Past History Of Diabetes Mellitus Research Articles

Cytomegalovirus-related neutropenic enterocolitis with negative CMV antigenemia as the initial presentation in an acute myeloid leukemia patient

Dear Editor, A 35-year-old gentleman, with the past history of diabetes mellitus for 2 years, was transferred to our hospital in 2007 because of cecal enterocolitis with septic shock and pancytopenia. Fever and right lower quadrant (RLQ) abdominal pain without nausea, vomiting, or diarrhea developed 8 days before admission, and he visited another hospital 3 days after onset of symptoms. Pancytopenia with absolute neutrophil count of 250/mL was detected at that time, and abdominal computed tomography (CT) scan revealed prominent wall thickening with submucosal edematous change in cecum and ascending colon. Although broad-spectrum antibiotics were used for several days, abdominal pain and pancytopenia persisted. So, he was transferred to our hospital. On admission, the patient was mildly febrile (37.8°C); physical examination showed distended abdomen with a tenderness over RLQ. Laboratory findings disclosed: white blood cell count, 5.0×10/l (absolute neutrophil count 300/mL, segment 3%, band 3%, blast 15%, atypical lymphocyte 74%), hemoglobin, 11.5 g/dl; platelet, 44× 10/l; C-reactive protein, 156.7 mg/l. After bone marrow exam, acute monocytic leukemia (M5b) was diagnosed. Cefepime, metronidazole, and IV fluid support for bowel rest were given for his neutropenic enterocolitis. He received induction chemotherapy with the regimen, idarubicin 12 mg/m/day for 3 days, and cytarabine 100 mg m day for 7 days. However, fever, abdominal pain, and RLQ tenderness with abdominal fullness persisted even after white blood cell count recovered from nadir. There was no diarrhea or bloody stool during the course. Blood cultures, urinalysis, and stool cultures all yielded negative results. Serology test was negative for anti-HIV. Abdominal CT scan was repeated and revealed thickening of cecal wall with peri-colic inflammation. Because typhlitis with ileus persisted under conservative treatment, he underwent right hemicolectomy. Histological examination of the cecum showed: (1) ulceration and necrotic debris over the mucosal wall of cecum; (2) some enlarged cells with eosinophilic nuclear inclusions (Fig 1.) which were positive for cytomegalovirus (CMV) stain by CMV monoclonal antibody (clone CMV 01, Neomarkers; Fig. 2). The diagnosis of typhlitis with CMV infection was made. CMV-pp65 antigenemia assay, as determined by immunofluorescence, was negative. Three weeks of Ganciclovir was added. No more fever or abdominal pain was noted after operation, and the patient recovered gradually with normal oral intake. Neutropenic enterocolitis or typhlitis is a clinical syndrome in neutropenic patients characterized by fever and abdominal pain. It was originally described in children following induction chemotherapy for acute leukemia [1] and subsequently reported in both adults and children with a variety of hematologic and solid malignancy, in patients with acquired immunodeficiency syndrome, and as a complication of bone marrow transplantation [2]. The development of typhlitis has historically been attributed to a variety of chemotherapeutic regimens. Mucosal injury caused by cytotoxic drugs combined with neutropenia and impaired host defense to intestinal organism leads to the occurrence of typhlitis [3]. However, in this patient, neutropenic enterocolitis is the initial presentation of acute leukemia before treatment of any chemotherapeutic agents Ann Hematol (2009) 88:279–280 DOI 10.1007/s00277-008-0596-3

Malpositioning of a nasogastric tube: a pitfall in the emergency department

A 57-year-old man had a past history of diabetes mellitus controlled by oral hypoglycaemic agents. He was brought into the emergency department one day by paramedics after ingesting over 200 ml of synthetic pyrethroid insecticide (alpha-cypermethrin). The patient was vomiting and agitated; therefore, a nasogastric tube was immediately inserted in order to perform gastric lavage. Routine chest X-ray was also done before admission (Fig. 1). Fig. 1 Chest X-ray revealed nasogastric tube inserted into right main stem bronchus Placement of a nasogastric tube is indicated to decompress the stomach by aspiration of gastric contents, to introduce fluids and to assist in the clinical diagnosis of the ingested contents or gastric contents. Accidental misplacement of a nasogastric tube can occur in high-risk patients such as sedated patients, patients with weak cough reflex, endotracheally intubated patients and agitated patients [1]. Various methods to verify nasogastric tube placement in the stomach include the use of chest X-ray, aspiration of gastric content with the irrigating syringe, audible sounds of air entering the stomach while a 30 cc air bolus is injected with the syringe, and able to talk without coughing, choking or cyanosis. It is important to verify nasogastric tube placement in the stomach because the result of misplacement can be fatal such as aspiration pneumonitis or aspiration pneumonia.

