Cutaneous allergy to insulin: could statins and ACE inhibitors play a role? A case report

Insulin allergy is rare. Both statins and angiotensin converting enzyme (ACE) inhibitors may cause local urticarial skin reactions and have been implicated to precipitate local reactions to insulin. We describe a case of a localised urticarial allergic reaction related to insulin use in a patient co-prescribed an ACE inhibitor and statin.

The causes of hypopituitarism in the absence of abnormal pituitary imaging

BACKGROUND

Hypopituitarism in the absence of a history of pituitary pathology or abnormal pituitary imaging is rare.

AIM

To identify the cause of hypopituitarism in individuals in whom pituitary imaging was normal.

DESIGN

Retrospective analysis of electronic patient record.

METHOD

A review of the pituitary function in the 506 patients on the Morriston Hospital pituitary database revealed 230 had some degree of hypopituitarism and of these, 21 (9%) had normal pituitary imaging.

RESULTS

Of this group, six patients had a past medical history of subarachnoid haemorrhage, head injury or meningitis, and mainly suffered from a deficiency of antidiuretic hormone. One patient had a stroke resulting in multiple anterior hormone deficiencies and six individuals had idiopathic cranial diabetes insipidus (DI). Subsequent investigations of the remaining eight patients with normal pituitary imaging revealed that two had neurosarcoidosis both of whom had panhypopituitarism. Four patients had haemochromatosis which resulted in gonadotropin deficiency in two, DI in one and panhypopituitarism in the other. There were two individuals with confirmed hypopituitarism and multiple hormone deficiencies in which no cause could be identified.

CONCLUSION

These results show that hypopituitarism in the absence of pituitary pathology or an identifiable cause is rare. In patients with multiple anterior pituitary hormone deficiencies haemochromatosis and sarcoidosis should be considered.

Adrenal insufficiency following bariatric surgery

A 35-year-old woman with morbid obesity and amenorrhoea underwent a bilo-pancreatic diversion (BPD). Surgery was successful with good weight loss, restoration of menstruation and almost immediately she conceived for the first time. She was commenced on routine vitamin supplements after surgery but failed to attend follow-up clinic. Five years later, she presented with limb girdle pains, lethargy, night blindness, skin pigmentation, amenorrhoea and dizziness. She had stopped taking supplements prescribed after the surgery. Investigations showed severe vitamin A and D deficiency along with iron and calcium deficiency. Her cholesterol was low at 3.5 mmol L⁻¹. Despite aggressive vitamin replacement, she continued to complain of lethargy and dizziness. Subsequently, three short adrenocorticotropic hormone-stimulation tests were suboptimal (basal cortisol: 196, 185 and 223 nmol L⁻¹; 30 min cortisol: 421, 453 and 435 nmol L⁻¹). She was subsequently commenced on adrenal replacement and her symptoms resolved and she conceived. We describe for the first time in the literature the unexpected finding of adrenal insufficiency following a BPD.

Foot ulceration in a secondary care diabetic clinic population: a 4-year prospective study

Diabetes guidelines recommend that feet are stratified into low-risk, increased-risk and high-risk. We examined prospective foot ulceration in our secondary care diabetes clinic. At 4-year follow-up, foot ulceration was present in 1/586 (0.17%) in the low-risk, 10/305 (3.3%) in those at increased-risk and 28/236 (11.9%) in the high-risk group.

Clinical experience with exenatide in a routine secondary care diabetes clinic

Exenatide use in type 2 diabetes is limited in routine clinical practice. We examined a cross-section of 90 patients. Mean weight and HBA(1c) were 114.9+/-20.6 kg, 10.3+/-2.1% at initiation; 108.0+/-15.3 kg (p<0.0001), 9.0+/-2.1% (p<0.001) at 3 months; 109.2+/-18.2 kg (p<0.0001), 9.5+/-2.3% (p=0.08) at 6 months. Exenatide appears effective in reducing HBA(1c) and weight.

Use of a patient linked data warehouse to facilitate diabetes trial recruitment from primary care

Recruitment into clinical trials from primary care may be difficult. Our aim was to use the Secure Anonymised Information Linkage (SAIL) databank to identify potential participants for two factitious trials. We identified 284 and 711 participants for each study (population=250,086). This method appears promising in identifying trial participants.

The role of endothelial dysfunction in the pathophysiology of erectile dysfunction in diabetes and in determining response to treatment

BACKGROUND

Erectile dysfunction (ED) in diabetes is related to autonomic neuropathy and endothelial dysfunction. We studied the relative importance of these factors in diabetic and non-diabetic men with ED and determined if they predict responses to treatment with sildenafil.

METHODS

Thirty-three men, aged 35-65 years, with ED (20 diabetic, 13 non-diabetic), 15 of whom were sildenafil responders and 18 non-responders, were compared with 30 age and risk-matched control subjects (15 diabetic, 15 non-diabetic). Subjects with ED completed the International Index of Erectile Function (IIEF) questionnaire. Endothelial function was assessed by changes in brachio-radial and femoro-tibial arterial pulse-wave velocity (pulse-wave velocity) during reactive hyperaemia, expressed as percentage endothelium-dependent dilatation. Autonomic function was assessed by heart rate variation during expiration and inspiration (E/I ratio) and during the valsalva manoeuvre.

