Ved V. Gossain

Hyperparathyroidism and pregnancy: case report and review

In pregnant women with symptomatic hyperparathyroidism, parathyroidectomy should be undertaken during the second trimester. We feel that the woman who is initially diagnosed well into the third trimester should be treated medically unless the hypercalcemia worsens or other complications occur. Since the treatment of asymptomatic hyperparathyroidism itself is controversial, it is even more difficult to define the treatment plan for an asymptomatic pregnant patient who has primary hyperparathyroidism. However, a recent consensus panel recommended that young patients with asymptomatic hyperparathyroidism be treated surgically. Accordingly, we believe that the asymptomatic pregnant patient should also be treated surgically, preferably in the second trimester. Whether a patient is treated medically or surgically in these situations, the pregnancy should be considered high-risk. The neonate should be monitored carefully for signs of hypocalcemia or impending tetany. If the mother is treated medically to term (or if spontaneous or elective abortion occurs), the mother should be monitored for hyperparathyroid crisis postpartum. Sudden worsening of hypercalcemia can result from the loss of the placenta (active placental calcium transport may be somewhat protective) and dehydration. Finally, every effort should be made to make the definitive diagnosis early in pregnancy in order to initiate optimal management. The diagnosis should be suspected during pregnancy if the following conditions exist: appropriate clinical signs or symptoms (especially nephrolithiasis or pancreatitis), hyperemesis beyond the first trimester, history of recurrent spontaneous abortions/stillbirths or neonatal deaths, neonatal hypocalcemia or tetany, or a total serum calcium concentration greater than 10.1 mg/dL (2.52 mmol/L) or 8.8 mg/dL (2.2 mmol/L) during the second or third trimester, respectively.

Hormonal effects of smoking--II: Effects on plasma cortisol, growth hormone, and prolactin.

Effect of smoking on the plasma levels of cortisol, growth hormone, and prolactin was evaluated in a group of smokers and nonsmokers. Plasma levels of these hormones were measured under basal conditions and following a short burst of smoking. In addition, to determine the mechanism of action of nicotine on the release of these hormones, rat renal cortical slices were incubated with nicotine and the generation of cyclic AMP was measured in vitro. Increasing concentration of nicotine in the incubation meidum resulted in increased generation of cyclic AMP. Basal levels of plasma cortisol were similar for both smokers and nonsmokers. After smoking, the cortisol levels increased significantly among smokers only and the levels achieved were significantly higher compared with nonsmokers. Mean prolactin curves were higher among nonsmokers compared with smokers, whereas growth hormone levels were similar in the two groups. There data suggest that the effects of smoking on pituitary/adrenal hormones differ among smokers and nonsmokers and that these effects may be mediated through increased generation of cyclic AMP induced by nicotine.

Effect of oral contraceptives on plasma glucose, insulin, and glucagon levels☆

Effects of oral contraceptive agents (mestranol and norethindrone) on carbohydrate metabolism were evaluated in a group of 18 healthy young women. Plasma glucose, insulin, and glucagon responses were evaluated after a glucose load (oral and intravenous) and an amino acid challenge (oral and intravenous). The oral glucose tolerance was normal and was unaltered by the use of oral contraceptive agents. However, following intravenous administration of glucose, plasma glucose levels were slightly but significantly elevated when subjects were using oral contraceptives. Plasma insulin concentrations were slightly but significantly higher than control values in response to oral and intravenous administration of glucose while subjects were using oral contraceptives. Plasma glucagon concentrations in response to oral and intravenous glucose were similar whether the subjects were using oral contraceptive agents or not. No significant differences from control values were observed after oral and intravenous amino acid challenges when subjects were using oral contraceptive agents. Mild elevations of glucose and insulin without any significant change in glucagon concentrations suggest that glucagon levels do not play a major role in the development of insulin resistance seen in some patients using oral contraceptive agents.

