Drug therapy for the hypertensive diabetic patient: implications for the diabetes educator

A variety of side effects associated with the use of antihypertensive medications may occur in any patient with diabetes mellitus. Also, some antihypertensive agents produce symptoms that would be insignificant to the nondiabetic patient but may be life-threatening to the patient with diabetes mellitus. Therefore, it is imperative to instruct patients to be aware of any changes they may notice after starting an antihypertensive medication or changing their antihypertensive drug regimen. With this increased awareness and an increase in glucose monitoring (when necessary), the patient is prepared to recognize subtle changes in blood glucose levels or other conditions related to diabetes mellitus--changes that might otherwise go unnoticed. As diabetes educators, being knowledgeable about the pharmacodynamics of various antihypertensive medications, their influence on diabetes, and any risks the drugs may impose on the diabetic patient gives us a sound base to intervene with patients and prevent potentially life-threatening complications.     

Failure of bretylium to suppress inducible ventricular tachycardia

Five patients with recurrent, life-threatening ventricular arrhythmias were given bretylium tosylate intravenously for a minimum of 4 days. Arrhythmias were not related to acute ischemia in any patient. Four patients had inducible ventricular tachycardia, and one patient had inducible ventricular fibrillation requiring cardioversion while taking no medications. Programmed electrical stimulation was then repeated to assess the ability of bretyllum to suppress inducible ventricular tachycardia. Bretylium tosylate, at a mean dose of 2.3 mg intravenously per minute, did not suppress inducible ventricular arrhythmias in any patient. Rapid ventricular tachycardia was induced in all patients, and ventricular fibrillation was induced in one patient. Two patients required external cardioversion to terminate their arrhythmias. Bretylium tosylate, given in relatively large doses chronically, did not suppress inducible ventricular arrhythmias in these five otherwise drug-refractory patients with chronic recurrent ventricular tachycardia. This failure to suppress inducible ventricular arrhythmias cannot be attributed to the initial catecholamine release which occurs in the first hour or two after the drug is administered.     

Rheumatoid nodulosis. Sporadic and familial diseases.

Two patients are described with longstanding, multiple, subcutaneous nodules with the histopathological features of rheumatoid nodules. Neither patient had any clinical evidence of rheumatic disease. One patient had a family history of smiliar nodules transmitted as an autosomal dominant trait. Leukocyte function studies failed to reveal any defect to account for the nodule formation.     

Antinuclear antibodies and the diagnosis of systemic lupus erythematosus in patients with acute intermittent porphyria.

To investigate the previously postulated association of systemic lupus erythematosus (SLE) and porphyria 38 patients with various types of porphyria were investigated for clinical and laboratory evidence of a connective tissue disease. Antinuclear antibodies (ANAs) were found in 8/15 (53%) patients with acute intermittent porphyria. These patients were more likely to have had a recent acute attack of porphyria, but only one patient had clinical evidence of SLE. Antinuclear antibodies were not found in any patients with latent acute intermittent porphyria or appreciably in any of the other types of porphyria studied. This finding of ANAs in patients with acute intermittent porphyria may explain the previously described association with SLE. Strict diagnostic criteria need to be used in any one patient as these two disorders have many similar clinical manifestations.     

Solitary beta-blocker therapy for idiopathic life-threatening ventricular tachyarrhythmias

To determine the clinical characteristics of patients with life-threatening ventricular tachyarrhythmias with no identifiable heart disease, we analyzed six patients who presented with either cardiac arrest or syncope associated with documented ventricular tachycardia or fibrillation. Electrocardiographic and echocardiographic examination and cardiac catheterization results were normal in all patients. Electrocardiographic monitoring revealed ventricular tachycardia in all patients. Exercise testing did not provoke sustained ventricular tachycardia in any patient. Programmed extrastimulation did not induce ventricular tachycardia in any patient. Isoproterenol infusion facilitated provocation of sustained ventricular tachycardia in only one patient. All six patients were treated with solitary beta-blocker therapy. Following treatment, there was a significant reduction in the incidence of ventricular tachycardia, couplets and total ventricular ectopic beats. During a follow-up period ranging from 16 to 36 (mean 22) months, all patients remain alive without clinically significant recurrence. Therefore, patients with life-threatening ventricular tachyarrhythmias without identifiable heart disease may respond to solitary beta-blocker therapy.     