RESULTS

The respective changes in pulse-wave velocity, in the arm and leg [mean (sd)] were 0.71 (6.5)% and 3.5 (6.4)% in the impotent diabetic men, 0.7 (7.6)% and 2.4 (5.9)% in the non-diabetic impotent men, -0.68 (5.7)% and -1.31 (7.2)% in the non-impotent diabetic men and 7.7 (3.7)% and 7.6 (3.4)% in the control subjects. There was a significant interaction between ED and diabetic status such that there was significantly impaired vascular response in the diabetic group (both with and without ED) and in the non-diabetic group with ED compared with the non-diabetic control group (P = 0.01 and P = 0.001 for brachio-radial and femoro-tibial measures, respectively). The E/I ratios of the diabetic men were significantly lower than those of the control subjects [1.17 (0.14) vs. 1.33 (0.16), P < 0.02), but there were no differences in the measures of autonomic neuropathy between the groups with ED and those with normal erectile function. Amongst diabetic men, the initial IIEF scores (maximum score 30, low score indicates more severe ED) were significantly higher in sildenafil-responders than non-responders [16.3 (8.4), vs. 6.8 (7 1), P < 0.02]. The rate of sildenafil response was not significantly affected by the measures of endothelial or autonomic function.

CONCLUSIONS

ED in both diabetic and non-diabetic men is characterized by marked endothelial dysfunction in comparison with non-diabetic control subjects. Response to sildenafil is not predicted by either endothelial function or autonomic function, but in diabetic men appears to be related to the initial degree of erectile dysfunction.

Androgen status in healthy premenopausal women with loss of libido

Androgen deficiency may contribute to female sexual dysfunction and loss of libido. The role of the active metabolite of testosterone, dihydrotestosterone (DHT), in these conditions is uncertain. The aim of this study was to determine the role of androgens and DHT in the etiology of loss of libido in healthy women. We studied 29 premenopausal women with reduced libido (subjects) and 12 healthy females (controls). They were aged 18 to 45 years and in a stable heterosexual relationship. At 9 a.m. we took venous blood in the follicular phase for serum estradiol, total testosterone, and DHT, dehydroepiandrosterone sulfate (DHEAS), and SHBG levels. Subjects were interviewed by a psychosexual counsellor. Using the modified Wilson's sexual fantasy questionnaire (Baumgartner, Scalora, & Huss, 2002) and sexual satisfaction by Golombok-Rust Inventory of Sexual Satisfaction (GRISS Rust & Golombok, 1985, 1986) we assessed sexual drive. The total testosterone and DHT levels (mean +/- SD) were respectively 0.97 +/- 0.38 mmol/L and 0.76 +/- 0.37 nmol/L in subjects and 0.97 +/- 0.41 mmol/L and 0.77 +/- 0.15 nmol/L in controls. The SHBG and DHEAS were respectively 65 +/- 42 mmol/L and 3.76 +/- 1.0 umol/L in subjects and 65 +/- 29 mmol/L and 3.67 +/- 2.6 in controls. The scores of the Wilson questionnaire and GRISS were respectively 21 +/- 14.1 and 5 +/- 2.1 in subjects and 35 +/- 14.8 & 2 +/- 1.2 in controls. Subjects were more likely than controls to have low income (48% versus 8%, p < 0.02), a minor illnesses (57% versus 17%, p < 0.02), a history of depression (57% versus 8%, p = 0.025) and to report sexual problems in their partners (24% versus 0%, p = 0.053). Loss of libido in otherwise healthy women may be related to relationship problem, depression, psychosocial factors, and sexual dysfunction in the partner but do not appear to be related to androgen status.

Clinical guidelines online: do they improve compliance?

BACKGROUND

The introduction of intranet services in a district general hospital provided an opportunity to put evidence based national guidelines online to facilitate access and promote application of best practice in acute medical care. This study evaluated the effectiveness of this approach.

METHOD

Local guidelines were made available online at ward terminals after they had been distributed in paper form. An interrupted time series design was used to evaluate the impact on compliance with three preselected guidelines, which addressed the management of suspected deep vein thrombosis, upper gastrointestinal bleeding, and stroke. This was supplemented by a qualitative assessment of the views of medical staff.

RESULTS

There was a significant increase in the adherence to the guidelines for stroke when they were made available online, but this was not demonstrable for deep vein thrombosis or upper gastrointestinal bleeding. Qualitative interviews with junior medical staff and consultants after the study was completed revealed that there was confusion regarding the application of the guidelines for deep vein thrombosis and little active support from the gastroenterologists for the guidelines for upper gastrointestinal bleeding. The stroke guidelines were actively promoted by their author and widely supported.

CONCLUSION

Making guidelines available online will not be effective unless they are actively promoted and represent a consensus view.

Low but detectable serum thyroid-stimulating hormone concentrations in ambulant subjects not receiving thyroxine

BACKGROUND

In laboratories employing 'front-line' sensitive thyroid-stimulating hormone (TSH) measurement, it is generally accepted that a fully suppressed serum TSH concentration (third-generation assay) alongside normal serum concentrations of free thyroid hormones indicates subclinical hyperthyroidism. However, other explanations are often provided for low but detectable serum TSH concentrations, such as drug effects or non-thyroidal illness.

METHODS

We investigated 25 consecutive ambulant individuals, identified over an 18-month period as having low but not fully suppressed TSH concentrations (third-generation assay; sensitivity 0.003 mIU/L) with additional free thyroxine (T(4)), free tri-iodothyronine (T(3)) and thyroid microsomal antibody estimations and thyroid isotope scanning (technetium).

