Saleh Aldasouqi

Gestational diabetes: should it be added to the syndrome of insulin resistance?

OBJECTIVE The significance of gestational diabetes mellitus (GDM) results from its short-term detrimental effects on the fetus and its long-term prediction of NIDDM in the mother. We compared several variables associated with insulin resistance between GDM and non-GDM pregnant women to show the similarities between GDM and NIDDM (and thus insulin resistance). RESEARCH DESIGN AND METHODS On the basis of a 3-h oral glucose tolerance test (OGTT), 52 GDM patients and 127 non-GDM patients were recruited from pregnant, non-diabetic women who had a nonfasting 1-h-50-g glucose screening test ≥ 7.2 mmol/l (130 mg/dl) performed between 16 and 33 weeks of gestation (a total of 518 of 3,041 women drawn from six community health care prenatal clinics were screened positive). During the OGTT, several potential markers of insulin resistance were measured at fasting and 2-h time points, in addition to the standard glucose measurements. The relationship of these variables with the diagnosis of GDM was studied. RESULTS GDM patients, compared with non-GDM patients, had 1) higher prepregnancy weight (P = 0.011), prepregnancy BMI (P = 0.006), C-peptide at fasting (P = 0.002) and at 2 h (P < 0.001), insulin at fasting (P = 0.001) and at 2 h (P < 0.001), triglycerides at fasting (P = 0.005) and at 2 h (P = 0.003), free fatty acids at fasting (P = 0.017), β-hydroxybutyrate at fasting (P = 0.007); and 2) lower HDL cholesterol at fasting (P = 0.029). These variables were all predictive of GDM (P < 0.036) individually. Using stepwise logistic regression with all of these variables available, fasting (P = 0.019) and 2-h (P < 0.001) insulin levels, fasting free fatty acids (P = 0.031), and fasting β-hydroxybutyrate (P = 0.036) were statistically significant as jointly predictive of GDM. Comparisons between GDM patients and non-GDM patients matched by BMI confirmed that the metabolic abnormalities persisted when difference in BMI was taken into account. Concomitant blood pressure measurements in women with GDM did not differ significantly from those without GDM. CONCLUSIONS Our results show that many of the known metabolic components of the syndrome of insulin resistance (syndrome X) are predictive of GDM. These results are in keeping with the argument that GDM is one phase of the syndrome of insulin resistance. We suggest that GDM be looked upon as a component of the syndrome of insulin resistance that provides an excellent model for the study and prevention of NIDDM in a relatively young age-group.

Glycohemoglobin A1c: A promising screening tool in gestational diabetes mellitus

CONTEXT: Current screening tests for gestational diabetes mellitus (GDM) are inconvenient. Therefore, alternative screening tests for GDM are desirable. The use of glycohemoglobin A1c (HbA1c) in screening for GDM remains controversial. AIM: We undertook this study to evaluate the utility of HbA1c in screening for GDM. SETTINGS AND DESIGN: Retrospective study in a tertiary teaching hospital. MATERIALS AND METHODS: Laboratory records were reviewed to identify pregnant women who underwent both oral glucose tolerance test (OGTT) and HbA1c measurements over a 16-months period. The association of OGTT with HbA1c was evaluated. STATISTICAL ANALYSIS USED: Data were collected using SPSS software. Comparisons of the means and calculations of sensitivities were performed. RESULTS: Of 145 eligible patients, 124 had GDM and 21 patients did not, per OGTT. The percentages of patients with HbA1c values (reference range of 4.8%–6.0%) equal to or above sequential cut-point values of 5.0%, 5.5%, 6.0%, 6.5% and 7.0% (i.e., sensitivity values) were 100%, 98.4%, 87.1%, 62.9% and 39.5%, respectively. The mean HbA1c of the patients with GDM was 6.9 + 0.8% compared to 6.4 + 0.6% for those without GDM (P< 0.006). At an arbitrary cut-off value of 6.0% (the upper limit of normal), HbA1c would have picked up 87.1% of patients with GDM. CONCLUSIONS: This study suggests that HbA1c is a reasonably sensitive screening measure of GDM in this high-risk population. Acknowledging limitations resulting from the study design, further prospective studies are warranted to verify this conclusion, and to evaluate the specificity of HbA1c as a screening test for GDM.

