Stony Brook, NY, United States
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News Article | May 4, 2017

Having diabetes is all about maintaining a healthy blood sugar level. So, you may think it's a good thing if your blood sugar dips. However, low blood sugar can be just as worrisome as high blood sugar. "There's a happy range of blood sugar that our body likes, and having it too high or too low affects us," says Cindy Cooke, a family nurse practitioner in Huntsville, Alabama, and president of the American Association of Nurse Practitioners. Hypoglycemia, another term for low blood sugar, is when your blood sugar dips below 70 milligrams per deciliter, according to the American Diabetes Association. (If you have diabetes, you likely already use a blood glucose meter to regularly check your blood sugar.) The symptoms of hypoglycemia are shakiness, sweating, poor concentration and feeling weak or lightheaded. [See: 6 Tips to Keep Diabetics Out of the Hospital.] Just what causes hypoglycemia? One common cause is skipping meals. "In our office, we call it feeling hangry," says Lory Gonzalez, a nurse educator at the Diabetes Research Institute Foundation at the University of Miami Miller School of Medicine. Hangry cleverly combines the words hungry and angry, a feeling you've probably experienced when you haven't eaten in a while. Anyone, not just those with diabetes, can feel the effects of hypoglycemia. However, if you have diabetes, other causes of low blood sugar include increased physical activity or taking too much of your diabetes medication. For instance, you may experience hypoglycemia if your recommended medication dosage is too strong and it lowers your blood sugar, or you may take too much insulin and skip a meal, leading to hypoglycemia. How can you prevent low blood sugar and hypoglycemia? Don't skip meals and keep a high-sugar snack nearby (see examples below). "This will keep you from going south," Gonzalez says. If you think you're experiencing hypoglycemia, check your blood sugar. If it's below 70, you need to consume 15 grams of fast-acting sugar. This can include four ounces of juice or six ounces of regular soda (not diet). Many people traditionally think of orange juice to help hypoglycemia, but any type of fruit juice will work, Gonzalez says. You can also consume glucose tablets that are available over the counter. Each tablet typically has 4 grams of carbohydrates, so you'll want to take four tablets. Another approach to treat low blood sugar is the 30/30 rule, recommended by Dr. Joshua Miller, an endocrinologist and medical director of diabetes care for Stony Brook Medicine in Stony Brook, New York. With this, you consume 30 grams of fast-acting sugar, and then check your blood sugar every 30 minutes to make sure it's rising. Make sure to check your blood sugar regularly until it returns to a normal range. You want to keep a close watch on it to make sure you're not shooting it too high, Miller cautions. If your next meal is one to two hours away, have a snack that combines protein, fat and carbohydrates, like cheese and crackers, peanut butter and crackers or nuts and yogurt. Steer away from a carb-heavy snack, which may not be effective enough in lowering your blood sugar, Cooke says. It's important to keep snacks and quick sugar sources handy at all times. Stash extras around your house, at work or in your car. [Read: Don't Fall for These 6 Myths About Eating With Diabetes.] Although a one-time hypoglycemia experience may be nothing to worry about, talk to your doctor if it happens often. "One thing I counsel patients is that diabetes is a moving target," Miller says. Even if you do the right things to treat your diabetes, your body may require changes in medication to avoid drastic blood sugar changes. If you have diabetes, the effects of severe hypoglycemia can include seizures or fainting. In these situations, treatment may involve administering a shot of glucagon, a special hormone. Glucagon kits are available by prescription, and your health care provider can let you know if you need one. If you require a glucagon kit, the people around you most often should know how to give you an injection if you experience severe hypoglycemia, or they can call 911 for help. Sometimes a person living with diabetes can unknowingly have persistent low blood sugar levels -- a condition called hypoglycemia unawareness -- and it can be dangerous. "Having low blood sugar can mimic being drunk when you're driving," Gonzalez says. She recommends always carrying identification that says you have diabetes so people know what might be happening. And make sure to check your blood sugar before you drive a car so you know that you're not driving with a dangerous blood sugar level. Hyperglycemia means you have high blood sugar, generally defined as above 200 mg/dl. Uncontrolled hyperglycemia sometimes has no symptoms. Other times, symptoms can include increased thirst, urination and hunger as well as fatigue. If hyperglycemia persistently occurs -- meaning you have uncontrolled diabetes -- you're prone to the typical complications associated with diabetes, including blindness, circulation problems and kidney failure, Gonzalez says. If you are already diagnosed with diabetes, you know the risks associated with high blood sugar. If you think you've experienced hyperglycemia but don't yet have diabetes diagnosed, talk to your health care provider. "Diabetes is a lifelong disease process, but a lot of people tend to ignore it," Cooke says. However, the symptoms of hypoglycemia and hyperglycemia can be similar, so it's always best to test your blood sugar to see what's going on. If you experience several episodes of hyperglycemia within a short period, it could be that you've had too much of the wrong food or you've taken too little medication to help control your blood sugar. It could be a sign of not getting enough physical activity. Also, having a cold or infection can raise your blood sugar. In that case, your blood sugar should return to normal once you're feeling better. "I always warn my patients in this situation and tell them not to panic about their blood sugar," Cooke says. [Read: 7 Things Not to Say to Someone With Diabetes.] If you experience hyperglycemia, try drinking water. You can also take a walk to help counteract the effects of foods that spike your blood sugar. However, if your blood sugar is above 240, check your urine for ketones, the American Diabetes Association recommends. You'll want to avoid physical activity if there are ketones in your urine because they could raise your blood sugar even higher. If you experience hyperglycemia more often than usual, you may want to work with a registered dietitian on your meal planning. Vanessa Caceres is a Health freelancer for U.S. News. She's a nationally published health, travel and food writer, and she has an undergraduate degree in journalism and psychology from Hampshire College and a graduate degree in linguistics/bilingual education from Georgetown University. Connect with her on Twitter at @FloridaCulture.