Hypoglycemia in a patient with a huge malignant solitary fibrous tumor of the pleura

Solitary fibrous tumor of the pleura (SFTP) is rare. A 73-year-old man, without past history of diabetes mellitus, was admitted to hospital with profound hypoglycemia, loss of consciousness and respiratory failure. CT indicated a huge heterogenous mass lesion (12 x 12 x 17 cm) at the right thoracic cavity with total atelectasis of the right lower lung. He underwent a standard thoracotomy with complete excision of the tumor. Pathology indicated malignant SFTP with insulin-like growth factor-binding protein-2 production. There were no further incidences of hypoglycemia or respiratory failure after excision of the tumor. Hypoglycemia resulting from a solitary fibrous tumor is uncommon. Standard thoracotomy and complete resection of this giant tumor provided a good result for the present patient.

Frequency and Risk Factors for Intraocular Pressure Elevation After Posterior Sub-Tenon Capsule Triamcinolone Acetonide Injection

This study investigated the effects of posterior sub-Tenon capsule (PST) injection of triamcinolone acetonide (TA) on intraocular pressure (IOP) in the human eye. The study included 115 patients who received PST injections of 40-mg TA to treat macular edema with diabetic retinopathy (n=57), branch retinal vein occlusion (n=35), central retinal vein occlusion (n=13), or other disorders (n=10). IOP measurements were performed on the day of injection, and 0.5, 1, 2, 3, 6, 9, and 12 months later. In 26 (22.6%) of the 115 eyes, an IOP of 24 mm Hg or higher was observed during the 12-month follow-up period after PST TA injection. IOP elevation significantly correlated with young age, but not with past history of diabetes mellitus or systemic hypertension, sex, or type of retinal disease with macular edema. In total, 23 eyes were treated with antiglaucoma medications to control elevated IOP (24 mm Hg or higher). External trabeculotomy was performed in 1 case where medications failed to correct elevated IOP. PST TA injection is associated with high rates of steroid-induced IOP elevation in eyes with previously normal IOP. However, IOP elevation may be less common after PST injection than after intravitreal injection. Our findings indicate that IOP must be carefully monitored after PST TA injection.

The Adult Chest Pain Patient with a Nondiagnostic ECG

FigureA 52-year-old woman with a past history of diabetes mellitus presented to the ED with chest pain. The pain began one hour prior to presentation, and was associated with diaphoresis and dyspnea. The physical examination demonstrated a diaphoretic woman in mild distress with clear lung fields. Vital signs were significant for a blood pressure of 109/78 mmHg. A 12-lead ECG (Fig. 1) revealed normal sinus rhythm with a prominent R wave in leads V1 to V3 associated with minimal ST segment depression, also was seen in leads V4 and V5.Figure 1: 12-lead ECG on presentation.The patient received appropriate therapies in the ED, including aspirin, nitrates, and morphine sulfate while serum marker and chest radiographs were obtained. The patient's pain continued with no significant alteration in the 12-lead ECG occurring. Within 15 minutes, the serum troponin was markedly elevated, potentially consistent with AMI. An additional enhanced ECG was performed. What is your next move? See p. 20.

