Elliot Sternthal

Learning in a virtual world: experience with using second life for medical education.

Background Virtual worlds are rapidly becoming part of the educational technology landscape. Second Life (SL) is one of the best known of these environments. Although the potential of SL has been noted for health professions education, a search of the world’s literature and of the World Wide Web revealed a limited number of formal applications of SL for this purpose and minimal evaluation of educational outcomes. Similarly, the use of virtual worlds for continuing health professional development appears to be largely unreported. Methods We designed and delivered a pilot postgraduate medical education program in the virtual world, Second Life. Our objectives were to: (1) explore the potential of a virtual world for delivering continuing medical education (CME) designed for physicians; (2) determine possible instructional designs using SL for CME; (3) understand the limitations of SL for CME; (4) understand the barriers, solutions, and costs associated with using SL, including required training; and (5) measure participant learning outcomes and feedback. We trained and enrolled 14 primary care physicians in an hour-long, highly interactive event in SL on the topic of type 2 diabetes. Participants completed surveys to measure change in confidence and performance on test cases to assess learning. The post survey also assessed participants’ attitudes toward the virtual learning environment. Results Of the 14 participant physicians, 12 rated the course experience, 10 completed the pre and post confidence surveys, and 10 completed both the pre and post case studies. On a seven-point Likert scale (1, strongly disagree to 7, strongly agree), participants’ mean reported confidence increased from pre to post SL event with respect to: selecting insulin for patients with type 2 diabetes (pre = 4.9 to post = 6.5, P= .002); initiating insulin (pre = 5.0 to post = 6.2, P= .02); and adjusting insulin dosing (pre = 5.2 to post = 6.2, P= .02). On test cases, the percent of participants providing a correct insulin initiation plan increased from 60% (6 of 10) pre to 90% (9 of 10) post (P= .2), and the percent of participants providing correct initiation of mealtime insulin increased from 40% (4 of 10) pre to 80% (8 of 10) post (P= .09). All participants (12 of 12) agreed that this experience in SL was an effective method of medical education, that the virtual world approach to CME was superior to other methods of online CME, that they would enroll in another such event in SL, and that they would recommend that their colleagues participate in an SL CME course. Only 17% (2 of 12) disagreed with the statement that this potential Second Life method of CME is superior to face-to-face CME. Conclusions The results of this pilot suggest that virtual worlds offer the potential of a new medical education pedagogy to enhance learning outcomes beyond that provided by more traditional online or face-to-face postgraduate professional development activities. Obvious potential exists for application of these methods at the medical school and residency levels as well.

Lymphocytic Thyroiditis and Diabetes in the BB/W Rat: A New Model of Autoimmune Endocrinopathy

The Bio Breeding/Worcester (BB/W) rat develops spontaneous insulin-dependent diabetes mellitus secondary to lymphocytic infiltration and destruction of the pancreatic beta-cells. This destructive process in the pancreas has been postulated to be based on a thymus-dependent cell-mediated autoimmune process. In view of the well recognized association in man of diabetes mellitus and another autoimmune endocrinopathy, chronic thyroiditis (Hashimotos thyroiditis), the present studies were carried out to determine whether lymphocytic thyroiditis occurred with increased frequency in the diabetic, insulin-treated BB/W rat. The incidence of lymphocytic thyroiditis was strikingly increased in 8–10-mo-old diabetic rats (59%) as compared with their nondiabetic cohorts (11%) (P < 0.001). Relative thyroid weight was significantly greater in diabetic as compared with nondiabetic rats (P < 0.01) and in diabetic rats with thyroiditis than in diabetic rats without thyroiditis (P < 0.025). Lymphocytic thyroiditis was not accompanied by any consistent changes in serum T4, T3, and TSH concentrations or in the serum TSH response to thyrotropin-releasing hormone (TRH) suggesting that the thyroiditis was not of sufficient severity or duration to induce primary thyroid gland failure. The BB/W rat represents the first animal model of multiple autoimmune endocrinopathies and provides a unique opportunity to study the pathogenesis of these disorders.

