Ami Schattner

Increased Risk of Type 2 Diabetes in Noncirrhotic Patients With Chronic Hepatitis C Virus Infection

OBJECTIVESnTo investigate whether patients with chronic hepatitis C virus (HCV) infection without evidence of cirrhosis have an increased risk of diabetes mellitus (DM) and to evaluate possible risk factors for diabetes in this group.nnnPATIENTS AND METHODSnWe conducted a case-control study of 45 consecutive eligible patients with HCV infection and no clinical, scintigraphic, or histological evidence of cirrhosis, and a control group of 90 subjects without liver disease matched by age, sex, and body mass index and similar in their origin distribution. Eighty-eight patients with chronic hepatitis B virus (HBV) infection with no evidence of cirrhosis were also evaluated. The diagnosis of diabetes was based on the 1997 American Diabetes Association criteria.nnnRESULTSnFifteen patients (33%) with HCV infection were found to have type 2 diabetes compared with 5.6% in the control group without liver disease (P < .001) and 12% in the group with HBV infection (P = .004). Comparison of the patients with and without diabetes revealed that positive family history of diabetes, HCV 1b genotype, and a more severe liver histology were significantly associated with DM.nnnCONCLUSIONSnPatients with chronic HCV infection have an increased prevalence of type 2 diabetes, and this prevalence is independent of cirrhosis. The pathogenesis is intriguing, appears to be unique to HCV, and requires further study.

Tumor necrosis factor-alpha-induced insulin resistance may mediate the hepatitis C virus-diabetes association.

OBJECTIVES:Among patients infected with hepatitis C virus (HCV), 13–33% develop type 2 diabetes mellitus (DM). The mechanism for this remains unclear. Because tumor necrosis factor–α (TNF-α) has been identified as a mediator of insulin resistance and is induced by HCV, we examined TNF-α and proinflammatory cytokines in noncirrhotic patients with chronic hepatitis C, both with and without diabetes.METHODS:HCV-infected patients with type 2 DM (n = 23) were compared with age- and sex-matched patients with chronic hepatitis C and without DM (n = 28), patients with DM and without HCV (n = 31), and healthy controls (n = 21). Serum levels of TNF-α, interleukin-1β (IL-1β), interleukin-6 (IL-6), and soluble TNF receptors (sTNFR) 1 (p55) and 2 (p75) were determined by ELISA.RESULTS:Detectable serum TNF was found in 74% of the HCV/DM patients, versus 64% of the nondiabetic HCV group and ≤10% in the other groups. Mean sTNFR1 in the HCV/DM group was 1931 pg/ml (95% CI = 1449–2413), compared with 1289 pg/ml (95% CI = 1101–1476) in nondiabetic HCV patients, with similar values in the other two groups (p = 0.001). The mean sTNFR2 level in the HCV/DM patients was 3326 pg/ml (95% CI = 2924–3727) compared with 2367 pg/ml (95% CI = 1951–2784) in the nondiabetic HCV patients, and similar results in the other groups (p < 0.0001). Serum IL-1β, IL-6, and C-reactive protein were not significantly different between HCV patients with or without DM.CONCLUSIONS:Excessive TNF-α response characterizes HCV-infected patients who develop DM. STNFR may be a marker for the development of DM in chronic hepatitis C.

Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.

