ECTOPIC ACTH SECRETION WITH CONCOMITANT HYPERAMYLASEMIA IN A PATIENT WITH SMALL CELL LUNG CARCINOMA: CASE REPORT.

Histologically confirmed small cell lung cancer associated with Cushing's syndrome and elevated amylase is rarely described in the literature. We present a case of a 63-year-old patient admitted to cardiology department due to shortness of breath, exhaustion, palpitations and nausea. Elevated values of troponin and electrocardiography suggested that he could have acute coronary syndrome. According to the radiologist's opinion, plane lung radiography was normal. Elevated level of amylase was found in both serum (3802 U/L, normal range 28-100) and urine (12012 U/L, normal range 0-450 U/L), as well as elevated sodium (156 mmol/L, normal range 137-147 mmol/L), hyperglycemia (12 mmol/L, normal range 3.8-6.1 mmol/L) and lowered serum potassium (1.7 mmol/L, normal range 3.5-5.3 mmol/L). Computerized tomography (CT) of the abdomen revealed a tumor of the left adrenal gland and enlargement of the right adrenal gland with normal structure of the pancreas. During hospitalization, the patient had blood while coughing and CT scan of the lungs showed a tumor 48x38x51 mm in size localized in the laterobasal segment of the left lung with mediastinal lymphadenopathy. He also had bilateral pleural effusions with signs of pulmonary embolism, which explained elevated troponin values. Biopsy confirmed microcellular lung carcinoma and tumor cells were diffusely positive for TTF-1 and focally for CK7, expressing markers of neuroendocrine differentiation (chromogranin +++, synaptophysin +++, NSE ++). Since neuroendocrine tumor was confirmed and the patient had low potassium and high glucose, hypercortisolism was suspected. High morning cortisol (1784 mmol/L, normal range 171-536) and unsuppressed ACTH (214 pg/L, < 60), as well as a high level of chromogranin (1339 µg/L, < 65) were determined. During hospital stay, the patient developed heart and respiratory failure and died in the second week of hospitalization.

Risk factors clustering within the metabolic syndrome: a pattern or by chance?

INTRODUCTION: An accumulation of various cardiovascular risk factors has been noted to occur within the clinical diagnosis of metabolic syndrome. However, it remains unclear whether specific risk factors aggregate following a predefined pattern or whether this happens by chance. METHODS: This cross-sectional study involved 1715 adults, 37% males and 63% females, aged 34-80 years, who were consecutively recruited from cardiology and endocrinology outpatient clinics, and from internal medicine specialists in the primary healthcare physician office setting in Serbia, on a one-third basis. According to the AHA/NHLBI criteria, the actual prevalence of a combination of 3 or more of the following risk factors was determined: abnormal waist circumference, hypertension, high triglycerides, low high-density lipoprotein cholesterol, and abnormal fasting glucose. In addition, the prevalence of a corresponding combination of 3 factors was predicted from the prevalence of each factor in a given population, assuming that their combination occurred as the result of chance. RESULTS: The most frequent risk factor was hypertension (87%), followed by waist circumference (60%), dyslipidemia (55%), and abnormal fasting glucose level (50%). Metabolic syndrome was identified in 1135 participants (66.2%). The actual prevalence of the combination of increased waist circumference, elevated blood sugar and hypertension was found to be 5 times more frequent than would be expected to occur by chance (10% actual vs. 2% predicted; p<0.0001). CONCLUSIONS: A predefined aggregation pattern of risk factors within the metabolic syndrome was found for abdominal obesity, abnormal fasting glucose and hypertension. These risk factors do cluster more frequently than coincidental phenomena in the subjects of the given population, implying common underlying pathophysiological mechanisms.

The analysis of factors associated with improved glycemic control in patients with insulin-requiring type 2 diabetes mellitus after treatment.

AIM: To observe the effect of standardized ten-day diabetes prevention and control program on glycemic control, and to analyze factors contributing significantly to improvement of glycemic control after the program/intervention. METHODS: A cross-sectional nested case-control study on 91 adult patients with insulin-requiring type 2 diabetes mellitus who underwent a standardized ten-day diabetes program in the Specialized Hospital "Merkur" in Vrnjacka Banja, Serbia, from June the 1st to August 1st 2010 was performed. All necessary data were obtained from patients' medical files archived in this institution. Cases (n=32) and controls (n=32) were matched for age and sex. RESULTS: Diabetes program led to a significant decrease in mean daily blood glucose (p=0.039), achieved at the expense of the reduction of postprandial hyperglycemia (p=0.013). Male patients, patients with mean daily glycemia above the acceptable range before the intervention, and patients who were receiving combined therapy (insulin plus oral antidiabetics) before the intervention, were significantly more likely to achieve such positive outcome (ORadjusted = 344.48, 12.83, and 25.44 respectively, with 95%CIs that not included 1). CONCLUSION: Standardized ten-day diabetes educational and rehabilitation program in the Specialized Hospital "Merkur" could be efficient in improving glycemic control, especially for male patients whose glucoregulation was poor despite the combined therapy with insulin and oral antidiabetic agents. Further investigation on determinants of efficiency of this program are necessary to understand better how to facilitate and support improvements in diabetes control at the population level.

[The degree of coronary atherosclerosis as a marker of insulin resistance in non-diabetics].

INTRODUCTION: The metabolic syndrome and its influence on coronary artery disease development and progression remains in focus of international research debates, while insulin resistance, which represents its core, is the key component of hypertension, dyslipidaemias, glucose intolerance and obesity. OBJECTIVE: The aim of this study was to establish relationship between basal glucose and insulin levels, insulin sensitivity and lipid panel and the degree of coronary atherosclerosis in nondiabetic patients. METHODS: The coronary angiograms were evaluated for the presence of significant stenosis, insulin sensitivity was assessed using the intravenous glucose tolerance test with a minimal model according to Bergman, while baseline glucose (GO), insulin (10) and lipid panel measurements (TC, HDL, LDL, TG) were taken after a 12-hour fasting. RESULTS: The protocol encompassed 40 patients (19 men and 21 women) treated at the Institute for Cardiovascular Diseases of the Clinical Centre of Serbia, Belgrade. All were non-diabetics who were divided into 3 groups based on their angios: Group A (6 patients, 15%, with no significant stenosis), Group B (18 patients, 45%, with a single-vessel disease) and Group C (16 patients, 40%, with multi-vessel disease). Presence of lower insulin sensitivity, higher 10 and TC in the group of patients with a more severe degree of coronary atherosclerosis (insulin sensitivity: F = 4.279, p = 0.023, A vs. C p = 0.012, B vs. C p = 0.038; 10: F = 3.461 p = 0.042, A vs. B p = 0.045, A vs. C p = 0.013; TC: F = 2.572, p = 0.09), while no significant difference was found for GO, LDL, HDL and TG. CONCLUSION: Baseline insulinaemia, more precisely, fasting hyperinsulinaemia could be a good predictor of significant coronary atherosclerosis in non-diabetic patients, which enables a more elegant cardiometabolic risk assessment in the setting of everyday clinical practice.