scholarly journals Non-Fasting Hypoglycemia Secondary to Opioid Induced Adrenal Insufficiency: A Case Report

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A145-A146
Author(s):  
Alaa Kubbar ◽  
Maryann Banerji
Keyword(s):  
Blood Pressure ◽  
Suicide Attempt ◽  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Clinical Case ◽  
Complete Blood Count ◽  
The United States ◽  
Adverse Outcomes ◽  
Inadequate Response ◽  
Fasting Hypoglycemia

Abstract Background: A patient on chronic methadone therapy presented following a suicide attempt, was noted to have recurrent episodes of non-fasting symptomatic hypoglycemia and was diagnosed with opioid induced adrenal insufficiency (OIAI). Opioid induced endocrinopathies are underappreciated, particularly in the midst of a growing opioid epidemic in the United States. We believe this is the first reported clinical case of OIAI associated with non-fasting hypoglycemia. Clinical Case: A 33-year-old female with history of depression and heroine abuse on methadone therapy presented after a suicide attempt by methadone overdose. Home medications included 170mg of methadone daily for the past 5 years. She was afebrile, heart rate of 68, blood pressure 102/72, respiratory rate of 10, oxygen saturation 92%. On exam she was lethargic with altered mental status and had pinpoint pupils. Labs showed a normal complete blood count and metabolic panel. Urine toxicology was positive for methadone. Clinical picture improved temporarily after Narcan administration however 1 hour later she was confused again, with a fingerstick glucose of 50mg/dL and she was admitted to ICU for monitoring. In the ICU she continued to be lethargic with dizziness, nausea and headaches. She continued to have approximately 4 spontaneous episodes of hypoglycemia per day, despite having a good appetite and increased parenteral glucose administration. Blood pressure continued to be marginal, ranging from 85–100/50–60. There was no obvious source of infection. Urine sulfonylurea screen was negative. Investigations showed a morning cortisol of 2.23 ug/dL. A 250 µg ACTH stimulation test showed an inadequate response. The am basal plasma cortisol was 2.25 ug/dL with 15.28 ug/dL and 15.13 ug/dL at 30 and 60 minutes respectively (6.20–19.40ug/dL). She was diagnosed with hypoglycemia secondary to OIAI. Given the patient’s critical condition she was initially started on stress dose of hydrocortisone 80mg every 8 hours. Attempts to down titrate the methadone dose were unsuccessful. Patient’s symptoms improved and hypoglycemia subsided. She was discharged home on hydrocortisone 10mg qam & 5 mg qpm and she was continued on Methadone 170mg daily. Conclusion: OIAI is an under-recognized clinical entity with potentially serious adverse outcomes. Currently, 3% to 4% of US adults receive long-term opioid treatment. OIAI is present in 9—29% of individuals on chronic opioids. Opioids act through suppression of the HPA axis, primarily at the level of the hypothalamus, mediated through either delta or kappa receptors leading to a decrease in ACTH and cortisol secretion. Management should include decreasing and ideally discontinue opioids, along with glucocorticoid replacement until documented recovery of the HPA axis. Reference: Reference: (1)Donegan, Diane et al. Opioid-Induced Adrenal Insufficiency. Mayo Clin. Proc. 2018 93(7), 937–944.

Development and validation of risk stratification models for adult spinal deformity surgery

2019 ◽  
Vol 31 (4) ◽  
pp. 587-599 ◽  
Author(s):  
Ferran Pellisé ◽  
Miquel Serra-Burriel ◽  
Justin S. Smith ◽  
Sleiman Haddad ◽  
Michael P. Kelly ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
The United States ◽  
Adverse Outcomes ◽  
High Rate ◽  
Prognostic Models ◽  
Time To Event ◽  
European Continent ◽  
Event Risk ◽  
Risk Estimates