RESULTS

Concentrations of serum hormones (median, inter-quartile range) were: TSH, 0.23, 0.17-0.26 mIU/L (reference range 0.34-5.6 mIU/L); free T(4), 14.6, 10.6- 17.6 pmol/L (reference range 10-25 pmol/L); free T(3), 6.1, 5.7-6.6 pmol/L (reference range 4.5-7.5 pmol/L). Thyroid antibodies were negative in all but one individual. On isotope scanning, nine individuals had hot nodules and ten individuals had multinodular goitres (MNG). Of the six with normal scans, ultrasound scanning showed a definite MNG (n = 1) and early MNG (n = 2).

CONCLUSIONS

A low but detectable serum TSH concentration, obtained using a third-generation assay, found in an ambulant individual, is frequently a pointer to underlying thyroid disease.

Assessment of the efficacy and safety of Viagra (sildenafil citrate) in men with erectile dysfunction during long-term treatment

Long-term efficacy and safety of sildenafil was assessed in 1008 patients with erectile dysfunction (ED) enrolled in four flexible-dose (25 - 100 mg), open-label, 36- or 52-week extension studies. After 36 and 52 weeks, 92% and 89% of patients felt that treatment with sildenafil had improved their erections. Responses to a Sexual Function Questionnaire indicated that 52 weeks of sildenafil treatment resulted in clinically significant improvements in the duration and firmness of erections, overall satisfaction with sex life, and the frequency of stimulated erections. Commonly reported adverse events (AEs) were headache, flushing, dyspepsia, and rhinitis, which were generally mild to moderate. Reports of abnormal vision were consistent with previous clinical trials. The occurrence of treatment-related cardiovascular AEs, such as hypertension, tachycardia, and palpitation, was <1%. Discontinuations due to treatment-related AEs were low (2%). Long-term therapy does not diminish the efficacy of sildenafil in patients with ED and remains well tolerated.

Esthetic restoration of a single-tooth dental implant using a subepithelial connective tissue graft: a case report with 3-year follow-up

This case report describes the use of a subepithelial connective tissue graft to restore the gingival papillae and augment ridge soft tissues adjacent to a dental implant. The patient was referred for periodontic and prosthodontic evaluation after the placement of an implant--with the implant head 6.5 mm below the adjacent cementoenamel junction--in an area of inadequate bone volume with deficient interproximal papillae and ridge soft tissues. The resulting esthetic defect was restored by means of a combined technique that used a subepithelial connective tissue graft and an emergence profile-contoured crown. A 3-year clinical follow-up with complete regeneration of the gingival papillae is described.

Sildenafil: study of a novel oral treatment for erectile dysfunction in diabetic men

The efficacy and safety of oral sildenafil, a potent inhibitor of phosphodiesterase type 5, were evaluated in men with diabetes mellitus and erectile dysfunction (ED). Twenty-one men (aged 42-65 years) were enrolled in a double-blind, placebo-controlled, three-way crossover study conducted in two parts. In part I, the effect of a single dose (25 mg or 50 mg) of sildenafil or placebo on penile rigidity was assessed by penile plethysmography during visual sexual stimulation. In part II, daily diary records of erectile activity and a global efficacy question were used to evaluate once-daily dosing with 25 mg or 50 mg of sildenafil or placebo for 10 days. After a single 50 mg dose of sildenafil, the adjusted geometric mean duration (min) of penile rigidity >60% at the base of the penis during visual sexual stimulation was significantly increased (10.1 min) compared with placebo (2.8 min; p = 0.0053). In part II, sildenafil significantly increased the number of erections considered sufficiently hard for vaginal penetration compared with placebo (p = 0.0005). Improved erections were reported by 50% and 52% of patients treated with 25 mg and 50 mg of sildenafil, respectively, compared with 10% of those receiving placebo (p values < 0.05). Adverse events were mostly mild or moderate in nature and included muscular pains, headache, and dyspepsia. Sildenafil is a well-tolerated and potentially efficacious oral treatment for ED in men with diabetes mellitus.

Massive hepatosplenomegaly, jaundice and pancytopenia in miliary tuberculosis

A 29-year-old Caucasian woman presented to hospital with a 2-day history of diarrhoea, anorexia and rigors. Investigations showed abnormal liver function tests, hyponatremia, hypoalbuminaemia and lymphopenia. The initial chest radiograph was normal. A bone marrow trephine biopsy showed non-caseating granulomata and she subsequently developed miliary shadowing on the chest radiograph. A transjugular liver biopsy confirmed the presence of acid-alcohol fast bacilli. Despite starting triple therapy for miliary tuberculosis she remained febrile and developed massive hepatosplenomegaly, jaundice and pancytopenia. Standard triple therapy was substituted with ethambutol, streptomycin and oral prednisolone and the patient made a dramatic recovery. The clinical symptoms of miliary tuberculosis are frequently non-specific and the onset of the illness is often insidious. The liver is involved in almost all patients with miliary tuberculosis, but massive hepatosplenomegaly and jaundice are rare. Standard triple-therapy should be discontinued when there is significant liver dysfunction, and corticosteroids should be considered for patients with miliary tuberculosis who fail to respond to conventional therapy.