With growing awareness of medical fallibility, researchers need to develop tools to identify and study medical mistakes. We examined the utility of hospital readmissions for this purpose in a prospective case-control study in a large academic medical center in Israel. All patients with nonelective readmissions to 2 departments of medicine within 30 days of discharge were interviewed, and their medical records were carefully examined with emphasis on the index admission. Patient data were compared to data for age- and sex-matched controls (n = 140) who were not readmitted. Medical records of readmitted and control patients were blindly evaluated by 2 senior clinicians who independently identified potential quality of care (QOC) problems during the index admission. Inhospital and late mortality was determined 6 months after discharge. Over a period of 3 months there were 1988 urgent admissions; 1913 discharges and subsequently 271 unplanned readmissions occurred (14.1% of discharges). Readmissions occurred an average of 10 days after discharge, and readmitted patients were sicker than controls (mean, 4.3 vs. 3.3 diagnoses per patient), although their length of stay was similarly short (3.4 ± 2.8 d). Analysis of all readmissions revealed QOC problems in 90/271 (33%) of readmissions, 4.5% of hospitalizations. All were deemed preventable. Interobserver agreement was good (83%, kappa = 0.67). Among matched controls, only 8/140 admissions revealed QOC problems (6%, p < 0.001) (k = 0.77). The preventable readmissions mostly involved a vascular event or congestive heart failure; they occurred within a mean of 10 ± 8 days of the index admission, and their inpatient mortality was 6.7% vs. 1.7% among readmissions that had no QOC problems (odds ratio, 4.1; 95% confidence interval, 1.0-16.7). The main pitfalls identified during the index admission included incomplete workup (33%), too short hospital stay (31%), inappropriate medication (44%), diagnostic error (16%), and disregarding a significant laboratory result (12%). In many patients more than 1 pitfall was identified (mean, 1.5 per patient). Risk factors for preventable readmission include older age and living in an institution (p < 0.05). Almost two-thirds of the readmitted patients with QOC problems were discharged after spending 2 days or fewer at the hospital. In conclusion, unplanned readmissions within 30 days of discharge are frequent, more prevalent in sicker patients, and possibly associated with increased mortality. In a third of readmitted patients a QOC problem can be identified, and these problems are preventable. Thus, readmission may be used as a screening tool for potential QOC problems in the department of medicine. Routine monitoring of all readmissions may provide a simple cost-effective means of identifying and addressing medical mistakes. Abbreviations: 95% CI = 95% confidence interval, LOS = length of stay, NS = not significant, OR = odds ratio, QOC = quality of care.

Utility of Clinical Examination in the Diagnosis of Emergency Department Patients Admitted to the Department of Medicine of an Academic Hospital

Comment. In this large retrospective study of copied documentation of lifestyle counseling in patients with diabetes, we have demonstrated that, unlike original records, copied documentation of lifestyle counseling was not associated with improvement in glucose control. In fact, its effect on HbA1c was undistinguishable from no counseling at all. These findings were consistent for all 3 types of lifestyle counseling we analyzed—diet, exercise, and weight loss. These results lead us to question whether copied electronic documentation is a reliable representation of patient care. If it is not, it could be either an honest mistake or deliberate falsification. In the latter case, copied documentation that does not reflect the actual events is a serious breach of medical ethics. In either case, it carries a significant financial and legal risk. Efforts must therefore be made to decrease the incidence of inappropriately copied electronic documentation. These could include training and education of health care providers as well as technical solutions, such as software that automatically detects overly similar notes or their components. In order for EMRs to benefit patients, we must make sure the information they contain is meaningful.

The Silent Dimension: Expressing Humanism in Each Medical Encounter

ED MONTHLY FROM THE JOURNALS A Free Public-Service Publication

Absence of Kaposi Sarcoma Among Ethiopian Immigrants to Israel Despite High Seroprevalence of Human Herpesvirus 8

OBJECTIVEnTo determine the prevalence of Kaposi sarcoma (KS) and human herpesvirus 8 (HHV-8) seropositivity in Ethiopian Jewish immigrants to Israel.nnnMETHODSnA Western blot assay was used to determine the seroprevalence of HHV-8 in serum samples from 202 randomly selected human immunodeficiency virus (HIV)-negative and 47 HIV-positive Ethiopian immigrants; samples were obtained on arrival of the immigrants in Israel. The Israel Cancer Registry provided comprehensive data on the occurrence of KS among Ethiopian immigrants and in the non-Ethiopian population of Israel.nnnRESULTSnA total of 39.1% and 57% of the HIV-negative and HIV-positive Ethiopians, respectively, were infected with HHV-8 (P<.03). However, none of the Ethiopians examined and none of the other HIV-negative Ethiopians among about 45,000 immigrants had KS. Moreover, only 1 (0.85%) of 118 Ethiopian patients with acquired immunodeficiency syndrome (AIDS) developed KS compared with 49 (12.5%) of 391 non-Ethiopian AIDS patients (P<.001).nnnCONCLUSIONnAlthough HHV-8 infection is common in Ethiopian Jewish immigrants to Israel, these patients almost never develop KS, in marked contrast to the strong association usually observed. The mechanism behind this populations unique protection requires further study.

