HbA1c and hemoglobin "La Desirade" are they compatible for monitoring patients with diabetes? Contribution of a clinical case.

A NEW DIGITAL SOLUTION TO UNLOCK THE POTENTIAL OF SMART WEARABLES FOR REMOTE PATIENT CARDIAC MONITORING

A well-known and dangerous complication of COVID-19 infection is the development of hypercoagulation, which leads to thrombosis of various localization. Therefore, the problem of anticoagulant therapy was widely discussed during the first months of the pandemic and continues to be relevant. At the same time, concomitant cardiac pathology is associated with a more severe course of COVID-19 and higher risks of complications and mortality. Therefore, patients who underwent cardiac surgery require special attention. Individuals with prosthetic metal heart valves must constantly receive anticoagulant therapy, however, the literature describes cases of intracardiac thrombotic complications despite anticoagulation during COVID-19 infection. Currently, there are no randomized studies on this issue, and only individual clinical cases provide this information. The aim of the work was to describe a clinical case of thrombosis at the left ventricular apex during COVID-19 infection in a patient with a prosthetic aortic valve who received adequate warfarin therapy and to compare the tactics of patient management and therapeutic outcomes with other clinical cases. Materials and methods. The patient was followed-up after aortic valve replacement for 2 years. During the visits, a general clinical examination, laboratory examinations – clinical blood test, blood glucose, urea, creatinine, bilirubin, INR, NT-proBNP, echocardiography were performed. Results. The patient with a congenital heart defect, a condition after aortic valve replacement, mitral and tricuspid valve annuloplasty (15.03.2022) due to bicuspid aortic valve, combined aortic defect with predominance of stage III-IV regurgitation; stage III secondary arterial hypertension; chronic heart failure IIA, functional class III, stage C, reduced systolic left ventricular function; a two-chamber pacemaker due to complete AV blockade; paroxysmal atrial flutter presented to a cardiologist with worsening shortness of breath and weakness one month after a moderate COVID-19 infection. The patient received bisoprolol 5 mg, amiodarone 200 mg, spironolactone 50 mg, perindopril 8 mg, warfarin 5 mg, INR was carefully controlled, at presentation – 3.7. Echocardiography revealed a left ventricular apex thrombus, a decrease in left ventricular ejection fraction (LVEF) from 46 % to 38 %. Aspirin 75 mg/day, torasemide 10 mg/day, dapagliflozin 10 mg/day, and metabolic therapy were added to the treatment. After 1 month, the patient’s condition improved, no thrombus was detected in the left ventricular cavity, LVEF increased to 46 %. Conclusions. This case demonstrates the problem of careful cardiovascular system state monitoring in patients with prosthetic valves during and after COVID-19, since symptoms of heart cavity or valve thrombosis, worsening heart failure can be mistakenly considered as signs of a viral infection or respiratory failure.

Prostate cancer (PCa) is the second most common cancer in the world, with a steady increase in incidence every year. Regardless of the chosen treatment method for patients with localized PCa, the development of local relapse occurs in at least 15 % of cases. The key point in monitoring patients with PCa today is dynamic monitoring of prostate-specific antigen levels. When biochemical recurrence is detected, the subsequent diagnostic algorithm strategy should be aimed at visualizing the tumor site, which can be local, in the lymph nodes, or metastatic. Multiparametric magnetic resonance imaging can serve as a method for diagnosing and monitoring relapses of PCa located locally or in the lymph nodes of the pelvis. When assessing relapses located in the pelvic area, one should remember possible rare sites of their localization, as demonstrated in our clinical case. The optimal treatment for recurrent PCa is still controversial and requires further study.

