Analysis: biomedically enabled soldiers: super-resilient, not superhuman.
Explore the source record for details and available documents.
Blood Glucose↗
Biomedical subjects
Robert A Vigersky
Publications and source records attributed to Robert A Vigersky.
The sensitivity and specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy.
OBJECTIVE: The objective of this study was to determine the sensitivity and specificity of Joslin Vision Network nonmydriatic digital stereoscopic retinal imaging (NMDSRI) as a screening tool in detecting diabetic retinopathy. RESEARCH DESIGN AND METHODS: We reviewed the records of 244 patients with diabetes who had a dilated funduscopic examination (DFE) and NMDSRI done within 1 year of each other at four locations in the metropolitan Washington, DC, area. The images were transmitted through a local area network to a central reading location where they were graded by a single retinal specialist. RESULTS: Images of 482 eyes from 243 patients were included in the study. Four images did not transmit, and 35% of the images were not gradable. Of the remaining 311 eyes, there was 86% agreement in the grading between NMDSRI and DFE: 227 eyes with no diabetic retinopathy and 40 eyes with diabetic retinopathy. In 46 eyes (15%) there was a disagreement between gradings made by the two techniques. NMDSRI detected diabetic retinopathy in 35 eyes reported as normal by DFE, and in the remaining 11 eyes, the DFE grade was one grade higher than the NMDSRI grade. Adjudicated nonconcordant examinations were within one grade. In the 76 eyes with diabetic retinopathy, retinal thickness could not be assessed in 17 (21%) eyes. When the NMDSRI result was gradable, the overall sensitivity of NMDSRI was 98% and the specificity was 100% for retinopathy within one grade of the DFE. In the limited number of eyes that had diabetic retinopathy with macular edema (six), agreement with the clinical examination was 100%. CONCLUSIONS: NMDSRI is a sensitive and specific method for the screening and diagnosis of diabetic retinopathy, which may help improve compliance with the standards of eye care for patients with diabetes.
Aged↗
Thyrotropin suppression by metformin.
CONTEXT: Drug-drug interactions are common but often are discovered only long after initial drug release. Metformin has been available in the United States for 9 yr and elsewhere for many years, but as of yet there are no reports that the drug modifies thyroid hormone economy. OBJECTIVE: The objective of the study was to describe the clinical and biochemical findings of four patients with chronic hypothyroidism, previously euthyroid on fixed doses of L-T4 for several years, in whom the metformin was initiated. DESIGN: This was a retrospective review. SETTING: The study was conducted at a tertiary care military hospital providing care to active-duty soldiers, sailors, and marines, retirees of the armed forces, and their eligible dependents. PARTICIPANTS: Four patients with chronic hypothyroidism who were placed on metformin participated in the study. INTERVENTION, MAIN OUTCOME MEASURE: Serum TSH, free T4, and free T3 levels were measured during metformin treatment. RESULTS: Initiation of treatment with metformin (three for diabetes mellitus and one for nonalcoholic steatohepatitis) caused suppression of TSH to subnormal levels without clinical symptoms of hyperthyroidism in any patients. There was no change in free T4 or free T3 in patient 1. CONCLUSIONS: No other potential causes of TSH suppression, including medication changes or interference in the TSH assay, could be identified. The mechanism of the fall in serum TSH in these four patients is unclear at this time. Should these findings be confirmed in larger prospective studies, metformin's ability to suppress TSH without causing clinical or chemical hyperthyroidism might render this drug a useful adjunct to the treatment of patients with thyroid cancer.
Aged↗
Goldilocks and menopause.
Explore the source record for details and available documents.
Administration, Cutaneous↗
Optimizing management of type 2 diabetes in hospitalized patients who are not critically ill.
Explore the source record for details and available documents.
Blood Glucose↗
A modeled economic analysis of a digital tele-ophthalmology system as used by three federal health care agencies for detecting proliferative diabetic retinopathy.
