Leonid Poretsky

Effects of an Intervention by a Diabetes Team in Hospitalized Patients With Diabetes

OBJECTIVE Hospitalized patients with diabetes have a prolonged length of stay in the hospital. We conducted a controlled prospective randomized feasibility study of the effects of a diabetes team (a diabetes nurse educator and an endocrinologist) on the length of stay and other outcomes of hospitalization in these patients. RESEARCH DESIGN AND METHODS A total of 179 hospitalized patients with diabetes were randomly assigned to receive usual care supplemented with (85 patients) or without (94 control patients) a diabetes team intervention. Outcome measures included the length of stay, blood glucose control, and rates of readmission. RESULTS For the primary diagnosis of diabetes, the median length of stay was 5.5 days (95% CI 4-8 days) for patients who received diabetes team intervention and 7.5 days (5–11 days) for the control patients (NS). For the secondary diagnosis of diabetes, the median length of stay was 10.0 days (8–13 days) in the intervention group and 10.5 days (8–13 days) in the control group (NS). One month after the team intervention was initiated, 75% of patients in the intervention group were in good glycemic control, compared with 46% in the control group. Readmissions at 3 months after discharge included 13 (15%) patients from the intervention group and 30 (32%) patients in the control group (P = 0.01). CONCLUSIONS Randomized controlled prospective trials of clinical interventions in hospitalized patients with diabetes are feasible. Diabetes team intervention appears to reduce the hospital length of stay and to improve glycemic control. Team intervention significantly reduces the rate of recurrent hospitalization.

Kikuchi’s disease associated with Hashimoto’s thyroiditis

We describe a unique association of histiocytic necrotizing lymphadenitis (Kikuchi’s disease) and chronic lymphocytic (Hashimoto’s) thyroiditis in a patient who presented with significant cervical lymphadenopathy and a goiter. This case illustrates the value of lymph node biopsy combined with the fine needle aspiration of the thyroid in determining the nature of the relationship between the goiter and lymphadenopathy.

COMBINATION OF GEMFIBROZIL AND ORLISTAT FOR TREATMENT OF COMBINED HYPERLIPIDEMIA WITH PREDOMINANT HYPERTRIGLYCERIDEMIA

OBJECTIVE To present a case of combined hyperlipidemia with predominant hypertriglyceridemia unresponsive to conventional diet and single-agent drug therapy but successfully treated with a combination of gemfibrozil and orlistat. METHODS We describe a nonobese Asian Indian man with combined hyperlipidemia. Predominant hypertriglyceridemia was unresponsive to conventional therapy. Orlistat was added to the maximal dose of gemfibrozil, and baseline lipid profiles were compared with posttreatment values after repeated challenges with each drug individually and in combination. The relevant literature was also reviewed. RESULTS At baseline, the patients serum triglyceride level was 766 mg/dL and total cholesterol level was 241 mg/dL. On repeated measurements 4 months later, these values were 959 mg/dL and 309 mg/dL, respectively. With use of a reduced-fat diet and gemfibrozil (600 mg orally twice a day), serum triglyceride levels were 830 mg/dL and 909 mg/dL on two different occasions. Combination treatment with the same dosage of gemfibrozil and orlistat at 120 mg orally three times a day reduced triglyceride levels to 279 mg/dL and 244 mg/dL on two separate occasions. Rechallenges with drug monotherapy yielded triglyceride levels of up to 1,159 mg/dL with gemfibrozil alone and of up to 896 mg/dL with orlistat alone. A reduction of serum triglyceride levels to 269 mg/dL and 224 mg/dL occurred when combined treatment with both gemfibrozil and orlistat was reinstituted on two additional occasions. CONCLUSION The combination of gemfibrozil and orlistat was extremely effective in reducing serum triglyceride levels in this patient with combined hyperlipidemia and predominant hypertriglyceridemia, whereas either one of these agents, when used alone, was ineffective. Determining the mechanisms of this synergy will necessitate further investigation. Additional studies of the use of the gemfibrozil-orlistat combination in patients who have combined hyperlipidemia with predominant hypertriglyceridemia are needed.

