Absence Of Classical Risk Factors Research Articles

Poster 309: A Rare Cause of Ischemic Stroke in the Absence of Classical Risk Factors in an Otherwise Healthy 34-Year Old: A Case Report

PM&RVolume 9, Issue 9S1 p. S230-S230 Neurological Rehabilitation Poster Hall: Case Report Poster 309: A Rare Cause of Ischemic Stroke in the Absence of Classical Risk Factors in an Otherwise Healthy 34-Year Old: A Case Report Justin A. Raper MD, Justin A. Raper MD Albert Einstein College of MedicineSearch for more papers by this authorFrancis J. Lopez MD, Francis J. Lopez MD Albert Einstein College of MedicineSearch for more papers by this author Justin A. Raper MD, Justin A. Raper MD Albert Einstein College of MedicineSearch for more papers by this authorFrancis J. Lopez MD, Francis J. Lopez MD Albert Einstein College of MedicineSearch for more papers by this author First published: 19 September 2017 https://doi.org/10.1016/j.pmrj.2017.08.249Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume9, Issue9S12017 AAPM&R Annual Assembly AbstractsSeptember 2017Pages S230-S230 RelatedInformation

Aortic aneurysm in a patient with syphilis-related spinal pain and paraplegia.

The tertiary stage of syphilis is nowadays extremely rare, showing predilection for the cardiovascular and nervous systems.A 57-year-old Caucasian man sought medical assistance due to back pain that evolved to paraplegia of the lower limbs. A thoracic CT scan demonstrated an important aneurysmatic lesion of the descending thoracic aorta causing erosion of the vertebral bodies and VDRL and FTA-abs positivity.Although rare, syphilitic aortitis, the hallmark of cardiovascular syphilis, should be considered in the differential diagnosis in patients with thoracic aneurysm when in the absence of classic risk factors for atherosclerosis, especially in cases that progress with erosion of vertebral bodies.

Sitosterolemia: A multifaceted metabolic disorder with important clinical consequences

Sitosterolemia is a metabolic disorder characterized by increased intestinal absorption and tissue accumulation of phytosterols. Although sitosterolemia is considered a rare disease, its prevalence may be significantly higher than initially thought. Indeed, accumulating evidence suggests that patients with unexplained hematologic abnormalities or premature cardiovascular disease in the absence of classic risk factors may exhibit disordered phytosterol metabolism. In this review, we present a patient with sitosterolemia, describe the pathophysiology and the clinical picture of this disorder, and discuss the clinical value of phytosterol supplementation in patients with primary dyslipidemias.

P233 A Case of CMV (Cancer Mimicking Virulence)

Background/introduction Generalised lymphadenopathy and fatigue have a broad differential diagnosis ranging from curable infections to lymphoma. Certain diagnoses can be delayed or missed altogether when patients do not present to sexual health clinics. Aim(s)/objectives Highlight secondary syphilis as a cause of lymphadenopathy amongst non-sexual health colleagues. Expand syphilis testing beyond sexual health clinics, even in the absence of classical risk factors. Methods Case report of secondary syphilis which was misdiagnosed despite numerous investigations in primary and secondary care. Results A 23 year Caucasian lady was referred to lymphoma clinic by her GP with a three month history of lymphadenopathy and fatigue. She was diagnosed with a primary CMV infection and lost to follow up after her symptoms resolved. One year later she attempted to donate blood. Positive syphilis serology with a low RPR was detected on routine blood screening by the transfusion service. The patient was referred to Bristol Sexual Health Centre where sexual history taking revealed she had a bi sexual partner at the time of her illness who also tested positive for syphilis. An archived blood sample from the time of her illness revealed active syphilis infection with a high RPR. Discussion/conclusion Secondary syphilis can mimic numerous illnesses. However syphilis testing remains uncommon outside of sexual health clinics for a variety of reasons. A change of culture is required to ensure medical professionals are prepared for routine sexual enquiry and consider syphilis as a potential cause for lymphadenopathy.

