Brian Eisenberg

The relationship between glycemic control and morbidity and mortality for diabetics on dialysis.

This study was conducted to determine the association between glycemic control and clinical outcomes of diabetic patients maintained on chronic dialysis. The study group consisted of 226 diabetics (60 Type I and 166 Type II) classified as having either good glycemic control (>5 0% of blood glucose determinations within 3.3-11.1 mmol/L) or poor glycemic control (<50% of blood glucose measurements >3.3 and <11.1 mmol/L). The following variables were analyzed in each group: demographics; vascular and diabetic complications; laboratory values; and patient survival. In comparison to diabetics with poor control (Type I, n=44; Type II, n=57), those with good control, either Type I (n=16), or Type II (n=109), were dialyzed for longer periods and had shorter hospitalizations, lower prevalence rates of myocardial infarctions, congestive heart failure, orthostatic hypotension, gastroparesis and enteropathy, and higher mean serum albumin. Mean patient survival by life-table analysis was as follows: Type I diabetics, good control 128.9 + 8.1 months, poor control 29.5 + 5.0 months, p=0.0014. Type II diabetics, good control 56.9 + 6.8 months, poor control 22.8 + 4.6 months, p<0.0001. Good glycemic control during the first 6 months of dialysis predicted long-term survival for Type II but not for Type I diabetics. Poor glycemic control is associated with increased morbidity from vascular and diabetic complications, malnutrition, and shortened survival in diabetics on chronic dialysis. Although further studies are needed to determine whether poor glycemic control causes shortened survival or merely reflects comorbid conditions shortening survival, good glycemic control may constitute a Worthwhile therapeutic goal for diabetics on dialysis.

Tc-99m sulfur colloid demonstration of diffuse pulmonary interstitial extramedullary hematopoiesis in a patient with myelofibrosis: a case report and review of the literature

&NA; A 60‐year‐old man with a myeloproliferative syndrome and extramedullary hematopoiesis had progressive respiratory and cardiac insufficiency during the previous 18 months, with advancing interstitial pulmonary disease on chest x‐ray. During analysis of his respiratory disease, results of a transbronchial biopsy showed interstitial involvement with increased numbers of megakaryocytes and other panhematopoietic staining elements. Results of a bone marrow scan demonstrated diffuse replacement of pulmonary interstitium with bone marrow, as a component of known ongoing extramedullary hematopoiesis.

Gastroparesis in Diabetics on Chronic Dialysis: Clinical and Laboratory Associations and Predictive Features

Clinical and laboratory features and risk factors for diabetic gastroparesis (DGP) were investigated in 226 diabetics on chronic dialysis; 106 subjects (43%) had DGP diagnosed by persistent vomiting improved with the use of prokinetic agents and 120 (control group) had no clinical DGP. Type 1 diabetics had DGP more frequently than type 2 diabetics (70 vs. 37%). The DGP group had longer duration of diabetes (21 +/- 8 vs. 13 +/- 6 years), higher frequency of diabetic orthostatic hypotension (95 vs. 33%), enteropathy (49 vs. 5%), blindness (52 vs. 23%), myocardial infarction (86 vs. 42%), extremity gangrene (54 vs. 27%) and cerebrovascular accidents (43 vs. 25%), lower serum albumin 32.3 +/- 3.9 vs. 35.4 +/- 3.8 g/l), urea (24.0 +/- 5.5 vs. 25.5 +/- 5.5 mmol/l) and creatinine (710 +/- 210 vs. 820 +/- 220 mumol/l), and higher serum TCO2 (20.9 +/- 3.1 vs. 19.8 +/- 2.7 mmol/l) than the control group (all differences significant at p +/- 0.004). Glycemic control was adequate in 24% of the DGP group subjects and 83% of the control subjects (p < 0.001). Annual hospitalization rate was 49 +/- 48 days/patient in the DGP group and 16 +/- 27 days/patient in the control group (p < 0.001). Median patient survival was 24 +/- 2 months in the DGP group and 61 +/- 9 months in the control group (p < 0.0001). Logistic regression identified long duration of diabetes and poor glycemic control as risk factors for DGP. In diabetics on dialysis, DGP is associated with high frequency of other diabetic complications, low serum albumin and creatinine, and high morbidity and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteomyelitis: sensitivity of 0.064 T MRI, three-phase bone scanning and indium scanning with biopsy proof.