Correcting impotence in the male dialysis patient: experience with testosterone replacement and vacuum tumescence therapy

Sexual dysfunction remains a common and often distressing problem in the male dialysis population. Traditionally its management has consisted of correction of anemia, optimization of dialysis, removal of implicated medication, and finally depot injections of a testosterone ester. At a dedicated renal impotence clinic, we studied the effectiveness of testosterone replacement in men with biochemically proven hypogonadism and then vacuum tumescence therapy in those with continued erectile dysfunction. Depot testosterone was given to 27 patients (aged 52.4+/-2.5 years; duration of dialysis, 2.00+/-0.40 years; and duration of sexual dysfunction, 2.92+/-0.49 years): sexual function was fully restored in only three (11.1%), and two gradually lost the response over 18 months. Nineteen patients (70.3%) had partial responses, varying from an increased sense of well-being alone to restored sexual function apart from an impairment of the duration of penile erection. Five patients (18.5%) had no response, and testosterone was contraindicated in another four. Four of the treated patients (14.8%) reported fluid retention. Vacuum tumescence devices were then offered to 32 patients who remained impotent but declined by six. Twenty-six patients (aged 49.6+/-2.2 years; duration of dialysis, 2.50+/-0.58 years; and duration of sexual dysfunction, 3.26+/-0.56 years) used the devices, with 19 (73.1%) having full correction of their erectile dysfunction; six also continued with depot testosterone to maintain their libido. Penile discomfort was described by five patients (19.2%) whose potency was not restored. A further five predialysis patients have used the devices, and all had correction of their erectile dysfunction. The correction of biochemical hypogonadism in the male dialysis population with testosterone rarely restores sexual function to normal, whereas vacuum tumescence therapy corrects penile erection dysfunction in most patients.

Erythropoietin and sexual dysfunction

BACKGROUND

Erythropoietin (rHuEpo) therapy has been shown to improve sexual function in the male dialysis population, with several studies suggesting a direct effect upon endocrine function, as well as correction of anaemia. Nevertheless many male dialysis patients receiving rHuEpo continue to complain of sexual dysfunction.

METHODS

At a dedicated renal impotence clinic, 65 male dialysis patients were screened for endocrine disturbances. Baseline serum sex hormones were compared between those receiving and not receiving rHuEpo, using either the two-sample t test or the Mann-Whitney U test, after assessing for normality. Results from four patients were excluded on account of either medications (antiemetic phenothiazines), hepatic dysfunction, or carcinomatosis.

RESULTS

Twenty-five patients (41.0%) were receiving rHuEpo, the recipients and non-recipients being well matched for haemoglobin (10.19 +/- 0.29 vs 10.55 +/- 0.25 g/dl, n.s.), age (51.1 +/- 1.9 vs 53.6 +/- 2.1 years, n.s.) and duration of sexual dysfunction (median, 3.0 vs 3.0 years, n.s.). The rHuEpo recipients had a higher median creatinine (1090 vs 972 micromol/l, P < 0.02), but similar nutritional status to the non-recipients (albumin 41.0 vs 39.0 g/l, n.s.). The total duration of rHuEpo therapy was 0.85 +/- 0.14 years. Prolactin levels were similar in both the rHuEpo recipients and non-recipients (440 vs 541 mu/l, n.s.), as were LH (11.0 vs 10.5 iu/l, n.s.) and FSH (8.0 vs 6.5 iu/l, n.s.). However, there were significant elevations of testosterone (19.8 +/- 1.3 vs 16.1 +/- 1.1 nmol/l, P < 0.05) and sex hormone binding globulin (SHBG) (40.5 vs 26.0 nmol/l, P < 0.01), with a trend toward elevated oestradiol (304 vs 248 pmol/l, P = 0.095) in the rHuEpo-treated group. Forty-eight subjects (78.7%) received peritoneal dialysis (PD), with the 19 rHuEpo recipients (39.6%) demonstrating increased serum testosterone (21.0 +/- 1.5 vs 16.6 +/- 1.3 nmol/l, P < 0.05), SHBG (40.5 vs 26.5 nmol/l, P < 0.01), LH (15.0 vs 10.0 iu/l, P < 0.01) and FSH (12.0 vs 5.3 iu/l, P < 0.05). These differences were not demonstrated in the 13 haemodialysis (HD) subjects.

CONCLUSIONS

Male dialysis patients complaining of sexual dysfunction after correction of anaemia with rHuEpo are characterized by higher levels of serum testosterone and SHBG, but not suppression of hyperprolactinaemia or hyperoestrogenism. Male PD subjects receiving rHuEpo also demonstrated increased LH and FSH.

Laboratory evaluation of women experiencing reproductive failure

Reproductive life table analysis indicates that the majority of reproductive failures result from post fertilization failures, whether before or after implantation. It is important to have a set of tests to clarify the diagnosis of the reproductive failure so that appropriate therapy can be instituted. To determine the frequency of abnormal immunologic tests among women experiencing reproductive failure, 108 patients were evaluated for the presence of antiphospholipid antibodies (APA); lupus anticoagulant (LA); thyroid-thyroglobulin and microsomal antibodies (TGT); embryotoxic factor (ETA); and systemic CD56+/CD16- cells. The frequency of abnormal results obtained from testing for APA, LA, TGT, ETA, and CD56+/CD16- cells among 108 patients with diagnoses of recurrent pregnancy loss (RPL)(n = 45), unexplained infertility (n = 45) including IVF failure (n = 10), endometriosis (n = 10), premature ovarian failure (n = 5), and polycystic ovaries (n = 3) were compared with 15 normal controls. Seventy of one hundred eight (65%) women experiencing reproductive failure had at least one positive test, compared to 1 of 15 (7%) controls (P = 0.0001). Presence of phospholipid antibodies was the most frequently abnormal result followed by elevated CD56+/CD 16 cells. The prevalence of a particular abnormal test varied among the diagnoses. The most frequent abnormal test among women with RPL was an increased percentage of CD56+/CD16- cells (40%), followed by APAs (29%), TGT (9%), and ETA (7%). The most frequent abnormal result among women with unexplained infertility was the presence of APAs (42%), followed by CD56+/CD16- cells (16%), ETA (16%), and TGT (9%). APA, CD56+/CD16- cells, ETA, and TGT are useful tools to assist in the diagnosis of reproductive failure.