Personal features and dropout from diabetic care

To investigate the personal features associated with dropout from regular outpatient care among persons with type 2 diabetes mellitus (DM). A total of 160 DM patients were enrolled in the study. As a retrospective analysis, outpatient's clinical characteristics, lifestyle, or social features were gathered from their medical records or interview sheets. All the subjects were divided into two groups by adherence to diabetic care, namely, 'dropout case' (DC), or 'ongoing case' (OC), and were subjected to comparative analysis. We called the patients who did not receive outpatient treatment from the clinic on a regular basis, including treatment from other clinics or dropout of diabetic care, as DC. In contrast, patients who regularly visited the clinic were defined as OC. An unconditional multiple logistic regression analysis was performed to analyze the association of a dherence to diabetic care with several personal features. Sixty-eight of 160 subjects (42.5%) were recognized as DC. The remaining 92 subjects (57.5%) were considered as OC. Young age (p=0.045), low plasma glucose (p=0.005) and hemoglobin A1c (HbA1c) levels (p=0.005), nonmedication (p<0.001) and no past history of DM (p=0.007) at the initial visit were the features related to dropout by crude analysis. Even after adjustment for age and gender by multivariate analysis, there remained significant inverse associations of dropout with HbA1c level, medical treatment (oral agents or insulin) and previous DM history. Neither occupation, distance from residence to clinic, smoking habit nor drinking habit was associated with dropout. Dropout mostly occurred after the initial or second visit. A mild condition of DM may be related to dropout from regular outpatient care. It may be necessary to clearly show the objectives and importance of regular visit to an outpatient clinic for diabetic care, particularly for screened mild DM cases in public health activities.

X‐Ray Quiz: A Woman with Knee Pain

The case study of a 40 year old woman with increasing neck pain and past history of diabetes mellitus, knee osteoarthritis and rheumatoid arthritis, is presented. The abnormality and diagnosis, causes of this condition and other helpful investigations are discussed.

We-P11:12 Relationship of coronary heart disease mortality to casual blood glucose level and self-reported past history of diabetes mellitus

We-P11:12 Relationship of coronary heart disease mortality to casual blood glucose level and self-reported past history of diabetes mellitus

Staphylococcus capitis Endocarditis

Staphylococcus capitis Endocarditis

Ischemic colitis during interferon treatment for chronic hepatitis C

A 35-year-old man with anti-HCV-antibody positive chronic hepatitis was treated with interferon (IFN) ‐α2b from December 27, 1999. On February 4, he complained of lower abdominal pain and melena, and was admitted as an emergency. Total colonoscopy revealed mucosal edema and erosions in the descending colon. The biopsied specimen showed interstitial edema with infiltration of inflammatory cells. IFN treatment was discontinued and patient was conservatively followed up. Colonoscopy performed 10 days after admission revealed improvement of erosions and mucosal edema. He had no past history of diabetes mellitus, hyperlipemia, or heart disease. Thus it appeared that ischemic colitis was associated with the IFN treatment. The mechanisms of ischemic colitis is thought to be related to an autoimmune phenomenon by IFN. Other mechanisms may be caused by cytokines associated with IFN. Only nine cases of ischemic colitis during IFN treatment had been reported. We reported a rare case of ischemic colitis complicated with IFN treatment.

