Which is a better treatment for hypertensive patients with diabetes: a combination of losartan and hydrochlorothiazide or a maximum dose of losartan?

BACKGROUND: This 12-month study compared the effects of a combination of losartan 50 mg and hydrochlorothiazide 12.5 mg with a maximum dose of losartan (100 mg) in hypertensive patients with diabetes. METHODS: This was a multicenter randomized open-label study. RESULTS: A similar reduction in systolic/diastolic blood pressure from baseline to month 3 was observed in both groups. There was also a similar decrease in UACR in both groups. A significant decrease in uric acid was observed in the maximum-dose group only. eGFR decreased in the combination group after 1 year. CONCLUSIONS: The combination of losartan and a diuretic may be a useful option in such hypertensive patients with diabetes, provided that metabolic parameters are closely monitored. In patients with hyperuricemia and impaired renal function, a maximum dose of losartan may be more beneficial.

Nutritional Status and Nutritional Management Implementation for Residents with Disabilities in Welfare Facilities: A Nationwide Survey in Japan.

In Japan, fees for nutritional management (NM) was introduced in April 2009 to improve nutritional care for persons with disabilities residing in welfare facilities. The present study aimed to clarify (1) the nutritional status as well as eating-related functions and behaviors of such residents and (2) status of incorporating claim fees for NM and oral maintenance in facilities supporting persons with disabilities. This cross-sectional study approached 2,510 welfare facilities for persons with disabilities across Japan. Anonymous questionnaire surveys were conducted in August 2018. Among the 1,543 responses, 1,538 (61.3%) were valid for analysis. The median number of residents in a facility was 50. Among all residents (n=80,322), 16.9% were underweight (body mass index [BMI]<18.5) and 14.5% were obese (BMI≥25.0). Of the residents, 38.9% adjusted food form and 15.2% had eating behavior-related problems. In total, 723 (47.0%) and 54 (3.5%) facilities, claimed the fees for NM and oral maintenance, respectively. The main reasons for not implementing the claim fees for NM was the lack of time for nutritional care and management (NCM; 30.2%), absence of a registered dietitian (29.3%), and difficulty in assessing swallowing function (24.1%). Our results revealed that the implementation rates of claim fees for NM and oral maintenance were low despite most respondents having problems with the double burden of malnutrition and necessity of oral care, suggesting the importance of securing time for NCM, appointing registered dietitians, and evaluating swallowing function.

Relationship between the Thyroid Function and Cognitive Impairment in the Elderly in Japan.

Objective The reference ranges of serum thyroid hormone levels are determined by the values of normal subjects aged 15 or 20 to 60 years old in Japan and may differ from the values in elderly patients. In addition, the relationship between the thyroid function and cognitive function remains controversial. We assessed the thyroid function of elderly subjects ≥60 years old and its impact on the cognitive function in Japanese adults. Methods We compared the thyroid function by age group and gender and investigated the effects of cognitive impairment on the thyroid function. This study was a cross-sectional, multi-institutional joint study. Patients The serum concentrations of thyroid hormones in 1,136 patients were measured; however, those taking thyroid hormones, anti-thyroid drugs, and steroid hormones were excluded. Among them, 1,016 cases in which the cognitive function was evaluated were divided into five groups according to their free thyroxine (FT4) levels. Results Excluding overt thyroid dysfunction (5.8%), the average age of the 1,070 remaining patients was 77.5 years old. The rate of cognitive impairment was lowest at FT4 levels of 1.1-1.2 ng/dL and highest at FT4 levels <0.9 ng/dL for both genders. Thyroid-stimulating hormone (TSH) levels in the elderly varied widely by age group and gender. The upper limit of the reference range of TSH for those ≥60 years old may be higher (7.7-9.2 mIU/L for men; 8.2-8.6 mIU/L for women) than the current range for those <60 years old (4.23 mIU/L). Conclusion The thyroid function seemed to be slightly higher (lower TSH and higher FT4) in the population without cognitive impairment than in those with cognitive impairment, except for men in their 90s.

Primary hyperparathyroidism presumably caused by chronic parathyroiditis manifesting from hypocalcemia to severe hypercalcemia.

