Fred W. Whitehouse

Fat infiltration of myocardium as a cause of cardiac conduction defect.

Abstract Fatty infiltration has only rarely been reported as a cause of a cardiac conduction defect. A case of chronic sinoatrial block and atrial fibrillation with severe fatty infiltration of the myocardium and the conduction system is reported. The literature on conduction defects due to fatty infiltration is reviewed.

Evaluation of the insulin jet injector as a potential source of infection

In recent years jet injection of insulin has been widely used by patients with diabetes mellitus. Jet injectors may become contaminated by bacteria because of repeated use without cleaning; cleansing every 2 weeks is recommended. We investigated the occurrence of bacterial contamination by culturing jet injectors in everyday use by 19 patients with diabetes. Swabs from the interior chambers were cultured on blood agar plates. Only one of 20 cultures yielded bacterial growth, and the organism recovered was a presumed contaminant that could not be identified as any common pathogen. No study patient, nor any of more than 70 patients whom we instructed in jet injection, showed any clinical evidence of infection attributable to jet injector use. Jet injectors are unlikely to become colonized by bacteria or to cause infection in patients using them for insulin administration. The low rate of colonization may be due to the antibacterial preservatives added to commercial preparations of insulin. Additional data based on larger numbers of patients would be useful in further clarifying the risk of infection associated with jet injectors.

The Diagnosis of Diabetes: How to Determine Which Patients to Treat

The diagnosis of diabetes depends on identifying a compatible clinical picture with confirmation by demonstrable abnormalities in blood glucose levels. In florid diabetes, classical symptoms of diabetes and high glucose in blood and urine make the diagnosis easy. For asymptomatic diabetes; if confirmed fasting blood glucose measures over 125 mg per 100 ml, the diagnosis is accepted. When the fasting blood glucose measures under 125 mg per 100 ml, I recommend an oral glucose tolerance test and apply suitable criteria for interpretation. The United States Public Health Service criteria represent a reasonable, moderate approach when one modifies the interpretation by cognizance of environmental factors in the patient and by identifying interfering influences as drugs, physical inactivity, fever or starvation. Indeed, one should postpone a glucose tolerance test until these interfering factors abate. Management of the patient with an abnormal glucose tolerance test includes sharing the prognostic dilemma with the patient regarding the likelihood of deterioration in glucose tolerance to florid diabetes. In this situation the term, abnormal glucose tolerance test, is preferred over chemical diabetes. The physician and the patient must develop some degree of comfort with a clinical state that often remains nebulous. Though the writings of authorities occasionally sound dogmatic, rigid, and conflicting, they reflect a viewpoint which opines that no clear answers are available; that the clinician and his patient must accept this posture; and that together they must develop the best therapeutic program for the individual in question.

Evaluation of a new chemical dip strip for detecting ketonemia in the emergency setting

The utility of a new urine dipstick, Chemstrip uK, was evaluated using serum in place of urine to quantify serum ketones in 29 acutely ill patients with suspected ketosis treated in the emergency department. The serum Chemstrip uK method accurately predicted the level of ketonemia as assessed by the Acetest tablet method (r = .94; P less than .0001). There were no false-negative and no false-positive results. The use of this strip is recommended for evaluating subjects with suspected ketosis.

Significance of the flat oral glucose tolerance test.

A flat blood sugar response to the oral glucose tolerance test has long been accepted as an implication of impaired intestinal absorption of carbohydrate. However, this study indicates that the flat response is a normal variant and depends on how the test is performed and when the blood is sampled. It also is conjectured that the carbohydrate challenge may trigger a burst of insulin that modifies the blood sugar response.

169 – Management of Diabetes in Stroke

This chapter discusses management of diabetes in stroke. The patient with diabetes is two to three times more likely to develop ischemic stroke and hemorrhagic stroke is not more common than in the nondiabetic peer. Transient ischemic attacks are also more frequent in the diabetic population. It is suggested that when a stroke occurs in a diabetic patient, the physician must be certain that the signs and symptoms are not due to a major blood glucose aberration. Severe hyperglycemia with dehydration and hypotension and hypoglycemia might lead to alterations in neurologic function and consciousness similar to those seen in stroke. Excepting the patient with minimal carbohydrate intolerance, insulin therapy should be used when the patient is acutely ill. Oral antidiabetic medications often give unpredictable responses for desired therapeutic goals. When the patient is clinically stable, eating, and recovering motor and cognitive function, basal insulin is started. This intermediate-acting insulin is best given every 12 hours with a starting dosage approximating 0.2–0.3 units/kg body weight/day. The use of neutral protamine Hagedorn (NPH) or lente insulin in patients with chronic intrajejunal feeding achieves smoother glucose control when NPH or lente insulin is used with amounts of regular insulin given as a supplement for hyperglycemia.