Prevalence and Risk Factors of Diabetes Mellitus in an Egyptian Village

Diabetes mellitus is emerging as a clinical and public health problem in rural Egypt. OBJECTIVE: to determine the Magnitude of the problem of diabetes by its different types Insulin Dependent Diabetes Mellitus, Non Insulin Dependent Diabetes Mellitus, Impaired Glucose Tolerance and Gestational Diabetes Mellitus [IDDM, NIDDM, IGT &GDM] in an Egyptian village and the possible risk factors contributing to that problem. To determine complications and dyslipidemia of the uncontrolled patients and their KAP towards management the of the disease. SUBJECTS AND METHODS: . A cross sectional survey of all the target groups by past history of diabetes mellitus or treatment. The childhood and adolescents group [5-<20 years= 1768] were screened for the asymptomatic glucosuria and confirmed by measurement of fasting serum glucose and serum glucose two hours after a 75 g oral glucose load. The pregnants [N=172] were subjected to a glucose challenge test with a 50 g glucose load .The adults 220 years [N=2409] were screened by a random capillary glucose testing and those with =5.6 mmol/l were subjected to measurement of fasting serum glucose and serum glucose two hours after a 75 g oral glucose load. All diagnosed cases were subjected a questionnaire interview covering the possible risk factors according to the type of diabetes. A case control study was done where the diagnosed NIDDM [142] and IGT [55] cases and an age and sex matched non diabetic control group [205] were subjected to a questionnaire interview, estimation of body mass index, determination of Sedentary lifestyle and HCV antibody determination. A comparative study between the controlled [Hemoglobin A1c <7%] and uncontrolled [Hemoglobin A1c>7%] previously diagnosed NIDDM and IGT patients were subjected to KAP study about management of the disease,clinical examination with special reference to cardiovascular and neurological examination and examination of the ocular fundi and any other diabetic complication and Lipid profile study. RESULTS: The prevalence of of IDDM 1.1/1000. The possible risk factors were winter season , family history, past history of viral infection and consanguinity. The overall prevalence of GDM was 2.9% and the most frequent possible risk factors of GDM were; previous GDM, =3rd –- gravida, sedentary life, high socio-economic score, obesity, overweight and family history of diabetes. The prevalence of the previously diagnosed, newly diagnosed and overall prevalence of NIDDM were 4.3%, 1.6% and 5.9% respectively and that the prevalence of the previously diagnosed, newly diagnosed and overall prevalence of IGT patients was 0.5%, 1.8% and 2.3% respectively. The possible risk factors of NIDDM were obesity [OR=10.4], sedentary life [OR=10.3], virus C hepatitis [OR=6.4), Family history of NIDDM [OR=6.4], overweight [OR=5.2], high socio-economic score [OR=3.6] and consanguinity [OR=2.9] ; while the possible risk factors of IGT were sedentary life [OR=16.8], high socio-economic score [OR=6.4], overweight [OR=6.1], obesity [[OR=4.1], middle socio-economic score [OR=3.6], virus C hepatitis [OR=3.5], and Family history of NIDDM [OR=3.3].The paternal history of NIDDM and IGT were significantly more risky than the maternal history [OR=31 and 13.6 respectively]. About 73.1% and 58.3% of the previously diagnosed NIDDM and IGT cases were uncontrolled depending on the level of glycosylated haemoglobin and most of the complications were among the uncontrolled NIDDM cases with higher mean levels of serum total cholesterol, serum triglycerides, serum LDL-C, and serum uric acid compared to the controlled .There was a significant statistical difference between controlled and uncontrolled NIDDM and IGT cases as regards good knowledge about diabetes mellitus, positive attitudes towards the disease and most of the healthful practices as proper diet control, weight monitoring, adherence to the prescribed medicine, periodic blood pressure check up, and regular blood glucose check up . Further survey studies in similar rural areas are recommended and the issue of diabetes mellitus and its risk factors as obesity and virus C hepatitis should be addressed on the primary health care level.

Fatal overdosage with sildenafil citrate (Viagra1): first report and review of the literature

A fatal case of sildenafil citrate (Viagra) overdosage is presented. The deceased was a 56-year old male found dead at home, with a past history of diabetes mellitus, hypertension, chronic alcoholism, anxio-depressive disorders, and erectile dysfunction. The main autopsy findings were cardiomegaly (650 g) with dilated cardiomyopathy, diffuse coronary atherosclerosis with no sign of acute ischaemic disease, and extensive fibrosis of the myocardium, especially affecting the cardiac conducting tissue. As measured by HPLC/MS, sildenafil concentration in postrmortem blood (6.27 microg/mL) exceeded at least four times the highest therapeutic levels previously reported. The results are discussed in the light of the literature about the cardiovascular side effects of sildenafil, with special emphasis on the recently evidenced arrhythmogenic potential of the drug. This is the first report of a fatality caused by sildenafil overdosage.