The objective of this study was to compare, using a 12-month time frame, the cost-effectiveness of a non-mydriatic digital tele-ophthalmology system (Joslin Vision Network) versus traditional clinic-based ophthalmoscopy examinations with pupil dilation to detect proliferative diabetic retinopathy and its consequences. Decision analysis techniques, including Monte Carlo simulation, were used to model the use of the Joslin Vision Network versus conventional clinic-based ophthalmoscopy among the entire diabetic populations served by the Indian Health Service, the Department of Veterans Affairs, and the active duty Department of Defense. The economic perspective analyzed was that of each federal agency. Data sources for costs and outcomes included the published literature, epidemiologic data, administrative data, market prices, and expert opinion. Outcome measures included the number of true positive cases of proliferative diabetic retinopathy detected, the number of patients treated with panretinal laser photocoagulation, and the number of cases of severe vision loss averted. In the base-case analyses, the Joslin Vision Network was the dominant strategy in all but two of the nine modeled scenarios, meaning that it was both less costly and more effective. In the active duty Department of Defense population, the Joslin Vision Network would be more effective but cost an extra 1,618 dollars per additional patient treated with panretinal laser photo-coagulation and an additional 13,748 dollars per severe vision loss event averted. Based on our economic model, the Joslin Vision Network has the potential to be more effective than clinic-based ophthalmoscopy for detecting proliferative diabetic retinopathy and averting cases of severe vision loss, and may do so at lower cost.
Cost-Benefit Analysis↗
Telehealth practice recommendations for diabetic retinopathy.
Telehealth holds the promise of increased adherence to evidenced-based medicine and improved consistency of care. Goals for an ocular telehealth program include preserving vision, reducing vision loss, and providing better access to medicine. Establishing recommendations for an ocular telehealth program may improve clinical outcomes and promote informed and reasonable patient expectations. This document addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. The recommendations also form the basis for evaluating diabetic retinopathy telehealth techniques and technologies. Recommendations in this document are based on careful reviews of current evidence, medical literature and clinical practice. They do not, however, replace sound medical judgment or traditional clinical decision-making. "Telehealth Practice Recommendations for Diabetic Retinopathy" will be annually reviewed and updated to reflect evolving technologies and clinical guidelines.
Diabetic Retinopathy↗
Perioperative management of type 1 diabetes mellitus.
Clearly, perioperative management of diabetic patients requires thorough preoperative evaluation and planning whenever possible. A firm understanding of the pathophysiology of type 1 diabetes mellitus, the metabolic stress response, and the interactions between various forms of insulin and other variables such as supplemental nutrition and glucocorticoids can greatly assist in achieving a positive outcome. Consultation with an endocrinologist, internist, or other primary care provider comfortable with managing type 1 diabetes patients is strongly recommended to assist in the details of in-patient care and overseeing of proper ancillary support. It may also be helpful to allow the patient to function as an active decision-maker in the coordination of care, especially because a large percentage of type 1 diabetes patients (particularly those who are on insulin pumps) are well-educated about their disease process and their own physiologic idiosyncrasies. This knowledge can save valuable time and effort toward achieving the ultimate united goal of avoiding perioperative morbidity and mortality by maximizing glycemic control.
Blood Glucose↗
A wireless diabetes management and communication system.
Current diabetes management requires the collection of a large volume of data by the patient for analysis by his or her provider. There are numerous practical and technical barriers to doing this effectively and efficiently. In addition, the calculation of the correct insulin dose is complex because it requires considering anticipated carbohydrate consumption and exercise in addition to the current blood glucose level. A Diabetes Management and Communication System (DMCS) has been developed using a Compaq iPAQ Pocket PC with a Sprint PCS wireless AirCard. This system circumvents the problem of multiple proprietary programs for each brand of meter and permits the accurate determination of the proper insulin dose. Privacy is maintained by using only the iPAQ serial number as the patient identifier with access to the website protected by unique patient and provider passwords. The iPAQ was programmed with formulas that included: insulin sensitivity factor, current glucose level, amount of carbohydrates, appropriate carbohydrate:insulin ratio for that meal, and duration/intensity of exercise. Once the information is entered, an insulin dose is calculated, although an alternative dose can be selected. The data are downloaded to http://www.HealthSentry.net, where they are displayed in both tabular and graphic form. The patient may view the glucose data in both tabular and graphic form on the iPAQ. Thus a DMCS has been developed to assist patients and providers in improving glycemic control. A proof-of-concept study is underway to determine the effectiveness of the DMCS in patients with Type 1 diabetes mellitus who are currently using insulin pumps.
Automation↗
A model to determine workforce needs for endocrinologists in the United States until 2020.