Suppression of thyroid radioiodine uptake by various doses of stable iodide.

We studied the effect of various doses of sodium iodide on thyroid radioiodine uptake in euthyroid volunteers by giving single doses of 10, 30, 50, and 100 mg and then daily doses of 10, 15, 30, 50, or 100 mg for 12 days thereafter. All single doses above 10 mg suppressed 24-hour thyroid uptake of 123I to 0.7 to 1.5 per cent. Continued daily administration of 15 mg of iodide or more resulted in values consistently below 2 per cent. A small but statistically significant fall in serum thyroxine (T4) and triiodothyronine (T3) and a rise in serum thyrotropin (TSH) concentrations were observed after eight and 12 days of iodide treatment. These data suggest that the thyroid uptake of radioactive iodine can be markedly suppressed by single-dose administration of 30 mg of stable iodide and that suppression can be maintained with daily doses of at least 15 mg. This study provides guidelines for stable iodide prophylaxis in the event of exposure to radioactive iodine.

Pharmacotherapy of type 2 diabetes: An update

Type 2 diabetes (T2DM) is a leading cause of morbidity and mortality worldwide and a major economic burden. The prevalence of T2DM is rising, suggesting more effective prevention and treatment strategies are necessary. The aim of this narrative review is to summarize the pharmacologic treatment options available for patients with T2DM. Each therapeutic class is presented in detail, outlining medication effects, side effects, glycemic control, effect on weight, indications and contraindications, and use in selected populations (heart failure, renal insufficiency, obesity and the elderly). We also present representative cost for each antidiabetic category. Then, we provide an individualized guide for initiation and intensification of treatment and discuss the considerations and rationale for an individualized glycemic goal.

STATE-Of-ThE-ART INPATIENT DIAbETES CARE: ThE EVOluTION Of AN ACADEMIC hOSPITAl

Submitted for publication November 6, 2009 Accepted for publication February 8, 2010 From the 1Department of Endocrinology, Diabetes, and Nutrition and 2Department of Pharmacy, Boston University Medical Center, Boston, Massachusetts. Address correspondence and reprint requests to Dr. Marie E. McDonnell, 88 E Newton St, Evans 201, Boston Medical Center, Boston, MA 02118. E-mail: marie. mcdonnell@bmc.org. Published as a Rapid Electronic Article in Press at http://www. endocrine practice.org on March 29, 2010. DOI: 10.4158/EP09319.CO

Self-Monitoring of Blood Glucose with Finger Tip Versus Alternative Site Sampling: Effect on Glycemic Control in Insulin-Using Patients with Type 2 Diabetes

OBJECTIVE This study compared glycemic control in finger tip versus forearm sampling methods of self-monitoring of blood glucose (SMBG). RESEARCH DESIGN AND METHODS One hundred seventy-four insulin-using patients with type 2 diabetes were randomized to SMBG using either finger-tip testing (FT) or forearm alternative site testing (AST) and followed up for 7 months. Hemoglobin A1C (HbA1C) was measured at baseline, month 4, and month 7. The study was designed to test the noninferiority of the AST method for the primary end point of change in HbA1C from baseline to month 7. Adherence with the testing schedule and frequency of hypoglycemic episodes were also measured. RESULTS The FT (n = 85) and AST (n = 89) groups each had significant decreases in mean HbA1C from baseline to month 7 (FT, -0.4 +/- 1.4%, P = 0.008; AST, -0.3 +/- 1.2%, P = 0.045), and noninferiority between groups was demonstrated with a margin of equivalence of 0.5 (P = 0.043). There was no observable difference in HbA1C change between the groups (P = 0.442). Adherence was better in the FT (87%) than the AST (78%) group (P = 0.003), which may have been because of the difficulty some subjects had in obtaining blood samples for AST. The number of hypoglycemic episodes was too small to assess for a difference between groups. CONCLUSIONS SMBG by the AST, rather than FT, method did not have a detrimental effect on long-term glycemic control in insulin-using patients with type 2 diabetes. Although adherence with testing was expected to be better in the AST group, it was actually better in the FT group.