Tan M.,National University of Singapore | Law L.S.-C.,National University of Singapore | Gan T.J.,Stony Brook Medicine
Canadian Journal of Anesthesia | Year: 2015

Purpose: The optimal management of postoperative pain using multimodal analgesia is a key component of Enhanced Recovery After Surgery (ERAS). Pain has adverse clinical implications on postoperative recovery, including prolonging the time to recovery milestones and length of hospital stay. Moreover, the ubiquity of opioids in postoperative analgesic regimens results in adverse effects, such as sedation, postoperative nausea and vomiting, urinary retention, ileus, and respiratory depression, which can delay discharge. Thus, multimodal analgesia, i.e., the use of more than one analgesic modality to achieve effective pain control while reducing opioid-related side effects, has become the cornerstone of enhanced recovery. The purpose of this review is to address the analgesic techniques used as part of multimodal analgesic regimens to optimize postoperative pain control and to summarize the evidence for their use in reducing opioid requirements and side effects.Principal findings: There is a wide variety of analgesic techniques available for multimodal postoperative analgesia. These modalities are divided into pharmacological and non-pharmacological techniques. Systemic pharmacological modalities involve opioids and non-opioids such as acetaminophen, non-steroidal anti-inflammatory drugs, N-methyl-D-aspartate receptor antagonists, anticonvulsants (e.g., gamma-aminobutyric acid analogues), beta-blockers, alpha-2 agonists, transient receptor potential vanilloid receptor agonists (capsaicin), and glucocorticoids. Other pharmacological modalities include central neuraxial techniques, surgical-site infiltration, and regional anesthesia. Evidence supports the use of these pharmacological techniques as part of multimodal analgesia, but each has its own advantages and specific safety profile, which highlights the importance of selecting the appropriate analgesics for each patient. Adjunctive non-pharmacological techniques include acupuncture, music therapy, transcutaneous electrical nerve stimulation, and hypnosis. There is mixed evidence regarding such techniques, although a lack of harm is associated with their use.Conclusion: There are continuing advancements in multimodal analgesic techniques; however, postoperative pain in general continues to be undermanaged. Furthermore, a continuing challenge in multimodal pain research related to ERAS is the difficulty in carrying out randomized trials to determine the relative importance of any one component, including analgesia. © 2014, Canadian Anesthesiologists' Society.

