P=0.15), PEG placement was 5.75% vs 2.13% (P=0.004), seizures were 14.04% vs 11.28%(P=0.20), and venous thromboembolism was 8.09% vs 3.83% (P=0.006). There were too few patients with stroke and myocardial infarction for meaningful analysis of those outcomes. Conclusion: TXA use in non-acute subdural hematomas is associated with an increased incidence of venous thromboembolism and PEG tube placement. In addition, TXA use was not found to benefit mortality 6 months post-operatively. It was not significantly associated with ventilator dependence or the occurrence of seizures, stroke, or myocardial infarction. Further research is needed to determine if hematoma characteristics, such as volume, may be related to outcomes seen in this study

Risk Factors for Dyspepsia in Sub-Saharan Africa: A Community-based Study and Multivariable Predictive Model

Purpose: Low middle-income countries (LMICs) are particularly affected by dyspepsia and peptic ulcer disease. However, the true prevalence in rural/suburban areas of Sub-Saharan Africa, such as the Eastern Region of Ghana, remains unknown.  The objective of this study was to determine the prevalence and risk factors of dyspepsia in Sub-Saharan Africa. Methods: A population-based survey was conducted in Ghana’s Eastern Region of adults not seeking active medical treatment. Demographic, medical history, and current symptoms of dyspepsia were obtained through a cross-sectional survey. 149 individuals were included in the survey. Results: Prevalence of dyspepsia was 25.5% (38/149). Risk factors for dyspepsia include NSAID use (OR 2.16; 95% CI 0.91 to 5.55, p = 0.09) and previous diagnosis of anemia (OR 4.64; 95% CI 1.45 to 15.45, p = 0.01). Higher level of education was found to be protective against dyspepsia (OR 0.22; 95% CI 0.06 to 0.49, p = 0.03). A multivariable, predictive model created from survey data was found to predict 74% of participants with dyspepsia. Conclusions: Dyspepsia has a high prevalence in Eastern Ghana. Recognition of dyspepsia can be made at the community level with minimal resources and can identify disease and direct early and low cost intervention for dyspepsia

Type of Oral Contraceptive Pills in Patients with Complete ACL Tears: A Retrospective Study

Purpose: Differences in sex hormones are one of the proposed mechanisms for the increased risk of anterior cruciate ligament (ACL) injury in female athletes. Oral contraceptive pills (OCPs) may reduce the risk of ACL injuries in females, but the effects of different types of OCPs have not been examined. This study aimed to investigate the type of OCPs used in women diagnosed with ACL tears. We hypothesized that a greater proportion of women with ACL tears will be exposed to OCPs containing high estrogen and less androgenic progestins than other types of OCPs. Methods: Medical records from Hospital for Special Surgery (New York, NY) for women ages 16-55 with diagnosis of an ACL tear while concurrently taking OCPs were reviewed from January 2016 to June 2018 for demographic data, documentation of ACL injury, type of OCP at time of injury, ethinyl estrogen dose, and progestin dose. OCP androgenicity was determined by multiplying the dose of progestin by the progestin’s androgenicity. Results: A total of 223 patients sustained an ACL tear while taking OCPs. The most commonly used OCP was a high estrogen/low androgenicity progestin pill (107/223=48%).When each hormone was considered individually, the majority of women were exposed to OCPs with high estrogen (58.7% vs 41.3%, p<0.0001) and low androgenicity progestin (84.8% vs 15.3%, p<0.0001). Conclusion: A large portion of women who sustained ACL tears were taking a high estrogen/low androgenicity progestin OCP at the time of injury and this is different than population data where the majority of women are exposed to moderately high androgenicity progestins. Future studies should be conducted to determine if OCPs with high estrogen and low androgenicity progestin correlate with increased risk of ACL injury

Prevalence of Risk of Obstructive Sleep Apnea in Hospitalized Internal Medicine Patients in a Rural Academic Medical Center

Purpose: This study aims to determine the prevalence of obstructive sleep apnea risk within hospitalized patients utilizing the STOPBANG questionnaire, evaluate patient interest in follow-up testing and determine the factors that influence their interest in follow-up. Methods: A researcher approached eligible patients hospitalized at a tertiary hospital, explained the study, and acquired verbal consent. They administered the STOPBANG questionnaire, discussed participants’ risk, and provided information about follow-up polysomnography. Results: Of 335 patients approached, 121 patients were excluded and 60 (17.9%) were already diagnosed with obstructive sleep apnea. Of the 154 participants screened, 42.2%, 35.7% and 22.1% were at low, intermediate and high risk of obstructive sleep apnea, respectively. Of those at intermediate to high risk, 44 expressed interest in following up with polysomnography and 32 were not interested. Older patients were less likely to express interest in follow-up (OR 0.098 95% CI: 0.012-0.893) and patients that reported snoring were more likely to express interest in follow-up (OR 3.15 CI: 1.14-8.75). Conclusions: There is a high prevalence of intermediate to high obstructive sleep apnea risk (57.8%) in undiagnosed patients in a rural tertiary care center. Younger patients were 10 times more likely to consider polysomnography (PSG), which supports arguments for early screening for obstructive sleep apnea. Snorers were 3 times more likely to consider PSG, which may reflect the narrow focus of public awareness of obstructive sleep apnea

Combatting Neurophobia: Neurology Exposure in Preclinical Years and Residency Match Trends

Purpose: We sought to investigate whether there are any factors that may affect student interest in neurology among medical students at Penn State College of Medicine (PSCOM), and how the neurology curriculum impacts this interest. Methods: Penn State College of Medicine students were surveyed to evaluate their perception and exposure to neurology in two surveys. Publicly available match data from PSCOM and the United States were compared to determine neurology match trends. Results: PSCOM pre-clinical students reported less than satisfactory neurology exposure on two surveys, with clinical students reporting satisfactory exposure. Furthermore, PSCOM showed a higher proportion of students matching into neurology during 2011-2020 compared to national data (4.05 ± 0.27%. versus 1.78 ± 0.086%; p < .00001). Conclusions: Career exploration programs such as Student Interest Group in Neurology, and early integration of clinical neurology can help combat neurophobia by increasing student exposure to neurology