An evaluation of a nurse case-managed program for children with diabetes.

This study evaluates an integrated model of care for children with diabetes that was developed at a health maintenance organization (HMO). This model program of 56 subjects included a nurse case manager, a multidisciplinary clinic team, and educational and counseling interventions to empower families to improve self-management of the children's diabetes. The purpose of the program was to improve diabetes self-management as measured by pre- and post-intervention glycosylated hemoglobin values, quality of life, and self-efficacy ratings. There were improvements in means of all measures of self-management and a statistically significant improvement in self-efficacy beliefs of the parents. The higher quality of life and self-efficacy ratings are related to adherence to a complex diabetic regimen that is critical to effective self-management. This model provides comprehensive, effective care to a service-intensive population.

Rest-redistribution 201-Tl single-photon emission CT imaging for determination of myocardial viability: relationship among viability, mode of therapy, and long-term prognosis.

BACKGROUND: The diagnosis of viable myocardium in the setting of ischemic left ventricular systolic dysfunction might indicate which patients have the greatest prognostic benefit from myocardial revascularization. Single-photon emission CT (SPECT) thallium-201 (201Tl) scintigraphy for the detection of viable myocardium is widely available in the community, but outcome data using this imaging modality are limited. METHODS: Thirty-seven patients (mean [+/- SD] age, 62+/-12 years) with ischemic left ventricular dysfunction (mean ejection fraction, 30+/-9%) initially referred for rest-redistribution SPECT thallium scintigraphy were evaluated 29+/-19 months after coronary bypass surgery (n = 15) or medical therapy alone (n = 22). The relationship among myocardial viability, mode of therapy, and long-term prognosis was evaluated. RESULTS: Significant myocardial viability (defined as a viability index [VI] of > 0.5) was present in 19 patients. Among patients with a VI > 0.5, the 48-month actuarial event-free survival was 89+/-10% for patients undergoing surgical revascularization, compared with 0% for the medical treatment subgroup (p = 0.005). In contrast, patients in the low-viability subgroup tended to have intermediate event-free survival rates, which were not statistically different for patients receiving either surgical (62+/-21%) or medical therapy (50+/-14%; p = 0.55). CONCLUSIONS: Survival is significantly more favorable for surgically revascularized patients with ischemic left ventricular dysfunction and myocardial viability as detected by SPECT 201Tl scintigraphy.

Esophageal passage of iodine-131 capsules.

UNLABELLED: The purpose of this study was to determine the orogastric transit time of standard 131I capsules and the incidence of transit delay. METHODS: We studied 58 consecutive subjects receiving outpatient diagnostic and therapeutic 131I dosages. A standard ion chamber survey meter, placed over the left upper quadrant of the abdomen, monitored orogastric transit. Each subject had ample water to subjectively swallow their capsule. Orogastric transit times, volume of water ingested, capsule size, and demographic and historical data were recorded for each subject. RESULTS: Seventeen subjects (29%) had delayed transit, with an orogastric transit time > 90 sec (median 140 sec, range 100-930 sec). Forty-one subjects had normal transit (median 14 sec, range 4-51 sec). We identified delayed transit in 7 of 37 women (19%) and 10 of 21 men (48%) (p = 0.035). Age, capsule size and initial water volume ingested did not differ significantly between subject groups. CONCLUSION: Men were more likely than women to have prolonged orogastric transit of standard 131I capsules. Other than sex, we found no identifiable clinical feature or medical history to predict delayed orogastric transit. A standard survey meter can identify adherent capsules to minimize esophageal radiation exposure.

Insidious illness in active seniors: decoding atypical presentations.

Older athletes and active seniors may have serious medical problems without commonly recognized signs and symptoms. The cases of an older tennis player, a golfer, and a deep-sea sport fisherman illustrate unusual presentations of coronary artery disease, bacterial pneumonia, and peptic ulcer disease in senior patients. Alertness for the effects of coexisting illnesses, chronic use of medicines, reduced physiologic and immunologic reserves, altered pain perception, and symptom denial can facilitate prompt treatment of active senior patients.

Localization of an ectopic parathyroid adenoma by double-phase technetium-99m-sestamibi scintigraphy.

Double-phase planar scintigraphy using 99mTc-MIBI has been introduced as a means to detect and localize parathyroid adenomas. Focal uptake on both early and delayed imaging is typical of these entities. We report a patient with persistent hypercalcemia following subtotal parathyroidectomy, who was found scintigraphically to have an ectopic parathyroid adenoma. Following initial detection within the mediastinum using planar scintigraphy, the adenoma was more precisely localized using SPECT imaging. This case suggests that double-phase parathyroid planar scintigraphy augmented with SPECT imaging, if needed, is cost-effective, and often necessary, in the assessment of primary hyperparathyroid patients before surgical reexploration.

Right atrial and pulmonary thromboembolism mimicking unstable angina.

Pulmonary thromboembolism is a potentially fatal disease characterized by a highly variable clinical presentation. Mortality rises dramatically with right atrial thromboembolism. In our case right atrial and pulmonary thromboembolism mimicked unstable angina. A high index of suspicion and early use of echocardiography can lead to the prompt diagnosis and timely treatment of this condition. Although the optimal treatment remains controversial, prompt therapeutic intervention is mandated by an otherwise poor prognosis.

Endogenous endophthalmitis due to Salmonella arizonae and Hafnia alvei.

Enteric pathogens rarely involve organs other than those of the gastrointestinal system. We have reported the case of a woman with rheumatoid arthritis who had endogenous endophthalmitis due to Salmonella arizonae and Hafnia alvei. The infection probably resulted from the use of snake powder as a food seasoner. After appropriate intravenous, intraocular, subconjunctival, topical, and oral antibiotic therapy based on laboratory susceptibility studies, the patient's condition clinically improved, but complications resulted in therapeutic enucleation. Because of the ubiquitous nature of these and other potentially pathogenic organisms, great care must be taken in evaluation, management, and education of immunocompromised patients.