The Actual and Self-Perceived Knowledge of Diabetes Among Staff Nurses:

The actual and self-perceived knowledge of diabetes among staff nurses was evaluated utilizing previously validated and standardized instruments. One hundred twenty-seven staff nurses employed at three university-affiliated community hospitals participated in the study. Actual knowledge was assessed by the Diabetes Basic Knowledge Test (DBKT) and self-perceived knowledge was assessed by the Diabetes Self-Report Tool (DSRT). There was a direct relationship between self-perceived knowledge and number of correct responses on the DBKT. Nurses with a higher level of education performed better than those with fewer years of education. Nurses with fewer years of experience did better than those with greater years of experience. Although some areas of knowledge deficit were identified, we concluded that staff nurses employed at community hospitals are fairly competent in the field of diabetes and have a realistic perception of their knowledge deficiencies. Based on these findings, we believe that it should be possible to design in-service and continuing education programs for nurses to further improve their knowledge in the field of diabetes.

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.

Effect of pregnancy on thyroxine binding globulin (TBG) in partial TBG deficiency.

An unusual opportunity was afforded to study the effect of endogenous increase in estrogen on thyroxine binding globulin (TBG) throughout pregnancy in a partially TBG-deficient female who conceived subsequent to initial examination. TBG binding of 125I-thyroxine (T4) before and up to four months of pregnancy was low in comparison to normal. Starting from six months and up to the end of pregnancy, TBG activity showed a definite increase although still below normal. TBG binding capacity increased from a low value of 4.2 microgram T4/100 ml ,efore pregnancy to a value 9.3 microgram T4/100 ml in the last month of pregnancy. This was accompanied by an increase in immunoassayable TBG from less than 1 mg/100 ml in the second month of pregnancy to 1.9 mg/100 ml in the last month, and an increase of T4 from 3.1 microgrom/100 ml to 4.3 microgram/100 ml. Two weeks after delivery, TBG binding of 125I-T4 showed a precipitous decline to the abnormally low distribution noted prior to and during the early months of pregnancy. TBG binding activity was normal in the cord blood of the infant. These studies provide the first direct evidence that increase in endogenous estrogen results in detectable increases in TBG concentration in the human with partial TBG deficiency.

Hypertension in Asian/Pacific Island Americans

Asian/Pacific Islander Americans (APIAs) are the fastest growing population in the United States by percentage. Hypertension is common and increases cardiovascular risk to a great extent in this population. The medical problems of this group are being increasingly encountered by US physicians. Many gene mutations associated with hypertension are more common in Asians. The significance of these polymorphisms in the pathogenesis of hypertension in APIAs is unclear. The percentage of APIAs who are aware, treated, and controlled is small. There may be some differences in the responses to antihypertensive medications between APIAs and whites. The results of human studies on the effect of drinking of tea on blood pressure in different groups are conflicting. Cough associated with angiotensin‐converting enzyme inhibitor therapy may be more common in APIAs than in whites. There is a need for more education of APIAs regarding hypertension and for more effective treatment of hypertension by the physicians caring for this population.

Contemporary Adult Diabetes Mellitus Management Perceptions

AbstractBackground: Over 180 million people have been diagnosed with diabetes mellitus worldwide, with this number expected to more than double by 2030. Due to the increasing mortality and morbidity associated with this epidemic, the improved primary-care management of diabetes during routine office visits remains an emerging international challenge. Objective: To report the results of a series of exploratory semi-structured group interview sessions with a sample of 44 American adults with type 2 diabetes, concerning their diabetes management perceptions and office-based diabetes care processes. Methods: A total of 44 adults from a Midwest Internal Medicine Clinic were interviewed during 2004 and 2005 before starting a larger, quantitative, shared decision-making intervention study. During group interviews, participants offered their perceptions of their self-management practices, interactions with office clinicians, and diabetes-related health outcomes to date. A total of 178 audio-taped interview comments (across 44 participants) were transcribed and analyzed for core themes and sub-themes. Results: Many participants reported frustrating experiences regarding the relationship between their personal diabetes self-management practices and typical office visit interactions with clinicians. Most participants perceived these diabetes management processes as inherently different from each other. Many participants were intrigued with the proposed shared decision-making management approach of the larger intervention study. Conclusions: Primary-care clinicians should assess how patients may perceive their self-management strategies relate to office-based diabetes care processes. Patients’ self-management beliefs and practices should be routinely evaluated since they frequently affect the nature of key diabetes care office visit decisions. These qualitative results suggest that clinicians should convey the increasing interdependence between their patients’ daily diabetes self-management practices and contemporary office visit decision-making discussions.

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.