Volume 116, Issue 6

Background: Hyperglycemia is commonly seen in hospitalized patients. Glycated hemoglobin (HbA 1c ) correlates with the average blood glucose level over the previous 8 to 12 weeks. Thus, an HbA 1c test offers a longitudinal view that reduces etiologic ambiguity of disease. Screening of HbA 1c levels plays an important role in the diagnosis and management of diabetes mellitus in the outpatient setting but remains underused in the evaluation of hyperglycemia with undiagnosed diabetes in the inpatient setting. The underuse of the HbA 1c test may be a missed opportunity for early diabetes detection in the hospital. Objective: To examine the use of HbA 1c tests in identifying previously undiagnosed diabetes mellitus among patients with hyperglycemia in a rural inpatient setting. Methods: A retrospective review of medical records of hospitalized patients with hyperglycemia in a rural community teaching hospital in the Midwest. Descriptive and inferential statistical methods were used. Results: Medical records of 348 unique patients with hyperglycemia were reviewed. Fifty patients treated for hyperglycemia had medical records with no known history of diabetes (NKHD). Of the 50 patients with NKHD, 31 (62%) had an HbA 1c test. Of the 31 patients tested, 6 (19%) had HbA 1c levels consistent with the diagnosis of prediabetes, and 18 (58%) had levels consistent with diabetes. Seventeen (55%) of the 31 patients had a discharge diagnosis that included diabetes. Of the 19 patients with NKHD who did not have an HbA 1c test, 2 (11%) received a discharge diagnosis that included diabetes. Conclusion: Hospitalized patients with NKHD and hyperglycemia are more likely to receive an appropriate diagnosis if HbA 1c is measured. Failing to fully use HbA 1c tests in the inpatient setting constitutes a missed opportunity to distinguish transient hyperglycemia from chronic disease. The HbA 1c level can elucidate the course of dys-glycemia and trigger mechanisms for timely intervention.

Context: Gastrointestinal (GI) endoscopy provides a novel means of correlating visceral abnormalities with somatic dysfunction. Objective: To assess the correlation of palpatory findings of somatic dysfunction with GI abnormalities determined by endoscopy and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities. Methods: In this observational, cross-sectional study, participants who were scheduled to receive an esophagogastroduodenoscopy (EGD), colonoscopy, or both were examined by 2 osteopathic physicians immediately prior to endoscopy for the presence of vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings); tenderness of anterior Chapman reflex points; and tenderness of visceral sphincters. Each type of somatic dysfunction and the somatic dysfunction burden (sum of findings) were compared with the type of endoscopic procedure and abnormal endoscopic findings. Results: Sixty-six adults participated: 43 received an EGD, 40 received a colonoscopy, and 17 received both. The incidence of vertebral TART findings ranged from 70% at T12 to 98% at the sacrum. Participants who received only EGD had a higher somatic dysfunction burden than those who received only colonoscopy and those who received both procedures ( P =.002). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve. Statistically significant positive associations were found between specific vertebral TART findings and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, and sigmoid colon; specific Chapman reflex point tenderness and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, descending colon, sigmoid colon, and rectum; and specific visceral sphincter tenderness and abnormalities of the duodenum, ascending colon, and sigmoid colon. Conclusions: The current study found numerous associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral TART findings and the lack of normal controls for many GI regions made establishing meaningful relationships between specific somatic dysfunction and specific GI abnormalities challenging. Future investigations should include more participants to ensure a higher number of normal endoscopic findings and limit the physical examination to elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness and tissue texture abnormalities. (ClinicalTrials.gov number NCT01394198)

