Nacide Ercan-Fang

Neuroleptic Malignant Syndrome Associated with Olanzapine

OBJECTIVE: To report a case of neuroleptic malignant syndrome (NMS) associated with the use of olanzapine. CASE SUMMARY: A 67-year-old white man with bipolar disorder developed nausea and vomiting. After 12 days, he became confused, delirious, and manic. His only medications were olanzapine 10 mg/d and divalproex sodium 500 mg bid. He was admitted to a hospital and treated for dehydration and mania. Olanzapine was given on 6 of the first 7 hospital days. On hospital day 6, typical NMS developed with the body temperature increasing to 39.9 °C, obtundation, rigidity, tremor, diaphoresis, fluctuating pupillary diameter, labile tachycardia and hypertension, hypernatremia, and elevated serum creatine kinase. Olanzapine was stopped after hospital day 7, and the syndrome resolved by hospital day 12. DISCUSSION: The patient had all of the major manifestations of NMS. There was no other likely explanation for his illness and he received no other drug likely to be associated with the syndrome. This is the first case reported in which NMS was associated with olanzapine.

Acute Metabolic Response to High-Carbohydrate, High-Starch Meals Compared With Moderate-Carbohydrate, Low-Starch Meals in Subjects With Type 2 Diabetes

OBJECTIVE The monosaccharides resulting from the digestion of ingested carbohydrates are glucose, fructose, and galactose. Of these three monosaccharides, only ingested glucose resulted in a large increase in the plasma glucose concentration. Fructose (Metabolism 41:510–517, 1992) and galactose (Metabolism 42:1560–1567, 1993) had only a minor effect. Therefore, we were interested in determining whether we could design a mixed meal, using foods of known monosaccharide, disaccharide, and starch composition, the ingestion of which would result in only a small rise in plasma glucose concentration. RESEARCH DESIGN AND METHODS The experimental meal was composed of very little readily digestible starch but rather large amounts of fruits and vegetables. It contained 43% carbohydrate, 22% protein, and 34% fat. The results were compared with a second type of meal that contained 55% carbohydrate, 15% protein, and 30% fat, with an emphasis on complex carbohydrates (starch). It also was compared with a third meal that contained 40% carbohydrate, 20% protein, and 40% fat, typical of that consumed by the average American. The test meals were ingested in random order by people with type 2 diabetes who were not treated with oral hypoglycemic agents or insulin. Each subject ingested each type of meal. The same identical meal was ingested at 0800, 1200, and 1700. RESULTS The integrated 24-h plasma glucose area response was statistically significantly smaller (P < 0.05) after ingestion of the low-starch meals compared with the high-starch, highcarbohydrate meals or the typical American meals. The 24-h integrated serum insulin area response also was statistically significantly less (P < 0.05) after ingestion of the low-starch meals compared with the high-starch meals or the typical American meals. The serum triglyceride area response was similar after ingestion of all three test diets. CONCLUSIONS A diet in which fruits, nonstarch vegetables, and dairy products are emphasized may be useful for people with type 2 diabetes.

Effect of Nurse Case Management Compared With Usual Care on Controlling Cardiovascular Risk Factors in Patients With Diabetes A randomized controlled trial

OBJECTIVE To determine whether nurse case management with a therapeutic algorithm could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia compared with usual care among veterans with diabetes. RESEARCH DESIGN AND METHODS A randomized controlled trial of diabetic patients that had blood pressure (BP) >140/90 mmHg, hemoglobin A1c (HbA1c) >9.0%, or LDL >100 mg/dL. Intervention patients received case management (n = 278) versus usual care (n = 278) over a 1-year period. The primary outcome was the percentage of patients achieving simultaneous control of all three parameters (defined by BP <130/80 mmHg, HbA1c <8.0%, and LDL <100 mg/dL) at 1 year. Secondary outcomes included improvements within each individual component of the composite primary outcome. Differences between groups were analyzed using t tests, Pearson χ2 tests, and linear and logistic regression. RESULTS A greater number of individuals assigned to case management achieved the primary study outcome of having all three outcome measures under control (61 [21.9%] compared with 28 [10.1%] in the usual care group [P < 0.01]). In addition, a greater number of individuals assigned to the intervention group achieved the individual treatment goals of HbA1c <8.0% (73.7 vs. 65.8%, P = 0.04) and BP <130/80 mmHg (45.0 vs. 25.4%, P < 0.01), but not for LDL <100 mg/dL (57.6 vs. 55.4%, P = 0.61), compared with those in the usual care group. CONCLUSIONS In patients with diabetes, nurse case managers using a treatment algorithm can effectively improve the number of individuals with control of multiple cardiovascular risk factors at 1 year.