The objective of this study was to define the workforce needs for the specialty of endocrinology, diabetes, and metabolism in the United States between 1999 and 2020. An interactive model of factors likely to influence the balance between the supply and demand of endocrinologists during the next 20 yr was constructed. The model used data from a wide range of sources and was developed under the guidance of a panel of experts derived from sponsoring organizations of endocrinologists. We determined current and projected numbers and demographics of endocrinologists in the United States workforce and the anticipated balance between supply and demand from 1999 to 2020. There were 3,623 adult endocrinologists in the workforce in 1999, of which 2,389 (66%) were in office-based practice. Their median age was 49 yr. Both total office visits and services performed by endocrinologists (particularly for diabetes) increased substantially during the 1990s. Waiting time for an initial appointment is presently longer for endocrinologists than for other physicians. Compared with a balanced, largely closed-staff health maintenance organization, the current national supply of endocrinologists is estimated to be 12% lower than demand. The number of endocrinologists entering the market has continuously fallen over the previous 5 yr, from 200 in 1995 to 171 in 1999. Even if this downward trend were abruptly stopped, the model predicts that demand will exceed supply from now until 2020. Whereas this gap narrows from 2000 to 2008 due to projected growth of managed care, it widens thereafter due to the aging of both the population and the endocrine workforce. Inclusion of other factors such as projected real income growth and increased prevalence of age-related endocrine disorders (e.g. diabetes and osteoporosis) further accentuates the deficit. If the number of endocrinologists entering the workforce remains at 1999 levels, demand will continue to exceed supply from now through 2020 for adult endocrinologists, and the gap will widen progressively from 2010 onward. The present analysis indicates that the number of endocrinologists entering the workforce will not be sufficient to meet future demand. These data suggest that steps should be taken to stop the ongoing decline in the number of endocrinologists in training and consideration should be given to actions designed to increase the number of endocrinologists in practice in the years ahead.
Aging↗
A model to determine workforce needs for endocrinologists in the United States until 2020.
The objective of this study was to define the workforce needs for the specialty of Endocrinology, Diabetes, and Metabolism in the United States between 1999 and 2020. An interactive model of factors likely to influence the balance between the supply and demand of endocrinologists during the next 20 years was constructed. The model used data from a wide range of sources and was developed under the guidance of a panel of experts derived from sponsoring organizations of endocrinologists. We determined current and projected numbers and demographics of endocrinologists in the U.S. workforce and the anticipated balance between supply and demand from 1999 to 2020. There were 3,623 adult endocrinologists in the workforce in 1999, of which 2,389 (66%) were in office-based practice. Their median age was 49 years. Both total office visits and services performed by endocrinologists (particularly for diabetes) increased substantially during the 1990s. Waiting time for an initial appointment is presently longer for endocrinologists than for other physicians. Compared with a balanced, largely closed-staff health maintenance organization, the current national supply of endocrinologists is estimated to be 12% lower than demand. The number of endocrinologists entering the market has continuously fallen over the previous 5 years, from 200 in 1995 to 171 in 1999. Even if this downward trend were abruptly stopped, the model predicts that demand will exceed supply from now until 2020. While this gap narrows from 2000 to 2008 due to projected growth of managed care, it widens thereafter due to the aging of both the population and the endocrine workforce. Inclusion of other factors such as projected real income growth and increased prevalence of age-related endocrine disorders (e.g., diabetes and osteoporosis) further accentuates the deficit. If the number of endocrinologists entering the workforce remains at 1999 levels, demand will continue to exceed supply from now through 2020 for adult endocrinologists, and the gap will widen progressively from 2010 onward. The present analysis indicates that the number of endocrinologists entering the workforce will not be sufficient to meet future demand. These data suggest that steps should be taken to stop the ongoing decline in the number of endocrinologists in training and consideration should be given to actions designed to increase the number of endocrinologists in practice in the years ahead.
Endocrinology↗
Glycemic control with regular versus lispro insulin sliding scales in hospitalized Type 2 diabetics.
PURPOSE: The aim of this study was to compare glycemic control with either regular or lispro insulin sliding scales in hospitalized Type 2 diabetics who were not using insulin as outpatients. METHODS: Forty-three patients with Type 2 diabetes, who were taking oral agents only, were admitted to a medical inpatient service and randomized to receive either regular or lispro insulin sliding scale. Oral agents for diabetes were held upon admission and patients were followed throughout their hospital stay. RESULTS: There was no significant difference (P>.05) between the average finger-stick blood glucose (FSBG) in the regular insulin group (157.78+/-40.16 mg/dl) and the lispro insulin group (152.04+/-27.71 mg/dl). No significant difference was found between the daily dose of insulin (regular, 5.83+/-5.01 units; lispro, 4.27+/-3.40 units), total amount of insulin used during hospitalization (regular, 11.87+/-10.78 units; lispro, 12.77+/-14.39 units), glucose excursion (regular, 110.13+/-25.86 mg/dl; lispro, 106.77+/-52.65 mg/dl), or length of hospital stay (regular, 2.33+/-1.23 days; lispro, 2.69+/-1.59 days). CONCLUSION: No significant difference in glycemic control was found in hospitalized Type 2 diabetic patients who received either regular or lispro insulin sliding scales. Both insulin sliding scales used in this study are inadequate to achieve current recommended glycemic targets in this patient population, when used as the only inpatient treatment for diabetes.