Antiphospholipid antibody prevalence in patients with IVF failure

Antiphospholipid antibodies (APAs) have been associated with reproductive wastage. The purpose of this study was to establish the prevalence of APAs in women who have had at least 12 embryos transferred during several in vitro fertilization (IVF) cycles without ensuing pregnancy. Sera from 42 women with IVF failure and 42 women who successfully conceived after IVF were tested for the presence of APAs by ELISA. Successful post-IVF pregnancy was determined by obtaining two consecutive rising beta-hCG levels followed by an ultrasound to confirm a viable conceptus. The sera were tested for three isotypes of antibody: IgA, IgG, and IgM against seven phospholipids: cardiolipin (CL), phosphatidylethanolamine (PE), phosphatidylinositol (PI), phosphatidic Acid (PA), phosphatidyl-glycerol (PG), phosphatidylcholine (PC), and phosphatidyl-serine (PS). From the IVF failure group, 11/42 (26.2%) were positive for APAs. From the control group, 2/42 (4.8%) were found positive only for IgA against PE. The difference between IVF failure and successful IVF groups was significant (P = 0.01). These results suggest that antiphospholipid antibodies should be considered an important marker for increased risk of IVF failure. Patients who are involved with an IVF program should be tested for the presence of APAs prior to initiation of an IVF cycle.

Relationship of self-management to personality types and indices

This study addressed the relationship between self-management (as measured by the Lifestyle Approaches Inventory, Williams, Moore, Pettibone, & Thomas, 1992) and personality types and indexes (as measured by the Myers-Briggs Type Indicator, Myers & McCaulley, 1985) in a sample of 347 university students. Correlational analyses indicated that the self-management factor most consistently linked to the Myers-Briggs indices was Organization of Physical Space. The Myers-Briggs index most consistently correlated with the self-management factors was Judgment-Perception. Overall, male and female subjects showed similar patterns of relationships between the self-management and personality indices. When the self-management scores were compared for the various Myers-Briggs types, the analysis indicated that types having a J (planful and organized) or S (precise and practical) in the typology tended to score higher than those having a P (spontaneous and flexible) or N (imaginative and insightful).

The mortality of elderly people with diabetes

To assess the full effect of diabetes on survival in elderly subjects, residents of Melton Mowbray aged 65, 70, 75, 80, and 85 years were screened by glucose tolerance test and followed up for 4.5 years. Death occurred in 56 of 520 normal subjects, 9 of 44 subjects with impaired glucose tolerance, 7 of 19 newly diagnosed diabetic subjects, and 27 of 52 known diabetic subjects. Diabetic subjects were 4.5 times (95% confidence interval 2.9-7.0) more likely to die than subjects with normal glucose tolerance. Thus elderly diabetic subjects have a substantially increased risk of death compared to their normal glucose tolerant peers.

Growth of children before onset of diabetes

OBJECTIVE

To examine the growth of children before the onset of diabetes.

RESEARCH DESIGN AND METHODS

Heights before diagnosis, expressed as SDS, of each diabetic child identified from the diabetes register and of two age- and sex-matched control subjects were obtained from records of routine examinations performed at 3.5, 6, 11, and 13 yr. The heights of their siblings, with control subjects, also were obtained.

RESULTS

Diabetic children were considerably taller than control subjects before diagnosis (0-1 yr before diagnosis SDS 0.82 +/- 0.26 vs. 0.16 +/- 0.14, P less than 0.05, n = 24; 1-2 yr before diagnosis SDS 1.02 +/- 0.17 vs. 0.16 +/- 0.14, P less than 0.001, n = 30; 2-3 yr before diagnosis SDS 0.97 +/- 0.23 vs. 0.04 +/- 0.20, P less than 0.005, n = 16). At more than 3 yr before diagnosis, the diabetic children were not significantly taller than control subjects (SDS 0.8 +/- 0.2 vs. 0.27 +/- 0.13, respectively; n = 33). The siblings of the diabetic children were no taller than control subjects.

CONCLUSIONS

Diabetic children, but not their siblings, were taller than control subjects before diagnosis, suggesting growth-inducing metabolic changes may precede the onset of clinical diabetes by at least 3 yr.

