Taiba Zornitzki

Cardiac abnormalities as a new manifestation of nonalcoholic fatty liver disease : Echocardiographic and tissue doppler imaging assessment

Nonalcoholic fatty liver disease (NAFLD) is linked to the metabolic syndrome. The aim of the present study is to determine the effect of the metabolic syndrome on left ventricular (LV) geometry and function using as a model patients with NAFLD. Thirty-eight patients with NAFLD, less than 55 years of age and with a normal exercise test, were compared with an age and sex-matched control group. Patients with diabetes mellitus, hypertension, and body mass index>40 were excluded. A complete echocardiographic study including tissue Doppler imaging (TDI) was performed. The following parameters were assessed by echo Doppler: peak velocities of early (E) and late (A) diastolic filling, E/A ratio, flow propagation velocity (Vp). Using TDI early diastolic velocity (E′), and systolic velocity (S′) of mitral annulus were obtained. The patients with NAFLD had a significantly higher body mass index (31.4±5 vs. 26.4±4 kg/m2, P=0.01), higher glucose (100.6±13 vs. 83.0±10 mg/dL, P=0.01), and triglyceride levels (126.5±44 vs. 206.5±67 mg/dL, P<0.001). Increased thickness of the intraventricular septum, posterior wall (11.03±2.2 vs. 8.9±2.9 mm, P=0.001; 8.5±1.7 vs. 9.7±2.3 mm, P=0.04), and larger LV mass and LV mass/height (160.7±58.7 vs.115.3±35.4 g, P=0.001 and 92.6±29.5 vs. 69.2±19.8 g/m, P=0.001, respectively) were found in NAFLD group. LV systolic function was similar in both groups. Patients with NAFLD had a lower E (73.6±11.0 vs. 86.4±20.0 cm/s, P<0.006) and E/A ratio (1.0±0.3 vs. 1.76±0.8 P<0.0001). Moreover, the Vp and the E′ on TDI were significantly lower compared with the control group (49.0±9.7 vs. 74.7±18.4 cm/s, P<0.0001 and 10.3±2.0 vs. 13.8±1.7 cm/s, P<0.0001, respectively). On multivariate analysis the E′ on TDI was the only independent parameter associated with NAFLD. In conclusion, patients with NAFLD in the absence of morbid obesity, hypertension, and diabetes have mildly altered LV geometry and early features of left ventricular diastolic dysfunction. Early diastolic velocity on TDI was found to be the only index that could identify the patients with NAFLD and metabolic syndrome.

Utility of Clinical Examination in the Diagnosis of Emergency Department Patients Admitted to the Department of Medicine of an Academic Hospital

Comment. In this large retrospective study of copied documentation of lifestyle counseling in patients with diabetes, we have demonstrated that, unlike original records, copied documentation of lifestyle counseling was not associated with improvement in glucose control. In fact, its effect on HbA1c was undistinguishable from no counseling at all. These findings were consistent for all 3 types of lifestyle counseling we analyzed—diet, exercise, and weight loss. These results lead us to question whether copied electronic documentation is a reliable representation of patient care. If it is not, it could be either an honest mistake or deliberate falsification. In the latter case, copied documentation that does not reflect the actual events is a serious breach of medical ethics. In either case, it carries a significant financial and legal risk. Efforts must therefore be made to decrease the incidence of inappropriately copied electronic documentation. These could include training and education of health care providers as well as technical solutions, such as software that automatically detects overly similar notes or their components. In order for EMRs to benefit patients, we must make sure the information they contain is meaningful.

Interferon therapy in hepatitis C leading to chronic type 1 diabetes.

AIM To review the prevalence, clinical data and course of interferon- associated type 1 diabetes in chronic hepatitis C virus (HCV) infection. METHODS Search of all interferon (INF)-related type 1 diabetes mellitus (T1DM) cases published in the English literature from 1992 to December 2013 according to the key words: chronic hepatitis C infection, diabetes mellitus type 1, insulin dependent diabetes mellitus, and interferon treatment. We found 107 cases and analyzed their clinical and laboratory data and long-term follow-up. Due to the predominance of cases described in Japanese literature, we analyzed separately cases of Caucasian and Japanese origin. In addition we describe a representative case with HCV who developed INF-related T1DM. RESULTS Our data show that INF treatment increases the risk of developing T1DM by 10-18 fold compared with the corresponding general population and the median age of onset was 43 years (range: 24-66 years) in Caucasians and 52 years (range: 45-63 years) in Japanese. Most patients developed T1DM during INF treatment, after a median time-period of 4.2 and 5.7 mo in Caucasian and Japanese groups, respectively. The clinical course was characterized by a fulminant course with abrupt severe hyperglycemia or ketoacidosis, a high titer of anti-islet autoantibodies and almost all patients (105/107) permanently required insulin therapy with a follow-up of up to 4 years. A substantial number of patients had evidence for other autoimmune disorders mainly thyroid diseases (25% and 31% in Caucasian and Japanese groups, respectively). CONCLUSION INF-associated T1DM in HCV has a fulminant course, often associated with other autoimmune diseases, and results almost inevitably in permanent insulin therapy requirement.

