Diabetes mellitus and thyroid disease.

Diabetes mellitus not infrequently coexists with hypo- and hyperthyroidism. Hyperthyroidism aggravates glucose intolerance. A review of this phenomenon reveals multiple mechanisms, which include increased hexose intestinal absorption, decreased responsiveness to insulin, and increased glucose production. Conflicting results are obtained when circulating insulin level is measured in thyrotoxicosis. The role of glucagon and alpha-cell sensitivity is unclear. Diabetes mellitus influences the assessment of thyrotoxicosis by falsely decreasing the blood levels of thyroxine (T4) and triiodothyronine (T3) during severely uncontrolled hyperglycemia. Hypothyroidism is found in about 3% of patients with insulin-dependent diabetes mellitus (IDDM). Moreover, 13-20% of IDDM patients have elevated blood thyrotropin levels and anti-thyroid antibodies. Hypothyroidism per se seems to ameliorate hyperglycemia. A subtype of IDDM shares similar immunogenetic features with familial autoimmune thyroiditis. Studies of IDDM probands who show a high prevalence of circulating thyroid antibodies reveal the presence of such antibodies in their first-degree relatives. Circulating islet-cell antibodies, detected in a majority of IDDM patients at the onset of their disease, tend to persist only in those patients with coexistent polyendocrine autoimmune disease, including thyroiditis. Similar human leukocyte antigen (HLA) locus types are associated with thyroiditis and IDDM, namely HLA-Dr3 and -Dr4.

Transient state of NIDDM in a patient with AIDS.

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.

Hepatitis B virus markers in diabetes mellitus.

Serum markers for hepatitis B virus (HBV) were studied in 395 healthy control subjects and in 100 diabetic patients. Of the patients, 28 had type I diabetes, 31 had type II diabetes requiring insulin, and 41 had type II diabetes treated with oral agents or diet alone. None gave history of previous icterus or other signs of hepatitis, had received blood transfusions, or had been on hemodialysis. There was a significant difference in the prevalence of HBV markers (mainly HB surface antibody) between the diabetic group and the controls (51% versus 25%, P less than 0.001). The control subjects included hospital personnel and, hence, their risk of HBV exposure was already relatively high. The increased occurrence of HBV markers did not seem to be related to diabetes duration, patient age, intake of insulin injections, or presence of microvascular complications. This study reveals a high degree of exposure to HBV in a moderately controlled diabetic group and possibly a high degree of proneness to subclinical hepatitis B.

Ocular surgery in patients with diabetic nephropathy.

Patients with severe diabetic nephropathy often have diabetic retinopathy requiring eye surgery. During the course of their nephropathy, which was treated medically (group A, N = 34), with dialysis (group B, N = 18), or with renal transplantation (group C, N = 2), 54 diabetic patients have had eye surgery. The ophthalmologic procedures included cataract extraction, vitrectomy, scleral buckling, and cyclocryosurgery. The complications included postoperative hemorrhagic glaucoma and persistent retinal detachment. These were encountered in two patients of group A and in two of group B. All other cases showed uneventful intra- and postoperative courses. Major eye surgery can be performed safely during therapy for diabetic nephropathy, including hemodialysis with anticoagulation and transplantation with immunosuppression.

Clofibrate-induced muscular syndrome. Report of a case with clinical, electromyographic and pathologic observations.

In this report the clinical features of a case of clofibrate-induced muscular syndrome, as well as the electromyographic, histochemical, light- and electron-microscopic findings are described. The clinical features are similar to those of previously reported cases. Electromyography was consistent with a myopathy. Histochemical profile was normal. The myopathology included breakdown of contractile material, deranged mitochondria, dilated sarcoplasmic reticulum profiles, accumulation of membrane bound dense bodies, discontinuities in sarcolemma and thickening of capillary basement membrane. Macrophages invaded severely affected fibers.

An outpatient model of integrated diabetes treatment and education: functional, metabolic, and knowledge outcomes.

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.

The role of birth injury and the consequences of inadequately treated hypogonadism in longstanding panhypopituitarism.

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.

Successful withdrawal of thyroid hormone therapy in nursing home patients.

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.

Longitudinal study of a diabetes education and care intervention: predictors of improved glycemic control.

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.

New-onset diabetes mellitus as a harbinger of pancreatic carcinoma. A case report and literature review.

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.

Clofibrate-induced myotoxicity in rats. Temporal profile of myopathology.

In this report, the temporal sequence of myopathology during a clofibrate-induced muscular syndrome and its recovery in rats is described using histopathologic, histochemical and electron microscopic technics. Two stages of myopathology are described: an early stage characterized by myopathic features, and a later stage characterized by neurogenic features. Although muscle histology returns to normal after 1 week of discontinuing the drug, electron microscopic abnormalities persist through the second week. It is proposed that clofibrate, in addition to its myotoxic effect, may be neurotoxic.