Predisposing factors for the diabetic hyperosmolar state.

To better understand risk factors for the development of diabetic hyperosmolar state (DHS), we studied 135 patients with DHS and 135 age-matched randomly selected diabetic controls admitted to two general hospitals during an 11-year period. To be eligible for the study, patients had to have a hospital admission glucose level of greater than 600 mg/dL (33.3 mmol/L) and an osmolality of greater than 325 mOsm/L (32.5 mmol/L). Patients were significantly more likely than controls to be female (71% vs 53%), to be nursing-home residents (28% vs 15%), to be newly diagnosed diabetics (36% vs 7%), to have a history of dementia (18% vs 8%), and to have an acute infection at the time of admission to the hospital (39% vs 19%). Multivariate analysis revealed three significant independent predictors of DHS: female gender, newly diagnosed diabetes, and acute infection; nursing-home residence and dementia had no independent effect. Other functionally debilitating diseases, acute illnesses, or medications that may impair glucose tolerance were not significantly associated with DHS.

Natural history of fever following seizure.

Generalized tonic-clonic seizure, like vigorous exercise, can cause a rise in body temperature. To describe the course of fever following a generalized seizure, the temperature curves of 93 hospitalized postictal patients were reviewed retrospectively. Forty patients (43%) had an elevation of body temperature above 37.8 degrees C (100 degrees F). No underlying infectious illness was identified in two thirds of the febrile patients, 89% of whom had become and remained afebrile by 48 hours. One third of the febrile patients who did have an infection were still febrile after 48 hours. This finding may help clinicians determine the timing of appropriate tests to rule out infections during the postictal period.

Infected aortic aneurysm.

Aortic aneurysms may become infected. This unusual complication carries a highly unfavorable prognosis. In any patient with sepsis and a known aneurysm, spread of the sepsis to the aneurysm should be suspected if no other source of infection can be found. A case report is presented, together with a brief review of the literature.

Prognostic factors in the diabetic hyperosmolar state.

To evaluate the current outcome of patients hospitalized with diabetic hyperosmolar state (DHS), we retrospectively studied 135 patients admitted to two general hospitals over an 11-year period. Mortality was 17%. Patients who died had a mean age of 77 years, compared to 68 years for the survivors (P = 0.008). They were also more likely to be nursing home residents (48 versus 23%, P = 0.01). Additionally, mean serum osmolality was significantly higher among those who died (383 versus 358 mosm/L, P less than 0.0001) as was blood urea nitrogen (81.3 versus 62.3 mg/dl, P = 0.006) and sodium (148 versus 137.4 mEq/L, P less than 0.001). However, mean glucose level and anion gap were similar among patients who died and patients who survived (1068 versus 1092 mg%; 23 versus 24 mEq/L, respectively). The presence of a chronic disease or an acute comorbid illness was not associated with mortality. Diminished physiologic reserve, attendant comorbidity, or functional disability may explain the effect of age and nursing home residence. High osmolality may indicate a greater water deficit and a more advanced stage of DHS at the time of diagnosis.

When the patient cannot come to the doctor: a medical housecalls program.

OBJECTIVES: To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients. PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems. PARTICIPANTS: Patients are eligible for the housecalls program if they live within a 15- minute drive of the center and are unable to leave their home. PROGRAM EVALUATION: The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient-year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one-quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes. CONCLUSIONS: A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.

Uterine choriocarcinoma fourteen years following bilateral tubal ligation.

A patient who developed choriocarcinoma of the uterus 14 years after bilateral tubal ligation and resection is presented. Non-patency of the fallopian tubes was demonstrated radiologically. The various mechanisms of occurrence of the clinical picture are discussed. Activation of dormant chorionic cells present since the patient's last known pregnancy (1960) appears to be the most probable explanation for the origin of the choriocarcinoma.

The use of the "range of uncertainty".

