Stephen A. Geraci

Association of A1C levels with vitamin D status in U.S. Adults: data from the national health and nutrition examination survey.

OBJECTIVE Data relating vitamin D status with indices of glucose homeostasis as manifested by A1C in the U.S. adult population are few. RESEARCH DESIGN AND METHODS We examined the association between serum 25 hydroxyvitamin D [25(OH)D] and A1C levels in 9,773 adults (age ≥18 years old) participating in the 2003–2006 National Health and Nutrition Examination Survey. Multivariate linear regression analyzed the association after accounting for potential confounders. RESULTS Serum 25(OH)D levels were inversely associated with A1C levels in subjects age 35–74 years (P = 0.0045) and those who did not report a history of diabetes (P = 0.0282). CONCLUSIONS These findings support a mechanistic link between serum vitamin D concentrations, glucose homeostasis, and the evolution of diabetes in a large segment of the U.S. adult population. Screening people with elevated A1C levels for vitamin D insufficiency should be considered.

Competency-Based Education and Training in Internal Medicine

Recent efforts to improve medical education include adopting a new framework based on 6 broad competencies defined by the Accreditation Council for Graduate Medical Education. In this article, the Alliance for Academic Internal Medicine Education Redesign Task Force II examines the advantages and challenges of a competency-based educational framework for medical residents. Efforts to refine specific competencies by developing detailed milestones are described, and examples of training program initiatives using a competency-based approach are presented. Meeting the challenges of a competency-based framework and supporting these educational innovations require a robust faculty development program. Challenges to competency-based education include teaching and evaluating the competencies related to practice-based learning and improvement and systems-based practice, as well as implementing a flexible time frame to achieve competencies. However, the Alliance for Academic Internal Medicine Education Redesign Task Force II does not favor reducing internal medicine training to less than 36 months as part of competency-based education. Rather, the 36-month time frame should allow for remediation to address deficiencies in achieving competencies and for diverse enrichment experiences in such areas as quality of care and practice improvement for residents who have demonstrated skills in all required competencies.

Methods to reduce outpatient non-attendance.

Abstract:Non-attendance reduces clinic and provider productivity and efficiency, compromises access and increases cost of health care. This systematic review of the English language literature (November 1999–November 2009) compares telephone, mail, text/short message service, electronic mail and open-access scheduling to determine which is best at reducing outpatient non-attendance and providing net financial benefit. Telephone, mail and text/short message service interventions all improved attendance modestly but at varying costs. Text messaging was the most cost-effective of the 3, but its applicability may be limited. Few data are available regarding electronic mail reminders, whereas open-access scheduling is an area of active research.

Subclinical Thyroid Disease

Subclinical thyroid disease, a term applied to patients with no or minimal thyroid-related symptoms with abnormal laboratory values, is diagnosed more frequently with the use of thyroid-stimulating hormone (TSH) screening and newer high-sensitivity assays. These are laboratory diagnoses, with subclinical hypothyroidism defined as an elevated TSH with a normal free thyroxine and triiodothyronine concentration, and subclinical hyperthyroidism as a subnormal TSH with normal free thyroxine and triiodothyronine levels. Although studies defining which patients require treatment are few, decisions should be individualized based upon laboratory values and symptoms. This article reviews the etiologies, diagnoses, treatments and indications, and monitoring of patients with subclinical thyroid disease.

Major sleep disorders among women: (women's health series).

Abstract Disruption of sleep causes adverse health outcomes and poor quality of life. People with sleep disruption have higher levels than people without disrupted sleep of depression and anxiety and increased rates of cardiovascular diseases. Women have a higher incidence than men of insomnia and depression related to poor sleep. The types of complaints differ significantly between the sexes. Women are more likely than men to complain of insomnia, headache, irritability, and fatigue than the “typical” symptoms of loud snoring and breathing cessation during sleep. Hormones play an important role in sleep in women. Reproductive hormones were found to have a protective effect on sleep apnea in women of premenopausal age. Pregnancy is another period when the prevalence of sleep apnea and restless leg syndrome increases from hormonal effect. Cardiovascular mortality is high in women with obstructive sleep apnea. Continuous positive airway pressure therapy improves outcomes in most cases of obstructive sleep apnea. The epidemiology, risk factors, diagnostic criteria, and therapies for the three most common sleep disorders (insomnia, obstructive sleep apnea, and restless leg syndrome), along with effects of menopause, pregnancy, and social factors on sleep in women, are key considerations for clinicians caring for female patients across the adult life span.

Surveillance and Monitoring of Adult Cancer Survivors

Advances in early detection and treatment have improved survival in common adult cancers. Surveillance for late recurrence and secondary primary malignancies is recommended for most patients. Initial treatment with surgery, radiation, chemotherapy, or hormonal therapy can result in both local and systemic sequelae, including treatment-related new cancers. Patients with head and neck, lung, breast, colorectal, and prostate cancers constitute the largest groups requiring long-term monitoring and follow-up care.

Acute Urinary Retention in Elderly Men

Acute urinary retention is a urologic emergency that can affect elderly men. It requires prompt bladder decompression and identification of the underlying cause. Elderly patients with acute urinary retention often have associated fecal impaction, delirium, and constitutional symptoms. With increasing age, hospitalization for acute urinary retention may be necessary to treat precipitating events, whereas acute urinary retention itself might precipitate or exacerbate comorbid medical conditions, necessitating hospitalization. Multiple causative factors operate via 3 main mechanisms: obstructive, neurogenic, and detrusor underactivity. More than 1 mechanism might exist in a single patient. Definitive treatment must be individualized on the basis of the quality of life, life expectancy, caregiver support, and presence of other chronic medical conditions. Urology consultation may be needed for invasive diagnostic testing or management of refractory cases.

Osteoporosis in Postmenopausal Women: Considerations in Prevention and Treatment

Abstract Osteoporosis, the most common human bone disease, affects 8 million American women and has significant morbidity and mortality. Screening is important in older women and younger postmenopausal women with additional risk factors for osteoporosis/fracture. Preventive measures include avoiding smoking, excessive alcohol/caffeine intake, and falls in addition to maintaining adequate calcium/vitamin D intake and exercise. Estrogen/hormone therapy may be considered in some patients. Various medications have proven efficacy in treating postmenopausal osteoporosis; however, potential adverse effects such as hypocalcemia, worsening of renal impairment, and osteonecrosis of the jaw must be considered. The optimal duration of therapy requires further investigation.

Adult Immunizations: Update on Recommendations

The Advisory Committee for Immunization Practices recommends universal influenza vaccination for 2010-2011. Older adults should be offered protection against herpes zoster, and younger adults should receive immunization against human papilloma virus and pertussis. Hepatitis B vaccination should be encouraged in non-immune adults. Recommendations also address vaccinations for tetanus/diphtheria, hepatitis A, pneumococcus, measles/mumps/rubella, and meningococcus.

Calcium abnormalities in hospitalized patients.

Abstract Depending upon the method of measurement, hypocalcemia occurs in 15% to 88% and hypercalcemia occurs in 15% of hospitalized patients. Ionized calcium should be measured in place of total serum calcium to avoid errors related to hypoalbuminemia, which is seen commonly in acutely ill patients. Symptomatic hypocalcemia requires prompt intravenous calcium administration. Symptomatic hypercalcemia (most often caused by hyperparathyroidism or malignancy) warrants aggressive intravenous hydration to correct volume depletion and, usually, additional therapy with diuretics, bisphosphonates, calcitonin, or corticosteroids. Identification and treatment of the underlying cause of the calcium derangement must be addressed after the acute electrolyte abnormality is stabilized.