A 67-year-old woman who presented with hypocalcemia compatible with idiopathic hypoparathyroidism gradually changed into a state of primary hyperparathyroidism. The left upper parathyroid gland, which was larger and harder than other glands, was resected. Despite the operation, hypercalcemia and high levels of intact PTH persisted. Six weeks later total parathyroidectomy was done to induce remission. The resected gland in the first operation had clusters of lymphoid follicles with germinal centers indicating a chronic autoimmune inflammation. This case suggests a transition from hypoparathyroidim to hyperparathyroidism associated with chronic parathyroiditis, possibly by a mechanism analogous to that observed in chronic thyroiditis.

Primary hyperparathyroidism due to atypical vertically long cystic adenoma.

UNLABELLED: Parathyroid cystic adenomas are often misdiagnosed as thyroid cysts and routine preoperative diagnostic tools, such as ultrasonography (US) or 99m technetium-sestamibi (99mTc-MIBI) scans, cannot clearly distinguish between these entities. We present a 67-year-old hypercalcemic woman with a cervical cystic lesion who had negative sestamibi scan results. Her laboratory data indicated primary hyperparathyroidism (serum calcium concentration 14.0 mg/dl, phosphate concentration 2.3 mg/dl, and intact parathyroid hormone (PTH) concentration 239 pg/ml). The cervical US and computed tomography scans revealed a large and vertically long cystic mass (12×11×54 mm). A mass was located from the upper end of the left thyroid lobe to the submandibular region and was not clearly distinguishable from the thyroid. For preoperative definitive diagnosis, we carried out a parathyroid fine-needle aspiration (FNA) and PTH assay (PTH-FNA) of liquid aspirated from the cyst. The intact PTH-FNA concentration was 1.28×10(6) pg/ml, and the patient was diagnosed with primary hyperparathyroidism due to a cystic mass. She underwent a left upper parathyroidectomy and her serum calcium and intact PTH concentration immediately decreased to normal levels. This report describes the usefulness of PTH-FNA for localizing and differentiating an atypical functional parathyroid lesion from nonfunctional tissue in primary hyperparathyroidism. LEARNING POINTS: Cystic parathyroid lesions, even in the case of elevated PTH levels, can produce negative results in 99mTc-MIBI scans.Preoperative diagnosis of parathyroid cysts detectable on US is possible by parathyroid FNA and PTH assay (PTH-FNA) of liquid aspirated from the cyst, if malignancy is not suspected. PTH-FNA could be helpful in the differential diagnosis of an equivocal cervical tumor.

Bright pituitary stalk on MR T1-weighted image: damming up phenomenon of the neurosecretory granules.

Characteristic findings of the pituitary stalk on magnetic resonance (MR) imaging, which suggest a damming-up phenomenon of neurosecretory granules, were reported. Neurosecretory granules containing vasopressin influence the signal intensity on MR T1-weighted image (T1WI). The normal posterior lobe of the pituitary gland appears as a bright signal on T1WI. The bright signal of the posterior lobe represents the normal content of neurosecretory granules and disappears in patients with central diabetes insipidus. The normal pituitary stalk appears as a low-intermediate intensity signal on sagittal and coronal T1WIs with 3 mm-slice thickness. The pituitary stalk appeared as a bright signal in 20 patients; 13 with pituitary adenoma, 4 with an intrasellar cystic lesion, one with cavernous sinus mass, and 2 with no abnormal MR findings. The pituitary stalk was not severed in any of the cases. The normal bright signal of the posterior lobe disappeared in 17 patients. No patients suffered from symptoms of central diabetes insipidus when the bright pituitary stalk appeared. It is suggested that the origin of the bright signal in the pituitary stalk is the damming up and accumulation of neurosecretory granules in the nerve fibers of the hypothalamohypophyseal tract obstructed by adenoma, postoperative scarring, cystic mass and so on. Probably, the damming-up phenomenon on MR imaging represents the functional integrity of the hypothalamo-neurohypophyseal system, and should be distinguished from an ectopic posterior lobe formation which is caused by stalk transection.