Drug-induced pancreatitis: A rare manifestation of doxycycline administration

Context:Drug-induced pancreatitis (DIP) is rare, but as there are no systematic data on it, the true incidence is not known. Although numerous and varied drugs have been associated with DIP, the clinical evidence on doxycycline-induced pancreatitis is sparse.Case Report:We present the case of a 58-year-old female who presented with complaints of nausea and severe epigastric pain. Her medications included doxycycline which she had been on for only 2 days. Computed tomography of her abdomen showed mild enlargement of body of the pancreas with peripancreatic fatty infiltration, along with lipase level suggestive of acute pancreatitis. In the absence of classical risk factors for acute pancreatitis, a diagnosis of DIP secondary to doxycycline therapy was made. Immediate withdrawal of the drug was accompanied by relief of symptoms and resolution of pancreatitis.Conclusion:This report implicates doxycycline as an etiological factor for acute pancreatitis. Knowledge regarding doxycycline related pancreatitis is of paramount importance in order to diagnose cases early and institute effective treatment in patients who are undergoing therapy with this drug.

Abstract 237: Family History Of Premature Cardiovascular Events And Total Plaque Area

Although the positive family history for premature cardiovascular events has been considered a putative risk factor for decades, it has not been incorporated along with other established risk factors such as hyperlipidemia, hypertension, and cigarette smoking in the daily clinical practice when physicians evaluates the cardiovascular risk of a patient. One of the reason may be the presence of multiple risk factors coexisting during these evaluations. The objective of this research was to investigate if patients with a family history of premature cardiovascular events have higher total plaque area than patients without it, in the absence of other classical risk factors. Design and method: Patients from the primary prevention database of Blossom DMO program were identified to have positive family history of premature cardiovascular events (FHPCVE). After apply excluding criteria (absence of any classical risk factor) 23 patients qualified. A control group was generated reaching same data in variables (blood pressure, age, body weight, LDL cholesterol), except carotid total plaque area which was reported at the end of groups formation, once both groups were formed. We used the same definition as the Framingham study (family history of <55 years in men and <65 years in women, first degree relatives) to consider a patient with FHPCVE. Results: The group with FHPCVE was similar to the control group. Age 59±2 sv 60±1 yo, blood pressure 126±2/75±1 mmHg vs 127±1/74±1 mmHg, body mass index, 23±1 vs 24±1 Kg/cm 2 and LDL cholesterol 116±15 vs 139±20 mg/dl. When total plaque area was determined by Doppler, patients with FHPCVE had a TPA of 49±8 mm 2 while control group 33±4 mm 2 (p<0.05). Framingham risk score were similar, while the post test for acute myocardial infarction was lower in control group (16±1% vs 20±3%, p<0.05). Conclusions: Our data indicates that patients with positive family history for premature cardiovascular events have larger total plaque area than patients without it, indicating enhanced risk to develop a cardiovascular event, even in the absence of other classical risk factor. Physicians should identify early and treat accordingly these patients to prevent arterial deterioration.

Unexplained Spontaneous Complete Uterine Rupture in the Second Trimester: A Rare Event. Case Report and Literature Review

Abstract Background: Rupture of a pregnant uterus occurs most often in a scarred uterus, and spontaneous rupture of an unscarred uterus in the second trimester is very rare. Case: An extremely rare case of spontaneous uterine rupture involving uterine fundus at 16 weeks of gestation in an unscarred uterus, and with no apparent risk factors, is reported. Results: Surgery was performed to remove the fetus and placenta, the patient received a transfusion of red blood cells as well as antibiotics. The postoperative period was uneventful, and the patient was discharged in stable condition. Conclusions: Uterine rupture should be considered as a possibility in a pregnant woman with severe abdominal pain, regardless of gestation, and even in absence of classic risk factors. (J GYNECOL SURG 30:108)

Potentially resistant microorganisms in intubated patients with hospital-acquired pneumonia: the interaction of ecology, shock and risk factors