An abdominal aortic aneurysm (AAA) is defined as a localized dilatation of the abdominal aorta of ≥ 3 cm. With a prevalence of 4-8 %, AAA is one of the most common vascular diseases in Western society. Radiological imaging is an elementary component in the diagnosis, monitoring, and treatment planning of AAA patients. This is a narrative review article on preoperative imaging strategies of AAA, incorporating expert opinions based on the current literature and standard-of-care practices from our own center. Examples are provided to illustrate clinical cases from our institution. Radiological imaging plays a pivotal role in the initial diagnosis and monitoring of patients with AAA. Ultrasound is the mainstay imaging modality for AAA screening and surveillance. Contrast-enhanced CT angiography is currently considered the gold standard for preoperative imaging and image-based treatment planning in AAA repair. New non-contrast MR angiography techniques are robustly applicable and allow precise determination of aortic diameters, which is of critical importance, particularly with regard to current diameter-based surgical treatment guidelines. 3D imaging with multiplanar reformation and automatic centerline positioning enables more accurate assessment of the maximum aortic diameter. Modern imaging techniques such as 4D flow MRI have the potential to further improve individualized risk stratification in patients with AAA. · Ultrasound is the mainstay imaging modality for AAA screening and monitoring. · Contrast-enhanced CT angiography is the gold standard for preoperative imaging in AAA repair. · Non-contrast MR angiography allows for accurate monitoring of aortic diameters in AAA patients. · Measurement of aortic diameters is more accurate with 3D-CT/MRI compared to ultrasound. · Research seeks new quantitative imaging biomarkers for AAA risk stratification, e. g., using 4D flow MRI.

Optimization of glycemic control with continuous glucose monitoring in a patient with type 1 diabetes mellitus undergoing maintenance hemodialysis

The purpose of this study is to examine healthcare usage, morbidities, and alcohol consumption monitoring in patients before a diagnosis of mental manifestations to assist in the early identification of individuals at risk. Biological markers of alcoholism are separated into two groups: those biological variables that highlight with great confidence and validate the presence of a predisposition to alcoholism, also called trait markers, or those that highlight alcohol consumption, called markers of alcoholism ("status markers"). Biomarkers are the true "gold standard" for the diagnosis of alcoholism. They are valuable for tracking evolution and progress during biological and psychological therapy and for highlighting relapse. This review compiles the existing data from research on healthcare utilization, comorbidities, and alcohol consumption monitoring in patients before a diagnosis of mental manifestations to aid in the early identification of individuals at risk. This documentary study took place over three to four months by searching for terms on the Science Direct platform, PubMed, Web of Science, and Google Scholar such as alcoholism, alcohol use disorders, alcohol abuse, and biomarkers. Studies reporting on the development, characteristics, and utilization of blood biomarkers for alcohol consumption were included in the search. The initial search included a number of 11.019 articles that contained the keywords biomarkers and alcohol. Finally, a total of 50 research articles were considered. I am involved in clinical studies, meta-analyses, reviews, and case studies regarding alcohol consumption detection, as well as potential alcohol markers.

HER2-positive metastatic breast cancer represents a significant therapeutic challenge. Its prognosis has been altered thanks to significant advances in targeted anti-HER2 therapies. These treatments, such as trastuzumab and pertuzumab, have significantly improved the management of this pathology, enhancing patient survival, but are also responsible for adverse effects. Hypothyroidism, although less frequent than other complications, is an important side effect to recognize and manage. This clinical case presents a 47-year-old patient with HER2-positive metastatic breast cancer treated with chemotherapy combined with a dual anti-HER2 blockade using trastuzumab and pertuzumab, along with letrozole. After 52 cycles of dual blockade, the patient developed overt hypothyroidism. Levothyroxine replacement therapy improved her symptoms. This case illustrates the clinical importance of endocrine monitoring in patients receiving targeted anti-HER2 therapies, highlighting the need for a multidisciplinary approach to optimize the management of adverse effects and the quality of life of patients. A diagnostic delay of hypothyroidism can potentially impact the prognosis of the disease.

The article is devoted to the use of ultrasound diagnostics methods to assess the functional state of the cardiovascular system in critical conditions in children and the choice of optimal hemodynamic support. The need for careful detailed monitoring in patients in pediatric intensive care units has been demonstrated, the low sensitivity and specificity of the currently widely used clinical signs are reflected, which limits their use in the choice of treatment methods. As an alternative, it is proposed to use ultrasound diagnostics that assess cardiac output, allowing you to make an informed decision on medical measures taking into account the current clinical situation. The wide possibilities and numerous advantages of ultrasonic navigation in providing assistance to patients with a wide variety of life-threatening conditions are described. The main advantage is the possibility of obtaining information in real time, directly at the bedside. A clinical case of a target-oriented intensive therapy of left ventricular systolic dysfunction in a nine-year-old child against the background of a septic process using methods of ultrasonic assessment of hemodynamic status is presented. The use of ultrasound imaging methods made it possible to identify the cause of the deterioration of the condition and conduct a reasonable treatment correction, which ensured the fastest regression of hemodynamic disorders and contributed to a favorable outcome of the disease. The simplicity and accessibility of the Teicholz estimate of the ejection fraction was noted, which allows it to be used in routine practice to select the optimal hemodynamic support and assess the effectiveness of treatment over time.

