Bilateral gangrene of fingers in a patient on empagliflozin: First case report

BACKGROUND Sodium glucose cotransporter 2(SGLT2)inhibitors use has been associated with toe amputations and non-healing ulcers and gangrene mostly of lower extremities.There are no case reports about association of Empagliflozin with finger ulcers or gangrene.This is the first case report of Empagliflozin(Jardiance)an SGLT2 inhibitor causing gangrene of fingers and second case in literature about any SGLT2 inhibitor causing gangrene of upper extremity.CASE SUMMARY A 76-year-old man with type 2 diabetes mellitus sustained minimal trauma to both middle fingers,which started healing.He was started on empagliflozin a week later for management of type 2 diabetes mellitus and started developing gangrene to both middle finger tips along with neuropathic pain which worsened over the course of next four months.Investigations were negative for vascular insufficiency,infection and vasculitis and imaging of hand was normal.Discontinuation of empagliflozin slowed progression of gangrene and caused symptomatic improvement with reduction in neuropathic pain.CONCLUSION This case report suggests possible association of empagliflozin and finger gangrene and recommends that more research and awareness among clinicians is needed in this area.

The Effect of Anterior Corneal Astigmatism Orientation on Toric Intraocular Lens Outcomes

Background: It is unclear whether post-operative errors after toric intraocular lens implantation would be more amenable to pre-operative correction with a fixed adjustment or a correction ratio that scales with the magnitude of pre-operative astigmatism. Purpose: To investigate the effect of pre-operative anterior corneal astigmatism orientation on outcomes of toric intraocular lens implantation in a large population. Methods: A retrospective cohort study of 625 patients undergoing refractive lens exchange through a superior clear corneal incision with Oculentis M-Plus toric intraocular lens implantation at an Optical Express, Inc. located in the United Kingdom and Ireland. Patients were stratified by axis of astigmatism on automated keratometry as with-the-rule, against-the-rule, or oblique. Analysis of visual acuity and refractive outcomes was performed using American National Standards Institute (ANSI) guidelines on astigmatic corrections with non-vector as well as vector analyses. Analysis was limited to one eye per patient. Results: Patients who had with-the-rule (WTR) astigmatism, compared with oblique and against-the-rule (ATR), had higher vector magnitudes of surgically induced refractive correction (2.89D, 2.55D, 2.42D;p Conclusions: Refractive lens exchange surgery using toric intraocular lenses overcorrected patients who had with-the-rule astigmatism. Degree of overcorrection did not vary with severity of pre-operative astigmatism. Incorporation of axis of astigmatism in lens selection and reduction of astigmatic correction among with-the-rule patients by an absolute value of 0.25D - 0.35D, rather than proportional adjustments, may reduce cylindrical over-correction.

Hyponatremia is associated with more severe biliary disease

BACKGROUND Sodium level is an important clinical predictor of complex biliary disease.Hyponatremia has been observed in conjunction with biliary disease,however the nature of this association remains unclear.AIM To investigate the association between serum sodium and severe biliary disease.METHODS Of 920 patients with gallstone disease treated at the SFVA Hospital from 1989-2019 were studied.We conducted multivariate analyses of correlation between sodium level and biliary disease severity,the presence/location of biliary bacteria,and other factors.Minimum sodium level pre-intervention was collected.Gallstones,bile,and blood(as relevant)were cultured.Illness severity was characterized:(1)None(no infectious manifestations);(2)Systemic inflammatory response syndrome;(3)Severe illness(gangrenous cholecystitis,cholangitis,necrotizing pancreatitis);and(4)Multiple organ dysfunction syndrome(bacteremia,hypotension,organ failure).Comorbidity was defined using the Charlson Comorbidity Index(CCI).RESULTS Decreased sodium level significantly correlated with worsening illness severity,ascending bacterial infection,gangrenous changes,elevated CCI score,increasing age,male sex,and glucose.On multivariate analysis,all factors,except age,gender and glucose,independently correlated with sodium level and factors were additive.CONCLUSION This unique study is the first to explore,with such granularity,the relationship between biliary disease and sodium.No prior studies have examined specific culture and clinical data.It illustrates an inverse,independent correlation between illness severity and sodium.Culture data demonstrate that sodium decreases as infection ascends from gallstone colonization to bactibilia to bacteremia.Patient comorbidity and gangrenous changes also independently correlate with sodium on multivariate analysis.Sodium level is an important clinical indicator of disease severity for patients with biliary disease.

