Pre-clinical Cushing's syndrome: an unexpected frequent cause of poor glycaemic control in obese diabetic patients

OBJECTIVE Autonomous cortisol secretion without clinical stigmata of Cushing's syndrome (CS) has been recently recognized and termed pre-clinical or sub-clinical CS. The common assumption is that CS is an extremely rare cause of uncontrolled diabetes; however, the prevalence of this entity has not been studied. We assessed the prevalence of pre-clinical CS among obese patients with uncontrolled diabetes. PATIENTS AND DESIGN (1) In a retrospective analysis, the medical records of 63 patients with endogenous CS were reviewed. (2) In a cross-sectional study, 90 obese patients (BMI >25 kg/m²) followed in a University Hospital and the local Health Fund endocrine and diabetes clinics, with poorly controlled diabetes (glycosylated haemoglobin >9%), underwent an overnight 1 mg dexamethasone suppression. In patients with non-suppressible cortisol levels (>140 nmol/l), Liddle's 2 and 8 mg dexamethasone suppression tests and imaging studies were performed. MEASUREMENTS The prevalence of poorly controlled diabetes, the major presenting symptom of CS, was assessed in the retrospective analysis. The prevalence of ‘true’ CS and the false positive rate in the overnight dexamethasone suppression test were calculated. The endocrine evaluation of the patients with pre-clinical CS and the effects of surgical cure on glycaemic control are described. RESULTS In the retrospective analysis, 11 (17.5%) had diabetes and 2 (3.2%) lacked the classic physical characteristics of the syndrome. In the cross-sectional study, 4 patients failed to suppress plasma cortisol (<140 nmol/l). In one patient the diagnosis of CS was not confirmed by a standard Liddle’s test and was therefore considered false positive. In the other 3, the diagnosis of CS was confirmed (prevalence of 3.3%, 95% confidence interval 1–9%). In all other patients the overnight cortisol suppression test was normal (cortisol level 47.3 ± 2.5 nmol/l (mean ± SEM)). After surgical treatment of CS, glycaemic control was markedly improved in all 5 patients (2 from retrospective and 3 from cross-sectional studies). CONCLUSIONS The prevalence of pre-clinical Cushing's syndrome in obese patients with poorly controlled diabetes appears to be considerably higher than previously believed. The overnight dexamethasone suppression test proved to be a simple, sensitive and highly specific screening test for Cushing's syndrome despite the presence of obesity and hyperglycaemia.     

Microcystic adnexal carcinoma following radiotherapy in childhood

A 36-year-old man was treated by radiotherapy for tinea capitis many years before discovery of microcystic adnexal carcinoma (MAC). Because of patient's refusal of any surgical intervention, we were able to follow the natural course of this tumor for 13 years. This case emphasizes the typical slow development of (MAC). The implication of the association of MAC and radiotherapy are discussed.     

IgA, IgG, IgM, and IgE levels in normal, healthy, non-atopic Israeli children

IgA, IgG, IgM, and IgE levels in healthy, non-atopic, Israeli-born children aged 20 days to 16 years were analyzed and showed similar age-related values and dynamics as those of white populations found in other countries. No significant effect of sex of the individual or ethnic origin of the parents was found on the IgE values at different ages. This may indicate that total IgE levels are strongly influenced by environmental factors. Establishing tolerance limits at 97.5, 95, 75, 25 and 5th percentiles and the geometric mean provides the practitioner with more complete reference values. The use of multivariate control charts with tolerance limits from normal IgA, IgG, IgM, and IgE levels is described and is offered as an additional tool for the diagnosis of an allergic individual.     

Adult patients' adjustability to orthodontic appliances. Part I: a comparison between Labial, Lingual, and Invisalign™

This prospective study examined the adult patient's perception of recovery after insertion of three types of orthodontic appliances: Buccal, Lingual and Invisalign. The sample consisted of sixty-eight adult patients (45 females and 23 males) who comprised three groups: 28 Buccal, 19 Lingual, and 21 Invisalign patients. After appliance insertion, patients completed a Health-Related Quality of Life questionnaire daily for the first week and again on day 14, in order to assess patients' perception of pain and analgesic consumption. In addition, four areas of dysfunction were assessed: oral dysfunction, eating disturbances, general activity parameters, and oral symptoms. Lingual appliance was associated with more severe pain and analgesic consumption, the greatest oral and general dysfunction, and the most difficult and longest recovery. The Invisalign patients complained of relatively high levels of pain in the first days after insertion; however this group was characterized by the lowest level of oral symptoms and by a similar level of general activity disturbances and oral dysfunction compared to the Buccal appliance. Many Lingual and some Buccal patients did not reach a full recovery from their eating difficulties by the end of the study period. The present study provides information to adult patients and clinicians assisting them in choosing the most appropriate treatment modality in relation to Health-Related Quality of Life parameters.     