We compared the ability of magnetic resonance imaging (MRI) using a 0.064 T permanent magnet, three-phase bone scanning, and indium-labeled white blood cell (111In-WBC) scanning, to diagnose osteomyelitis. Twenty-three patients underwent biopsy. All patients were examined at presentation with all three modalities. Sensitivities for each modality were calculated using biopsy as a gold standard. The results were 72% for MRI, 68% for bone scan, and 45% for 111In-WBC. Specificities were not calculated because of lack of negative biopsies. MRI was as sensitive as bone scanning in the diagnosis of osteomyelitis. All modalities had lower than previously reported sensitivities for imaging osteomyelitis.

Factors affecting bone mineral density in elderly men receiving chronic in-center hemodialysis.

Twenty-five elderly men receiving chronic hemodialysis had measurements of their bone mineral density (BMD) by dual-photon absorptiometry (DPA). Loss of BMD was much more pronounced in femoral necks than in lumbar vertebrae. Stepwise multiple linear-regression analysis showed that low BMD was associated with 1) hypoalbuminemia, hypermagnesemia, hyperaluminemia, and high serum alkaline phosphatase for femoral necks and 2) hypercalcemia and hypermagnesemia for lumbar vertebrae. These observations suggest that the femoral neck is the preferred site for measurement of BMD in dialysis patients. Along with factors directly affecting bone metabolism, nutritional factors may affect BMD in such patients.

Cold defects in in-111 labeled leukocyte imaging of osteomyelitis in the axial skeleton.

Use of ln-111 oxine labeled leukocytes in the detection of osteomyelitis of the peripheral skeleton usually presents few problems. However, the diagnosis of osteomyelitis is more difficult in marrow-bearing areas because uptake of indium is normal. Sixty-one ln-111 labeled leukocyte scans, that had been performed to exclude osteomyelitis of the axial skeleton, pelvis, and proximal long bones, were reviewed. Eight cold defects were identified at sites of suspected osteomyelitis. Five of these were surgically proven osteomyelitis. Nineteen percent of all cases of osteomyelitis in these areas (5 of 26) presented as cold defects. This incidence of osteomyelitis presenting as cold defects is higher than previously reported. Therefore, the possibility of osteomyelitis should be strongly considered when a cold defect is identified in red marrow areas.

Technetium-99m MDP bone scan and MRI correlation in the detection of occult bone infarction

A 37-year-old female on prednisone therapy for inflammatory bowel disease had chronic focal knee pain bilaterally for several months. Plain film imaging results were normal. However, Tc-99m MDP bone scintigraphy obtained the same day revealed diffuse increased uptake of radionuclide within the distal femoral metaphases and knees bilaterally. Additional diffuse increased activity was seen in the left tibial plateau, with a second small focal area of activity within the proximal tibial diaphysis

Pleuroperitoneal communication in a patient with right pleural effusion and ascites diagnosed by technetium-99m sulfur colloid imaging

A 55-year-old man with an 11-year history of intermittent right pleural effusions had continued fevers and a large right transudative pleural effusion. Minimal ascites was noted by ultrasound examination. A communication between the thorax and intraperitoneal cavity was established by radionuclide examination of the chest and abdomen. Tc-99m sulfur colloid was injected into the peritoneal cavity, and imaging at 1 and 4.5 hours confirmed passage from the peritoneal to the pleural cavity. Repeated attempts to sclerose the pleural cavity failed to decrease the transudative accumulations. The patient was subsequently treated with the placement of a LeVeen shunt.

Pitfalls of bone mineral density evaluation by dual-photon absorptiometry.

Material absorbing photons aligned with the lumbar vertebrae can create falsely elevated measurements of bone mineral density during dual-photon absorptiometry. Three cases illustrating this phenomenon are presented. Although bone mineral density was overestimated in each case, calculated fracture risk was normal in two cases and greatly increased in the third. Photon-absorbing material can create overestimates of bone mineral density during dual-photon absorptiometry, even when a greatly increased fracture risk is computed.

Paraprosthetic Cecal Fistula: CT Demonstration— A Case Report

A case in which repeated infection defied diagnosis after aortobifemoral bypass graft is reported. The key investigation proved to be computed tomography (CT), which detected the right limb of the graft penetrating the cecum. This is a complication of graft surgery that has not been previously reported.