A case of multiple endocrine neoplasia: hyperparathyroidism, insulinoma, GRF-oma, hypercalcitoninaemia and intractable peptic ulceration

A 42-year-old woman with a family history of multiple endocrine neoplasia type 1 (MEN 1) presented with symptomatic hypoglycaemia and peptic ulceration. Investigation revealed an insulinoma, hyperparathyroidism, hypercalcitoninaemia with a positive pentagastrin stimulation test, acromegaly due to a GRF-oma, hyperprolactinaemia and normal serum gastrin levels. Five pancreatic tumours were removed at laparotomy and immunostaining was positive for insulin, calcitonin, somatostatin and glucagon. Post-operatively she developed elevated serum gastrin levels and gross peptic ulceration, despite H2-blockers, and died of gastro-intestinal haemorrhage suggesting that removal of the somatostatinoma may have allowed increased gastrin secretion from a gastrinoma. This case emphasizes the importance of measuring a wide variety of tumour marker peptides in MEN 1 and suggests that caution is required in interpretation of the pentagastrin stimulation test in such cases. Patients with MEN 1 and known peptic ulceration may require perioperative omeprazole treatment even if serum gastrin levels are normal.

Diabetic neuropathic cachexia associated with malabsorption

Diabetic neuropathic cachexia is characterized by neuropathic pain and severe weight loss of unknown aetiology. We describe four patients with diabetic neuropathic cachexia who were found to have malabsorption. Four diabetic patients presented with neuropathic pain, anorexia, depression and weight loss of 16 (range 10-21) kg. None complained of diarrhoea. There were three males and one female, median age 54 (46-67) years. A butterfat test showed a serum turbidity difference of 9 (6-10) light scattering units (normal greater than 60 units). The median serum xylose was low and there was delayed urinary xylose excretion. Urinary indicans, small bowel histology, liver function tests, and thyroid and renal function were normal. Ultrasound scans of liver, gall bladder and pancreas, and endoscopic retrograde cholangiopancreatogram were normal. The patients were treated with pancreatic supplements and a high calorie diet. Three have completely recovered and the other patient is improving. Thus these cases of diabetic neuropathic cachexia appeared to be associated with malabsorption which may be due to pancreatic dysfunction. It is suggested that the management of diabetic neuropathic cachexia should include the investigation and treatment of malabsorption.

A retrospective audit of the combined pituitary function test, using the insulin stress test, TRH and GnRH in a district laboratory

OBJECTIVE

To assess the value of the combined insulin stress test (IST), thyrotrophin-releasing hormone (TRH) and gonadotrophin hormone-releasing hormone (GnRH) tests.

DESIGN

A retrospective audit of 232 such tests performed between 1980 and 1989 inclusive.

PATIENTS

One hundred and ninety-seven patients with known or suspected pituitary disease.

MEASUREMENTS

IST, TRH and GnRH responses were retrieved from laboratory records. Case notes were surveyed for clinical data and additional results.

RESULTS

A basal serum cortisol level of less than 100 nmol/l (or less than 200 nmol/l in patients who had recently received glucocorticoid replacement therapy) accurately predicted a subnormal response to hypoglycaemia. All patients with a basal cortisol level of greater than 400 nmol/l, except those who had recently received steroids, showed a normal cortisol response. In retrospect, by consideration of such basal values, 55% of ISTs could have been avoided if the only aim was to assess cortisol reserve. A deficient growth hormone (GH) response to hypoglycaemia was, however, common in patients with a normal cortisol response. Two-thirds of patients with GH deficiency would have been missed if an IST had been avoided on the basis either of basal cortisol levels alone, or of cortisol responses to an alternative test which did not test GH reserve. There was poor agreement between the pituitary response to TRH and GnRH and basal levels of thyroxine and gonadotrophins respectively, suggesting that these releasing hormone tests are misleading.

CONCLUSIONS

The IST provides information regarding pituitary function not provided by other tests of the hypothalamic-pituitary-adrenal axis, so that the choice between the IST and alternative tests must depend on a critical assessment of what information is required. Routine TRH and GnRH testing appears to yield little information of practical clinical value.

The management of impotence in diabetic men by vacuum tumescence therapy

The treatment of impotence in diabetic men with vacuum tumescence therapy was studied in a specialist clinic. Of 54 diabetic men referred with impotence, seven declined treatment, three chose self-injection with papaverine, and 44 chose vacuum therapy. Patients underwent autonomic function testing (heart rate response to respiration), measurement of penile blood flow (duplex Doppler scanning), and estimation of serum prolactin and testosterone levels. After 2 months, 33 men (75%) were able to have satisfactory intercourse using vacuum therapy. Three others could produce a satisfactory erection with vacuum therapy but their partners found it unacceptable. Eight men (18%) were unable to have satisfactory intercourse; six of these were later treated by self-injection. The median frequency of use of vacuum therapy was 5.5 (1-26) times a month. Outcome was independent of penile blood flow, autonomic function or endocrine status. Impotent diabetic men should be given counselling and offered a choice of the available treatments. Vacuum tumescence therapy is an effective and simple treatment which requires little investigation.

Changes in circulating thyroid hormone levels and systolic time intervals in acute hypothyroidism

OBJECTIVE

We have previously reported that, in thyrotoxic patients treated with carbimazole, serum T4 and T3 levels are the first parameters to return to normal, followed by the systolic time interval (STI, a marker of thyroid function at tissue level) and then the serum TSH. The aim of this study was to compare the rate of change of thyroid hormones, TSH and STI in treated hypothyroid patients after the sudden withdrawal of thyroxine.

DESIGN AND PATIENTS

Serum T4, T3 (free and total) and TSH were measured in 12 patients taking thyroxine for primary hypothyroidism; seven were biochemically euthyroid and five were over-replaced, as defined by an elevated free T4 and a sub-normal TSH. Thyroxine was withdrawn and the measurements repeated three times a week until the STI rose above the euthyroid range (0.26-0.32).