Nitrofurantoin-Induced Immune-Mediated Lung and Liver Disease

A 60-year-old woman with multiple sclerosis and recurrent urinary tract infections (UTI) was evaluated for the recent onset of a dry cough, dyspnea on exertion, and jaundice. Investigation demonstrated interstitial lung disease with bilateral infiltrates and unilateral effusion, as well as a severe chronic active hepatitis with marked fibrosis. Other notable features were positive antinuclear antibodies and anti-smooth-muscle antibodies and the absence of any possible cause except for nitrofurantoin treatment (Macrodantin, 100 mg/day), which the patient had been taking for the previous 3 years as a prophylactic measure against UTI. The patient died of pneumococcal septicemia less than 30 days after presentation. Pulmonary or hepatic injury caused by nitrofurantoin treatment is rare; their combined occurrence is hardly ever described. Combined drug-induced pulmonary and hepatic toxicity is reviewed and should be considered early in the differential diagnosis to allow reversibility and avoid serious outcomes.

Successful treatment of aggressive HIV-associated non-Hodgkin's lymphoma with combination chemotherapy, biotherapy with rituximab and HAART: presentation of a therapeutic option.

The incidence of non-Hodgkins lymphoma (NHL) in individuals infected with human immunodeficiency virus (HIV) is more than 60 times higher than in matched controls. In the vast majority of cases aggressive pathological subtypes and advanced stages prevail, extranodal sites are involved and systemic symptoms are present. The prognosis of HIV-NHL remains poor and the optimal therapeutic approach has yet to be defined. We report a 48-year-old Ethiopian woman with advanced-stage HIV infection, who developed diffuse large cell, immunoblastic type B-cell NHL and was treated with a modified CHOP-like chemotherapy combined with Rituximab and supported with growth factor. Highly active antiretroviral therapy (HAART) and opportunistic infections prophylaxis were administered concomitantly. The patient completed 6 cycles of therapy and currently, 76 weeks after diagnosis, is in complete clinical remission. Despite the fact that there was a transient decrease in the CD4-positive cell number and a 1.5 log increase in plasma viral load there were no opportunistic infections, nor was life-threatening toxicity seen. Rituximab seems a well-tolerable and advantageous adjunct to chemotherapy and HAART in the treatment of aggressive HIV-associated NHL and should be investigated in large trials in the future.

Systemic granulomatosis and hypercalcaemia following intravesical bacillus Calmette-Guérin immunotherapy.

Abstract.u2002Schattner A, Gilad A, Cohen J (Kaplan Medical Center, Rehovot; and Hebrew University‐Hadassah Medical School, Jerusalem, Israel). Systemic granulomatosis and hypercalcaemia following intravesical bacillus Calmette–Guérin immunotherapy (Case report). J Intern Med 2002; 251: 272–277.

Thrombotic Thrombocytopenic Purpura as an Initial Presentation of Primary Sjo¨gren’s Syndrome

Abstract A healthy woman presented with ecchymoses due to thrombocytopenia, with numerous bone marrow megakaryocytes, microangiopathic haemolytic anaemia, disorientation, irritability, and normal renal function. Thrombotic thrombocytopenic purpura (TTP) was diagnosed and treated successfully by plasma exchange therapy, both on presentation and during a further three relapses. The TTP was considered idiopathic until, 4 months later, definite primary Sjo¨gren’s syndrome (1°SS) was diagnosed following the appearance of sicca symptoms. Only four similar cases have been cited in the literature. TTP should be added to the varied haematological manifestations that may occur in patients with 1°SS. The possible presentation of 1°SS not with classic sicca symptoms but rather with haematological abnormalities, including TTP, should be recognised.