Sodium glucose co-transporter-2 inhibitor-induced diabetic ketoacidosis following tooth extraction: improving awareness among dental practitioners.

Sodium glucose co-transporter-2 inhibitors (SGLT-2i) are a relatively new class of oral glucose lowering agents that improve glycaemic control and also provide significant cardiac and renal benefits. However, SGLT-2i use is associated with a small but significant increased risk of diabetic ketoacidosis (DKA) especially during periods of reduced oral intake such as following dental procedures, bowel preparation for colonoscopy, surgery and concurrent illness. In contrast with typical DKA, in many cases of SGLT2i-associated DKA, the blood glucose is normal or only slightly elevated, giving rise to the term euglycaemic DKA (euDKA). Patients with euDKA often present with non-specific symptoms. Moreover, their normal or only mildly elevated blood glucose levels might lead to delayed diagnosis and treatment and hence potentially life-threatening complications. Not only should patients taking an SGLT-2i be informed about the risk of euDKA, and be provided with SGLT-2i sick day management education, but clinicians should also be alert to this diagnosis.

Recombinant human thyroid-stimulating hormone (Thyrogen) in thyroid cancer follow up: experience at a single institution.

BACKGROUND: Recombinant human thyroid-stimulating hormone (Thyrogen; Genzyme Corporation, Cambridge, MA, USA) (rhTSH)-stimulated serum thyroglobulin (Tg) (stim-Tg) and (131)I whole-body scanning (WBS) have been reported to allow follow up of patients with thyroid cancer without the symptoms of thyroxine withdrawal and with equivalent diagnostic information to that obtained after thyroxine withdrawal. The aim of the study was to report results of rhTSH use at the Alfred Hospital, Melbourne, from 1999 to 2006 and in particular to examine the significance of detectable serum Tg after rhTSH in relation to thyroid cancer staging and to compare the sensitivity of rhTSH-stimulated serum Tg to whole-body (131)I scanning (WBS) in the detection of residual and recurrent thyroid cancer. METHODS: The study was a retrospective chart review. RESULTS: In 90 patients, rhTSH was used for 96 diagnostic episodes and 18 doses of rhTSH were used to facilitate treatment with (131)I. In stages I and II cancer (n = 42), of three patients with stim-Tg 1-2 microg/L, none had identifiable disease, and the three patients who had stim-Tg >2 microg/L did not experience recurrent disease during follow up. In contrast, in stages III and IV cancer (n = 43) 2 of 5 with stim-Tg 1-2 microg/L had identifiable disease and 7 of 10 with stim-Tg >2 microg/L had identifiable disease. In Tg-positive, WBS-negative disease, further imaging identified persistent/recurrent disease. CONCLUSION: rhTSH was effective and safe in the management of thyroid cancer follow up for diagnosis of persistent/recurrent cancer and to enable (131)I treatment. In no case did rhTSH-stimulated WBS identify the presence of disease not also identified by raised basal Tg or stim-Tg. Therefore, in low risk cancer WBS may be omitted.

Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors.

OBJECTIVE: To assess whether selective screening for gestational diabetes mellitus (GDM) on the basis of risk-factor assessment is a practicable alternative to universal screening. DESIGN: Case-control study. SETTING: A 212-bed regional specialist hospital in Melbourne, providing services in obstetrics and gynaecology, paediatrics, geriatrics and rehabilitation. SUBJECTS: 6,032 women who gave birth at the hospital, May 1996 to August 1997 and November 1997 to August 1998; all were screened for GDM, and 313 were diagnosed with the condition. MAIN OUTCOME MEASURES: Odds ratios (ORs) for risk factors (age, obesity, family history of diabetes mellitus and high-risk racial heritage) in women with GDM compared to those without GDM; proportion of women with GDM whose diagnosis would have been missed by selective screening. RESULTS: ORs were 1.9 for age > or = 25 years (95% CI, 1.3-2.7), 2.3 for body mass index > or = 27kg/m2 (95% CI, 1.6-3.3), 2.5 for high-risk racial heritage (95% CI, 2.0-3.2), and 7.1 for family history of diabetes mellitus (95% CI, 5.6-8.9). Other proposed criteria (previous GDM and glycosuria) added no further diagnostic power. Selective screening using the above four criteria would have missed two of 313 cases (0.6%) and could have saved screening up to 1,025 women without GDM (17% of all women). CONCLUSIONS: Selective screening for GDM based on prior risk assessment can reduce the need for testing, with negligible loss of diagnostic efficiency.

Effects of thyroid hormone on sex hormone-binding globulin gene expression in human cells.

We have used a human hepatoblastoma cell line to establish a model system for thyroid hormone (T3) action in human cells. HepG2 cells were grown for 3 days in Dulbecco's Modified Eagle's Medium containing fetal calf serum and were maintained in serum-free medium for experimental manipulations. [125I]T3 incubated with cells was bound by newly secreted protein and degraded. After 24-h exposure to HepG2 cells in Dulbecco's Modified Eagle's Medium, only 35-40% of the radioactivity was recovered as authentic T3. Degradation of hormone was neither time nor concentration dependent, and occurred to a greater degree in the absence of cells, suggesting an interaction between the hormone and the plastic culture dish. After 4 days, in the absence of fetal calf serum and considering hormone binding and degradation, the concentration of free T3 available to cells was approximately 15% of that added initially. Sex hormone-binding globulin (SHBG) was secreted by HepG2 cells in the absence of T3 and was specifically stimulated by the addition of T3. After 4 days, maximum stimulation occurred with added T3 concentrations of 10(-8) M or greater, and half-maximal stimulation of SHBG secretion was observed at about 3 x 10(-11) M free T3. No significant changes in total secreted protein or cellular DNA content were observed under similar conditions. Northern analysis of RNA extracted from HepG2 cells revealed a SHBG mRNA of 2 kilobases, which was stimulated in a dose-responsive manner by T3. No stimulation of corticosteroid-binding globulin mRNA was seen. Stimulation of the SHBG gene in HepG2 cells may be a useful model for investigation of T3 action in human cells.