OBJECTIVEAdult spinal deformity (ASD) surgery has a high rate of major complications (MCs). Public information about adverse outcomes is currently limited to registry average estimates. The object of this study was to assess the incidence of adverse events after ASD surgery, and to develop and validate a prognostic tool for the time-to-event risk of MC, hospital readmission (RA), and unplanned reoperation (RO).METHODSTwo models per outcome, created with a random survival forest algorithm, were trained in an 80% random split and tested in the remaining 20%. Two independent prospective multicenter ASD databases, originating from the European continent and the United States, were queried, merged, and analyzed. ASD patients surgically treated by 57 surgeons at 23 sites in 5 countries in the period from 2008 to 2016 were included in the analysis.RESULTSThe final sample consisted of 1612 ASD patients: mean (standard deviation) age 56.7 (17.4) years, 76.6% women, 10.4 (4.3) fused vertebral levels, 55.1% of patients with pelvic fixation, 2047.9 observation-years. Kaplan-Meier estimates showed that 12.1% of patients had at least one MC at 10 days after surgery; 21.5%, at 90 days; and 36%, at 2 years. Discrimination, measured as the concordance statistic, was up to 71.7% (95% CI 68%–75%) in the development sample for the postoperative complications model. Surgical invasiveness, age, magnitude of deformity, and frailty were the strongest predictors of MCs. Individual cumulative risk estimates at 2 years ranged from 3.9% to 74.1% for MCs, from 3.17% to 44.2% for RAs, and from 2.67% to 51.9% for ROs.CONCLUSIONSThe creation of accurate prognostic models for the occurrence and timing of MCs, RAs, and ROs following ASD surgery is possible. The presented variability in patient risk profiles alongside the discrimination and calibration of the models highlights the potential benefits of obtaining time-to-event risk estimates for patients and clinicians.

Effects of Intensive Blood Pressure Control in Patients with Evident Cardiovascular Disease: An Investigation Using the SPRINT Study Data

2019 ◽  
Vol 17 (3) ◽  
pp. 298-306 ◽  
Author(s):  
Charalambos Vlachopoulos ◽  
Dimitrios Terentes-Printzios ◽  
Konstantinos Aznaouridis ◽  
Nikolaos Ioakeimidis ◽  
Panagiotis Xaplanteris ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cardiovascular Disease ◽  
Beneficial Effect ◽  
Harmful Effect ◽  
Adverse Outcomes ◽  
Intensive Treatment ◽  
Serious Adverse Events ◽  
Stroke Incidence ◽  
Increased Risk ◽  
All Cause Mortality

Background: Recent data advocate adoption of a more intensive treatment strategy for management of blood pressure (BP). </P><P> Objective: We investigated whether the overall effects of the Systolic Blood Pressure Intervention Trial (SPRINT) are applicable to cardiovascular disease (CVD) patients. </P><P> Methods: In a post hoc analysis we analyzed data from SPRINT that randomly assigned 9361 individuals to a systolic BP (SBP) target of <120 mmHg (intensive treatment) or <140 mmHg (standard treatment). 1562 patients had clinically evident CVD (age=70.3±9.3 years, 24% females) at study entry and were followed for 3.1 years. Further, we assessed the effect of low (<150 mmHg) baseline SBP on outcome. </P><P> Results: In CVD patients, there was no benefit from the intensive treatment regarding all endpoints, except for a marginally significant benefit on all-cause mortality (hazard ratio [HR]: 0.67; 95% confidence interval [CI], 0.45 to 1.00; p=0.0509). Further, while there was no increase in serious adverse events (SAE) in the intensive group, there was increased risk for study-related SAE, acute renal failure and electrolyte abnormalities. In patients with low baseline SBP there was a beneficial effect on allcause mortality (HR: 0.56; 95% CI: 0.33 to 0.96; p=0.033), but with greater stroke incidence (HR: 2.94; 95% CI: 1.04 to 8.29; p=0.042). </P><P> Conclusion: We confirm the beneficial effect of the intensive strategy in SPRINT study on all-cause mortality and the harmful effect on specific adverse outcomes in patients with CVD. However, in patients with low baseline SBP stroke may increase.

scholarly journals Protective Effectiveness of Long-Lasting Permethrin Impregnated Clothing Against Tick Bites in an Endemic Lyme Disease Setting: A Randomized Control Trial Among Outdoor Workers

2020 ◽  
Vol 57 (5) ◽  
pp. 1532-1538
Author(s):  
Cedar Mitchell ◽  
Megan Dyer ◽  
Feng-Chang Lin ◽  
Natalie Bowman ◽  
Thomas Mather ◽  
...  
Keyword(s):  
United States ◽  
Rhode Island ◽  
The United States ◽  
Amblyomma Americanum ◽  
Adverse Outcomes ◽  
Control Group ◽  
Tick Bites ◽  
Outdoor Workers ◽  
Significant Difference ◽  
Protective Effectiveness