Adult↗
Incidence and clinical significance of elevated macroprolactin levels in patients with hyperprolactinemia.
OBJECTIVE: To determine the prevalence and clinical characteristics of patients with macroprolactinemia in an endocrinology practice at a tertiary care military medical center in the United States. METHODS: We reviewed the medical records of 40 patients who had been referred for evaluation of hyper-prolactinemia between June 2003 and August 2004 in whom macroprolactin had been measured. RESULTS: Of the 40 patients, 18 (9 men and 9 women) (45%) had an elevated macroprolactin level (mean, 75% of the total prolactin). The demographic characteristics of these patients were similar to those of patients with elevated monomeric prolactin. Most of the men with macro-prolactinemia (78%) had erectile dysfunction as the presenting complaint, whereas the most frequent symptom in women was menstrual irregularities (56%). Fifty percent of patients had no identifiable cause for their presenting complaint other than macroprolactinemia. Of the 18 patients with macroprolactinemia, 16 underwent magnetic resonance imaging (MRI) of the pituitary, of whom 56% had normal findings. Of the patients with abnormal MRI findings, 57% had a microadenoma, and 43% had either an atrophic anterior lobe or a prominent hypophysis. No significant relationship was detected between MRI findings or symptoms and the presence of elevated macroprolactin levels. Approximately 40% of patients in the macroprolactin group were treated with a dopamine agonist, 28% of whom had normalization of the total prolactin level. CONCLUSION: Although macroprolactin is commonly found in patients with hyperprolactinemia, neither symptoms nor MRI findings are useful in predicting its presence. Patients with macroprolactinemia often have symptoms similar to those in patients with elevation in monomeric prolactin. The clinical significance of macro-prolactinemia remains uncertain.
Adult↗
A model to determine workforce needs for endocrinologists in the United States until 2020.
The objective of this study was to define the workforce needs for the specialty of Endocrinology, Diabetes, and Metabolism in the United States between 1999 and 2020. An interactive model of factors likely to influence the balance between the supply and demand of endocrinologists during the next 20 years was constructed. The model used data from a wide range of sources and was developed under the guidance of a panel of experts derived from sponsoring organizations of endocrinologists. We determined current and projected numbers and demographics of endocrinologists in the U.S. workforce and the anticipated balance between supply and demand from 1999 to 2020. There were 3,623 adult endocrinologists in the workforce in 1999, of whom 2,389 (66%) were in office-based practice. Their median age was 49 years. Both total office visits and services performed by endocrinologists (particularly for diabetes) increased substantially during the 1990s. Waiting time for an initial appointment is presently longer for endocrinologists than for other physicians. Compared with a balanced, largely closed-staff health maintenance organization, the current national supply of endocrinologists is estimated to be 12% lower than demand. The number of endocrinologists entering the market has continuously fallen over the previous 5 years, from 200 in 1995 to 171 in 1999. Even if this downward trend were abruptly stopped, the model predicts that demand will exceed supply from now until 2020. While this gap narrows from 2000 to 2008 due to projected growth of managed care, it widens thereafter due to the aging of both the population and the endocrine workforce. Inclusion of other factors such as projected real income growth and increased prevalence of age-related endocrine disorders (e.g., diabetes and osteoporosis) further accentuates the deficit. If the number of endocrinologists entering the workforce remains at 1999 levels, demand will continue to exceed supply from now through 2020 for adult endocrinologists, and the gap will widen progressively from 2010 onward. The present analysis indicates that the number of endocrinologists entering the workforce will not be sufficient to meet future demand. These data suggest that steps should be taken to stop the ongoing decline in the number of endocrinologists in training and consideration should be given to actions designed to increase the number of endocrinologists in practice in the years ahead.
Diabetes Mellitus↗