As per 2005 American Thoracic Society and Infectious Disease Society of America (ATS/IDSA) guidelines for managing hospital-acquired pneumonia, patients with early-onset pneumonia and without risk factors do not need to be treated for potentially resistant microorganisms (PRM). This was a secondary analysis of a prospective, observational, cohort, multicentre study conducted in 27 ICUs from nine European countries. From a total of 689 patients with nosocomial pneumonia who required mechanical ventilation, 485 patients with confirmed etiology and antibiotic susceptibility were further analysed. Of these patients, 152 (31.3 %) were allocated to group 1 with early-onset pneumonia and no risk factors for PRM acquisition, and 333 (68.7 %) were classified into group 2 with early-onset pneumonia with risk factors for PRM or late-onset pneumonia. Group 2 patients were older and had more chronic renal failure and more severe illness (SAPS II score, 44.6 ± 16.5 vs. 47.4 ± 17.8, p = 0.04) than group 1 patients. Trauma patients were more frequent and surgical patients less frequent in group 1 than in group 2 (p < 0.01). In group 1, 77 patients (50.7 %) had PRM in spite of the absence of classic risk factors recognised by the current guidelines. A logistic regression analysis identified that presence of severe sepsis/septic shock (OR = 3.7, 95 % CI 1.5-8.9) and pneumonia developed in centres with greater than 25 % prevalence of PRM (OR = 11.3, 95 % CI 2.1-59.3) were independently associated with PRM in group 1 patients. In patients admitted to ICUs with a prevalence of PRM greater than 25 % or with severe sepsis/septic shock, empiric therapy for group 1 nosocomial pneumonia requiring mechanical ventilation should also include agents likely to be effective for PRM pathogens.

Lipid Tetrad Index (LTI) and Lipid Pentad Index (LPI) in Healthy Subjects

The prevalence of cardiovascular disease (CVD) has increased steadily in recent years. Literature data show that about 35% of atherosclerotic events occur in the absence of classic risk factors, requiring a broader assessment of the individual to better characterize the risk. Lipid Tetrad Index (LTI) and Lipid Pentad Index (LPI) constitute a new and efficient evaluation of the lipid profile and CVD risk. This study assessed LTI and LPI in undergraduate students, seeking to establish the parameters of these indices in healthy subjects and correlate them with the conventional lipid profile. The study included 110 students, 48 (44%) males and 62 (56%) females, mean age 20.9 ± 1.7. Apolipoprotein-AI, apolipoprotein B, total cholesterol, lipoprotein(a), triglycerides, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) were assessed, using specific diagnostic methods. LTI and LPI indices were calculated using the equations LTI = [total cholesterol x triglycerides x lipoprotein(a) / HDL] and LPI = [total cholesterol x triglycerides x lipoprotein(a) x apolipoprotein B/apolipoprotein-AI], respectively. LTI and LPI values were significantly higher in females compared to males. As for the other parameters, there were significant differences between males and females only regarding total cholesterol, HDL and apolipoprotein-AI. There were significant and positive correlations between LDL and LTI and between LDL and LPI. Findings indicate that both LTI and LPI were associated with LDL, a parameter not used to calculate lipid indices and widely used in clinical practice for cardiovascular risk assessment.

Cutaneous Melioidosis in Adolescent Returning from Guadeloupe

Cutaneous Melioidosis in Adolescent Returning from Guadeloupe

HIV-1 and recombinant gp120 affect the survival and differentiation of human vessel wall-derived mesenchymal stem cells

BackgroundHIV infection elicits the onset of a progressive immunodeficiency and also damages several other organs and tissues such as the CNS, kidney, heart, blood vessels, adipose tissue and bone. In particular, HIV infection has been related to an increased incidence of cardiovascular diseases and derangement in the structure of blood vessels in the absence of classical risk factors. The recent characterization of multipotent mesenchymal cells in the vascular wall, involved in regulating cellular homeostasis, suggests that these cells may be considered a target of HIV pathogenesis. This paper investigated the interaction between HIV-1 and vascular wall resident human mesenchymal stem cells (MSCs).ResultsMSCs were challenged with classical R5 and X4 HIV-1 laboratory strains demonstrating that these strains are able to enter and integrate their retro-transcribed proviral DNA in the host cell genome. Subsequent experiments indicated that HIV-1 strains and recombinant gp120 elicited a reliable increase in apoptosis in sub-confluent MSCs. Since vascular wall MSCs are multipotent cells that may be differentiated towards several cell lineages, we challenged HIV-1 strains and gp120 on MSCs differentiated to adipogenesis and endotheliogenesis. Our experiments showed that the adipogenesis is increased especially by upregulated PPARγ activity whereas the endothelial differentiation induced by VEGF treatment was impaired with a downregulation of endothelial markers such as vWF, Flt-1 and KDR expression. These viral effects in MSC survival and adipogenic or endothelial differentiation were tackled by CD4 blockade suggesting an important role of CD4/gp120 interaction in this context.ConclusionsThe HIV-related derangement of MSC survival and differentiation may suggest a direct role of HIV infection and gp120 in impaired vessel homeostasis and in genesis of vessel damage observed in HIV-infected patients.

