RESUMEN

BACKGROUND: Studies of community-dwelling patients have indicated that substantial numbers of patients might have had thyroid hormone therapy prescribed inappropriately and that thyroid hormone therapy in some can be discontinued without adverse effects or evidence of clinical hypothyroidism. We wanted to find out whether thyroid hormone therapy in selected nursing home patients could be withdrawn without adverse effect. METHODS: Participants for the study were drawn from four skilled nursing facilities in Connecticut. All patients on thyroid hormone therapy who resided in one of the four facilities at the time the study began were eligible if they met the inclusion criteria and gave consent to participate in the study. We measured baseline thyrotropin (TSH) levels and reduced thyroid hormone therapy by approximately onehalf if baseline TSH levels were 7 mU/L or less. If at a 1-month follow-up measurement a patient's TSH level was 7 mU/L or less, we discontinued thyroid hormone therapy. If TSH levels remained 7 mU/L or less at the next follow-up measurement 1 month later, we measured the free thyroxine (T4) level. If the free T4 level was normal, the patient remained off thyroid hormone therapy, and a final TSH value was measured after a further 2 months. RESULTS: There were 915 patients residing at the four homes at the time the study began. One hundred fifteen were on thyroid hormone therapy; 40 had elevated TSH levels in their nursing home records; and 31 refused to participate in the study. Twenty-two patients were excluded because they died or were discharged before completion of the study, had an elevated baseline TSH reading, or were taking medications that could complicate the accurate measurement of TSH. Twenty-two patients began hormone withdrawal. One patient had an increase in psychiatric symptoms during the withdrawal phase. No other adverse effects were noted. Eleven patients (50%) had the thyroid hormone therapy withdrawn successfully. CONCLUSION: Thyroid hormone therapy was successfully withdrawn from one half of the nursing home residents studied. Previous studies conducted in community-dwelling patients have shown similar findings. Many older patients began taking thyroid hormone therapy when younger either for inappropriate reasons or for what turned out to be transient hypothyroidism. If the findings of this study are generalizable for other nursing home residents, there are important implications for health and health care costs.

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

We describe a middle-aged profoundly hypogonadal man with panhypopituitarism since infancy who was treated only with glucocorticoid and thyroid replacement. A magnetic resonance imaging study (MRI) revealed absence of pituitary stalk and ectopic neurohypophysis consistent with traumatic transection, probably resulting from a traumatic birth. The hormonal consequences of this stalk lesion were recognized but inadequately treated for 45 years resulting in avoidable endocrine and psychosocial defects. Androgen replacement was started at age 45 with good initial results. The unique hormonal replacement issues at this age are discussed.

Asunto(s)

RESUMEN

A cohort of 137 insulin-treated adults with diabetes was evaluated at enrollment in a diabetes education and care program; 69 completed follow-up evaluations (mean = 11.2 months) to ascertain clinical outcomes. Factors that predicted change in metabolic, functional, and knowledge status were identified. The metabolic status of this cohort also was compared with a similar group of patients from a health maintenance organization (HMO) in a neighboring state. The mean HbA1c decreased from 9.97% at enrollment to 7.53% at follow-up. Functional status scores did not improve from baseline to follow-up. The relationship between knowledge and metabolic control differed for subjects with diabetes of long duration and short duration. A predictor of improved HbA1c was baseline HbA1c. A predictor of improved symptom score included white race or Hispanic origin. Patients who attended this program had better metabolic outcomes than the comparison group of patients.

Asunto(s)

RESUMEN

OBJECTIVE: To describe a glucose abnormality in AIDS that is characterized by transient NIDDM followed by hyperinsulinemic normoglycemia. RESEARCH DESIGN AND METHODS: A 36-yr-old Hispanic man with AIDS was on long-standing aerosolized pentamidine therapy in 1986. He received a course of intravenous pentamidine 5 mo before the onset of diabetes. Nonketotic hyperglycemia responded to sulfonylurea, which had to be discontinued 3 mo later because of normoglycemia. RESULTS: Diabetes diagnosis was made by three separate fasting blood glucose values of 16.2, 18.1, and 29.9 mM, and HbA1C of 10.1% (normal 4.2-5.9). The patient became euglycemic 5 mo after diagnosis while on no treatment. An oral glucose tolerance test was then normal, and C-peptide stimulation showed supra-normal response. CONCLUSIONS: Transient severe NIDDM in this case could not be linked to acute stress. Pentamidine, in a progressively increasing cumulative dose, is one possible, albeit unusual, etiology because the diabetes was not permanent. After diabetes remission, the data suggest residual insulin resistance that is unusual in HIV-positive patients. Diverse glucose abnormalities exist in AIDS. Awareness of their presentation is clinically helpful.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: This study prospectively identifies those characteristics of office patients with diabetes that predict subsequent improvement in glycemic control in response to an educational intervention. METHODS: Data on demographic factors, disease characteristics, and glycemic control were obtained on a consecutive series of patients referred by their primary physician to a 4-day outpatient diabetes education and care program. Follow-up measurement of glycosylated hemoglobin (HbA1C) was obtained from the same laboratory 2 months later. Analysis using logistic response models identified baseline characteristics associated with improved HbA1C. RESULTS: Among the 169 study subjects, 74 (44 percent) had at least a 20 percent improvement in HbA1C levels 2 months after the program. Among these subjects, mean HbA1C level was 10.6 percent before and 7.4 percent 2 months after the program. Factors associated with improvement in HbA1C values in bivariate and multivariate logistic models included duration of diabetes less than 2 years (risk ratio = 1.90, 95 percent confidence interval (CI) 1.30-2.76) and initial HbA1C level greater than 10 percent (risk ratio = 2.75, 95 percent CI 2.08-4.01). Baseline functional status, health locus of control, social support, knowledge of diabetes self-care, age, weight as percentage of ideal body weight, age at diagnosis, race, sex, family history of diabetes, type of diabetes, and mode of treatment were not significant predictors of improved HbA1C. CONCLUSIONS: Patients with shorter duration of diabetes and poor baseline glycemic control were most likely to have clinically significant glycemic responses to this program. Severity of disease and regression to the mean were unable to account for this association, leaving unanswered the question of the mechanism of this association. The data also identified a group of patients who do not respond well to this educational approach and for whom novel approaches to behavior change should be considered.

Asunto(s)

Asunto(s)

RESUMEN

We report the case of a middle-aged man with a 6-month history of diabetes treated with insulin. He was referred for diabetes control and education. Six weeks after we saw him, he was euglycemic (hemoglobin, Hgb A1C 5.9%), but returned because of weight loss, diarrhea, and abdominal cramps. Pancreatic adenocarcinoma was diagnosed. We review the literature on the relationship between diabetes mellitus and pancreatic carcinoma with particular emphasis on situations in which recent-onset diabetes may be a harbinger of pancreatic carcinoma. Several reports are cited in which the onset of diabetes mellitus in middle-aged patients antedated by a short time the onset of clinically recognizable pancreatic carcinoma. An otherwise silent pancreatic carcinoma may present as new-onset diabetes. Although rare, pancreatic carcinoma should be considered in a recently diagnosed middle-aged diabetic person with unusual manifestations, e.g., abdominal symptoms and continuous weight loss despite euglycemia.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)