Most laboratory tests are hampered by overlap of the population with a disease and the population without the disease. An efficient approach to clinical problem solving is to order tests in sequence and focus on the overlap zone of each test--the "range of uncertainty." Indeed, only cases that fall in that range need further workup. All others will have the suspected diagnosis made or excluded with reasonable confidence and need no further testing. To demonstrate the application of this concept, we correlated the iron saturation test and ferritin levels sequentially with the presence or absence of stainable iron in the bone marrow of 139 patients. This model should be suitable for other laboratory tests; it may decrease the use of the laboratory in clinical decision making and reduce the discomfort and cost of additional tests.

The diabetic hyperosmolar state.

The diabetic hypersomolar state is defined by a serum glucose greater than 600 mg/dl and a serum osmolarity greater than 320 m Osm/L. Ketoacidosis or lactic acidosis may co-exist with DHS in the same patient. The incidence of this acute complication of diabetes is high enough (17.5 cases per 100,000 person-years) for primary care physicians to encounter a case every year or two. Predisposing factors include older age, female sex, nursing home residence, and infection. A substantial proportion of cases occur in patients with no prior history of diabetes. Common presenting signs include fatigue or weakness, polydipsia, polyuria, nausea, and alteration of consciousness. The mainstay of therapy is intravenous fluid replacement with close monitoring of glucose and electrolytes in a hospital setting. Current mortality figures are high, at 10% to 20%, and the chance of survival is adversely affected by older age, higher osmolarity, and the presence of an associated severe illness. Prevention includes screening for diabetes, educating diabetic patients and their care givers about the symptoms of hyperglycemia, prompt treatment of any infection in a diabetic person, avoidance of drugs that increase carbohydrate intolerance in diabetic people, and encouraging compliance with treatment of diabetes.

Macrocytosis in Down syndrome.

The mean corpuscular volume of erythrocytes in persons with Down syndrome is larger than normal in the absence of anemia. The mean mean corpuscular volume among our 61 subjects with trisomy 21 was 99.08 fl (range = 90 to 107). Red blood cell survival half-time was substantially shorter than normal in many of these patients. These findings suggest that erythrocytes have a younger mean age in persons with Down syndrome. The increased red blood cell turnover in this population may indicate an accelerated aging process of red blood cells.

Pulmonary embolism presenting as syncope: case report and review of the literature.

Syncope as an initial presentation of pulmonary embolism occurs in about 10% of patients. A 68-year-old woman was admitted to the hospital with syncope. A right lower lobe infiltrate was found on a chest x-ray film, and results of a ventilation-perfusion scan were interpreted to mean that a high probability of pulmonary embolism existed. Other causes of syncope were excluded. A Doppler scan of the lower extremities revealed deep venous thrombosis. Intravenous heparin was administered, and then an inferior vena cava filter was placed to prevent pulmonary embolism from recurring. The patient has been well for 16 months since that episode. A review of 20 case reports in the literature of 10 women and 10 men with pulmonary embolism presenting as syncope revealed that female patients were younger than male patients and that the outcome was fatal in 40% of all cases. Syncope as a presenting symptom of pulmonary embolism is difficult to diagnose. Physicians must be vigilant with patients who have syncope, because this symptom may be the "forgotten sign" of life-threatening pulmonary embolism. The need for prompt diagnosis is clear, because with appropriate treatment the majority of patients may survive.

The impact of age on the quality of life in persons with HIV infection.

The authors administered the Medical Outcomes Study (MOS 20) Short Form Health Survey to 369 persons with HIV disease. The MOS survey measures six domains of health: physical function, role function, social function, mental health, health perception, and pain. Additional data included sociodemographics, HIV risk group, time since HIV diagnosis, symptoms (dyspnea, diarrhea, fever, chills, sweats, weight loss, weakness, numbness, memory trouble, seizures), and CD4 lymphocyte count within 3 months of the MOS survey. Bivariate analyses revealed worse MOS scores associated with older age in five health domains: physical function (p less than .01), health perception (p <.10), role function (n.s.), social function (n.s.), and mental health (n.s.). Older subjects reported less pain. When controlling for CD4 count and for sociodemographic and clinical variables, older age was significantly (p less than .05) associated with worse MOS scores in physical function, social function, and health perception, nonsignificantly associated with worse MOS scores in role function and mental health, and nonsignificantly associated with less reporting of pain.