Diurnal changes of bile lipid concentration in hepatic bile of cholecystectomized man.

Diurnal variations of bile lipid concentration were studied in ten patients with a tube in the main bile duct following a cholecystectomy. 5-6 bile samples per 24 h were collected from each patient during 3-40 days. The enterohepatic cycle was not significantly modified since total bile samples did not exceed 40 ml/day. Significant diurnal variations were observed in cholesterol concentration. Changes in lecithin concentration seemed to be similar in seven patients but did not reach the level of significance in any individual patient. Maximal values were observed between 4 and 8 a.m. and minimal values at 4 p.m. Bile salt concentration varied without any circadian periodicity. Mean bile lipid concentration was calculated for each patient. The patients with highest cholesterol concentrations have also the highest mean lecithin concentration. Mean bile salt concentration does not differ much from one patient to another.     

Drug-related syncope

The records of 483 patients admitted to the emergency room because of syncope were reviewed. Forty-one patients were found to have drug-related syncope. Thirty-nine experienced syncope related to drugs administered for cardiovascular disease. The most frequently associated diseases were anginal syndrome (22 patients), hypertension (13 patients), and a history of myocardial infarction (6 patients). Thirty-eight patients experienced symptomatic orthostatic hypotension following drug taking (nitrates in 19 patients, beta blockers in 10 patients, nifedipine in 3 patients, prazosin and quinidine in 2 patients each, methyldopa and verapamil in 1 patient each). One patient developed complete heart block as a result of digoxin intoxication. Two patients developed the characteristic picture of anaphylactic reaction (1 with ampicillin, 1 with dipyrone). During one-year follow-up, without the offending medications, no further syncopal episodes were reported by these patients. We conclude that drug-related syncope was more common among our patients with syncope than had been reported previously. It is suggested that drug-related syncope should be taken into consideration in any patient with syncope who is treated by any of the above-mentioned drugs.     

Blindness following a diabetic foot infection: a variant to the ‘eye–foot syndrome’?

AIMS: The 'eye-foot syndrome' was initially described by Walsh et al. to highlight the important association of foot lesions in patients with diabetic retinopathy. We present a case of a 58-year-old patient with Type 2 diabetes mellitus who developed blindness following endogenous staphylococcal endophthalmitis from an infected foot ulcer. RESULTS: Our case describes the link between the eye and the foot but is somewhat different to the association as described by Walsh et al. Endogenous endophthalmitis is rare with diabetic patients being especially at risk, and we report the first case of endogenous staphylococcal endophthalmitis related to a diabetic foot lesion. CONCLUSIONS: Our case illustrates several important issues in the management of diabetic patients admitted to hospital with infection; the need to thoroughly examine the feet to ascertain any foot lesions and any underlying peripheral vascular disease or peripheral neuropathy, to treat aggressively any infected foot lesions to prevent serious complications of septicaemia and to consider rare conditions like endogenous endophthalmitis in any diabetic patient presenting with acute visual impairment and septicaemia.     

Choriocarcinoma in an AIDS patient--relapsing but not fatal

Choriocarcinoma is associated with high mortality in immunocompromised patients, in contrast to a good prognosis in immunocompetent individuals. Respiratory failure due to metatstatic choriocarcinoma is associated with high mortality in any patient. We report a case of a woman with AIDS that survived metastatic choriocarcinoma and respiratory failure. We also observed that in contrast to some in vitro studies, the markedly elevated levels of beta-subunit of human chorionic gonadotropin in this patient did not have any apparent inhibitory effect on viral replication.     

