Diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.

COVID-19 Vaccine-Associated Lymphadenopathy in Breast Imaging Recipients: A Review of Literature.

The unpredictability of the coronavirus disease 2019 (COVID-19) pandemic has created an ongoing global healthcare crisis. Implementation of a mass vaccination program to accelerate disease control remains in progress. Although injection site soreness, fatigue, and fever are the most common adverse reactions reported after a COVID-19 vaccination, ipsilateral lymph node enlargement has increasingly been observed. In patients undergoing routine screening and surveillance for breast cancer, interpreting lymphadenopathy (LAP) is challenging in the setting of a recent COVID-19 vaccination. With a growing proportion of the population receiving the vaccine, a multifaceted approach is necessary to avoid unnecessary and costly workup. In this comprehensive review, we summarize the existing literature on COVID-19 vaccine-associated LAP in breast imaging patients.

THE ENDOCRINOLOGY OF AGING: A KEY TO LONGEVITY "GREAT EXPECTATIONS".

ABBREVIATIONS: AMP = adenosine monophosphate CETP = cholesteryl ester transfer protein FOXO = Forkhead box O GH = growth hormone HDL = high-density lipoprotein IGF-1 = insulin-like growth factor 1 LDL = low-density lipoprotein miRNA = microRNA mTOR = mammalian target of rapamycin SIRT = sirtuin T4 = thyroxine TSH = thyroid-stimulating hormone "The Moving Finger writes; and, having writ, Moves on: nor all thy Piety nor Wit Shall lure it back to cancel half a Line, Nor all thy Tears wash out a Word of it." Omar Khayyam ( 1 ).

Novel insights into the pathophysiology and clinical aspects of diabetic nephropathy.

Diabetic nephropathy (DN) is a well-described complication of diabetes mellitus and the leading cause of end stage renal disease (ESRD). Although increased albuminuria has been the gold standard for screening, data suggests that renal damage starts long before the onset of clinically apparent increases in macro and even micro-albuminuria. Clinical practice guidelines for the prevention of DN have been traditionally focused on the control of serum glucose, blood pressure and dyslipidemia, with some focus on the renin-angiotensin-aldosterone system (RAAS) as a main target for successful therapy. Recent evidence has led to a better understanding of the underlying mechanisms of the pathophysiology of this disease and suggests that various novels pathways can be targeted to delay and even prevent the progression of DN. Hence a more comprehensive therapeutic approach to therapy is on the horizon, carrying the promise for a more successful and impactful management. This review will highlight new insights into the pathophysiology, clinical aspects and future diagnostic and therapeutic modalities for DN.

Severe Insulin Resistance Improves Immediately After Sleeve Gastrectomy.

Introduction. Obese individuals exhibit insulin resistance often leading to adverse health outcomes. When compared with intensive medical therapy, bariatric surgery has shown better outcomes mainly in terms of insulin resistance and glycemic control. Using the Homeostasis Model Assessment of insulin resistance (HOMA-IR), we report herein a case illustrating a drastic improvement in severe insulin resistance after sleeve gastrectomy in the immediate postoperative period. Case Report. A patient with long-standing history of morbid obesity, type 2 diabetes, obstructive sleep apnea, hypertension, and severe insulin resistance (requiring approximately 2 units of insulin per kg per day) was enrolled in the medical weight management program for 6 months during which he lost 40 lbs and his insulin requirements decreased. He then underwent a sleeve gastrectomy and did not require insulin therapy as of postoperative day 1. His HOMA-IR improved by about 76% between day 1 and day 14 postoperatively. Conclusion. Sleeve gastrectomy leads to a drastic improvement in severe insulin resistance as early as the first postoperative day.

Rathke cleft cyst apoplexy: a newly characterized distinct clinical entity.