075 Endothelial function during adolescence predicts left ventricular mass in early adult life

Background Left ventricular mass is a powerful independent predictor of mortality and morbidity in adults. Endothelial function may influence cause cardiac hypertrophy through modification of myocardial biology or arterial stiffness. We sought to determine whether endothelial dysfunction during adolescence and early adult life is independently associated with increased left ventricular mass. Methods Thirty healthy normotensive subjects (43% males) underwent assessment of endothelial function by flow mediated dilatation (FMD) of the brachial artery at the age of 15 years using ultrasound. Subjects were followed up at the age of 23–26 years for assessment of left ventricular mass (LVM) by cardiovascular magnetic resonance imaging (Siemens 1.5 T Sonata scanner), adjusted for body surface area (LVMI), and repeated FMD measurements using the same methods. Cardiovascular risk factors including body size, blood pressure, lipid profile, glucose tolerance and smoking were assessed at both time points. Results FMD in early adulthood was significantly related to LVMI (r −0.55, p 0.002). FMD at the age 15 was similarly inversely associated with LVMI 10 years later (r −0.41, p 0.02) with greater endothelial responses related to reduced left ventricular mass. Those with FMD consistently above the mean at both age 15 and 25 had significantly lower LVMI compared to those with FMD below the mean (58 g/m2 vs 68 g/m2 p Conclusion Endothelial responses during adolescence predict left ventricular mass 10 years later and those with consistently high endothelial responses over this time period have the lowest left ventricular mass. Endothelial function may influence cardiac structure in young people in the absence of classic risk factors such as hypertension and obesity.

Increased arterial stiffness in nonobese women with polycystic ovary syndrome (PCOS) without comorbidities: one more characteristic inherent to the syndrome?

Polycystic ovary syndrome (PCOS) is associated with adverse metabolic effects. Some cardiovascular disease (CVD) risk markers are increased in women with PCOS. However, early markers of atherosclerosis are also associated with obesity and insulin resistance, which are related to PCOS. These markers may result either directly from PCOS or indirectly as a consequence of the comorbidities associated with the syndrome. To assess the presence of early CVD markers in young, nonobese women with PCOS. Forty women with PCOS and 50 healthy women with regular menstrual cycles, matched for age and body mass index (BMI). The following CVD markers were assessed by ultrasonography: common carotid artery (CCA) stiffness index (beta), distensibility and intima-media thickness (IMT), and brachial artery flow-mediated dilatation (FMD). Inflammatory markers, including interleukin (IL)-6, tumour necrosis factor (TNF)-alpha, homocysteine, C-reactive protein (CRP), glycaemia, lipid profile and insulin, were also assessed. CCA beta was higher in PCOS than in control women (3.72 +/- 0.96 vs. 3.36 +/- 0.96, P = 0.04) and CCA distensibility was lower (0.31 +/- 0.08 vs. 0.35 +/- 0.09 mmHg(-1), P = 0.02). Waist circumference, total testosterone and the Free Androgen Index (FAI) were higher in PCOS patients than in controls (78.2 +/- 10.0 vs. 71.5 +/- 7.2 cm, P = 0.001; 88.1 +/- 32.4 vs. 57.1 +/- 21.2 ng/dl, P < 0.01; 12.7 +/- 15.7%vs. 4.7 +/- 2.3%, P < 0.01, respectively), while SHBG was reduced (37.9 +/- 19.1 vs. 47.8 +/- 18.3 nmol/l, P = 0.01). The remaining variables did not differ between the groups. Young women with PCOS exhibit changes in vascular elasticity even in the absence of classical risk factors for CVD, such as hypertension and obesity.

