[THE IMPACT OF ADMISSION TO THE MEDICAL WARD ON HEMOGLOBIN A1C LEVELS AMONG PATIENTS WITH TYPE-2 DIABETES].

INTRODUCTION: Blood glucose monitoring is a routine medical practice in the medical ward regardless of the cause of hospitalization of patients with diabetes. In this study we prospectively evaluated the impact of hospitalization on hemoglobin A1c (HbA1c) among patients with type-2 diabetes admitted to the medical ward, for reasons unrelated directly to their diabetes. METHODS: Patients with type-2 diabetes who were admitted to the medical ward for reasons not directly related to diabetes were asked to participate in our study. After consent , demographic, clinical and laboratory parameters were documented on admission, including age, sex, social status, years of study, duration of diabetes, type of anti-diabetic treatment, background medical problems and treatment, diagnosis on admission, temperature, blood glucose levels on admission to the medical ward, complete blood count and serum creatinine. In addition, HbA1c levels on admission, first 24-hour blood glucose levels at the medical ward, change of therapeutic treatment of their diabetes, diagnosis at discharge and recommended medication at discharge, were also documented. Three months following admission, the HbA1c study was repeated again. Paired t-test and Wilcoxon's rank sign test were used to compare between HbA1c levels at baseline and 3 months later among all the patients and among the subgroups. Multivariate regression analysis was used also to predict change in HbA1c levels among these patients. Physicians taking care of the patients on the medical ward were not aware of the study. RESULTS: Forty-four patients were recruited and 40 patients completed the study. There were 24 men (60%), with a mean age of 69.625±11.53 years for all the patients. The most common diagnosis on admission was infection followed by congestive heart failure. Mean 24-hour blood glucose level following admission was 209 mg% ±95. Among 12 patients there was an augmentation in diabetes treatment and in 3 there was dis-augmentation/discontinuation. Mean hemoglobin A1c levels on admission and 3 months later was 7.29% and 6.80% respectively (p=0.095). However, sub-analysis of patients with HbA1c levels >7.5% on admission, showed a significant decrease in the repeated HbA1c levels (p=0.003). CONCLUSIONS: Medical ward admission was associated with reduced HbA1C levels, yet not significant, among patients with type-2 diabetes who were admitted for reasons not directly related to diabetes.

The Impact of Intra-articular Depot Betamethasone Injection on Insulin Resistance Among Diabetic Patients With Osteoarthritis of the Knee: A Case-Control Study.

OBJECTIVE: The aim of this study was to evaluate the impact of intra-articular corticosteroid injection (IACI) of depot betamethasone at the knee joint on insulin resistance (IR). METHODS: Patients with type 2 diabetes, non-insulin treated, with painful osteoarthritis of the knee were requested to participate in our study. After consent, demographic, clinical, and laboratory parameters were documented in addition to fasting blood glucose (FBG) and fasting blood insulin levels just prior to IACI of 1 mL of depot betamethasone. Fasting blood glucose and fasting blood insulin levels were repeated the next day following the IACI and 8 days later. Age- and sex-matched group of patients with type 2 diabetes from the same clinic were recruited as a control group (case-control study). Insulin resistance was calculated using Homeostasis Model Assessment-Insulin Resistance. Mann-Whitney U test, χ test, and Wilcoxon signed rank tests were used for statistical analysis. RESULTS: Eleven patients were recruited in the patients' group and 10 patients in the control group. Median FBG in the patients' group at baseline was 148 ± 51 mg/dL, and median IR was 5.12 ± 2.46. One day following the IACI, median FBG level was 247 ± 104 mg/dL (P = 0.004, compared with baseline), with median IR of 20.8 ± 7.01 (P = 0.0039). The median ratios of blood glucose and IR 1 day following the IACI compared with baseline were 1.7 and 4.1, respectively. Eight days following the IACI, mean FBG and IR levels were not significantly different from baseline. CONCLUSIONS: Intra-articular corticosteroid injection of betamethasone at the knee joint among patients with diabetes was associated with a significant increase in IR levels compared with baseline levels, 1 day following the injection. The mean percentage of increase in IR was higher than that for FBG levels.

