Persistent renal hypertrophy and faster decline of glomerular filtration rate precede the development of microalbuminuria in type 1 diabetes

Soon after the onset of type 1 diabetes, renal hypertrophy and hyperfiltration become manifest, particularly among patients who will subsequently develop diabetic nephropathy. Whether these early renal dysfunctions are involved in the pathogenesis of diabetic nephropathy is currently unclear. We evaluated, during the same day, kidney volume and glomerular filtration rate (GFR) in 146 patients with type 1 diabetes and normal renal function. All the individuals were then monitored for a mean of 9.5 +/- 4.4 years for the development of microalbuminuria. Kidney volume and GFR were reevaluated in a subset of 68 patients 4 years after baseline. During follow-up, microalbuminuria developed in 27 of 146 diabetic patients. At baseline, kidney volume (312.8 +/- 52.6 vs. 281.4 +/- 46.1 vs. 236.8 +/- 41.6 ml/1.73 m(2), P < 0.05) but not GFR was increased in patients predisposed to microalbuminuria. Risk of progression was higher in patients with increased kidney volume (P = 0.0058). Patients predisposed to microalbuminuria showed a stable increase in kidney volume (P = 0.003), along with a faster decline of GFR (P = 0.01). Persistent renal hypertrophy and faster decline of GFR precede the development of microalbuminuria in type 1 diabetes. These findings support the hypothesis that renal hypertrophy precedes hyperfiltration during the development of diabetic nephropathy.     

Incidence and treatment of diplopia after three-wall orbital decompression in Graves' ophthalmopathy

PURPOSE: To describe our experience treating diplopia after orbital decompression in patients with thyroid orbitopathy. PATIENTS AND METHODS: From May 1997 to July 2001, we performed orbital decompression on 102 patients (34 men and 68 women) with severe proptosis. In 10 (9.8%) of these patients who had no diplopia preoperatively, diplopia in primary gaze occurred after decompression. In 19 (18.6%) of the patients with diplopia in primary gaze before surgery, there was no modification of diplopia after decompression. In 24 (23.5%) of the patients with diplopia in primary gaze before surgery, a more severe imbalance occurred after decompression. Forty-four (83%) of these 53 patients underwent adjustable extraocular muscle surgery with the use of viscoelastic substances to gain single vision in primary position. In 9 (17%) of the patients, diplopia was resolved with the use of prismatic lenses. RESULTS: In 31 (70.4%) of 44 patients, we obtained a stable resolution of diplopia in primary position (minimum follow-up, 6 months). In 10 (22.7%) of these patients, a second surgery on the oblique muscles was necessary 6 months after the first surgery to resolve torsional diplopia. In 3 (6.8%) of the patients, diplopia has been resolved with prismatic lenses. CONCLUSION: Orbital decompression reduces proptosis, but may cause diplopia or worsen it.     

The consultation psychiatrist as effective physician

The two fundamental tasks of the consultation psychiatrist, diagnosis and treatment, can sometimes seem at odds with the consultee's desired plan or outcome. While implicitly recognized, this fact is rarely explicitly taught to residents or addressed in the literature. The authors proffer three principles of inpatient consultation psychiatry aimed at dealing with tensions that can arise over issues of; 1) diagnosis (Principle I: Do not be afraid to refute notions of psychopathology); 2) medication (Principle II: Do not be afraid to discontinue unnecessary psychotropics); and 3) responsibility (Principle III: Do not be afraid to "sign off" when necessary). These principles emphasize the medical model, the status of the psychiatrist as a medical expert, and the importance of defining one's professional limits.     

Multimodal imaging characterization of peripheral drusen

Graefe's Archive for Clinical and Experimental Ophthalmology - To provide an integrate multimodal imaging characterization of peripheral drusen in the eyes with and without macular signs of...     

Isolated foveal hypoplasia

Purpose To describe a patient with isolated foveal hypoplasia. Methods A 55-year-old man with the clinical suspicion of foveal hypoplasia was given a complete ophthalmological examination, including optical coherence tomography (OCT), fluorescein angiography (FA) and fundus-related perimetry (FRP). Mutation screening for oculocutaneous albinism and aniridia was also performed, but the results were negative for both. Results Following a complete ophthalmological examination and genetic studies, we were able to confirm the clinical suspicion of isolated foveal hypoplasia in this otherwise healthy patient. Conclusions With this report we want to highlight the roles of OCT, FA and FRP in the diagnosis of such a singular condition as isolated foveal hypoplasia. The authors have no proprietary interest in the materials used in this study.