Risk factor screening for abnormal glucose tolerance in pregnancy

Objectives: To assess the prevalence and association of frequently used screening risk factors for gestational diabetes mellitus (GDM) and to compare the validity and cost of universal screening with risk factor screening. Method: A cross-sectional survey of 768 pregnant women at ≥24 weeks’ gestation who were attending the antenatal clinic at the Hospital Universiti Kebangsaan Malaysia (HUKM) was made. Risk factors were determined using a questionnaire. An abnormal oral glucose tolerance test was defined as a 2-h post-prandial blood sugar level of ≥7.8 mmol/l. Results: A total of 191 pregnant mothers (24.9%) had GDM. The most commonly identified screening factors were positive family history of diabetes mellitus (31.4%), history of spontaneous abortion (17.8%), vaginal discharge and pruritis vulvae in current pregnancy (16.0%), and maternal age greater than 35 years (14.7%). Five hundred and thirteen mothers (66.8%) had at least one risk factor. All screening risk factors, except past history of diabetes mellitus in previous pregnancy and maternal age, were not significantly associated with abnormal glucose tolerance (GT). Risk factor screening gave a sensitivity of 72.2% and a specificity of 35.0%. Universal screening would cost RM 12.06 while traditional risk factor screening would cost RM 11.15 per identified case and will have missed 53 of the 191 cases. Conclusions: Risk factor screening scored poorly in predicting GDM. Cost analysis of universal compared with traditional risk factor screening showed a negligible difference. Thus universal screening appears to be the most reliable method of diagnosing GDM.

FOURNIER'S GANGRENE CAUSED BY PENTRATION OF RECTAL CANCER IN AN ADULT

Fournier's gangrene is a specific type of necrotic fascitis. It is a fulminating infection characterized by a rapid progress of necrosis of subcutaneous tissue covering from the lower abdomen to the scrotum. It is necessary to detect the disease as early as possible and to perform incision, drainage snd debridement completely and without hesitation. A 51-year-old man who had a past history of diabetes mellitus was seen at our hospital because of pain, swelling, and redness of the perianal area and perineum to the right upper leg. Computed tomography revealed a widespread low-density area, from the perianal lesion to the right thigh. Colonoscopic examination showed type 2 advanced cancer in the lower portion of the rectun. Debridement of necrosed tissue was performed. Leakage of contrast material from the rectum into the pelvic cavity was detected on fluoroscopic study after surgery, suggesting that penetration of the rectal cancer might have caused the disease in this patient.

Clinical Features of Emergency Department Patients Presenting with Symptoms Suggestive of Acute Cardiac Ischemia: A Multicenter Study.

Identification of patients with acute cardiac ischemia (ACI) remains challenging. The object of this study was to examine the role of clinical findings in the diagnosis/triage of emergency department (ED) patients with symptoms suggestive of ACI. The study was designed as a secondary data analysis of a multicenter prospective controlled clinical trial. It was set in 10 midwest, southeast, and northeast U.S. hospitals, and 10,689 patients with chest pain or other symptoms suggesting ACI presenting from May 1993 to December 1993, participated. The results indicated that ACI patients were more likely to have chest pain as a chief complaint or presenting symptom (P = 0.001). The presenting symptom of nausea was more commonly associated with a final diagnosis of ACI (P = 0.003). Shortness of breath as the chief complaint and presenting symptoms of abdominal pain, nausea, dizziness, and fainting were less frequent among patients with a final diagnosis of ACI (P = 0.001). A past history of diabetes mellitus, myocardial infarction, or angina pectoris was more frequently associated with a final diagnosis of ACI (P = 0.001). A lower pulse rate in patients with a final diagnosis of ACI (P = 0.001) was not considered clinically significant. Median first and highest systolic blood pressures (SBPs) were higher, median lowest SBPs were lower, median diastolic blood pressure of the lowest SBPs were lower, and initial and highest pulse pressures were wider in patients with a final diagnosis of ACl (P = 0.001). On arrival, these blood pressure variables in AMI patients, subsequently classified as Killip class 4, were above the threshold for this classification. Rales were more commonly present in patients with a final diagnosis of ACI (P = 0.001). All primary ST-segment abnormalities, Q waves, and T-wave abnormalities, except T-wave flattening, were seen more frequently in patients with a final diagnosis ACI (P = 0.001). Normal ECGs were more frequently associated with a non-ACI final diagnosis, yet 20% of AMI patients and 37% of Unstable Angina Pectoris (UAP) patients had normal ECGs. It can be concluded that certain clinical features can help to identify ED patients with ACI. Initially normal ECGs can be seen in 20% of patients with AMI and 37% of patients with UAP. Patients with ACI can present with "normal" blood pressures and develop cardiogenic shock. Clinical outcome data for ACI patients are presented.