A Comprehensive Surgical Procedure in Conservative Management of Placenta Accreta: A Case Series

We aimed to present a combined surgical procedure in conservative treatment of placenta accreta based on surgical outcomes in our cohort of patients. The study was designed as a prospective cohort series study. The setting involved two education and research hospitals in Turkey. This study included 12 patients with placenta accreta who were prenatally diagnosed and managed.We offered the patients the choice of conservative or nonconservative treatment. We then offered 2 choices for patients who had preferred conservative treatment, leaving the placenta in situ as is the classical procedure, or our surgical procedure. One patient preferred nonconservative treatment, the others opted for our procedure.We evaluated demographic and obstetric characteristics of patients, sonographic and operative parameters of patients, and surgical outcomes.We operated on 11 patients using this surgical procedure that we have developed for placenta accreta cases. We found that there was no need for hysterectomy in any patient, and we preserved the uterus for all of these patients. No patient presented any septic complication or secondary vaginal bleeding.Our surgical procedure seems to be effective and useful in the conservative treatment of placenta accreta.     

A ten-year material of insulinoma: diagnosis and surgical treatment.

A 10-year series of patients operated for insulinoma at Sahlgren's Hospital, Gothenburg, is presented. Twelve patients (three men, nine women) aged 26--70 years are included in the material. The patients had a history of recurrent hypoglycemic symptoms of 1 month to 20 years. Hyperinsulinism was established by determinations of blood glucose and plasma insulin in the fasting state. Selective angiography could show the tumor in 3 out of the 12 patients. A through pancreatic mobilization and palpation was performed during operation. Solitary pancreatic tumor was found in 10 patients, and 1 of them had also metastases in the liver. One patient had two tumors, one in the head and one in the tail of the pancreas. In one patient it was not possible to find any tumor at operation. Distal pancreatic resection and splenectomy were performed when the tumor was localized in the body or tail or when no tumor was found. Tumours in the head were excised locally. Microscopy showed insulinoma without malignancy in 10 patients, malignant tumor in insulae with metastases in the liver in 1 patient, and multiple adenomatosis of insulae in the patient without any palpable tumor. The 11 patients with benign disease were examined 1--10 years after the operation and had no signs of hyperinsulinism or of diabetes.     

Refusal of treatment

The decision regarding refusal of treatment ultimately rests with competent adult patients. When the elderly patients is an inadequate or incompetent decision-maker, in order to protect the interests of the patient, the physician should have some knowledge of the way decisions are and ought to be made, particularly when a decision to forgo life-sustaining treatment is being deliberated. In acquiring this knowledge, the physician needs to develop clear understanding about who has the authority and responsibility to speak for the patient and what standards are to guide the decision-making process involving the incompetent patient. This is not an easy task for any physician. In many instances, the process can become clouded by a host of complex ethical and legal issues that make any decision a questionable one. A beginning point might be the acceptance of the fact that every elderly patient possesses values and goals that are quite unique to him, even though they might seem identical to those held by many other patients. This fact, more than anything else, will help to remove many of the impediments that face the physician during the decision-making process.     

Activity and safety profile of low-dose rituximab for the treatment of autoimmune cytopenias in adults

We conducted a retrospective analysis of 11 consecutive patients with various autoimmune cytopenias who failed to respond to conventional treatments and received a fixed-dose regimen of rituximab (100 mg weekly for 4 consecutive weeks). Sustained complete responses were achieved in 4 out of 7 patients with idiopathic thrombocytopenic purpura and in 1 patient with autoimmune pancytopenia. A partial response was observed in 1 patient with autoimmune hemolytic anemia. The immunotherapy had no effect in 1 patient with pure red cell aplasia or in 1 patient with autoimmune neutropenia. No infusion-related or delayed toxicities attributable to rituximab were experienced by any of the patients.     

Peut-on arrêter une désensibilisation aux venins d’hyménoptères ?