Twenty-four-hour urinary free cortisol in patients with acquired immunodeficiency syndrome

Many patients with acquired immune deficiency syndrome (AIDS) have symptoms consistent with adrenal insufficiency, but only a small subset of these patients meet criteria for adrenal insufficiency during a short corticotropin (ACTH) stimulation test. We hypothesized that patients with AIDS and symptoms of adrenal insufficiency who produce normal amounts of cortisol in response to administration of 0.25 mg cosyntropin may nevertheless produce lower amounts of cortisol in a course of 24 hours than comparably sick AIDS patients without symptoms of adrenal insufficiency or comparably sick patients without AIDS. We studied four groups of male patients: AIDS patients with symptoms suggestive of adrenal insufficiency but with a normal response to cosyntropin (group I), AIDS patients without symptoms suggestive of adrenal insufficiency (group II), human immunodeficiency virus (HIV)-negative patients with serious acute or chronic illness (group III), and healthy subjects (group IV). The following variables were examined: age, CD4 cell count, Acute Physiologic and Chronic Health Evaluation (APACHE) score, serum cortisol and plasma ACTH at baseline; serum cortisol at 30 and 60 minutes after intravenous administration of 0.25 mg cosyntropin; and 24-hour urinary free cortisol. The four groups had a similar mean age and baseline plasma ACTH and serum cortisol levels. However, a change in cortisol from baseline to 30 and 60 minutes after administration of cosyntropin was significantly smaller in both groups of AIDS patients than in the sick patients without AIDS and normal subjects. There were also differences noted between the two groups of AIDS patients: both baseline and stimulated levels of cortisol tended to correlate directly with ACTH levels in patients without symptoms of adrenal insufficiency, while this relationship appeared to be inverse in patients with symptoms suggestive of adrenal insufficiency (r = -.57 to -.7, P < .05 to .14). The 24-hour urinary free cortisol levels were similar among all groups, but correlated strongly with baseline and stimulated serum cortisol levels only in patients with AIDS and symptoms of adrenal insufficiency (r = .8 to .9, P < .002 to .015). We conclude that (1) AIDS patients with and without symptoms of adrenal insufficiency may have either normal adrenal function or somewhat suboptimal adrenal reserve as demonstrated by a blunted cortisol response during the short ACTH stimulation test in comparison to HIV-negative comparably sick patients or healthy subjects; and (2) 24-hour urinary free cortisol is not a useful test for detection of subtle abnormalities of adrenal function in patients with AIDS.

Hospital length of stay on a diabetes cluster unit.

OBJECTIVE To determine whether the length of hospital stay for patients with either a primary or a secondary diagnosis of diabetes mellitus can be reduced by use of a diabetes cluster unit. METHODS For a period of 12 months, we compared the length of hospital stay for 462 patients with diabetes who were admitted to a diabetes cluster unit and for 1,855 patients with diabetes who were admitted to the other medical and surgical units during the same period. Statistical analysis was done by comparing the calculated average length of stay for patients with primary and secondary diagnoses of diabetes admitted to both types of hospital accommodations and comparing these values with the expected lengths of hospital stay based on the New York Group Standard. RESULTS The mean length of hospital stay for patients who were admitted to the diabetes unit for a primary diagnosis of diabetes was 5.8 days shorter than for those admitted to regular medical and surgical units (7.6 days or 1% below the expected duration versus 13.4 days or 70% longer than the expected duration, respectively; P<0.0002). For a secondary diagnosis of diabetes, patients in the diabetes unit had an average length of stay of 15.5 days (35% longer than the expected duration) in comparison with 17 days (45% longer than expected) for patients on the other medical and surgical units (no significant difference). CONCLUSION For hospitalization of patients with diabetes, geographic clustering seems to reduce the length of stay for patients with a primary diagnosis of diabetes mellitus.