Abstract Tick-borne diseases are a growing threat to public health in the United States, especially among outdoor workers who experience high occupational exposure to ticks. Long-lasting permethrin-impregnated clothing has demonstrated high initial protection against bites from blacklegged ticks, Ixodes scapularis Say (Acari: Ixodidae), in laboratory settings, and sustained protection against bites from the lone star tick, Amblyomma americanum (L.) (Acari: Ixodidae), in field tests. However, long-lasting permethrin impregnation of clothing has not been field tested among outdoor workers who are frequently exposed to blacklegged ticks. We conducted a 2-yr randomized, placebo-controlled, double-blinded trial among 82 outdoor workers in Rhode Island and southern Massachusetts. Participants in the treatment arm wore factory-impregnated permethrin clothing, and the control group wore sham-treated clothing. Outdoor working hours, tick encounters, and bites were recorded weekly to assess protective effectiveness of long-lasting permethrin-impregnated garments. Factory-impregnated clothing significantly reduced tick bites by 65% in the first study year and by 50% in the second year for a 2-yr protective effect of 58%. No significant difference in other tick bite prevention method utilization occurred between treatment and control groups, and no treatment-related adverse outcomes were reported. Factory permethrin impregnation of clothing is safe and effective for the prevention of tick bites among outdoor workers whose primary exposure is to blacklegged ticks in the northeastern United States.

scholarly journals IMPROVING HYPERTENSION CONTROL IN THE UNITED STATES: UNDERSTANDING RACIAL/ETHNIC DIFFERENCES IN THE BLOOD PRESSURE CASCADE

2021 ◽  
Vol 77 (18) ◽  
pp. 1475
Author(s):  
Rahul Aggarwal ◽  
Nicholas Chiu ◽  
Rishi Wadhera ◽  
Andrew Moran ◽  
Changyu Shen ◽  
...  
Keyword(s):  
United States ◽  
Blood Pressure ◽  
Ethnic Differences ◽  
The United States ◽  
Hypertension Control ◽  
Racial Ethnic

scholarly journals Blood lead level and risk of hypertension in the United States National Health and Nutrition Examination Survey 1999–2016

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Man Fung Tsoi ◽  
Chris Wai Hang Lo ◽  
Tommy Tsang Cheung ◽  
Bernard Man Yung Cheung
Keyword(s):  
Blood Pressure ◽  
Lead Exposure ◽  
Blood Lead Level ◽  
Lead Level ◽  
Blood Lead ◽  
The United States ◽  
Study Data ◽  
Blood Lead Levels ◽  
Environmental Lead ◽  
Lead Levels

AbstractLead is a heavy metal without a biological role. High level of lead exposure is known to be associated with hypertension, but the risk at low levels of exposure is uncertain. In this study, data from US NHANES 1999–2016 were analyzed. Adults with blood lead and blood pressure measurements, or self-reported hypertension diagnosis, were included. If not already diagnosed, hypertension was defined according to the AHA/ACC 2017 hypertension guideline. Results were analyzed using R statistics version 3.5.1 with sample weight adjustment. Logistic regression was used to study the association between blood lead level and hypertension. Odds ratio (OR) and 95% confidence interval (95% CI) were estimated. Altogether, 39,477 participants were included. Every doubling in blood lead level was associated with hypertension (OR [95%CI] 1.45 [1.40–1.50]), which remained significant after adjusting for demographics. Using quartile 1 as reference, higher blood lead levels were associated with increased adjusted odds of hypertension (Quartile 4 vs. Quartile 1: 1.22 [1.09–1.36]; Quartile 3 vs. Quartile 1: 1.15 [1.04–1.28]; Quartile 2 vs. Quartile 1: 1.14 [1.05–1.25]). In conclusion, blood lead level is associated with hypertension in the general population with blood lead levels below 5 µg/dL. Our findings suggest that reducing present levels of environmental lead exposure may bring cardiovascular benefits by reducing blood pressure.