The indications for starting specific immunotherapy with hymenoptera venoms have been well documented for patients who have had a thorough, well-defined diagnostic workup. Once has been decided to start this treatment, the question of how long it should be continued must be considered by the physician and the patient. Different studies on the follow-up of patients after immunotherapy has been discontinued, with data on the patients’ subsequent status, have shown that the risk of a subsequent systemic reaction is not zero but falls between 5 and 10%. When they occur, such reactions are usually moderate and usually occur in patients at risk. More than diagnostic data, such as the evolution of skin tests, the results of assays for specific IgE and IgG, or challenge tests, the duration of the treatment can be considered to be the best criterion for stopping the treatment. In any case, at least five years of immunotherapy is usually recommended. When the patient is at risk for a severe reaction (e.g., patients with a severe initial reaction, those who have had a systemic reaction induced by a therapeutic injection, and patients with mastocytosis), immunotherapy for the rest of the patient’s life should be considered. Of course, the patient must be informed of the eventual risk of another reaction and therapy should only be continued with the patient’s consent, In any case, the patient should be supplied with an emergency kit that includes an adrenaline-containing syringe for self-injection.     

A Double-blind Placebo Controlled Study of Male Alcoholics Given a Subcutaneous Disulfiram Implantation

Twenty-one alcoholics participated in a double blind study to elicit information of the clinical effect of implanted disulfiram. They were randomized to either of two groups, 11 patients to the placebo group and 10 patients to the disulfiram group. Each patient was subjected to seven sessions of intravenous ethanol challenge, once before and six times during the first 20 weeks after implantation. The acute ethanol challenge did not result in any differences between the groups with respect to blood ethanol and acetaldehyde concentrations. No patient showed any clinical signs of disulfiram-ethanol reaction. After a study period of 20 weeks no significant differences were found between the groups with regard to the reduction in average ethanol consumption, days from implantation to the first drink and number of abstinent weeks. Our results do not support the idea that a 1 g disulfiram implant has any pharmacological or clinical action.     

Acute paraplegia: a presenting manifestation of aortic dissection

Two patients who presented with acute paralysis of the lower extremities as an initial manifestation of aortic dissection are described. The first patient had transient chest pain followed by flaccid paralysis of her lower extremities and severe back pain. In the second patient, sudden paralysis of both legs developed without pain of any sort. The paraplegia completely resolved in a few minutes; however, chest and back pain later ensued. Both patients had a proximal (type I or A) aortic dissection. The first patient's entrance tear in the aortic intima was just above the aortic valve with antegrade propagation, whereas in the second patient, the entrance tear was at the aortic isthmus, with both antegrade and retrograde dissection. Acute cardiac tamponade resulted in sudden deterioration and death in both patients, before any therapeutic intervention could be entertained.     

Safe Scanning,but Frequent Artifacts Mimicking Bradycardia and Tachycardia During Magnetic Resonance Imaging (MRI) in Patients with an Implantable Loop Recorder (ILR)

Background: Patients with implantable devices are generally not permitted to undergo magnetic resonance imaging (MRI) because of potentially deleterious interactions. Little has been reported regarding the safety and effects of MRI scanning of patients with implantable loop recorders (ILRs). We evaluated the safety of scanning patients with ILRs and the output of the ILR after undergoing MRI. Methods: Ten patients underwent 11 MRI scanning events. All patients had Reveal Plus (Medtronic, Minneapolis, MN) ILRs. Seven cranial, two lumbar‐spine, one shoulder, and one knee MRI were performed. All of the MRIs were performed with the understanding that the patient had an ILR. In each patient, the ILR was cleared moments before the scan and the integrity of the signal and time date stamp were verified. The devices were reinterrogated immediately after MRI in 10 patients and two days post MR scanning in one patient. Each patient was questioned post MRI regarding any symptoms experienced during the scan. Results: Both tachy and bradyarrhythmias appeared as artifacts as a result of ILR exposure to MRI. Post MRI, none of the ILRs showed diminished signal integrity, altered programmed parameters, diminished battery status, inability to communicate or be reprogrammed. No sensations of tugging or warmth at the implant site were noted. Conclusion: MRI was performed in ILR patients without harm to the patient or permanent damage to the ILR. MRI scanning of the Reveal appears safe. Artifact mimicking an arrhythmia was common, however, and must be excluded in any ILR patient undergoing MRI to avoid mistakenly attributing a syncopal episode, or palpitations to the artifacts produced from MRI exposure.     