Painful swelling in the thigh: diabetic muscle infarction

The case: A 52-year-old woman was admitted with painful swelling in her left thigh. She had a 12-year history of type 2 diabetes mellitus and hypertension, and she was a smoker (40 pack-year smoking history). At her last examination, her HbA1C level was 7.7%, her serum total cholesterol level was 8.

Increased MIB-1/Ki-67 labeling index as a predictor of an aggressive course in a case of prolactinoma.

Secondary resistance to dopamine agonists is a rare phenomenon in patients with a prolactinoma. We describe a 55-year-old male with a macroprolactinoma initially responding favorably to bromocriptine treatment with normalization of prolactin levels and tumor shrinkage. Two years later, he developed resistance to bromocriptine treatment and subsequently to cabergoline. The aggressive course of the disease necessitated three surgical interventions. Staining of the pituitary tissue revealed a very high MIB/Ki-67 labeling index that increased further in specimens derived from repeated surgery. This case demonstrates that high and increasing levels of the MIB/Ki-67 labeling index may indicate an aggressive course associated with secondary dopamine resistance.

High–molecular weight adiponectin is associated with coronary artery angiographic findings in Asian Indians

Asian Indians (AIs) have a higher prevalence and a more aggressive form of coronary artery disease (CAD), and it has been suggested that hypoadiponectinemia may have a role in this accelerated CAD. The present study was undertaken to determine the extent and severity of angiographic findings in 2 groups of CAD patients matched for age and sex, AIs (n = 29) vs whites (n = 30), and to elucidate the potential relationship between adiponectin (total and high-molecular weight [HMW] form) and the severity and extent of coronary angiographic findings in both groups. Angiographic findings were assessed using the modified Gensini index; and 2 scores, scores 1 and 2, were used to assess the severity and extent. Both Gensini index scores 1 and 2 were higher in the AI group compared with the white group (144.4 +/- 87.1 vs 93.5 +/- 56.3 and 127.2 +/- 86.5 vs 80.1 +/- 39.3, respectively; P < .05). Adiponectin levels were similar in both groups. Total adiponectin and HMW adiponectin were positively associated with Gensini index score 1 (r = 0.62, P = .004 and r = 0.64, P = .003) and score 2 (r = 0.51, P = .021 and r = 0.54, P = .013), respectively, in AI men, whereas there was no significant association in white men. Thus, AIs had more severe CAD compared with whites; and in AI men with CAD, total adiponectin and HMW adiponectin were associated with the severity of angiographic scores.

THE EFFECT OF PHLEBOTOMY-INDUCED HEMOLYSIS ON INSULIN LEVEL DETERMINATION.

OBJECTIVE To examine the effect of phlebotomy-induced hemolysis on serum insulin and C-peptide measurement by an immunochemiluminometric assay. METHODS As part of a study designed to evaluate β-cell function in a group of adults with newly diagnosed type 2 diabetes, we tested insulin and C-peptide levels in 1,048 samples. In order to evaluate the effect of phlebotomy-induced hemolysis, we determined insulin and C-peptide levels simultaneously in hemolyzed and nonhemolyzed samples. RESULTS Forty-seven (4.5%) of the 1,048 samples were affected by hemolysis. In 26 cases, we had paired hemolyzed and nonhemolyzed serum samples that allowed a simultaneous comparison. We found that all degrees of hemolysis led to a significant decrease in insulin level. In hemolyzed serum, the median (interquartile range) of the insulin was 5.6 (1.8 to 24.3) mIU/L, versus 21.3 (11.4 to 48.5) mIU/L in nonhemolyzed serum, representing a 25 to 98% loss. This phenomenon was not found for C-peptide levels. CONCLUSION Clinicians have to be aware that even a mild degree of phlebotomy-induced hemolysis has a significant effect on serum insulin level determination, which can lead to misinterpretation of test results. This finding has important implications, especially in the evaluation of suspected cases of hyperinsulinemic hypoglycemia.

pNET co-secreting GHRH and calcitonin: ex vivo hormonal studies in human pituitary cells.

Summary Acromegaly due to ectopic GHRH secretion from a neuroendocrine tumor (NET) is rare and comprises <1% of all acromegaly cases. Herein we present a 57-year-old woman with clinical and biochemical features of acromegaly and a 6 cm pancreatic NET (pNET), secreting GHRH and calcitonin. Following surgical resection of the pancreatic tumor, IGF1, GH and calcitonin normalized, and the clinical features of acromegaly improved. In vitro studies confirmed that the tumor secreted large amounts of both GHRH and calcitonin, and incubation of pNET culture-derived conditioned media stimulated GH release from a cultured human pituitary adenoma. This is a unique case of pNET secreting both GHRH and calcitonin. The ability of the pNET-derived medium to stimulate in vitro GH release from a human pituitary-cell culture, combined with the clinical and hormonal remission following tumor resection, confirmed the ectopic source of acromegaly in this patient. Learning points Signs, symptoms and initial work-up of acromegaly due to ectopic GHRH secretion are similar to pituitary-dependent acromegaly. However, if no identifiable pituitary lesion is found, somatostatin receptor scan and further imaging (CT, MRI) should be performed. Detection of GHRH in the blood and in the tumor-derived medium supports the diagnosis of ectopic GHRH secretion. Functional bioactivity of pNET-secreted GHRH can be proved in vitro by releasing GH from human pituitary cells.