Context: Cancer mortality rates in the United States have improved during the past 40 years. The improvement in mortality rates is not equal for all types of cancer or all geographic locations, however. Objective: To compare trends in cancer mortality rates in Virginia counties from 2005 through 2009. Methods: Publicly available data from the National Cancer Institute, the State Cancer Profile, and the Virginia Department of Health were accessed for this analysis. For all counties in Virginia with all-cancer and lung cancer mortality data available, the authors compared counties considered medically underserved areas (VMUAs) with non-VMUAs to examine trends in cancer mortality rates that increased, remained stable, or decreased from 2005 through 2009. The significance level for all data was set at P ≤.05. Results: Of 136 counties in Virginia, 134 had all-cancer and 123 had lung cancer mortality data available. The VMUAs had a 48% lower decreasing all-cancer mortality rate than non-VMUAs (13 [26%] vs 37 [74%], respectively; P =.004). Non-VMUAs had a 33.3% higher stable all-cancer mortality rate than VMUAs (50 [66.6%] vs 25 [33.3%], respectively; P =.004) and a 55.2% higher lung cancer mortality rate (17 [22.4%] vs 59 [77.6%], respectively; P <.001). Conclusion: The all-cancer and lung cancer mortality rates were found to either remain stable or, in the case of all-cancer mortality, to increase in VMUAs.

Many factors contribute to the diagnosis of obesity in a patient. Anthropometric measurements, such as the waist circumference and percentage of body fat, are used in the newly released obesity algorithm to risk stratify patients. Staging methods, which use the identification of comorbidities and disease burden to assess the severity of obesity, can result in treating a patient sooner than if the traditional body mass index is used. Obesity is a growing concern in the medical field, and providing additional avenues through which to diagnose obesity and address obesity-related health risks can improve prevention efforts and lead to expedited weight management. Obesity is a growing concern in the medical field, and providing additional avenues through which to diagnose obesity and address obesity-related health risks can improve prevention efforts and lead to expedited weight management.

Incorporating simulation-based medical education techniques is paramount to ongoing training of emergency physicians. Effective procedure laboratories give learners hands-on experience in life-saving procedures they may otherwise not have clinical exposure to and also prevent skill decay. Using procedural education, adult learning theory, deliberate practice, and mastery learning strategies, the authors offer 10 tips to educators for designing an effective emergency medicine procedure laboratory.

Context: The National Board of Osteopathic Medical Examiners uses the Osteopathic Manipulative Treatment (OMT) Global Rating Tool to score candidate performance in OMT during standardized patient encounters. To the authors’ knowledge, no validity research has been published on the underlying constructs measured by this instrument to date. Objective: To evaluate whether the OMT Global Rating Tool measures 1 holistic skill or multiple skill sets. Methods: Structural equation models were fit to data from first-time test-takers who took the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation (COMLEX-USA Level 2-PE) between July 7, 2014, and April 30, 2015. Two theoretical models were evaluated: a model that posited a single underlying skill set, and a model that posited 2 related but distinct skill sets. Results: The 1-factor and 2-factor models were fit to data from 4673 third- and fourth-year osteopathic medical students. Fit statistics indicated that the data were best fit by a model representing 2 factors: pre– and post–OMT technique assessment and OMT technique ( r =0.47). Conclusion: The OMT Global Rating Tool seems to measure 2 distinct but related skills. Although the results of this study are applicable to broad populations and cannot be used to provide skill-specific subscores, it might be helpful to remediation efforts to target pre– and post–OMT technique assessments and OMT techniques as distinct areas for intervention.

Cullen sign and Grey Turner sign, named after Thomas Stephen Cullen, MB, and George Grey Turner, MBBS, respectively, are signs of abdominal wall hemorrhage and are generally associated with acute pancreatitis. However, the research from which these signs arose was documented long before Cullen and Grey Turner made their contributions. The present article examines the history, pathologic mechanisms, and clinical application of these signs in relation to acute pancreatitis and ectopic pregnancy.

Severe adverse events associated with varicella-zoster virus (VZV) vaccination are rare. The authors describe a 53-year-old woman with no known immunodeficiency who presented with diffuse pruritic rash 17 days after receiving the varicella virus vaccine live. She had a low level of white blood cells and received a diagnosis of thrombocytopenia with elevated aminotransferase levels. Punch biopsy demonstrated positive VZV immunostaining and viral culture positive for VZV. After treatment with acyclovir, her rash improved and her white blood cell and platelet counts returned to normal. Mild reactions to vaccines including localized rash are well recognized. Disseminated infections have been reported in patients with congenital and acquired immunodeficiency, but systemic postvaccination infections are rare in immunocompetent adults. This case highlights the importance of recognizing adverse events associated with vaccination.