Slip sliding away: the need for continued discussion of the use of insulin sliding scale in hospitalized patients.

The use of sliding-scale regular insulin (RISS), as the sole closed-loop artificial pancreas, basal insulin, basal-bolus prescribed insulin treatment program for hospitalized patients, to achieve stable, near-normal glycemia is evocative of Paul Simon’s lyrics “You know the nearer your destination, themore you’re slip slidin’ away”[1]. The flaws of the use of RISS have been discussed in themedical literature formore than a decade [2,3]. Notable shortcomings include un-physiologic insulin replacement, failure to compartmentalize insulin as basal, nutritional and correction, and a “one-size fits all” solution to the complexity of insulin use in the hospital which pays little or no heed to issues of body weight, basal insulin requirements (derived from IV insulin drip rates), variable nutrition (oral/enteral and parenteral), and the counterinsulin effects of illness, inflammation, medications and glucotoxicity. Because RISS reacts to rather than anticipating and preventing hyperglycemia, the “destination” of adequate glycemia remains ever-distant. Nevertheless, the use of RISS still remains prevalent. While it is difficult to accurately gauge its world-wide use, recent reports from Spain [4], Brazil [5], Austria [6] and Malaysia [7] attest to its embeddedness in clinical practice. When examined carefully, the high frequency of RISS only use in hospitalized patient is astounding. In a study of 3000 hospitalized patients, Moreira et al [5] report 52% of patients on thewards and 61% of patients in the intensive care unit on RISS alone. Other similar but smaller studies corroborate this, reporting 64–75% use of RISS alone [6,8,9]. Small prospective RCTs have demonstrated the superiority of basal-bolus insulin therapy vs RISS in medical and surgical inpatients [2,10]. Another study showed that RISS, only when supplemented by rescue NPH, could equal the efficacy of basal insulin in combination with RISS in patients receiving enteral nutrition [11]. In this issue of Metabolism, Lee et al have reported their meta-analysis of eleven un-blinded RCTs comparing the effectiveness and safety of RISS vs other insulin treatment regimens (non-RISS) employed in hospitals [12]. The alternative insulin regimens included continuous IV insulin infusion,

Approach to the patient with atypical diabetes.

The overarching term “diabetes mellitus” represents a heterogeneous group of metabolic conditions characterized by hyperglycemia. All of these conditions are underpinned by a combination of various insulin secretory defects and impaired insulin action. According to the American Diabetes

Atypical diabetes: clarifying the muddy waters

This article was written for the practising primary care clinician, who may occasionally take care of a patient with diabetes who doesn’t seem to fit into our typical diabetes classification paradigm. It is not a comprehensive review of the topic for the expert practising endocrinologist. LADA is

Preserved Proinsulin Production in Homozygous Protein Tyrosine Phosphatase Nonreceptor Type 22 C1858T Variant Type 1 Diabetes: A Possible Explanation for Absence of Overt Ketoacidosis Despite Omission of Exogenous Insulin

OBJECTIVE To report a postulated mechanism for resistance to overt ketoacidosis due to prolonged insulin omission in a severely hyperglycemic woman with a 14-year history of autoimmune type 1 diabetes (T1D). METHODS History, physical examination, laboratory testing, and genotyping were performed. We also review the medical literature pertinent to this patients phenotype and genotype. RESULTS Proinsulin levels remained within the normal range (suppressed with hypoglycemia) despite simultaneous almost unmeasurable C-peptide levels during hyperglycemia. We confirmed a homozygous (TT) variant of protein tyrosine phosphatase nonreceptor type 22 (PTPN22) 1858T, a T1D susceptibility gene associated with higher proinsulin levels. CONCLUSION The extraordinarily preserved proinsulin biological activity may explain the unusual resistance to overt ketoacidosis despite omission of exogenous insulin administration for extended periods of time. The role of the associated PTPN22 1858TT variant remains speculative.