Life-threatening hypercalcemia associated with primary hyperparathyroidism during pregnancy: case report and review of literature.

OBJECTIVE To report a case of life-threatening hypercalcemia attributable to primary hyperparathyroidism in a pregnant patient and discuss the management of severe hypercalcemia during pregnancy. METHODS We describe a 28-year-old pregnant woman who had life-threatening hypercalcemia (serum calcium level of 25.8 mg/dL). Primary hyperparathyroidism was diagnosed. The patients management and the published medical literature on primary hyperparathyroidism during pregnancy are reviewed. RESULTS Our patient had the highest reported serum calcium level that we could find attributable to primary hyperparathyroidism during pregnancy. After initial stabilization, parathyroidectomy was successfully performed during pregnancy. To our knowledge, this is the first report in which this profound degree of hypercalcemia did not result in an adverse maternal or fetal outcome. CONCLUSION Although uncommon, primary hyperparathyroidism during pregnancy may be associated with severe maternal and perinatal complications. Life-threatening hypercalcemia due to primary hyperparathyroidism during pregnancy can be successfully managed surgically during pregnancy, with good maternal and fetal outcome.

A new purpose for tattoos: Medical alert tattoos

Tattooing has gained a tremendous popularity for the past twenty years. The motivations that drive an individual to acquire a tattoo are plentiful. Tattooing has also found its way in the field of medicine (corneal tattooing, gastrointestinal tattooing during endoscopy, permanent make-up tattooing, scar camouflage or radiotherapy field marking...). An emerging application of tattooing is for the purpose of medical identification for conditions requiring special attention during emergency situations, such as patients with diabetes who may be found unconscious due to hypoglycaemia or with allergy to specific medication. This new phenomenon, (practiced by patients on their own without medical consultation) can be found on the Internet. We review here this practice, which is seemingly underreported in the medical literature with its advantages and potential drawbacks.

Nephrolithiasis during pregnancy secondary to primary hyperparathyroidism

Nephrolithiasis secondary to primary hyperparathyroidism infrequently complicates pregnancy. It can cause severe maternal and fetal complications. We present a case of a pregnant woman with nephrolithiasis and primary hyperparathyroidism. We reviewed the management of nephrolithiasis due to primary hyperparathyroidism during pregnancy. We believe that early recognition and timely intervention can significantly reduce the incidence of complications.

IS SUBCLINICAL HYPOTHYROIDISM ASSOCIATED WITH HYPERHOMOCYSTEINEMIA

OBJECTIVE To evaluate whether subclinical hypothyroidism is associated with hyperhomocysteinemia, in an attempt to determine whether hyperhomocysteinemia may explain the observed increased risk of coronary artery disease in patients with subclinical hypothyroidism, as has been shown in patients with overt hypothyroidism. METHODS We prospectively enrolled consecutive patients with newly diagnosed subclinical hypothyroidism and a parallel group of euthyroid control subjects in this study. Subclinical hypothyroidism was defined as high thyrotropin and normal free thyroxine levels. Fasting plasma total homocysteine, thyrotropin, and free thyroxine levels were measured in all participants, and persistent subclinical hypothyroidism was confirmed at least once. RESULTS Forty-seven patients (42 women and 5 men; mean age, 38 +/- 15 years) with subclinical hypothyroidism and 50 control subjects (46 women and 4 men; mean age, 34 +/- 10 years) were enrolled in the study. The manufacturers reference range for the total homocysteine assay was 5 to 15 micromol/L, and we defined our own reference range as 3.9 to 10.8 micromol/L. The mean values (+/-SE) for total homocysteine in patients and control subjects were 7.44 +/- 0.5 micromol/L and 7.22 +/- 0.2 micromol/L, respectively (P = 0.68). CONCLUSION In this study, we found no association between subclinical hypothyroidism and hyperhomocysteinemia. Other contributing factors, such as associated hyperlipidemia, may explain the observed increased risk of coronary artery disease in patients with subclinical hypothyroidism.