Stimulation of Insulin Secretion by Fructose Ingested With Protein in People With Untreated Type 2 Diabetes

OBJECTIVE Ingested protein provides substrate for gluconeogenesis and strongly stimulates insulin and glucagon secretion, but it has little effect on the glucose concentration in people with type 2 diabetes. Ingested fructose also is a substrate for gluconeogenesis, modestly stimulates insulin and glucagon secretion, and has little effect on the plasma glucose. Therefore we were interested in determining if ingestion of fructose along with protein would result in an additive, greater than additive, or less than additive effect on circulating insulin, glucagon, and glucose concentrations. RESEARCH DESIGN AND METHODS Seven male subjects with untreated type 2 diabetes were fasted overnight and then were given either 25 g fructose, 25 g protein, 25 g fructose plus 25 g protein, or water only at 0800. Subjects also ingested 50 g glucose on two separate occasions. Plasma glucose, insulin, C-peptide, glucagon, α-amino nitrogen, urea nitrogen, nonesterified fatty acids, and triglyceride concentrations were determined over the subsequent 5 h. RESULTS The glucose concentration was only modestly increased and the area responses were similar when protein, fructose, or the combination was ingested. Thus, the glucose response to the combination was less than additive. The insulin area response to protein was 2.5-fold greater than to fructose, and the response to the two nutrients was additive and quantitatively similar to the response to 50 g glucose. The glucagon area response was less than additive, i.e., there was an interaction between the protein and fructose that resulted in a smaller than expected response. CONCLUSIONS When protein and fructose were ingested together, the insulin response was similar to that following ingestion of 50 g glucose. It also was as expected based on the response to the individual nutrients. In contrast, the glucose and glucagon responses were significantly less than expected. These data may be useful in dietary planning for subjects with type 2 diabetes.

Type I allergy to insulin: case report and review of localized and systemic reactions to insulin.

Allergic reactions to insulin preparations are not uncommon. Although patients often present with skin symptoms, most articles on insulin allergy are published in endocrinology and allergy journals. The purpose of this report is to describe a case of localized type I allergy to insulin as well as provide a review of the classification of insulin allergy, methods of evaluation, and management options.

Resident Research Experiences in Internal Medicine Residency Programs—A Nationwide Survey

AAIM is the largest academically focused specialty organization representing departments of internal medicine at medical schools and teaching hospitals in the United States and Canada. As a consortium of five organizations, AAIM represents department chairs and chiefs; clerkship, residency, and fellowship program directors; division chiefs; and academic and business administrators as well as other faculty and staff in departments of internal medicine and their divisions.

Factors associated with treatment success in veterans with diabetes and hyperlipidemia: a retrospective study.

Purpose The purpose of this study is to identify factors related to achieving a LDL <100 mg/dL. Methods Data from a recent randomized control trial of nurse case management versus usual care conducted at the Minneapolis Veterans Affairs Health Care System were analyzed. The trial consisted of 556 veterans with diabetes mellitus (DM) and at least 1 of the following: blood pressure (BP) >140/90 mmHg, and/or glycated hemoglobin (A1C) >9.0%, and/or LDL >100 mg/dL. The current analysis is focused on 275 patients in either treatment group who, at baseline, had LDL >100 mg/dL. Baseline characteristics and variables obtained during the trial of the 95 patients who reached goal LDL were compared to the 180 who did not. Results Patients who reached goal LDL had higher rates of preexisting coronary artery disease (CAD), cerebrovascular accident (CVA), congestive heart failure (CHF), and HMG-coenzyme A reductase inhibitor (statin) use. After adjustment for baseline LDL, preexisting CAD, CVA, and CHF increased the odds of patients achieving a goal LDL <100 mg/dL. This is possibly secondary to the increased prevalence of these conditions in patients with DM. These patients also likely had multiple other providers involved in their care promoting attainment of lower LDL. Baseline statin usage was not related to achieving a LDL<100 mg/dL, however, patients declining to take a statin at any time during the trial had decreased odds of reaching goal LDL. Patients with preexisting neuropathy were also less likely to reach goal LDL. Conclusions Preexisting CAD, CVA, or CHF all increased the odds of patients achieving a goal LDL <100 mg/dL while declining statin therapy and preexisting neuropathy reduced the odds.