scholarly journals The Road to Better Management in Resistant Hypertension–Diagnostic and Therapeutic Insights

Pharmaceutics ◽  
2021 ◽  
Vol 13 (5) ◽  
pp. 714
Author(s):  
Elisabeta Bădilă ◽  
Cristina Japie ◽  
Emma Weiss ◽  
Ana-Maria Balahura ◽  
Daniela Bartoș ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Renin Angiotensin System ◽  
Drug Regimen ◽  
Secondary Hypertension ◽  
Adverse Outcomes ◽  
Uncontrolled Hypertension ◽  
White Coat Hypertension ◽  
Mineralocorticoid Receptor Antagonist ◽  
Mortality And Morbidity

Resistant hypertension (R-HTN) implies a higher mortality and morbidity compared to non-R-HTN due to increased cardiovascular risk and associated adverse outcomes—greater risk of developing chronic kidney disease, heart failure, stroke and myocardial infarction. R-HTN is considered when failing to lower blood pressure below 140/90 mmHg despite adequate lifestyle measures and optimal treatment with at least three medications, including a diuretic, and usually a blocker of the renin-angiotensin system and a calcium channel blocker, at maximally tolerated doses. Hereby, we discuss the diagnostic and therapeutic approach to a better management of R-HTN. Excluding pseudoresistance, secondary hypertension, white-coat hypertension and medication non-adherence is an important step when diagnosing R-HTN. Most recently different phenotypes associated to R-HTN have been described, specifically refractory and controlled R-HTN and masked uncontrolled hypertension. Optimizing the three-drug regimen, including the diuretic treatment, adding a mineralocorticoid receptor antagonist as the fourth drug, a β-blocker as the fifth drug and an α1-blocker or a peripheral vasodilator as a final option when failing to achieve target blood pressure values are current recommendations regarding the correct management of R-HTN.

scholarly journals Efficacy and safety of fremanezumab in patients with migraine and inadequate response to prior preventive treatment: subgroup analyses by country of a randomized, placebo-controlled trial

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Egilius L. H. Spierings ◽  
Mikko Kärppä ◽  
Xiaoping Ning ◽  
Joshua M. Cohen ◽  
Verena Ramirez Campos ◽  
...  
Keyword(s):  
United States ◽  
Czech Republic ◽  
Adverse Events ◽  
Least Squares ◽  
The United States ◽  
Inadequate Response ◽  
Double Blind ◽  
Monthly Average ◽  
Preventive Medication ◽  
Subgroup Analyses

Abstract Background The FOCUS study evaluated the efficacy of migraine preventive medications across different countries within the same patient population, particularly for patients with difficult-to-treat migraine. These prespecified subgroup analyses evaluated efficacy by country in the FOCUS study of fremanezumab in adults with episodic migraine or chronic migraine and documented inadequate response to 2 to 4 migraine preventive medication classes. Methods Overall, 838 participants were enrolled in the FOCUS study, a randomized, double-blind, placebo-controlled, parallel-group, phase 3b study performed at 104 sites. For 12 weeks of double-blind treatment, patients were randomized (1:1:1) to quarterly fremanezumab, monthly fremanezumab, or matched placebo. The primary efficacy endpoint was the mean change from baseline in monthly average migraine days over 12 weeks of double-blind treatment, evaluated by country in these subgroup analyses. Results Of 14 countries contributing data, the Czech Republic (n = 188/838; 22%), the United States (n = 120/838; 14%), and Finland (n = 85/838; 10%) enrolled the most patients. Changes from baseline in monthly average migraine days over 12 weeks were significantly greater with fremanezumab versus placebo for patients in these countries: Czech Republic (least-squares mean difference versus placebo [95% confidence interval]: quarterly fremanezumab, − 1.9 [− 3.25, − 0.47]; P = 0.009; monthly fremanezumab, − 3.0 [− 4.39, − 1.59]; P < 0.001), the United States (quarterly fremanezumab, − 3.7 [− 5.77, − 1.58]; P < 0.001; monthly fremanezumab, − 4.2 [− 6.23, − 2.13]; P < 0.001), and Finland (quarterly fremanezumab, − 3.0 [− 5.32, − 0.63]; P = 0.014; monthly fremanezumab, − 3.9 [− 6.27, − 1.44]; P = 0.002). Results were comparable for the remaining 9 countries, with the least-squares mean difference versus placebo ranging from – 5.6 to – 2.4 with quarterly fremanezumab and from − 5.3 to − 1.5 with monthly fremanezumab. Incidences of serious adverse events and adverse events leading to discontinuation were low and comparable across countries and treatment groups. Conclusions Monthly and quarterly fremanezumab significantly reduced the monthly average number of migraine days versus placebo regardless of country and continent (North America versus Europe) in migraine patients with documented inadequate response to 2 to 4 migraine preventive medication classes. Trial registration ClinicalTrials.gov Identifier: NCT03308968.