Evaluation of adenosine triphosphate bioluminescence-based system in rooms occupied by patients with methicillin resistant Staphylococcus

Background:Adenosine triphosphate(ATP)-based monitoring systems can detect the amount of organic matter that remains on hospital surfaces after cleaning.We evaluated an ATP-based monitoring system in assessing con-tamination of high touched objects in rooms occupied by patients on methicillin resistant S.aureus precautions.Methods:We compared the ATP to standard aerobic cultures as well as to gloved hand culture to predict risk of healthcare-worker hand contamination.Results:More than a third of high touch object surfaces were measured unclean with ATP yet only reflects about 5%chance of contaminating healthcare-workers’hands.Conclusions:Our study emphasizes the shortcomings of using the ATP system even in pathogen specific environ-ment such as surfaces in methicillin resistant S.aureus rooms.

Storylines of family medicine Ⅸ:people and places—diverse populations and locations of care

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world.In‘Ⅸ:people and places—diverse populations and locations of care’,authors address the following themes:‘LGBTQIA+health in family medicine’,‘A family medicine approach to substance use disorders’,‘Shameless medicine for people experiencing homelessness’,“Difficult”encounters—finding the person behind the patient’,‘Attending to patients with medically unexplained symptoms’,‘Making house calls and home visits’,‘Family physicians in the procedure room’,‘Robust rural family medicine’and‘Full-spectrum family medicine’.May readers appreciate the breadth of family medicine in these essays.

北美神经内分泌肿瘤学会和核医学与分子影像学会有关177Lu-DOTATATE肽受体放射性核素治疗患者选择和合理应用共识

随着177Lu-1,4,7,10-四氮杂环十二烷-1,4,7,10-四乙酸-D-苯丙氨酸1-酪氨酸3-苏氨酸8-奥曲肽(DOTATATE)肽受体放射性核素治疗(PRRT)的日益普及,有关患者合理选择的问题日益增多。该文回顾了有关177Lu-DOTATATE在不同原发性神经内分泌肿瘤(NETs)中的应用文献,讨论了一些有争议的问题,并回顾了治疗的潜在禁忌证。此共识是由北美神经内分泌肿瘤学会(NANETS)和核医学与分子影像学会(SNMMI)共同制定的。NANETS是成立于2005年的北美多学科神经内分泌专家专业学会,目的在于通过增加研究和教育机会改善对NETs的管理。NANETS致力于多学科研究,由NETs涉及的不同专业的医师和科学家组成。SNMMI成立于1954年,旨在促进核医学科学、技术和实践应用的国际性科学专业组织,除了出版期刊、时事通讯和书籍外,还主办提高核医学从业人员能力和促进核医学科学新发展的国际会议及讲习班。

绝经后激素替代治疗 应以最低有效剂量和尽可能短的疗程治疗症状

2007年3月，北美绝经协会（North America Menopause Society，NAMS）公布了绝经后妇女使用激素替代治疗最新状况的说明。NAMS推荐将激素替代治疗作为治疗中重度潮热和阴道萎缩症状的一线用药，十分有效。对于预防骨质疏松性骨折同样有效。但是NAMS建议，激素替代治疗用于这一目的时应充分权衡其潜在危害，也应考虑其他一些已被证明的预防性治疗药物，如二膦酸盐。这些建议清楚、简明，以大量随机对照试验获得的确凿证据为基础。