Primary Care

We evaluated the utility of tissue Doppler-derived right ventricular (RV) Tei (or myocardial performance) index in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after pulmonary thromboendarterectomy (PTE) and assessed correlations with mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac output (CO).The assessment of RV function is limited with 2-dimensional echocardiography. The RV Tei index, an indicator of RV myocardial performance, is derived by Doppler measurements and is unaffected by RV geometry. The use of tissue Doppler imaging (at the lateral tricuspid annulus) for RV Tei index calculation is simple and eliminates the need for pulsed-wave Doppler recordings of both RV inflow and outflow.Ninety-three patients with CTEPH were prospectively studied along with 13 control patients. Right ventricular tissue Doppler imaging and right heart catheterization were performed before and after PTE. Right ventricular Tei index was compared with values of mPAP, PVR, and CO with the use of linear regression.Right ventricular Tei index was 0.52 ± 0.19 in patients with CTEPH and 0.27 ± 0.09 in control patients (p < 0.0001). After PTE, RV Tei index decreased to 0.33 ± 0.10 (p < 0.0001). Pulmonary vascular resistance correlated well with RV Tei index before (r = 0.78, p < 0.0001) and after (r = 0.67, p < 0.0001) surgery. Also, the absolute change in Tei index in each patient after PTE correlated well with the concomitant change in PVR (r = 0.75, p < 0.0001). RV Tei index did not correlate as well with mPAP (pre-operatively: r = 0.55, p < 0.0001; post-operatively: r = 0.26, p = 0.03) or CO (pre-operatively: r = 0.57, p < 0.0001; post-operatively: r = 0.43, p < 0.0001).These results demonstrate a correlation between RV Tei index and right heart hemodynamics (particularly PVR) in CTEPH. Because PVR is difficult to estimate noninvasively—and yet correlates with disease severity—the RV Tei index may be a valuable noninvasive parameter for monitoring disease severity in CTEPH and outcome after PTE.

Background The accurate evaluation of pulmonary vascular resistance (PVR) and mean pulmonary artery pressure is important to determine the optimal management and therapeutic strategy for patients with congenital heart disease (CHD). We evaluated the PVR and mean pulmonary artery pressure in 46 patients with several CHD types using the interventricular septum (IVS) motion determined by M-mode echocardiography. Methods We divided the patients into 2 groups according to the different IVS motions. We measured the maximum anterior displacement from the baseline during early systole (a) and the maximum posterior displacement from the baseline during early diastole (b). We defined type A to be a/b greater than or equal to 1.0, and type B to be a/b less than 1.0. Results The PVR and mean pulmonary artery pressure in type A patients were significantly higher than those in type B patients (p \ 0.05). Type A IVS motion predicted patients with high PVR ([2.5 unit/m 2 ) and high mean pulmonary artery pressure ([25 mmHg) (sensitivity 89%, specificity 89% and sensitivity 70%, specificity 91%, respectively). Conclusions Our method can noninvasively separate high and low PVR among patients with CHD. This noninvasive method is therefore considered to be useful in the management of patients with CHD in a clinical setting.

The prevalence of type 2 diabetes mellitus (T2DM) has reached epidemic proportions in the United States, the impact of which is seen in all medical practices. The tenets of osteopathic medicine are readily applicable to a proactive approach to patients with T2DM and are (1) the body is a unit; the person is a unit of body, mind, and spirit; (2) the body is capable of self-regulation, self-healing, and health maintenance; (3) structure and function are reciprocally interrelated; and (4) rational treatment is based upon an understanding of these basic principles. The authors examine the evidence that supports the application of these tenets to the prevention and management of T2DM and cover topics including the removal of noxious stimuli to help the body function optimally; the musculoskeletal system's role in disease prevention and management; the dynamic interaction of body, mind, and spirit, all 3 of which must be addressed to maintain health and limit disease; and intrinsic and extrinsic forces that can either promote or provoke a person's health.

Hypoglycemia is a common and serious complication of diabetes management. There is no uniformly accepted clinical definition of hypoglycemia. The American Diabetes Association (ADA) recommends that people with diabetes consider treating hypoglycemia when the self-monitored blood glucose (SMBG) level is 70 mg/dl (3.9 mmol/L). Hypoglycemia significantly affects mortality and quality of life. Normally, in people without diabetes, hypoglycemia is prevented by redundant protective counter-regulatory mechanisms. These counter-regulatory pathways become defective in people with Type 1 diabetes and those with long standing Type 2 diabetes.

emergency hospitalizations because of adverse drug reactions. The report showed that insulin and oral hypoglycemic agents caused nearly 25% of the medication-induced hospitalizations in older adults in the United States. A total of 24,520 hospitalizations resulted from these medications. (www.nejm.org/doi/ full/10.1056/NEJMsa1103053).

We present a 56-year-old female with a history of carbohydrate intolerance and ketotic hypoglycemia, dysmorphic features, mild developmental delay, lymphedema, altered pain sensation, and frequent fractures, who was found to have a heterozygous 8.09 Mb deletion of chromosome 8q24.11q24.13 containing more than 39 genes, as well as a duplication of 20q11.23 containing one gene. The deleted region overlaps that of two previously reported patients, who share a subset of clinical characteristics with the patient described here. Some of this patient's clinical features are consistent with the loss of genes in the deleted region. The diagnostic work-up of this patient clearly demonstrates the evolution of genetic testing techniques.

Diabetes management is a difficult task for patients, who must monitor and control their blood glucose levels in order to avoid serious diabetic complications. It is a difficult task for physicians, who must manually interpret large volumes of blood glucose data to tailor therapy to the needs of each patient. This paper describes three emerging applications that employ AI to ease this task and shares difficulties encountered in transitioning AI technology from university researchers to patients and physicians.

This paper presents a case-based decision support system prototype to assist patients with Type 1 diabetes on insulin pump therapy. These patients must vigilantly maintain blood glucose levels within prescribed target ranges to prevent serious disease complications, including blindness, neuropathy, and heart failure. Case-based reasoning (CBR) was selected for this domain because (a) existing guidelines for managing diabetes are general and must be tailored to individual patient needs; (b) physical and lifestyle factors combine to influence blood glucose levels; and (c) CBR has been successfully applied to the management of other long-term medical conditions. An institutional review board (IRB) approved preliminary clinical study, involving 20 patients, was conducted to assess the feasibility of providing case-based decision support for these patients. Fifty cases were compiled in a case library, situation assessment routines were encoded to detect common problems in blood glucose control, and retrieval metrics were developed to find the most relevant past cases for solving current problems. Preliminary results encourage continued research and work toward development of a practical tool for patients.

The prevalence and impact of type 2 diabetes in Appalachia is understudied despite the presence of high-risk socioeconomic conditions (e.g., low levels of education and income). Appalachian counties experience greater burdens of poverty, income inequality, unemployment (1), and diabetes compared with non-Appalachian counties (2-5). Rates of comorbid depression have not been documented in this region.

Abbreviations: (A1C) glycosylated hemoglobin, (AUC) area under the curve, (CGM) continuous glucose monitoring, (MAGE) mean amplitude of glycemic excursion, (PGF2) urinary 8-iso-prostaglandin F2 alpha excretion; (PV) perceived variability Abstract Objective: