Clinical Guidelines for the Management of Adrenal Incidentaloma

An adrenal incidentaloma is an adrenal mass found in an imaging study performed for other reasons unrelated to adrenal disease and often accompanied by obesity, diabetes, or hypertension. The prevalence and incidence of adrenal incidentaloma increase with age and are also expected to rise due to the rapid development of imaging technology and frequent imaging studies. The Korean Endocrine Society is promoting an appropriate practice guideline to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues in managing the patients with adrenal incidentaloma. After evaluating core proposition, we propose the most critical 20 recommendations from the initially organized 47 recommendations by Delphi technique.

Guidelines for the Management of Adrenal Incidentaloma: the Korean Endocrine Society, Committee of Clinical Practice Guidelines / 대한내과학회지

An adrenal incidentaloma is an adrenal mass found in an imaging examination performed for reasons unrelated to suspected adrenal disease. The prevalence of adrenal incidentaloma increases with age; there is no gender difference, but it is often accompanied by obesity, diabetes mellitus, or hypertension. The detection of adrenal incidentaloma is expected to rise with the rapid development of imaging technology and increasing frequency of imaging studies. The Korean Endocrine Society is promoting appropriate practice guidelines to meet the rising incidence of adrenal incidentaloma, in cooperation with the Korean Adrenal Gland and Endocrine Hypertension Study Group. In this paper, we discuss important core issues for treating adrenal incidentaloma, along with the most important factors for healthcare providers who treat and manage affected patients. Initially, we identified 47 recommendations using the Delphi technique, after evaluating core propositions. We reduced these to the 20 most critical recommendations.

Adult Multisystem Langerhans Cell Histiocytosis Presenting with Central Diabetes Insipidus Successfully Treated with Chemotherapy

We report the rare case of an adult who was diagnosed with recurrent multisystem Langerhans cell histiocytosis (LCH) involving the pituitary stalk and lung who present with central diabetes insipidus and was successfully treated with systemic steroids and chemotherapy. A 49-year-old man visited our hospital due to symptoms of polydipsia and polyuria that started 1 month prior. Two years prior to presentation, he underwent excision of right 6th and 7th rib lesions for the osteolytic lesion and chest pain, which were later confirmed to be LCH on pathology. After admission, the water deprivation test was done and the result indicated that he had central diabetes insipidus. Sella magnetic resonance imaging showed a mass on the pituitary stalk with loss of normal bright spot at the posterior lobe of the pituitary. Multiple patchy infiltrations were detected in both lung fields by computed tomography (CT). He was diagnosed with recurrent LCH and was subsequently treated with inhaled desmopressin, systemic steroids, vinblastine, and mercaptopurine. The pituitary mass disappeared after two months and both lungs were clear on chest CT after 11 months. Although clinical remission in multisystem LCH in adults is reportedly rare, our case of adult-onset multisystem LCH was treated successfully with systemic chemotherapy using prednisolone, vinblastine, and 6-mercaptopurine, which was well tolerated.

Preoperative Glycemic Control of Surgical Patients with Diabetes / 임상당뇨병

The patients with diabetes are treated with a variety of regimens and are scheduled for surgery at varying times of the day, there is no established consensus for optimal preoperative management. Perioperative glycemic control has a significant impact on the risk of infectious complications - including pneumonia, wound infection, urinary tract infection and sepsis - in patients with diabetes undergoing a variety of surgical procedures. Therefore, the goal of preoperative glycemic control is to avoid hypoglycemia, excessive hyperglycemia, lipolysis, protein catabolism, electrolyte disturbance and ketoacidosis. However, the effects of preoperative glycemic control are not definitive. Patients with type 1 diabetes should receive insulin replacement, while those with type 2 diabetes may need to discontinue oral medications prior to surgery and might require insulin therapy to maintain blood glucose control. The actual treatment should be individualized for each patient, based on diabetes classification, usual diabetes regimen, state of glycemic control, and extent of the surgical procedure. Medical judgment should override these recommendations as needed. Whenever possible, metabolic abnormalities should be corrected, and surgery should be scheduled early in the day.

The Effect of Cellular Phone-Based Telemedicine on Glycemic Control in Type 2 Diabetes Patients Using Insulin Therapy / 당뇨병

BACKGROUND: Cellular phones are extremely prevalent in modern society and they enable appropriate feedback mechanisms through real time monitoring and short message services regarding blood glucose levels. We investigated whether cellular phone-based telemedicine support system could improve blood glucose control in type 2 diabetes patients who were in inadequate glycemic control regardless of insulin therapy. METHODS: A randomized, controlled clinical trial was conducted involving 74 type 2 diabetic patients with suboptimal glycemic control (HbA1c levels > 7%) regardless of insulin therapy. The intervention (cellular phone-based telemedicine) group managed their blood glucose using a cellular phone for 3 months, while the control (self monitoring of blood glucose) group managed their blood glucose with a standard glucometer for the same period. RESULTS: Three months later, HbA1c levels were decreased in both groups. However, the decrease in the control group from 8.37% to 8.20% was only 0.20% (P = 0.152) which was not significant. In contrast, the intervention group had a significant reduction of 0.61% from 8.77% to 8.16% (P or = 8%, the patients in the intervention group showed a significant reduction of 0.81% from 9.16% to 8.34% (P < 0.001). CONCLUSION: HbA1c levels were significantly decreased in the cellular phone-based telemedicine group compared with the control group after 3 months. This study suggests that cellular phone-based telemedicine is helpful for better glucose control in type 2 diabetes patients who previously were unable to control glucose levels adequately with insulin therapy.

Effects of Telmisartan Compared with Valsartan on Plasma Adiponectin Levels and Arterial Stiffness in Patients with Type 2 Diabetes: A Pilot Study / 당뇨병

BACKGROUND: Telmisartan, used for the treatment of hypertension, has been shown to function as a partial agonist of peroxime proliferative activated receptor-nu (PPAR-nu). Theoretically, telmisartan which simultaneously blocks the angiotensin II receptor and activates PPAR-nu should be more effective in improving atherosclerotic surrogate markers than angiotensin II receptor blockers alone. Therefore, this pilot study was designed to evaluate and compare the efficacy of telmisartan and valsartan on plasma adiponectin levels and pulse wave velocity as a marker of arterial stiffness in patients with type 2 diabetes. METHODS: Thirty two patients with type 2 diabetes (mean duration 7.6 +/- 5.1 years) taking oral hypoglycemic agents were randomly assigned to receive telmisartan or valsartan for 12 weeks. RESULTS: Telmisartan and valsartan treatment significantly increased circulating adiponectin levels (P = 0.013 and P = 0.013, respectively) and reduced systolic (P = 0.001 and P = 0.002, respectively) and diastolic blood pressure (P = 0.001 and P < 0.001, respectively), and brachial-ankle PWV (P = 0.019 and P = 0.002, respectively), without significant differences between the two treatments. Before and after treatment, the fasting plasma glucose, interleukin-6, homeostasis model of assessment insulin resistance (HOMAIR) levels and lipid profile were unchanged in both treatment groups. CONCLUSION: Contrary to our expectation, telmisartan, even with its partial PPAR-nu activity, is not superior to valsartan in improving plasma adipocytokine levels and arterial stiffness in patients with type 2 diabetes. These data suggest that the partial PPAR-nu activity of telmisartan beyond valsartan may have less significant therapeutic implications than expected in treating patients with type 2 diabetes.

The prevalence of microalbuminuria and associated factors in newly diagnosed type 2 diabetes mellitus in Korea / 대한내과학회지

BACKGROUND: To determine the prevalence and the associated factors of microalbuminuria in Korean subjects with newly diagnosed type 2 diabetes mellitus. METHODS: A total of 304 patients with newly diagnosed type 2 diabetes mellitus that visited Anam Hospital, Korea University Medical Center, were studied cross-sectionally for the presence of microalbuminuria and other micro- and macrovascular complications. Microalbuminuria was calculated by the amount of albumin excretion in the urine for 24 hrs (30-299 mg/24hr) or by the albumin creatinine ratio in a spot urine sample (30-299 mg/g creatinine). Subjects were divided into two groups: the normoalbuminuria group and the microalbuminuria group. RESULTS: The prevalence of microalbuminuria, normoalbuminuria and overt proteinuria in patients with newly diagnosed type 2 diabetes mellitus was 17.1%, 80.3% and 2.6%. respectively. Microalbuminuria was significantly correlated with the body mass index (BMI), fasting insulin level, fasting C-peptide level and triglyceride level. The number of metabolic syndrome components was significantly correlated with the amount of microalbuminuria. In patients with microalbuminuria and without retinopathy, the correlation of microalbuminuria and the presence of metabolic syndrome was also significant. CONCLUSIONS: The prevalence of microalbuminuria in 304 Korean patients with newly diagnosed type 2 diabetes mellitus was 17.1%, and microalbuminuria had a correlation with the BMI, fasting insulin level, fasting C-peptide level, HOMA level, triglyceride level and the presence of metabolic syndrome.

Extensive venous thrombosis of the upper extremity in a diabetic patient with a hyperosmolar hyperglycemic state

We report a case of extensive venous thrombosis of the upper extremity in a patient with a hyperosmolar hyperglycemic state (HHS). Thrombosis of the upper extremities is generally found in 4% of cases with deep venous thrombosis. Extensive, symptomatic venous thrombosis of the upper extremity, as seen in this patient, is rare except with catheter-related thrombosis. Recent studies have supported the safety and efficacy of catheter-directed thrombolysis in patients with no contraindication to thrombolytic therapy, and have recommended early catheter-directed thrombolysis. Therefore, our patient was treated with early catheter-directed thrombolysis followed by anticoagulation.