Factitious hypoglycemia due to surreptitious administration of insulin. Diagnosis, treatment, and long-term follow-up

Ten patients had factitious hypoglycemia due to surreptitious insulin injections diagnosed and were followed for up to 15 years (median, 5 years; range, 2 months to 15 years). When available, demonstration of anti-insulin antibodies was the most helpful diagnostic test. Decreased plasma C-peptide levels corroborated the diagnosis. Young women (nine of ten) with knowledge of the medical profession or relatives with diabetes mellitus predominated in the sample. Five of the patients had a history of insulin-requiring diabetes mellitus. Two patients eventually committed suicide despite the best efforts at therapy. Only three of ten patients made a successful transition into productive life after the diagnosis of factitious hypoglycemia was established. Factitious hypoglycemia remains a difficult diagnosis to make, and the long-term outcome after the diagnosis is established is unpredictable. All efforts have to be made to confirm the diagnosis before the patients are approached. The confrontation is to be made by an experienced team of health care professionals who have gained the patient's confidence through an understanding but firm manner. Long-term therapy must be planned and initiated before the patient's discharge.     

Nursing home staff perspectives on adoption of an innovation in goals of care communication

Nursing homes (NH) are important settings for end-of-life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia. Study design was a cross-sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial. Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff. Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.     

Decreased responsiveness of GH3 cells to the dopaminergic inhibition of prolactin

The inhibitory regulation of PRL secretion by dopamine (DA) or the dopaminergic agonists bromergocryptine (CB-154) and apomorphine was studied in cultured GH3 cells, an established rat anterior pituitary cell line which produces both PRL and GH. The basal release of PRL from GH3 cells was unaffected when incubated for 6 h with DA concentrations as high as 10(-4) M. The inability of DA to suppress PRL secretion could not be explained by the catabolism of DA or the presence of unknown inhibitors (e.g. estradiol) in the fetal calf serum present in the incubation media. Apomorphine and CB-154 were only partially effective in suppressing PRL release at high concentrations of 10(-4) and 10(-5) M, respectively. Various concentrations of the dopaminergic antagonist d-butaclamol did not reverse the inhibitory action of 10(-5) M CB-154, while equal concentrations (10(-5) M) of both d- and l-butaclamol significantly suppressed PRL release. The greatly lowered responsiveness of GH3 cells to dopaminergic inhibition of PRL is suggestive of some impairment of DA receptors. This hypothesis is supported by radioligand binding studies in which high affinity dopaminergic binding sites are absent in the same cell line used in this study.     

Immunohistological demonstration of respiratory syncytial virus antigens in Paget disease of bone.

Respiratory syncytial virus antisera have been found to produce a positive immunohistologic response in osteoclasts in bone sections or in cells cultured from Paget disease lesions in 12 out of 12 patients tested. These experiments were carefully controlled by several means. Use of experimentally infected cells served as positive controls. Adsorption of antisera on human bone powder and KB cells did not remove the specific immunologic stain, but adsorption of the antisera by the virus did. Negative results were also obtained in osteoclasts of patients with primary or secondary hyperparathyroidism. In addition, negative results in specimens of Paget disease were found with antisera to measles; parainfluenza 1, 2, and 3; influenza A, B and C; rubella; and herpes simplex. These results are consistent with the hypothesis that the nuclear and cytoplasmic inclusions in the osteoclasts of Paget disease are a result of viral activity.     

Respiratory dyskinesias: extrapyramidal dysfunction and dyspnea

Four patients had acute dyspnea and chest pain due to primary neurologic disease, not to cardiac or pulmonary disorders. They suffered from severe, involuntary respiratory dyskinesias, which resulted in an irregular respiratory rate, shortness of breath, and chest discomfort. These respiratory dyskinesias occurred as one aspect of more generalized choreiform movement disorders. Three patients had neuroleptic-induced tardive dyskinesias, and one had levodopa-induced dyskinesias. As a result of their ages and the nature of their complaints, some of these patients were originally thought to have cardiac and pulmonary disorders. Respiratory dyskinesias should be considered as a possible cause of respiratory distress in patients with extrapyramidal dysfunction.     

Prevalence and prognostic significance of silent and symptomatic ischemia after coronary bypass surgery: a report from the Coronary Artery Surgery Study (CASS) randomized population

The prevalence and prognostic significance of postoperative myocardial ischemia, as detected by exercise testing, were prospectively assessed in 174 patients from the Coronary Artery Surgery Study (CASS) randomized surgical population who had exercise testing before and 6 months after coronary artery bypass graft surgery. Whereas the prevalence of symptomatic ischemia significantly decreased postoperatively (52% vs. 6%, p less than 0.001), the frequency of silent myocardial ischemia did not change (30% vs. 29%). Survival at 12 years after bypass surgery based on the 6-month postoperative exercise test results was significantly better for the 112 patients with no ischemia (80%) than for the 51 patients with silent ischemia (68%) or the 11 patients with symptomatic ischemia (45%). These data show that coronary artery bypass graft surgery diminishes the overall prevalence of symptomatic but not silent ischemia and that both silent and symptomatic ischemia adversely affect the postoperative prognosis of these patients.