OBJECT: Although most Rathke cleft cysts (RCCs) remain asymptomatic, some present with compression of surrounding structures and pituitary hormone dysfunction. A rare, but distinct presentation of the RCC includes hemorrhage into the cyst--a presentation that mimics the clinical syndrome of pituitary tumor apoplexy. The objective of this article is to present the authors' experience on the prevalence and the clinical, biochemical, pathological, and imaging characteristics of hemorrhage into an RCC and review published reports on this entity. METHODS: An institutional database for patients with pituitary masses was reviewed and data on cases involving surgery for a subsequently documented RCC were identified. Patients with documented hemorrhage within the RCC were included in the analysis. Documentation included intraoperative visualization of hemorrhage by the surgeon and/or pathological confirmation of hemorrhage within the RCC. The clinical, biochemical, pathological, and imaging characteristics of these patients were extracted from the database. All published data on RCC were also reviewed and confirmed cases of hemorrhage were extracted and included in the review. RESULTS: A total of 11 cases with hemorrhage within an RCC were identified to have been managed at the authors' institution over a 10-year span. This figure represented 20% of all surgically treated cases of RCC from that period. Among published reports, a total of 10 confirmed cases were evaluated. The clinical presentation of patients with hemorrhage within an RCC are classical and include sudden onset of severe headache--or a sudden increase in headache severity--associated with visual disturbances, impairment in pituitary function, and occasionally alterations in mental status. Leakage of the cystic contents into the subarachnoid space can occur rarely and may lead to associated chemical meningitis. There are no known precipitating factors for this phenomenon. The clinical presentation of such patients is difficult to distinguish from that of patients with pituitary tumor apoplexy. However, patients with RCC apoplexy often present with less severe symptoms, have a lower prevalence of pituitary dysfunction, and generally have smaller mass lesions than those with pituitary tumor apoplexy. Management of patients with RCC apoplexy is similar to that of those with pituitary tumor apoplexy. Surgery can provide definitive diagnosis and relief of symptoms and often leads to recovery from hypopituitarism. All patients with this syndrome require long-term follow-up to treat any residual sequelae. CONCLUSIONS: This article provides the first thorough review and characterization of patients with hemorrhage within an RCC. Based on the clinical manifestations of this presentation, we recommend using the term "Rathke cleft cyst apoplexy" to describe the syndrome.

The association of Hashimoto disease and Congo red negative amyloidosis.

Systemic amyloidosis which is characterized by extracellular deposition of monoclonal immunoglobulin light chains in various organs may be difficult to diagnose at an early stage, especially when the Congo red stain is negative. We describe herein a case of Congo red negative primary amyloidosis associated with Hashimoto thyroiditis. The patient presented with multiple organ involvement suggestive of amyloidosis including heart failure, renal failure, and macroglossia. Serum and urine immunofixation studies were positive for monoclonal chains. Even though a biopsy taken from the enlarged tongue of the patient was negative when stained with Congo red, electron microscopy showed ultrastructural features of amyloid deposition. In conclusion, we are reporting a rare case of primary amyloidosis with a negative Congo red stain associated with Hashimoto thyroiditis.

Effect of chronic hypoxia on leptin, insulin, adiponectin, and ghrelin.

The endocrine system plays an important role in the adaptation to hypoxia. The aim of this study was to assess the effect of chronic hypoxia on insulin, adiponectin, leptin, and ghrelin levels in a neonatal animal model. Sprague-Dawley rats were placed in a normobaric hypoxic environment at birth. Controls remained in room air. Rats were killed at 2 and 8 weeks of life. Insulin, adiponectin, leptin, and ghrelin were measured. At 2 weeks of life, there was no significant difference in insulin, adiponectin, and leptin levels between the hypoxic and control rats. The only statistically significant difference was found in ghrelin levels, which were lower in the hypoxic group (3.19 +/- 3.35 vs 24.52 +/- 5.09 pg/mL; P < .05). At 8 weeks of life, insulin was significantly higher in the hypoxic group (0.72 +/- 0.14 vs 0.44 +/- 0.26 ng/mL; P < .05) and adiponectin was significantly lower (1257.5 +/- 789.5 vs 7817.3 +/- 8453.7 ng/mL; P < .05). Leptin and ghrelin did not show significant difference in this age group, but leptin level per body weight was higher in the hypoxic group. Finally, we conclude that 2 weeks of continuous neonatal hypoxic exposure leads to a decrease in plasma ghrelin only with no significant change in insulin, adiponectin, and leptin and that 8 weeks of hypoxia leads to a decrease in adiponectin with an increase in insulin despite a significant decrease in weight.

Erectile dysfunction in diabetic patients.

Erectile dysfunction (ED) appears to be highly prevalent in diabetic patients (around 50% at 50 years of age) and more severe than in the rest of the population. Its etiology is multifactorial in this subset of patients. ED is highly correlated to multiple vascular risk factors and can be considered as a manifestation of endothelial dysfunction in general, alerting the physician to look at underlying silent coronary bed atherosclerosis. It is also dependent on the poor control of diabetes and on the presence of its chronic complications. Because of the multiple etiologies of ED in diabetics, a multifactorial approach is warranted to get an optimal response in treating such patients: diabetes control, use of phosphodiesterase 5 inhibitors, psychosexual counseling, and choice of antihypertensive medications.