Disclosure: M.S. Gong: None. D. Lee: None. R. Arceo-Mendoza: None. Introduction: We present a case of alemtuzumab-induced autoimmune thyroid disease in a patient with Multiple Sclerosis (MS). Clinical Case: A 42/F was evaluated by endocrine inpatient service for hyperthyroidism. She presented with tremors, dyspnea, and ataxic gait. She has known MS and was treated with Alemtuzumab (ALZ) in 2018 and in 2019, with her initial infusion being 4 years prior to this admission. Lab tests on admission showed TSH of <0.01 uIU/mL with elevated Free T3 and Free T4 of 1987 pg/dL (NV:171-371 pg/dL) and 3.9 ng/dL (NV:0.7-1.5 ng/dL) respectively. Her Thyroid Stimulating Immunoglobulin and TSH receptor binding antibody were elevated. Baseline TSH prior to starting ALZ and a follow up TSH in 2020 were in the normal range. She denies personal or family history of thyroid disease. Hospital course was further compounded by ongoing leukopenia, with a WBC of 2.3 and ANC of 1.1. Initiation of thionamide therapy was discussed however patient declined to start methimazole when risk of agranulocytosis, albeit low, was explained. She had opted to proceed with RAI therapy for definitive management but then changed her mind. We were just initially able to treat her with prednisone, beta blocker and cholestyramine with close biochemical monitoring as an outpatient. Her Grave’s hyperthyroidism was refractory to medical management hence she was eventually admitted again for medical optimization and surgical evaluation. Her hospital course upon readmission was complicated by worsening hemoptysis and a diagnosis of pulmonary embolism. At this point, it was decided she is not a good surgical candidate for thyroid surgery given comorbidities. She eventually agreed to start methimazole after undergoing bone marrow biopsy for worsening leukopenia and cleared by hematology to start the antithyroid drug. At this time, she remains to be on methimazole as an outpatient. Clinical course however, is unfortunately complicated by patient’s ongoing poor compliance to clinic follow up. Clinical Lesson: ALZ is an anti-CD52 monoclonal Ab which induces depletion of B and T lymphocytes causing lymphopenia and immunosuppression. It is an effective treatment for MS but is linked to a number of autoimmune adverse event. Thyroid autoimmune dysfunction may occur in 20-30% of patients, and Grave’s disease accounts for 60-70% of cases. The ALZ product label recommends TFT monitoring every 3 months for at least 48 months after the last infusion. Our patient presented with Grave’s disease in 4 years following initial ALZ administration. To our knowledge, there is no published case with reported ALZ-induced Grave’s disease with this length of interval since infusion. Our case highlights not only the importance of pretreatment screening but continued vigilance and close thyroid function monitoring in patients treated with ALZ even several years after therapy. Presentation Date: Saturday, June 17, 2023

A description of a clinical case of a complex treatment and monitoring of patient with prostate cancer at a very unfavorable initial forecast, the presence of bone metastases with a good clinical outcome.