Examining professional boundaries between nurses and physicians in neonatal intensive care units

Background

Medical and technological developments, financial constraints and a shortage of physicians have made it necessary to re-examine professional boundaries between physicians and nurses. Israel’s manpower shortage in Neonatal Intensive Care Units (NICUs) has changed the responsibility and authority of nurses. However, these changes have not evolved into a uniform policy defining the division of responsibility between physicians and nurses. This study was designed to examine the work processes and actual division of labor between NICU physicians and nurses; the attitude of physicians and nurses to greater empowerment of the nursing role; and to suggest a model to regulate work processes and develop the role of neonatal nurse specialists in NICUs.

Methods

Open interviews with NICU physician-directors and head nurses and a cross-sectional survey of some 50% of the physicians and nurses at 22 hospital NICUs (N?=?430).

Results

Main problems of NICUs: physician shortage, deficient infrastructures, fragmented work processes. Nurses do not perform many practices allowed to them due to the need for organizational approval and their own unawareness. Conversely, they sometimes conduct procedures and make decisions outside of their authority.Most physicians agree that nurse graduates of Post-Basic Education training (PBE) should be authorized to independently perform such activities as resuscitation and medication balancing while reserving invasive procedures for physicians. It is widely agreed that broadening the authority of nurses would improve the quality of NICU care even though it would increase the nursing workload.

Conclusions

The study provides important input into decisions about authorizing nurses over complete practice areas rather than isolated activities; the need to remove institutional restrictions on tasks currently permitted to nurses; introducing teamwork from within the NICUs, and expanding nursing decision-making. The study reveals that there is a basis on which to to build the role of the neonatal nurse,since most NICU nurses have the suitable academic and clinical training.

     

The “Cross-furrowed” forehead

Three middle-aged men were encountered whose foreheads showed a pattern of vertical lines as well as the standard transverse furrows. The etiology of these lines is obscure.     

Infectious complications of burns casualties during the yom-kippur war

Summary During the October 1973 military conflict, 41 burned patients hospitalized at the Sheba Medical Center were closely followed up. All the patients who had burns occupying 20% or more of the body surface developed wound infections. Pseudomonas aeruginosa was the major pathogen isolated. Most infections occurred during the second week following the injury. Serial cultures revealed that only the isolation of Proteus species and P. aeruginosa from wounds could predict an infection caused by those microorganisms. During treatment with gentamicin and carbenicillin a marked increase in carbenicillin-resistant P. acruginosa and gentamicin-resistant Klebsiella strains was noted. Cross-infection with carbenicillin-resistant P. aeruginosa was not a major cause in the development of resistant strains.

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Infektiöse Komplikationen von Verbrennungen während des Yom-Kippur-Krieges

Zusammenfassung Während des Yom-Kippur-Krieges wurden die Krankheitsverläufe von 41 Patienten mit Verbrennungen im Sheba Medical Center genau erfaßt. Alle Patienten, die Verbrennungen von 20% oder mehr der Hautoberfläche aufwiesen, entwickelten Wundinfektionen. Der am häufigsten isolierte Erreger war Pseudomonas acruginosa. Die meisten Infektionen traten während der zweiten Woche nach der Verbrennung auf. Verlaufskulturen bewiesen an Hand der alleinigen Isolierung von Proteus-Spezies und P. aeruginosa, daß eine Infektion durch diese Keime zustande kam. Während der Behandlung mit Gentamicin und Carbencillin trat ein deutlicher Anstieg von Carbencillin-resistenten P. aeruginosa und Gentamicin-resistenten Klebsiella-Stämmen auf. Die Übertragung von Carbencillin-resistenten P. aeruginosa im Hospital war nicht in erster Linie für das Auftreten der resistenten Stämme verantwortlich.