Age, resource consumption, and outcome for medical patients at an academic medical center

At the national level debate is growing about the effects of the diagnosis related group (DRG) hospital payment system on patient access and quality of care. Recent changes to the DRG system have dropped any stratification by age and have delayed any other major change to improve payment equity. We characterized hospital resource consumption and outcome by age for all medical admissions (N = 31,838) to a large academic medical center (January 1, 1985, through December 31, 1987) using the DRG format. Mean hospital cost per patient, hospital length of stay, percentage of outliers, and mortality increased with age. The mean DRG case-mix index and the number of diagnostic codes per patient also rose with age. The DRG payment for all patients would have produced an aggregate profit of $34,426,951 ($1081 profit per patient); however, patients aged 71 years or older generated loses (the highest with patients aged 85 years or older--a $2177 loss per patient). As the financial position of American hospitals continues to deteriorate, these data suggest that the current DRG payment scheme may be inequitable for the medical patient aged 71 years or older, thus providing financial disincentives to treat the elderly medical patient and perhaps limiting their access and quality of care in the future.     

Pneumonia in the elderly: the hospital admission and discharge decisions

Community-acquired pneumonia is both a common and a serious infection in the elderly population. The hospitalization and discharge decisions are among the most important management decisions physicians must make in caring for patients with this illness. Both of these decisions are important from a clinical, health services, and patient-oriented perspective. The hospitalization decision can be guided by a clinical algorithm that explicitly addresses five questions: (1) Does the patient have any life-threatening problems that require immediate stabilization (and de facto hospitalization)? (2) Does the patient have any prognostic factor(s) that increase the short-term risk of mortality? (3) Does the patient have any prognostic factor(s) that increase the short-term risk of morbidity or medical complications? (4) Does the patient have adequate functional skills or social support to allow care outside of the hospital? and (5) Does the patient require admission for a therapeutic modality or diagnostic evaluation? An affirmative response to any one of these questions indicates a need for hospitalization, whereas a negative response to all of the questions identifies potential candidates for outpatient care. The factors considered important in the hospitalization decision are also intimately related to the discharge decision. Before discharge, all acute physiological derangements should be corrected and laboratory abnormalities should be normalized or returning to baseline. All patients must be able to function socially outside of the hospital. Finally, treatment with an adequate course of antimicrobial therapy either must be completed or arranged on an ambulatory basis before discharge.     

Preoperative Serum Vascular Endothelial Growth Factor Is Not a Marker for Subsequent Recurrence During Long-Term Follow-Up of Colorectal Cancer Patients

BACKGROUND Serum vascular endothelial growth factor has been associated with stage of disease in colorectal cancer patients. We investigated whether preoperative serum vascular endothelial growth factor can provide any relevant clinical prognostic information during long-term follow-up of colorectal cancer patients.METHODS Preoperative serum samples of 79 colorectal cancer patients and serum of 28 healthy controls were stored at –80°C until later vascular endothelial growth factor analysis by enzyme-linked immunosorbent assay technique and carcinoembryogenic antigen concentration measurement were performed. There were three patient groups for comparison: 21 patients with overt liver metastases, 18 patients who developed recurrent disease after initial curative surgery, and 40 patients who remained disease-free for at least five years.RESULTS We could not demonstrate any significant difference in serum vascular endothelial growth factor values between the patient groups and controls, nor between the three patient groups (Mann-Whitney U test). There was no relevant correlation between serum vascular endothelial growth factor and carcinoembryogenic antigen concentrations (Pearson r = 0.2; P = 0.07).CONCLUSION Although vascular endothelial growth factor has been shown in previous studies to be a potent inducer of angiogenesis and metastases formation, the present data demonstrate that preoperative serum vascular endothelial growth factor concentration does not provide any relevant individual prognostic information in patients with colorectal cancer.Reprints are not available.