Improving quality of care using a diabetes registry and disease management services in an integrated delivery network.

Disease management for chronic conditions is a call for collaboration among all parties of the health care system. The Caritas Christi Health Care System established a unified American Diabetes Association (ADA) recognized outpatient diabetes self-management education program (DSME) in each of its six hospital communities and has established an Internet data portal with managed care organizations to improve preventive care for thousands of patients with diabetes. This article describes the stepwise process of building the successful Caritas Diabetes Care Program and the central role of the Caritas Diabetes Registry over a 5-year period.

A malignant aldosteronoma.

OBJECTIVE: To describe a case of primary aldosteronism due to an adrenocortical carcinoma (ACC) and highlight the need for thorough long-term follow-up. METHODS: We present the clinical, laboratory, radiologic, and pathologic findings in a patient with ACC and review the related literature. RESULTS: A 52-year-old woman with a history of hypertension and hypokalemia was referred for evaluation of a 6-cm adrenal mass. Her biochemical studies revealed a serum aldosterone-to-renin ratio of 52 without evidence of cortisol, catecholamine, or androgen excess. She underwent surgical resection of this mass, and histologic analysis showed a focally brisk mitotic rate but no evidence of capsular or vascular invasion. In light of these findings, the biologic nature of the tumor was difficult to predict. Thus, it was thought to be an adrenocortical neoplasm. The patient underwent follow-up clinically, biochemically, and with interval computed tomography. Nine years later, hypertension and hypokalemia redeveloped, and she was found to have metastatic ACC. CONCLUSION: ACC can generally be reliably diagnosed; however, in some cases, the true biologic behavior is difficult to predict. We emphasize the importance of careful clinical, biochemical, and radiologic surveillance in these difficult cases because surgical resection provides the best opportunity for cure in patients with adrenal cancer.

Pituitary apoplexy precipitating diabetes insipidus.

OBJECTIVE: To describe a case of pituitary apoplexy complicated by diabetes insipidus and to review management of patients with pituitary apoplexy and water excretion disturbances associated with transsphenoidal surgery. METHODS: We describe clinical, laboratory, and radiologic findings in a patient with pituitary apoplexy and central diabetes insipidus. RESULTS: A 74-year-old woman presented with severe headache and sudden loss of vision for 12 hours, accompanied by thirst and frequent urination. Visual field examination demonstrated bitemporal hemianopsia. Her laboratory findings were significant for a serum sodium level of 152 mEq/L and urine specific gravity of <1.005. A magnetic resonance imaging scan of her pituitary gland identified a 3.5-cm suprasellar mass compressing the optic chiasm. She subsequently underwent transsphenoidal pituitary surgery with subtotal resection of this mass. Microscopic evaluation of tumor tissue revealed a pituitary adenoma with evidence of recent infarct and hemorrhage. Her clinical and biochemical course was consistent with the triphasic response that may occur after pituitary surgery related to damage to the hypothalamus and supraopticohypophyseal tract. CONCLUSION: Pituitary apoplexy may be rarely associated with diabetes insipidus.