Weinstock M.B.,Ohio State University | Weingart S.,Stony Brook Medicine | Kaide C.,Ohio State University | Anderson J.,Mount Carmel Health System
JAMA Internal Medicine | Year: 2015

IMPORTANCE Patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the emergency department (ED) owing to concern about adverse events. Previous studies have looked at 30-day mortality, but no current large studies have examined the most important information regarding ED disposition: the short-term risk for a clinically relevant adverse cardiac event (including inpatient ST-segment elevationmyocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death). OBJECTIVE To determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with 2 troponin-negative findings, nonconcerning initial ED vital signs, and nonischemic, interpretable electrocardiographic findings. DESIGN, SETTING, AND PARTICIPANTS We conducted a blinded data review of 45 416 encounters obtained from a prospectively collected database enrolling adult patients admitted or observed with the following inclusion criteria: (1) primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure and (2) negative findings for serial biomarkers. Data were collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs of 3 community teaching institutions with an aggregate census of more than 1 million visits.We analyzed data extracted by hypothesis-blinded abstractors. MAIN OUTCOMES AND MEASURES The primary outcomewas a composite of life-threatening arrhythmia, inpatient ST-segment elevationmyocardial infarction, cardiac or respiratory arrest, or death during hospitalization. RESULTS Of the 45 416 encounters, 11 230 met criteria for inclusion. Mean patient age was 58.0 years. Of the 11 230 encounters, 44.83%of patients arrived by ambulance and 55.00% of patients were women. Relevant history included hypertension in 46.00%, diabetes mellitus in 19.72%, andmyocardial infarction in 13.16%. The primary end point occurred in 20 of the 11 230 patients (0.18%[95%CI, 0.11%-0.27%]). After excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, we identified a primary end point event in 4 of 7266 patients (0.06%[95%CI, 0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly iatrogenic. CONCLUSIONS AND RELEVANCE In adult patients with chest pain admitted with 2 negative findings for serial biomarkers, nonconcerning vital signs, and nonischemic electrocardiographic findings, short-term clinically relevant adverse cardiac events were rare and commonly iatrogenic, suggesting that routine inpatient admission may not be a beneficial strategy for this group.

Nemesure B.,Stony Brook Medicine | Wu S.-Y.,Stony Brook Medicine | Hennis A.,Stony Brook Medicine | Hennis A.,University of the West Indies | And 2 more authors.
Cancer Epidemiology Biomarkers and Prevention | Year: 2012

Background: The relationship between central adiposity and prostate cancer remains unclear. Methods: This report includes 963 newly diagnosed cases of histologically confirmed prostate cancer and 941 randomly selected age-matched controls ascertained from the population-based Prostate Cancer in a Black Population study conducted between July 2002 and January 2011 in Barbados, West Indies. Trained nurse interviewers obtained data on height, weight, waist and hip circumferences, family and medical history, and lifestyle factors. ORs and 95% confidence intervals (CI) were used to assess associations between anthropometric measures and prostate cancer. Results: A two-fold increased risk of prostate cancer was found among men in the highest quartile of waist-hip ratio compared with those in the lowest quartile (OR = 2.11, 95% CI, 1.54-2.88). Similarly, men with the largest waist circumferences had an OR of 1.84 (95% CI, 1.19-2.85) compared with those with the smallest waist sizes. Conclusions: These results suggest that measures of central rather than global adiposity may be more predictive of prostate cancer, especially in westernized African populations, where patterns of visceral fat distribution are different than other groups. Impact: The findings highlight the need to further elucidate the mechanisms underlying the relationship between central adiposity and prostate cancer in populations of predominantly African descent. ©2012 AACR.