Background: Graves’ disease is an immune-mediated cause of thyrotoxicosis treated with anti-thyroid drugs (ADTs), radioactive iodine (RAI) or thyroidectomy. Thyroidectomy has been documented to have the lowest rate of recurrence amongst treatment options1. Data regarding long-term recurrence rates is limited beyond 54 months.Clinical Case: An asymptomatic 59 year old female was found to have recurrent thyrotoxicosis on routine laboratory testing. The patient underwent thyroidectomy at age 19 years for Graves’ disease. Prior records unavailable to clarify initial surgical intervention. The patient had post-surgical hypothyroidism which was managed with levothyroxine 100mcg once daily for over 20 years. A biochemically euthyroid state was clearly documented on prior laboratory testing. Initial laboratory testing with TSH <0.01mIU/L (0.45-4.50), FT3 2.8ng/dL (0.8-1.7). Levothyroxine was discontinued with persistent thyrotoxicosis after 8 weeks: TSH <0.01, FT3 5.7, FT4 1.74. Radioactive Iodine Uptake and scan was obtained after administration of 6uCi of iodine-131 which demonstrated 50.8% uptake of radioactive iodine at 24 hours (Normal 10-30%). The left thyroid gland was noted to be in normal position and enlarged with diffuse increase intensity of radiotracer uptake. The right thyroid gland was surgically absent. The patient subsequently underwent completion thyroidectomy with endocrine surgery with resolution of hyperthyroid state. Surgical pathology was benign and consistent with Graves’ disease and multinodular goiter. The patient did become hypothyroid post-operatively and required levothyroxine replacement. She is clinically and biochemically euthyroid on levothyroxine 100mcg once daily 14 months post-operatively.Conclusion: This is a case of recurrent hyperthyroidism approximately 40 years after definitive treatment with thyroidectomy. Although it is unclear whether patient underwent total thyroidectomy or subtotal thyroidectomy for initial intervention, the recurrence of thyrotoxicosis after such a long period of time has not previously been reported in the literature to the knowledge of this writer. This has important implications regarding the underlying pathophysiology of Graves’ disease and the ability of remnant thyroid tissue to regenerate over time. This also has important implications for long-term monitoring in patients with history of thyroidectomy for Graves’ disease.Reference: 1. Sundaresh, V., Brito, J. P., Wang, Z., Prokop, L. J., Stan, M. N., Murad, M. H., & Bahn, R. S. (2013). Comparative effectiveness of therapies for Graves’ hyperthyroidism: a systematic review and network meta-analysis. The Journal of clinical endocrinology and metabolism, 98(9), 3671–3677.

A large inter-individual variability in methadone pharmacokinetics is observed in patients under maintenance treatment for major addiction to opiates. Therefore an individual dose titration of methadone is necessary, based on clinical response, i.e. symptoms of overdosage or withdrawal syndrome, but these symptoms are unspecific. However, a poor response to methadone treatment (asking for drug compliance) or the possibility of drug interactions may require the determination of methadone blood concentrations. Therapeutic drug monitoring (TDM) of those patients is performed using methadone trough blood concentrations measured by chromatography (GC or HPLC: reference methods) or by immunoassay, which gives more rapid results. A review of the literature led us to use the fluorescence polarisation immunoassay (FPIA technique) performed on a TDx-FLx analyzer. We confirmed the lack of "matrix effect" and FPIA was compared to GC-MS (gas chromatography-mass spectrometry) on patients samples. According to the literature, a methadone trough serum concentration target of 400 ng/mL is recommended; results under 100 ng/mL are considered as clinically ineffective, whereas methadone concentrations above 1000 ng/mL are frequently associated with drug toxicity. The linearity domain of the technique stays between 50 and 500 ng/mL, which is satisfactory. We describe some clinical cases from the Methadone Treatment Center of Tours (Centre Port-Bretagne), which showed that methadone blood concentration measurement may be helpful to achieve the optimal dose of methadone in each patient.

Use of multimodal analysis in the diagnosis and follow-up of a case of Acute Zonal Occult Outer Retinopathy (AZOOR).

Empleo del análisis multimodal para el diagnóstico y seguimiento de un caso de retinopatía aguda zonal oculta externa (AZOOR)

Compartment syndrome is defined as the pathology caused by the increase of pressure within a muscular compartment to the point where the vascular perfusion necessary for the viability of the tissues included therein is reduced. The diagnosis is established by clinical exam and pressure measurement. Measurement of intracompartmental pressure is an invasive method with no option of easy continuous monitoring. Continuous tissue oximetry, using near-infrared light spectroscopy, can estimate soft-tissue oxygenation several centimeters below the sensor placement. This method of monitoring has been used successfully in the diagnosis of compartment syndrome, presenting itself as a non-invasive method of continuous measurement that can be a very useful alternative in complex situations or doubtful cases. We present two clinical cases of patients with acute compartment syndrome, in which the use of near-infrared light spectroscopy was determinant, both for the diagnosis and to verify the surgical treatment performed.