LIFE-THREATENING HYPONATREMIA DUE TO THE SYNDROME OF INAPPROPRIATE SECRETION OF ANTIDIURETIC HORMONE (SIADH) IN A PATIENT WITH THE MILLER FISHER SYNDROME

We report a life-threatening hyponatremia due to SIADH which developed suddenly in a patient with the Miller Fisher syndrome (a variant of Guillian Barré syndrome characterized by complete ophthalmoplegia, ataxia, and areflexia). A 55 year-old female was admitted with a clinical picture of the Miller Fisher syndrome. Cerebrospinal fluid was acellular with elevated proteins, and electromyographic changes were characteristic of polyneuropathy. On the third day of admission the patient was found to be mentally confused with a serum sodium of 108 mmol/L. Serum osmolality was 236 mosm/L and urine osmolality was 636 mosm/L. Urine sodium was 103 mmol/L. The serum sodium normalized after treatment with a single dose of intravenous furosemide, hypertonic saline infusion and fluid restriction. To our knowledge, this is the first description of SIADH developing in a patient with the Miller Fisher syndrome.

Lymphoma of the thyroid mimicking thyroiditis in a patient with the acquired immune deficiency syndrome.

A 35-year-old man with AIDS and a history of a remission from the lymphoma of the right tonsil (previously treated with chemotherapy and radiation) presented with a variety of clinical, laboratory and radiological findings strongly suggestive of subacute thyroiditis. Fine needle aspiration biopsy failed to establish the tissue diagnosis. Pathological examination of the thyroid tissue obtained during an open surgical biopsy revealed a lymphoma. Appropriate chemotherapy produced a rapid clinical and laboratory improvement manifested by the reduction of the goiter and restoration of a euthyroid state. Hypothyroidism subsequently developed, but therapy with thyroid hormone resulted in a rapid normalization of thyroid function tests. The patient expired because of AIDS-related complications.

Coexistence of diabetes and phosphofructokinase deficiency.

OBJECTIVE To report the first case of coexisting diabetes mellitus and phosphofructokinase deficiency. METHODS We describe a 50-year-old woman who had a history of diabetes mellitus, muscle weakness, and mild hemolysis. Phosphofructokinase deficiency was diagnosed with use of the ischemic forearm exercise test and magnetic resonance spectroscopy during exercise. RESULTS The presence of phosphofructokinase deficiency affected the methods of follow-up and choices of diabetes therapy. Insulin therapy was avoided because insulin may exacerbate muscle weakness by suppressing production of free fatty acids. Strenuous exercise had to be avoided as well because it may induce myoglobinuria in patients with phosphofructokinase deficiency. Glycosylated hemoglobin measurements could not be used because they were falsely low (from hemolysis), and other indicators of long-term glycemic control were utilized instead. CONCLUSION Diabetes mellitus and phosphofructokinase deficiency can coexist. In such cases, choices of diabetes therapy and methods of monitoring of glycemic control must be adjusted to account for the presence of phosphofructokinase deficiency.

Absence of Acanthosis Nigricans in a Patient With the Type B Syndrome of Insulin Resistance and Preexisting Diabetes

Acanthosis nigricans is a skin lesion characterized by brown velvety hyperkeratotic plaques most often found in the axillae, the back of the neck, and other flexure areas (1). Histologically, prominent hyperkeratosis, epidermal papillomatosis, and infiltration of the dermis with glycosaminoglycans are present. Acanthosis nigricans is seen in a variety of insulin-resistant states, such as type A and type B syndromes of insulin resistance, polycystic ovary syndrome, and obesity (2-4). The cause of acanthosis nigricans in insulin-resistant states is unknown, but it is thought to be caused by the stimulation of either insulin receptors or type I insulin-like growth factor receptors on epidermal and melatonin-containing cutaneous cells by high circulating concentrations of insulin (2). Acanthosis nigricans is uniformly seen in the type B syndrome of insulin resistance, which is characterized by the presence of antiinsulin receptor antibodies (5). We recently observed a patient with type B insulin resistance and preexisting NIDDM in whom acanthosis nigricans was absent.