Laster M.L.,Medical Center | Fine R.N.,Stony Brook Medicine
Pediatric Transplantation | Year: 2014

One of the ultimate goals of successful transplantation in pediatric solid organ transplant recipients is the attainment of optimal final adult height. This manuscript will discuss the attainment of height following solid organ transplantation in pediatric recipients of kidney, liver, heart, lung, and small bowel transplantation. Age is a primary factor with younger recipients exhibiting the greatest immediate catch up growth. Graft function is a significant contributory factor with a reduction in glomerular filtration rate correlating with poor growth in kidney recipients and the need for re-transplantation with impaired growth in liver recipients. The known adverse impact of steroids on growth has led to modification of steroid dosage and even to steroid withdrawal and steroid avoidance. In kidney and liver recipients, this has been associated with the development on occasion of acute rejection episodes. In infant heart transplantation, avoidance of maintenance corticosteroid immunosuppression is associated with normal growth velocity in the majority of patients. With marked improvement in patient and graft survival rates in pediatric organ graft recipients, it is timely that the quality of life issues, such as normal adult height, receive paramount attention. In general, normal growth post-transplantation should be an achievable goal that results in normal adult height for many solid organ transplantation recipients. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Zhao W.,Stony Brook Medicine | Rowlands J.A.,Thunder Bay Regional Research Institute
ECS Transactions | Year: 2013

Active matrix flat panel imagers (AMFPI) have been commercialized for a wide range of x-ray imaging applications. They have demonstrated superior imaging performance except in fluoroscopy, where the electronic noise degrades the image quality, making it inferior to x-ray imaging intensifier (XRII). In this paper we will present two FPI approaches under investigation to overcome the electronic noise limitation. They use an amorphous selenium layer with programmable avalanche gain to detect light generated from an x-ray scintillator upon x-ray absorption. Two charge readout methods are being investigated: a thin-film transistor (TFT) array; and a field emitter array (FEA). The amorphous selenium (a-Se) avalanche photoconductor is called HARP (high-gain avalanche rushing photoconductor). The avalanche gain of HARP depends on both a-Se thickness and applied electric field ESe. At ESe of > 80 V/μm, the avalanche gain can enhance the signal at low dose (e.g. fluoroscopy) and make the detector x-ray quantum noise limited down to a single x-ray photon. At high exposure (e.g. radiography), the avalanche gain can be turned off by decreasing ESe to < 70 V/μm, thus ensuring a wide dynamic range without burdening the readout electronics. The potential x-ray imaging performance of both FPI approaches, especially the aspect of programmable gain to ensure wide dynamic range and x-ray quantum noise limited performance at the lowest exposure in fluoroscopy, have been investigated. © The Electrochemical Society.

Mehls O.,University of Heidelberg | Fine R.N.,Stony Brook Medicine
Pediatric Nephrology | Year: 2013

Growth retardation remains a clinical problem in children with chronic kidney disease (CKD) prior to and during end-stage renal disease. The growth of approximately 40 % of children on dialysis is stunted. Even so, growth hormone treatment (GH) is not used in the majority of small children prior to transplantation. Also, GH is effective in improving growth after transplantation, but again, it is only rarely used in this situation mainly for fear of triggering rejection episodes. In controlled studies, the number of patients who developed rejection episodes with GH was no greater than the number in untreated controls. However, patients with prior frequent rejection episodes developed further repeated subsequent rejection episodes. Many patients with repeated rejection episodes before GH treatment have reduced renal function and are expected to proceed to dialysis or retransplantation. We believe that in these patients, early individual decisions for or against GH treatment should be made as soon as other treatment strategies, such as steroid withdrawal, have failed or are not indicated. Decisions for GH treatment at a later pubertal age come too late for significant growth response and/or improvement of final height. © 2012 IPNA.