Tattooing: medical uses and problems.

Decorative tattooing is a custom thousands of years old and is growing in popularity today. Medical professionals may be less familiar with its medical applications—medical alert tattooing, reconstructive and cosmetic applications, endoscopic tattooing, corneal tattooing, tattooing in radiation oncology, and uses in forensic medicine. We review current medically related tattooing applications and discuss their potential risks and benefits. Tattooing is used in medical alerts, breast reconstruction, radiation oncology, endoscopy, forensic medicine, and other areas.

A proposal for a role of HbA1c in screening for gestational diabetes

S. E. Manley*†, K. A. Sikaris‡, Z. X. Lu‡, P. G. Nightingale§, I. M. Stratton–, R. A. Round*, V. Baskar** and S. C. L. Gough†† *Clinical Biochemistry, University Hospital Birmingham NHS Foundation Trust, Birmingham, †Division of Medical Sciences, University of Birmingham, Birmingham, UK, ‡Melbourne Pathology, Sonic Healthcare, Vic., Australia, §Wellcome Trust Clinical Research Facility, University Hospital Birmingham NHS Foundation Trust, Birmingham, –English National Diabetic Retinopathy Screening Programme, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, **Wolverhampton Diabetes Centre, New Cross Hospital, Wolverhampton, ††Selly Oak Hospital Diabetes Centre, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK

Severe Hypercalcemia and Acute Renal Failure: An Unusual Presentation of Sarcoidosis

Although hypercalcemia is a known metabolic complication of sarcoidosis, it is rarely a presenting manifestation. Long-standing hypercalcemia and hypercalciuria can cause nephrocalcinosis and chronic renal failure. Acute renal failure, although described, is also a rare presentation of patients with sarcoidosis. We describe two patients with sarcoidosis, who presented with severe hypercalcemia and worsening renal function. Parathyroid hormone levels were appropriately suppressed. This led to an extensive search for the cause of hypercalcemia. Finally, after a lymph node biopsy in both cases, a diagnosis of sarcoidosis was established, hypercalcemia resolved, and renal function improved in both cases after administration of prednisone.

Carcinoma of thyroglossal duct remnants: Report of three cases and a review of the literature

Neoplastic transformation in thyroglossal duct (TGD) remnants is estimated to occur in about 1% of TGD cysts, with a total of 243 cases reported in the literature. Three new cases and a review of the literature are presented. All cases of TGD cysts at Indiana University Medical Center between 1981 and 1994 were examined. Of 70 cases of TGD cysts, 3 were found to have TGD carcinomas (papillary carcinoma [2] and follicular carcinoma [1]). The latter is the sixth reported case. About 80% of the reported cases were papillary thyroid carcinomas. In most cases of TGD carcinoma, the diagnosis was not clinically apparent. Few reports emphasize the role of needle aspiration and imaging procedures in the preoperative diagnosis of these tumors. The Sistrunk procedure is the standard treatment of TGD carcinoma; the need for thyroidectomy, however, remains controversial. Recommendations for management include: 1) fine needle aspiration as appropriate for presurgical evaluation; 2) the Sistrunk procedure alone when the diagnosis is papillary carcinoma and there is no clinical or radiologic evidence of thyroid gland involvement; 3) total thyroidectomy and radioactive iodine therapy for TGD follicular carcinoma; and 4) long-term thyroid hormone suppressive therapy in all cases.