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Objective: Perioperative glucocorticoids are commonly given to reduce pain and nausea in patients undergoing surgery. However, the glycemic effects of steroids and the potential effects on morbidity and mortality have not been systematically evaluated. This study investigated the association between perioperative dexamethasone and postoperative blood glucose, hospital length of stay (LOS), readmission rates, and 90-day survival. Methods: Data from 4,800 consecutive orthopedic surgery patients who underwent surgery between 2000 and 2016 within a single health system were analyzed retrospectively. Results: Patients with and without diabetes mellitus (DM) who were given a single dose of dexamethasone had higher rates of hyperglycemia during the first 24 hours after surgery as compared to those who did not receive dexamethasone (hazard ratio lHR] was 1.81, and 95% confidence interval lCI] was l1.46, 2.24] for the DM cohort; HR 2.34, 95% CI l1.66, 3.29] for the nonDM cohort). LOS was nearly 1 day shorter in patients who received dexamethasone (geometric mean ratio lGMR] 0.79, 95% CI l0.75, 0.83] for patients with DM; GMR 0.75, 95% CI l0.72, 0.79] for patients without DM), and there was no difference in 90-day readmission rates. In patients without DM, dexamethasone was associated with a higher 90-day overall survival (99.07% versus 96.90%; P = .004). Conclusion: In patients with and without DM who undergo orthopedic surgery, perioperative dexamethasone was associated with a transiently higher risk of hyperglycemia. However, dexamethasone treatment was associated with a shorter LOS in patients with and without DM, and a higher overall 90-day survival rate in patients without DM, compared to patients who did not receive dexamethasone. Abbreviations: BMI = body mass index; CAD = coronary artery disease; CI = confidence interval; DM = diabetes mellitus; GMR = geometric mean ratio; HR = hazard ratio; IV = intravenous; LOS = length of stay; POD = postoperative day

Intravenous insulin with glucose is used in urgent treatment for hyperkalemia but has a significant risk of hypoglycemia. The authors developed an order panel within the electronic health record system that utilizes weight-based insulin dosing and standardized blood glucose monitoring to reduce hypoglycemia. As initial evaluation of this protocol, the authors retrospectively compared potassium and blood glucose lowering in patients treated with the weight-based (0.1 units/kg) insulin order panel (n = 195) with those given insulin based on provider judgment (n = 69). Serum potassium lowering did not differ between groups and there was no relationship between dose of insulin and amount of potassium lowering. There was a difference in hypoglycemia rates between groups ( P = .049), with fewer severe hypoglycemic events in the panel (2.56%) than in the non-panel group (10.14%). These data suggest weight-based insulin dosing is equally effective for lowering serum potassium and may lower risk of severe hypoglycemia.

CD8+ T cells drive protective responses against infection and cancer. In the context of chronic antigen stimulation, CD8+ T cells become progressively dysfunctional, losing the ability to proliferate, secrete cytokines, and kill target cells. While dysfunctional CD8 T cells have been characterized in infection, studies examining longitudinal responses in tumors have been limited. Here, in an autochthonous model of lung adenocarcinoma using high dimensional flow cytometry and single cell RNA sequencing, we demonstrate that tumor specific CD8 T cell heterogeneity is dynamic, revealing multiple dysfunctional-like CD8 T cell populations. Among these states, we identify TCF-1+ CD8 T cells, a population previously associated with superior functionality. Temporal analysis revealed heterogeneity within the TCF-1+ CD8+ T cell compartment - SlamF6+ CD8 T cells were predominant in early stage disease, while SlamF6- CD8 T cells appeared later and were the majority during progression. Functionally, the SlamF6+ population was proliferative and expressed more inhibitory receptors than SlamF6- cells. However, SlamF6+ CD8 T cells gradually lost the ability to divide and secrete cytokines over the course of tumorigenesis, demonstrating that they become dysfunctional over time. Collectively, our results provide new insights into longitudinal response of TCF-1+ T cells over the course of tumorigenesis and have therapeutic implications for modulating the anti-tumor T cell response.

Objective: Thyroid nodules with indeterminate cytology pose management challenges in clinical practice. The aim of this study was to determine the efficacy of ultrasound features in navigating clinical decision making in thyroid nodules with indeterminate cytology. Methods: We retrospectively reviewed ultrasound imaging from 186 adult patients with thyroid nodules and indeterminate cytology who underwent thyroidectomy at a quaternary hospital from 2010-2017. All nodules were classified based on the American Thyroid Association (ATA) and 2017 American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). Nodules were included if good quality pre-operative ultrasound imaging and surgical pathology were available. Results: A total of 202 thyroid nodules were included. The median age was 57 years; 82.8% were female. Risk of malignancy (ROM) in resected nodules with Bethesda 3 and 4 cytology was 19.4% and 30.3%, respectively. ATA high-suspicious and TI-RADS 5 nodules had high ROM, 100% in both systems for Bethesda 3 nodules; 66.7% and 50.0%, respectively, for Bethesda 4 nodules. For ATA very-low suspicious/TI-RADS 1 and 2, ROM was 0%. ROM in ATA low-suspicious/TI-RADS 3 nodules with Bethesda 3 cytology was lower (15.2% and 16.0%, respectively) than Bethesda 4 cytology (33.8% and 34.3%, respectively). ATA intermediate-suspicious/TI-RADS 4 nodules with Bethesda 4 cytology had a lower ROM (11.1% and 18.2%, respectively) than Bethesda 3 cytology (28.6 % and 31.6%, respectively). Conclusion: Using either the ATA or the TI-RADS system to risk-stratify nodules with indeterminate cytology may help clinicians plan better for additional diagnostic testing and treatment. Abbreviations: ACR = American College of Radiology; ATA = American Thyroid Association; AUS = atypia of undetermined significance; FLUS = follicular lesion of undetermined significance; FN = follicular neoplasm; PPV = positive predictive value; ROM = risk of malignancy; SFN = suspicious for follicular neoplasm; TI-RADS = Thyroid Imaging Reporting and Data System.

Type 2 diabetes and prediabetes are heterogeneous diseases that directly affect over 115 million Americans. Considerable gender differences exist with regard to diabetes risk factors, hormonal effects on glucose, and cardiovascular outcomes.Historically, diabetes studies have largely focused on men with the assumption that the data can safely be extrapolated to women. However, more recent investigations have illuminated significant differences between genders.Women are at higher risk of death from cardiovascular disease (CVD), are more likely to die following a myocardial infarction, and are treated less aggressively toward glycemic targets. Additionally, pregnancy and menopause have profound effects on the risks for diabetes and therefore warrant more aggressive diagnostic attention and monitoring. It is important for practitioners to understand that women who have gestational diabetes are at an increased risk for CVD even if they do not develop diabetes. Older age brings additional challenges with diabetes, including increased fracture risk even with normal bone mineral density.Recognizing the stages of life that are unique to women is critical as treatment and patient education can significantly impact patient well-being and outcomes. This article describes female-specific characteristics of prediabetes and diabetes during several distinct phases of life, including pregnancy, menopause, and older age. Diagnostic and management strategies for these populations are also discussed.