A population survey on bone mineral density in a fishing village in Wakayama Prefecture (Part 2); The analysis of the risk factors affecting the bone mineral density

The purpose of this study was to detect factors affecting lumbar bone mineral density (BMD) of general inhabitants in a rural community. A cohort consisting of 2261 inhabitants aged 40-79 years was set up based on the resident registration in Taiji town, Wakayama Prefecture in 1992. Fifty men and 50 women in each of four age strata (40-49, 50-59, 60-69, 70-79), totaling 400 inhabitants, were selected randomly. After completion of a questionnaire by an interviewer, items about physical characteristics such as height, body weight, wrist length and grip power were measured. Examination of BMD of the lumbar spine and proximal femur by dual energy X-ray absorptiometry was performed. Correlation coefficients between BMDs and values of physical characteristics were determined. Lumbar BMD was examined to determine whether the following factors were positive or negative: past history, alcohol consumption, smoking habit, dietary habit, exercise, and in addition, pregnancy times and menstrual status for women. Among the values of physical characteristics, body weight was the most closely correlated with lumbar BMD. The items that showed significantly high values as factors affecting lumbar BMD were a past history of diabetes mellitus (men and women in their 70s), and exercise (men in their 50s and women in their 40s). Regarding pregnancy times and menstruation, BMD in women with a history of childbirth was significantly higher than that in those without the history among the women in their 70s. Although the BMD in the women with lactation was significantly lower than that in those without it among the women in their 40s, there was no difference in BMD between the women with and without the history who were 50 years old or over. The effect of menstrual status was investigated according to years after menopause in the women in their 50s. BMD was significantly lower in the women with ar least six years after menopause than in those within five years.

Predictors of Survival and Barthel Score at Three Months After Acute Stroke

Out of 303 consecutive patients with acute stroke admitted over a six-month period to a regional general hospital, 28% had died by three months, 30% had regained full functional independence, and 42% had residual disability that was severe (Barthel score <15) in half of the patients. Eighty-six percent of deaths occurred within the first month after ictus, while 84% of those who were functionally independent by three months achieved their recovery within one month after ictus. Independent factors predicting mortality at three months include the Glasgow coma score, speech deficit and loss of consciousness on presentation, age, a past history of diabetes mellitus, and glucose concentration on admission. Using discriminant function analysis, 83% of patients were placed in correct outcome groups (alive or dead at three months). Independent factors predicting full functional recovery (assessed using the Barthel score) at three months include age, loss of consciousness, a past history of diabetes mellitus, and the Glasgow coma score. Sixty-six percent of patients were correctly grouped. These easily determined variables should be of use in the practical management of stroke patients.

Elevated Serum Fructosamine Concentration as an Index of Risk State of Abnormal Glucose Metabolism for Coronary Atherosclerosis

To examine the usefulness of hyperfructosaminemia as an index of risk state of abnormal glucose metabolism for coronary atheroscrelotic disease, serum fructosamine concentration was compared between 130 male cases with coronary stenosis, aged 60 years or younger, and 260 age-matched male controls. Past history of diabetes mellitus (DM) and information on confounders such as serum lipid concentration, obesity, smoking habits, and family history of ischemic heart disease were obtained from all the subjects. There was no difference in frequency of the past history of DM between the cases (8.5%) and the controls (6.9%), but that of hyperfructosaminemia (cases : 36.2%, controls : 15.0%) was significantly higher in the cases than in the controls (p<0.01). When confounding effects by other risk factors were adjusted by multiple logistic regression analysis, the odds ratio of the past history of DM (1.19, 95% confidence interval : 0.47˜3.03) was not significant, but that of hyperfructosaminemia (3.59, 95% confidence interval : 1.94˜6.65) was significant after the past history of DM was replaced by it. Thus, abnormal glucose metabolism evaluated by hyperfructosaminemia was an independent coronary risk factor, although that evaluated by the past history of DM was not. These results suggest that serum fructosamine is a useful index of coronary risk state related to abnormal glucose metabolism. J Epidemiol, 1992; 2 : 105-110.