RESULTS

After stopping thyroxine, the serum TSH and STI left the normal range, in advance of the free T4 and T3, after 9.5 +/- 0.95 and 12.2 +/- 1.5 days respectively (mean +/- SEM). The TSH was the first parameter to leave the euthyroid range in all subjects except one in whom the serum TSH was fully suppressed (less than 0.05 mU/l) initially. In the euthyroid group the TSH and STI increased rapidly after stopping thyroxine (time to leave euthyroid range 7.4 +/- 0.8 and 9.4 +/- 0.7 days respectively). In contrast, in the over-replaced group serum TSH and STI became elevated after 12.4 +/- 1.0 days (P less than 0.005 vs euthyroid group) and 16.0 +/- 2.7 days (P less than 0.05 vs euthyroid group) respectively. There was no delay in the fall in serum T4 or T3 in the over-replaced group when compared with the euthyroid group.

CONCLUSIONS

In the evolution of primary hypothyroidism, markers of thyroid function at a tissue level (TSH and STI) become abnormal in advance of thyroid hormones. After stopping thyroxine therapy in treated hypothyroid patients, there is a delayed rise in STI and serum TSH levels in subjects with a subnormal TSH level, as compared with those with a normal TSH on treatment. This suggests mild tissue thyrotoxicosis in these individuals.

Effect of aldose reductase inhibition on resistance to ischemic conduction block in diabetic subjects

OBJECTIVE

To study the effect of aldose reductase inhibition with ponalrestat on resistance to ischemic conduction block (RICB) in diabetic subjects.

RESEARCH DESIGN AND METHODS

Twenty-one healthy diabetic subjects without neuropathy were studied. Subjects were randomized to take either a double-blind trial of 600 mg ponalrestat or placebo once daily for 6 wk. The median nerve action potential (MNAP) and conduction velocity (NCV), before and after 20 min of forearm ischemia, were measured at the start and finish of the study.

RESULTS

RICB (MNAP remaining after ischemia) decreased from 39.5 to 29.4% in the ponalrestat-treated group (P less than 0.05) and increased from 48.1 +/- 10.2 to 49.5 +/- 6.5% in the placebo-treated group. MNAP and NCV were unchanged in both groups.

CONCLUSIONS

Aldose reductase inhibition with ponalrestat partly reverses RICB in diabetes, perhaps by improving nerve hypoxia or reducing nerve energy substrates.

Birthweight of babies born to mothers with type 1 diabetes: is it related to blood glucose control in the first trimester?

A retrospective study of 133 pregnancies in women with Type 1 diabetes was performed, and the 116 which progressed beyond 28 weeks were further analysed. Despite good maternal blood glucose control (mean (+/- SE) HbA1 levels 8.6 +/- 0.2% at the end of the first trimester; 6.9 +/- 0.2% at delivery; normal range 4.0-8.5%), 38% of babies had birthweights above the 90th centile and operative intervention occurred in 77 deliveries (66%). There was no significant correlation between birthweight and HbA1 level at any stage of pregnancy, but mothers with babies above the 90th centile for weight had a higher HbA1 at the end of the first trimester than mothers with babies below the 90th centile (9.3 +/- 0.5 vs 7.9 +/- 0.2%, p less than 0.05). In contrast there was no difference in the HbA1 levels at delivery (7.0 +/- 0.3 vs 6.8 +/- 0.2%). The perinatal mortality rate was 17.7 per 1000 births. The results confirm that in Type 1 diabetes large babies are common despite good blood glucose control, and suggest that maternal blood glucose control in the first trimester may be an important determinant of birthweight.

The effect of aldose reductase inhibition on erythrocyte polyols and galactitol accumulation in diabetic patients

Erythrocyte sorbitol level has previously been used as a measure of the efficacy of aldose reductase inhibitors, but its value is limited by fluctuations related to variations in blood glucose concentration. The aim of the study was to compare sorbitol content with the ability to accumulate galactitol during ex vivo incubation with galactose, of erythrocytes taken from diabetic patients following administration of a single 600 mg dose of the aldose reductase inhibitor, ponalrestat. Twelve patients were studied in a placebo-controlled crossover trial. Blood glucose levels were not statistically different during the placebo and ponalrestat treatment periods except at 1 h after the dose was taken (10.6 +/- 6.7 vs 7.7 +/- 4.6 mmol l-1 (+/- SD), p less than 0.05). Ponalrestat reduced erythrocyte sorbitol concentrations compared with placebo at 3, 5 and 7 h (0.82 +/- 0.36, 0.69 +/- 0.23, and 0.83 +/- 0.35 mg l-1 vs 1.79 +/- 0.67, 1.68 +/- 0.65, and 1.57 +/- 0.59 mg l-1 respectively, p less than 0.005) and 24 h post-dose (1.57 + 0.45 vs 2.01 + 0.73 mg l-1, p less than 0.05). Ponalrestat also reduced erythrocyte galactitol accumulation at 3, 5 and 24 h post-dose from 5.53 +/- 2.41, 5.43 +/- 1.89, and 5.42 +/- 1.96 mg l-1 2-h-1 to 1.47 +/- 0.30, 1.76 +/- 0.41, and 4.12 +/- 0.72 mg l-1 2-h-1 respectively, p less than 0.01. Galactitol accumulation rate appeared to be a less variable parameter than erythrocyte sorbitol and was not influenced by fluctuations in blood glucose.(ABSTRACT TRUNCATED AT 250 WORDS)