Plantar and palmar hyperkeratosis in young castrated women.

Three cases of palmar and plantar hyperkeratosis were observed in young women following bilateral oophorectomy. We found this condition, previously described as keratoderma climactericum, to be completely reversible with estrogen replacement therapy. In patients with hysterectomy in addition o oophorectomy, the major risk of estrogen administration, endometrial cancer, does not apply.

Physicians' use of health resources for terminal cancer patients: clinical setting versus physician specialty.

A large proportion of all Medicare reimbursements (22%) are made for terminally ill patients. Alternative methods of care for such patients (for example, hospice care) may be more appropriate and less costly. The role of physician characteristics in determining use of resources for terminal patients is compared with that of care setting (type of facility), using data from the National Hospice Study. Multiple logistic regression reveals a stronger relationship between care setting and resource utilization than between physician "aggressiveness" and utilization. Physician specialty has little effect on utilization. These findings suggest that care setting may influence physician practice behavior. This may be due to self-selection of particular types of physicians or patients, or to a characteristic of the facility itself.

Practice guidelines to reduce testing in the hospital.

OBJECTIVE: To reduce testing among hospitalized patients using practice guidelines for any of 14 medical problems. DESIGN: Comparison of test use before and after implementation of guidelines. The guidelines were developed by consensus panels of self-selected participating physicians. Non-participating physicians were monitored during the same periods. In addition, the two groups of physicians were evaluated similarly for their management of three medical problems for which guidelines were not developed. SETTING: Acute care hospital. PATIENTS/PARTICIPANTS: 1,638 hospitalized patients and their 79 physicians. INTERVENTION: Implementation of practice guidelines for the care of hospitalized patients. MEASUREMENT AND MAIN RESULTS: Geometric mean charges expressed in inflation-adjusted dollars were used as measures of test use. For the intervention group, laboratory tests decreased by 20.6%, x-rays by 42.3%, and EKGs by 34.2%. All the decreases were significant (p = 0.001). The non-participating physicians who were higher test users during both years of the study also achieved significant (p less than 0.05) but smaller reductions during the intervention year: 13.9% for laboratory tests, 30.3% for x-rays, and 21.8% for EKGs, perhaps because the same residents were involved in the care of both groups of patients. For the non-guideline diagnoses, the participating physicians achieved reductions of 11.1% for laboratory tests and 19.2% for x-rays, and a 3.5% increase in EKGs. Two-way analyses of variance that took into account the reductions in testing achieved by non-participants, or by participants with non-guideline diagnoses, revealed no significant reduction in testing attributable directly to the guidelines except for EKGs. Follow up of the participating physicians during the six months after the end of the intervention revealed that testing remained at the lower level achieved while the guidelines were in use. Outcome of care, as measured by deaths in the hospital, deaths within 90 days of discharge, and readmissions within 90 days of discharge, was not affected by the use of the guidelines. CONCLUSIONS: 1) A large group of physicians could be recruited in a hospital to establish practice guidelines by group consensus. 2) These self-selected physicians were willing to use the guidelines (or allow the housestaff to use them) while caring for their patients. 3) Participating physicians were able to achieve substantial and significant reductions in testing without any demonstrable adverse effect on quality of care as measured by deaths and readmissions, and without any demonstrable shifting of resources from the inpatient to the outpatient setting of care. 4) The reductions in testing, whether caused by the guidelines or not, persisted for at least six months beyond the end of the period of implementation.