Dietary and behavior changes following rdn-led corporate wellness counseling: A secondary analysis

Work ◽  
2021 ◽  
pp. 1-7
Author(s):  
Kristen K. Hicks-Roof ◽  
Mallory P. Franklin ◽  
Claudia V. Sealey-Potts ◽  
Robert J. Zeglin
Keyword(s):  
Blood Pressure ◽  
Hierarchical Linear Modeling ◽  
Wellness Programs ◽  
The United States ◽  
Nutrition Intervention ◽  
Behavior Changes ◽  
Worksite Wellness ◽  
Whole Grain ◽  
Lifestyle Behavior ◽  
Worksite Wellness Programs

BACKGROUND: Worksite wellness programs have the ability to activate health promotion and stimulate behavior change. OBJECTIVE: To measure longitudinal associations between visits with a Registered Dietitian Nutritionist (RDN), as part of worksite wellness programs, on dietary and lifestyle behavior changes. METHODS: The study sample included 1,123 employees with 77 different worksite wellness programs across the United States from March to December 2017. Hierarchical linear modeling was used to evaluate the associations of RDN visits with behavior changes. RESULTS: The mean BMI at baseline was 33.48, indicating over half of all employees are considered obese. Employees who attended more than one visit showed an increase in whole grain consumption and corresponding weight loss (t-ratio = 2.41, p = 0.02). Age played a significant factor in the rise of systolic blood pressure; employees who attended more visits showed an increase in whole grain consumption and corresponding blood pressure (t-ratio = –2.11, p = 0.04). CONCLUSIONS: RDNs as part of worksite wellness programs, can contribute to improvements in lifestyle behavior changes. These data highlight the need for nutrition intervention at the workplace. Research on nutrition-focused worksite wellness programs is needed to assess the long-term health outcomes related to dietary and lifestyle behavior changes.

scholarly journals Hypertension in the United States Fire Service

2021 ◽  
Vol 18 (10) ◽  
pp. 5432
Author(s):  
Saeed U. Khaja ◽  
Kevin C. Mathias ◽  
Emilie D. Bode ◽  
Donald F. Stewart ◽  
Kepra Jack ◽  
...  
Keyword(s):  
Blood Pressure ◽  
General Population ◽  
Age Groups ◽  
Total Sample ◽  
The United States ◽  
Fire Service ◽  
Atherosclerotic Cardiovascular Disease ◽  
Cardiac Events ◽  
Antihypertensive Medications ◽  
Increased Risk

Hypertension is a major risk factor for atherosclerotic cardiovascular disease and cardiac remodeling and is associated with an increased risk of sudden cardiac events, the leading cause of duty-related death in the fire service. We assessed systemic blood pressures and prevalence of hypertension among US firefighters by decade of life. Medical records of career firefighters (5063 males and 274 females) from four geographically diverse occupational health clinics were assessed. Hypertension was defined as systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg, or taking antihypertensive medication. Results from the firefighter sample were compared to the US general population (2015–2016 and 2017–2018 National Health and Nutrition Examination Surveys). Among the total sample, 69% of firefighters met the criteria for hypertension and 17% were taking antihypertensive medications. Percentages of hypertensive male and female firefighters were 45% and 11% among 20–29 years old, respectively, and increased to 78% and 79% among 50–59 years old, respectively. Compared to the general population, male firefighters had a higher prevalence of hypertension (p < 0.05) across all age groups (11–16% higher). In order to improve firefighter health and protect against sudden incapacitation in this public safety occupational group, increased efforts are necessary to screen for and manage high blood pressure.

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