Resistance to ischaemic conduction failure in chronic hypoxaemia and diabetes

Median nerve function was studied in twelve diabetic subjects, six subjects with chronic hypoxaemia and ten control subjects. Resistance to ischaemic conduction failure (RICF), a characteristic electrophysiological feature of diabetic neuropathy, was assessed by measuring the decline in median nerve action potential amplitude at minute intervals for up to 20 minutes while the arm was rendered ischaemic. Initial nerve conduction velocity and action potential amplitude was similar in all three groups. Following the onset of ischaemia the time to a 50% reduction in action potential amplitude was prolonged in both diabetic subjects and hypoxaemic subjects compared with controls. After 20 minutes of ischaemia no control subject had persisting nerve function, while function remained in 5 (80%) of hypoxaemic subjects and 10 (83%) of diabetic subjects. The time to a 50% reduction in action potential amplitude during ischaemia correlated with the blood oxygen saturation among the hypoxic subjects and haemoglobin Alc among diabetic subjects. These results are consistent with the hypothesis that hypoxia has a role in the pathogenesis of resistance to ischaemic conduction failure in diabetes.

Proliferative retinopathy after 60 years of complication-free diabetes

A patient developed proliferative retinopathy after more than 60 years of complication-free diabetes. This may have been precipitated by an episode of ketosis or by cataract extraction, and emphasizes the need for persistent vigilance in examination for retinopathy.

Effect of aldose reductase inhibition on nerve conduction velocity and resistance to ischemic conduction block in experimental diabetes

The relationships between nerve polyol levels and both nerve conduction velocity (NCV) and resistance to ischemic conduction block (RICB) in streptozocin-induced diabetic rats were examined in two studies. In the first study, sciatic NCV and RICB of the tail nerve, assessed by measuring the time to disappearance of the nerve action potential after the tail was rendered ischemic, were measured in nondiabetic rats, untreated diabetic rats, and diabetic rats given Statil, an aldose reductase inhibitor (ARI). Sciatic NCV was lower in the untreated diabetic animals than in control animals (P less than .05), and RICB of the tail nerve was greater (P less than .001). Treatment with the ARI completely prevented the slowing of NCV but had no significant effect on the increase in RICB. In the second study, similar groups of rats were treated with either ARI, insulin, or myo-inositol. Sciatic NCV was lower in the untreated diabetic rats than in the nondiabetic rats (P less than .001). In diabetic rats treated with the ARI and in those treated with insulin, NCV was greater than in the untreated diabetic rats (P less than .05 and P less than .001, respectively) and was not significantly different from the nondiabetic rats. NCV in the myo-inositol-treated rats was not significantly different from that in the untreated diabetic rats. RICB was assessed by measuring the decline in sciatic nerve action potential amplitude at minute intervals after death.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between peripheral nerve resistance to ischaemia and diabetic control

The cause of the abnormal resistance to ischaemia of peripheral nerve function in diabetes is unknown. Median nerve function was more resistant to ischaemia in diabetic patients than in control subjects. In diabetic patients the degree of resistance to ischaemia correlated closely with HbAlc but not with the coincident blood glucose level, the duration of diabetes, the vibration perception threshold at the thumb or the initial median nerve action potential amplitude. Thus in diabetes the resistance of peripheral nerve function to ischaemia is dependent on medium term metabolic control and is not directly related to the presence or absence of neuropathy.

Red cell sorbitol levels during hyper and hypoglycaemic clamp studies in insulin-dependent diabetic patients

The red cell sorbitol concentration has been suggested as a measure of polyol pathway activity. Red cell sorbitol levels were higher in 53 patients having insulin-dependent diabetes mellitus (IDDM) than in 16 control subjects. Six patients having IDDM underwent hyperglycaemic 'clamp' studies; the red cell sorbitol level returned to the normal range when the blood glucose was clamped at 5 mmol/l for 1 h and rapidly increased when it was clamped at 15 and 25 mmol/l for a further hour at each level. Seven patients with IDDM were rendered hypoglycaemic; red cell sorbitol levels rapidly fell to a level less than, but not significantly different from normal. The results of these studies suggest that in IDDM red cell sorbitol levels are a reflection of prevailing blood glucose concentration and do not indicate long-term sorbitol accumulation in other tissues.

The effect of low-dose phenobarbitone on three indices of hepatic microsomal enzyme induction

The effects of low-dose phenobarbitone on three indices of hepatic enzyme induction were studied. Eight healthy volunteers took phenobarbitone 7.5 mg daily for 4 weeks followed by 15 mg daily for 4 weeks; five subjects took 30 mg daily for a further 2 weeks. Phenobarbitone 15 mg daily produced a significant rise in antipyrine clearance (P less than 0.05). Phenobarbitone 30 mg daily produced a further rise, but probably because of the reduced numbers of subjects, this did not achieve significance (P = 0.06). Urinary 6-beta-hydroxycortisol and D-glucaric acid levels did not change significantly and remained within the range seen in subjects not taking enzyme-inducing drugs. We conclude that phenobarbitone 7.5 mg daily produces little (if any) enzyme induction whereas 15 mg, or more, may have the potential to produce drug interactions through enzyme induction.