Type 2 diabetes mellitus in a patient with malignant insulinoma manifesting following surgery.

BACKGROUND: Insulinomas, although they are rare, are the most common of pancreatic islet cell tumours. The incidence is estimated at only four per million person-years and only 5-12% of reported cases are malignant. Distinction between malignant and benign tumours can only be made by the presence of metastasis, as there are no specific morphologic, biochemical or genetic features distinguishing them. Most patients with malignant insulinoma have lymph node or liver metastases and, rarely, bone involvement. The coincidence of insulinoma and diabetes mellitus is an extremely rare condition and reported only in a few cases. CASE REPORT: We report a 45-year-old woman who was diagnosed with insulinoma on the basis of clinical and laboratory findings and endoscopic examination. Histopathological diagnosis revealed well-differentiated endocrine carcinoma of the pancreas with lymph node metastases. The case was accepted as malignant insulinoma and the patient underwent surgery. Interestingly, hyperglycaemia occurred after the removal of the insulinoma, with the requirement for insulin in the post-operative 3 weeks, which was changed to oral anti-diabetic agents as a permanent treatment. The patient is still being treated with oral anti-diabetic agents. We think that the patient might have had diabetes mellitus, because of insulin resistance that developed with a high-caloric intake stimulated by hypoglycaemia, and which had been masked for many years, but manifested overtly after removal of the tumour. CONCLUSIONS: Although this is a rare condition, clinicians should bear in mind that insulinomas may exist together with diabetes mellitus, and it is important to have this suspicion when considering the perioperative approach and for the prevention of morbidities.

Current iodine status in Turkey.

OBJECTIVES: To evaluate the current nationwide iodine status in Turkey by determining urinary iodine concentrations (UIC) and household salt iodine content. A follow- up monitoring study was also conducted in 30 urban areas. METHODS: A school-based survey was conducted in 2007 by using multistage 'proportionate to population size' (PPS) cluster sampling method. The study population was composed of 900 school-age children (SAC) from different urban, suburban, and rural areas. UIC and iodine content of the table salt used at home were analyzed. RESULTS: Median UIC was 107 microg/l (147 in urban, 42 in suburban and rural areas, p<0.001). There were severe iodine deficiency (ID) in 7.2%, moderate and mild ID in 20.6% and 19.3%, of the SAC, respectively. UIC was sufficient (>100 microg/l) in 50% of the study population, whereas it was excessive (>300 microg/l) in 10.5% of them. Of the 900 salt samples, 662 (73.5%) were iodized and 508 samples (56.5%) contained adequately iodized salt (iodine content >15 ppm). UIC of the study population and salt iodine levels correlated well (r=0.42, p<0.001). CONCLUSIONS: Moderate to severe ID still exists in 27.8% of the Turkish population, which is much better compared to 1997 and 2002 surveys (i.e. 58%, 38.9%, respectively). The follow-up monitoring study (in 2007) demonstrated that ID has been eliminated in 20 of 30 cities surveyed, and median UIC was 130 microg/l. ID has been eliminated in most of the urban population, however, it is still an important problem in rural areas and in particular geographical regions, which should be the target of future programs.

Ciprofloxacin-associated seizures in a patient with underlying thyrotoxicosis: case report and literature review.

BACKGROUND: Ciprofloxacin-associated seizures (CAS) occur most commonly in patients with special risk factors that may cause accumulation of drug (high doses of the drug, old age, renal insufficiency, drug interactions) or that may decrease the threshold of epileptogenic activity (electrolyte abnormalities, history of seizures, electroconvulsive therapy). OBJECTIVE: To report thyrotoxicosis as a risk factor previously not heralded for the development of CAS. CASE SUMMARY: A 24-year-old woman was admitted to the hospital because of convulsions, severe myopathy, and acute renal failure after taking ciprofloxacin for sinusitis, and urinary tract infections. Prior to ciprofloxacin ingestion, she had no seizure history, was not receiving any other medication, and her routine laboratory results including creatinine and electrolytes were within normal ranges. Electroencephalogram suggested epileptiform waves. Cranial magnetic resonance imaging was normal. Further laboratory examinations documented thyrotoxicosis in association with postpartum thyroiditis. DISCUSSION: In the reviewed literature, all cases of CAS occurred in the presence of at least one risk factor for CAS. CONCLUSIONS: CAS appear to be restricted to individuals with predisposing risk factors, therefore it is always necessary to search such fact. When a physician encounters the possibility of CAS, in addition to previously described risk factors, thyrotoxicosis should also be considered in the differential diagnosis. Further, in patients with untreated thyrotoxicosis, antibiotics other than ciprofloxacin might be preferable for therapy.

Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test among European intensive care nurses.

As part of a needs analysis preceding the development of an e-learning platform on infection prevention, European intensive care unit (ICU) nurses were subjected to a knowledge test on evidence-based guidelines for preventing ventilator-associated pneumonia (VAP). A validated multiple-choice questionnaire was distributed to 22 European countries between October 2006 and March 2007. Demographics included nationality, gender, ICU experience, number of ICU beds and acquisition of a specialised degree in intensive care. We collected 3329 questionnaires (response rate 69.1%). The average score was 45.1%. Fifty-five percent of respondents knew that the oral route is recommended for intubation; 35% knew that ventilator circuits should be changed for each new patient; 38% knew that heat and moisture exchangers were the recommended humidifier type, but only 21% knew that these should be changed once weekly; closed suctioning systems were recommended by 46%, and 18% knew that these must be changed for each new patient only; 51% and 57%, respectively, recognised that subglottic drainage and kinetic beds reduce VAP incidence. Most (85%) knew that semi-recumbent positioning prevents VAP. Professional seniority and number of ICU beds were shown to be independently associated with better test scores. Further research may determine whether low scores are related to a lack of knowledge, deficiencies in training, differences in what is regarded as good practice, and/or a lack of consistent policy.

Autoimmune polyendocrine syndrome with atrial septal defect.

Atrial septal defect is frequently reported with genetic syndromes. But, to the best of our knowledge, it has not been reported with autoimmune polyendocrine syndrome. Here, the case of a 44-year-old-woman with concomitant involvement of the salivary gland, thyroid, intestines, and, possibly endocrine pancreas, diagnosed with autoimmune polyendocrine syndrome type II, is reported with accompanying atrial septal defect. Celiac disease, Hashimoto thyroiditis, and Sjögren syndrome were symptomatic and laboratory confirmed diagnosis; anti-glutamic acid decarboxylase antibody was positive but asymptomatic for type-1 diabetes. She was known to have sinus venosus type atrial septal defect diagnosed at 38 years old, when she had tiredness and chest pain.