Oxidized LDL, Lipoprotein (a), and Other Emergent Risk Factors in Acute Myocardial Infarction (FORTIAM Study)

To determine the prevalence of acute myocardial infarction (AMI) without classical risk factors, and to ascertain whether affected patients exhibit a higher prevalence of emergent risk factors and whether the presence of specific emergent risk factors influence prognosis at 6 months. The FORTIAM (Factores Ocultos de Riesgo Tras un Infarto Agudo de Miocardio) study is a multicenter cohort study that includes 1371 AMI patients who were admitted within 24 hours of symptom onset. Strict definitions were used for classical risk factors and the concentrations of the following markers were determined: lipoprotein (a) [Lp(a)], oxidized low-density lipoprotein (oxLDL), high-sensitivity C-reactive protein, fibrinogen, homocysteine and antibody to Chlamydia. The end-points observed during the 6-month follow-up were death, angina and re-infarction. The prevalence of AMI without classical risk factors was 8.0%. The absence of classical risk factors did not affect the 6-month prognosis. The only emergent risk factors independently associated with a poorer prognosis were the Lp(a) and oxLDL concentrations. Cut-points were determined using smoothing splines: 60 mg/ dL for Lp(a) and 74 U/L for oxLDL. The associated hazard ratios, adjusted for age, sex and classical risk factors, were 1.40 (95% confidence interval, 1.06-1.84 ) and 1.48 (95% confidence interval, 1.06-2.06), respectively. The proportion of AMI patients without classical risk factors was low and their prognosis was similar to that in other AMI patients. Both oxLDL and Lp(a) concentrations were independently associated with a poorer 6-month prognosis, irrespective of the presence of classical risk factors.

Detection and characterization of international community-acquired infections by methicillin-resistant Staphylococcus aureus clones in Rio de Janeiro and Porto Alegre cities causing both community- and hospital-associated diseases

Community-acquired infections by methicillin-resistant Staphylococcus aureus (CA-MRSA) in the absence of classic risk factors for MRSA diseases have been reported in different continents. In the article presented here, using molecular typing methods as pulsed-field gel electrophoresis, staphylococcal cassette chromosome mec typing, and multilocus sequence typing, we characterized CA-MRSA isolates from Rio Janeiro and Porto Alegre. The results indicated the presence of international CA-MRSA clones in these 2 Brazilian cities. In addition, Panton–Valentine leukocidin and a number of staphylococcal enterotoxin encoding genes were accessed in these MRSA isolates by polymerase chain reaction detection.

Endothelial dysfunction, intima-media thickness, ankle-brachial pressure index, and pulse pressure in young post-myocardial infarction patients with various expressions of classical risk factors

Coronary risk assessment based on the presence of classical risk factors may be insufficient. Several markers of arterial function and morphology, such as endothelial dysfunction (ED), intima-media thickness (IMT), ankle-brachial pressure index (ABPI), and pulse pressure (PP) may be useful in coronary risk estimation. To investigate their usefulness, we compared them in young post-myocardial infarction (MI) patients with various expressions of classical risk factors. Young male patients (on average 44 years old) in the stable phase after MI were included in the study. Twenty patients had high and 21 patients low expression of risk factors, while 25 healthy age-matched males served as controls. Endothelial dysfunction (estimated by ultrasound measurement of the flow-mediated dilation [FMD] of the brachial artery), IMT (of common carotid arteries), ABPI, and PP were compared between both groups of patients and controls. Compared with the control group, endothelial function and IMT were significantly impaired in both groups of patients, whereas ABPI was significantly reduced only in high-risk patients, and PP was similar in patients and controls. In all subjects, the level of FMD was significantly negatively related to IMT (r = -0.38, P = 0.01). Our study showed that endothelial function and IMT (but not ABPI and PP) are impaired in young post-MI patients independently of presence or absence of classical risk factors. Thus, we conclude that in young patients ED and IMT better assess coronary disease than classical risk factors, and are probably better markers of coronary risk.

Endothelial Dysfunction in Post-Myocardial Infarction Patients with Various Expressions of Risk Factors

It has not been established yet whether patients who suffer myocardial infaction (MI) in the absence of classic risk factors also have endothelial dysfunction (ED), as has been shown for patients with risk factors, and if so, to what extent it is manifested. Young male patients in the stable phase after MI were included in the study. At the time of MI, 20 patients had high and 21 patients low expression of risk factors. The control group consisted of 35 healthy age-matched males. ED was estimated by ultrasound measurement of the endothelium-dependent dilation of the brachial artery, induced by the reactive hyperemia test. Compared to the control group, the level of endothelium-dependent vasodilation was significantly reduced in both groups of patients (controls: 9.1% +/- 5.6%; patients with high risk: 5.5% +/- 5.1%; patients with low risk: 5.6 +/- 3.5 %; ANOVA, p<.01). There was no difference between both groups of patients. These results showed that ED is not associated or due only to classic risk factors. It appears that ED may occur and precede development of atherosclerosis in the absence of classic risk factors. These novel findings can have important clinical implications.