Rose J.,University of California at San Diego | Parina R.P.,University of California at San Diego | Faiz O.,Imperial College London | Chang D.C.,University of California at San Diego | Talamini M.A.,Stony Brook Medicine
Annals of Surgery | Year: 2015

Objective: This study aims to determine the long-term outcomes of diverticulitis and to apply the findings to current practice patterns. Background: The long-term morbidity and mortality of diverticulitis are not well defined. Current practice guidelines for diverticulitis are based on limited evidence. Methods: The California Office of Statewide Health Planning and Development database was queried for longitudinal observations across all hospitals from 1995 to 2009. Recurrence up to 15 years, medical versus surgical treatment, and mortality after recurrence were analyzed for patients after emergent admission for diverticulitis. Results: Among the 210,268 patients admitted emergently with diverticulitis, 179,649 (85%) were managed medically at their index admission. Of these medically managed patients, 27,450 (16.3%) suffered a second diverticulitis episode. On multivariable analysis, predictors of mortality with recurrence included the following [hazard ratio (95% confidence interval)]: age more than 50 years [5.19, (3.05-8.29)]; previous tobacco use [1.40 (1.18-1.66)]; and complicated initial presentation with obstruction [1.33 (1.06-1.65)], abscess [2.18 (1.60-2.97)], peritonitis [3.14 (1.99-4.97)], sepsis [1.88 (1.29-2.73)], and fistula [3.50 (2.17-5.66)]. The mortality of delayed elective surgical intervention after the first episode of emergent diverticulitis was 0.3% compared to 4.6% for emergent resection during a second episode. Conclusions: Eighty-five percent of emergent diverticulitis patients do not recur after initial medical treatment. However, in view of significantly worse outcomes associated with diverticulitis recurrence, resection should be strongly considered for diverticulitis patients older than 50 years or those who present with a complicated clinical picture. © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Parikh P.Y.,Stony Brook Medicine | Lillemoe K.D.,Harvard University
Seminars in Oncology | Year: 2015

Distal pancreatectomy is the standard procedure for tumors located in the body and tail of the pancreas. In the last three decades, significant progress has been made with regard to technical aspects as well as perioperative care so that excellent mortality and morbidity rates can be achieved. Recently, there is growing evidence that distal pancreatectomy may be performed laparoscopically in selected patients, offering the advantages of minimally invasive surgery. Unfortunately, the oncologic outcomes for pancreatic adenocarcinoma remain poor, in part due to the late stage of presentation in most patients. We review the history of distal pancreatectomy, discuss current indications for performing this procedure, compare operative techniques in performing distal pancreatectomy, and review both the early complications seen in patients who have undergone a distal pancreatectomy and the long-term metabolic and oncologic outcomes of these patients. © 2015 Elsevier Inc. All rights reserved.

Pediatric dental patients who cannot receive dental care in the clinic due to uncooperative behavior are often referred to receive dental care under general anesthesia (GA). At Stony Brook Medicine, dental patients requiring treatment with GA receive dental care in our outpatient facility at the Stony Brook School of Dental Medicine (SDM) or in the Stony Brook University Hospital ambulatory setting (SBUH). This study investigates the time and cost for ambulatory American Society of Anesthesiologists (ASA) Class I pediatric patients receiving full-mouth dental rehabilitation using GA in these 2 locations, along with a descriptive analysis of the patients and dental services provided. In this institutional review board-approved cross-sectional retrospective study, ICD-9 codes for dental caries (521.00) were used to collect patient records between July 2009 and May 2011. Participants were limited to ASA I patients aged 36-60 months. Complete records from 96 patients were reviewed. There were significant differences in cost, total anesthesia time, and recovery room time (P < .001). The average total time (anesthesia end time minus anesthesia start time) to treat a child at SBUH under GA was 222 ± 62.7 minutes, and recovery time (time of discharge minus anesthesia end time) was 157 ± 97.2 minutes; the average total cost was $7,303. At the SDM, the average total time was 175 ± 36.8 minutes, and recovery time was 25 ± 12.7 minutes; the average total cost was $414. After controlling for anesthesia time and procedures, we found that SBUH cost 13.2 times more than SDM. This study provides evidence that ASA I pediatric patients can receive full-mouth dental rehabilitation utilizing GA under the direction of dentist anesthesiologists in an office-based dental setting more quickly and at a lower cost. This is very promising for patients with the least access to care, including patients with special needs and lack of insurance.

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