Prevalence of Toll-like receptor signalling defects in apparently healthy children who developed invasive pneumococcal infection

Human primary immunodeficiencies affecting Toll-like receptor (TLR) signalling reveal a non-redundant role for TLR function in defense against pneumococcal infection. To determine the clinical relevance of TLR abnormalities, we studied a population predicted to be enriched for TLR defects—healthy children who had developed invasive pneumococcal infection in the absence of classic risk factors for infection. We describe the development and optimization of a peripheral blood TLR assay. By testing 38 healthy control neonates, children and adults we demonstrated that TLR function was stable over the first six decades of life. We tested 50 children with a history of invasive pneumococcal infection and although TLR defects were predicted to be over-represented in this population, we did not identify any TLR abnormalities. Although TLR signalling defects are associated with greatly enhanced susceptibility to invasive pneumococcal infection, our results suggest that routine clinical screening for TLR defects in healthy children who develop invasive pneumococcal infection is not justified.

Is visceral obesity the cause of the metabolic syndrome?

Despite the fact that controversy remains around the underlying pathophysiological processes leading to the development of the metabolic syndrome (insulin resistance and/or hyperinsulinemia versus abdominal obesity), there is increased recognition that abdominal obesity is the most prevalent form of the metabolic syndrome. Although it has been well established that there is a greater prevalence of chronic metabolic diseases such as diabetes and cardiovascular diseases in obese patients than among normal weight individuals, obesity is a remarkably heterogeneous condition and not every obese patient is characterized by co‐morbidities. In this regard, body fat distribution, especially visceral adipose tissue accumulation, has been found to be a major correlate of a cluster of diabetogenic, atherogenic, prothrombotic and proinflammatory metabolic abnormalities referred to as the metabolic syndrome. Due to its anatomic location and peculiar metabolic, hyperlipolytic activity, the expanded visceral adipose depot is a key correlate of the altered cardiometabolic risk profile observed among individuals with a high‐risk abdominal obesity phenotype. Evidence suggests that this dysmetabolic profile is predictive of a substantially increased risk of coronary heart disease even in the absence of classical risk factors. Finally, a moderate weight loss in initially abdominally obese patients is associated with a preferential mobilization of visceral adipose tissue, which in turn leads to substantial improvements in the metabolic risk profile predictive of a reduced risk of coronary heart disease and of type 2 diabetes.

Case Study: Diabetes in a Patient With Cirrhosis

J.T. is a 72-year-old man with chronic hepatitis C and Child-Pugh grade A (clinically well-compensated) cirrhosis. He takes propranolol for esophageal variceal bleeding prophylaxis. He had a blood transfusion 25 years ago. Hepatitis C was diagnosed 10 years ago, and cirrhosis was diagnosed by liver biopsy 2 years ago. He does not drink alcohol. He has never been overweight. He has no personal or family history of diabetes. Over the past year, random plasma glucose levels have ranged from 110 to 180 mg/dl. The most recent random glucose was 210 mg/dl. The patient denies polydipsia, polyuria, nocturia, or any other symptoms of hyperglycemia. He weighs 150 lb (BMI 22 kg/m2). Physical examination findings are normal except for mild palmar erythema, spider angiomata on the upper chest, and a palpable spleen tip. Fasting blood glucose was 136 mg/dl, and a hemoglobin A1c (A1C) was 6.3%. Another fasting glucose several weeks later was 128 mg/dl. 1. Does this patient have type 2 diabetes? 2. Should medication be started to treat hyperglycemia? 3. How does the diagnosis of diabetes affect this patient’s prognosis? At first glance, many clinicians might assume this patient has type 2 diabetes. The history is compatible with this diagnosis. However, the absence of classic risk factors for type 2 diabetes and the appearance of new hyperglycemia in the …