The impact of corticosteroid treatment on hemoglobin A1C levels among patients with type-2 diabetes with chronic obstructive pulmonary disease exacerbation.

BACKGROUND: Corticosteroid-induced hyperglycemia is a known adverse effect. There are no studies on the impact of corticosteroid treatment on hemoglobin A1c (HbA1c) levels in type-2 diabetes patients with chronic obstructive pulmonary disease (COPD) exacerbation. METHODS: HbA1c levels were evaluated in type-2 diabetes patients with COPD exacerbation on admission to the hospital (group-1) and 3-months later. Demographic, clinical, laboratory variables and total steroid dose were documented. Age- and sex-matched group of type-2 diabetes patients with COPD who were admitted for other reasons (group-2), were asked to participate as a control group. Mann-Whitney and Chi square/Fischer's exact tests were used to compare between the parameters of the two groups. Wilcoxon's signed rank test was used to compare between HbA1c levels at baseline and 3 months later. Multi-variate linear regression analysis was used to find predictors for a change in HbA1c levels in group-1 patients. RESULTS: 23 and 21 patients in groups 1 and 2 respectively, completed the study. There were 39 male (∼89%) patients. Mean age of the patients was 66.2 ± 8.2 years. In both groups, anti-diabetic management was augmented. There was no significant change in the HbA1c levels in group-1 (p = 0.416), however there was a significant decrease in HbA1c levels in group-2 (p = 0.032). Total dose of steroids was a predictor for an increase in HbA1c levels in group-1 patients (p = 0.026). CONCLUSIONS: Type-2 diabetes patients who were treated with steroids for COPD exacerbation had no significant change in HbA1c levels. Total dose of steroids was a predictor for an increase in HbA1c levels.

Simultaneous bilateral knee injection of methylprednisolone acetate and the hypothalamic-pituitary adrenal axis: a single-blind case-control study.

OBJECTIVE: The objective of this study was to evaluate the effect of simultaneous bilateral intra-articular injection (IAI) of methylprednisolone acetate (MPA) on the hypothalamic-pituitary-adrenal axis in patients with knee osteoarthritis. METHODS: Nonselected patients with symptomatic bilateral knee osteoarthritis had simultaneous IAI of 80 mg MPA at each knee (group 1). Just before the injection and on weeks 1, 2, 4, 6, and 8 after it, patients had 1 µg adrenocorticotropin hormone stimulation test. Age- and sex-matched patients had simultaneous IAI of 60 mg of hyaluronic acid in each knee (group 2) and the same protocol of adrenocorticotropin hormone stimulation tests. Demographic, clinical, and laboratory parameters were documented in all the patients. Secondary adrenal insufficiency (SAI) was defined as poststimulation serum cortisol levels of less than 18 µg/dL. RESULTS: Twenty patients were enrolled in each group. There were 15 women and 5 men in each group. Mean age of the patients in group 1 was 60.3 (SD, 7.6) years. Twelve patients (60%) from group 1 had evidence of SAI versus 3 patients in group 2 (P = 0.003). In all the patients who had SAI in group 1, it was observed in week 1 with decreasing frequency of SAI at the subsequent time points. Yet, 2 patients (10%) from group 1 had evidence of SAI 8 weeks after the IAI. Secondary adrenal insufficiency did not significantly correlate with any demographic, clinical, or laboratory parameter. CONCLUSIONS: Secondary adrenal insufficiency was very common following simultaneous bilateral IAI of 80 mg of MPA. Although it was transient, SAI could still be observed nearly 2 months after the IAI, in 10% of the patients.

The effect of intra-articular injection of betamethasone acetate/betamethasone sodium phosphate at the knee joint on the hypothalamic-pituitary-adrenal axis: a case-controlled study.

BACKGROUND: Intra-articular corticosteroid injection (IACI) of betamethasone depot preparation is a popular procedure at the knee joint. Intra-articular corticosteroid injection in general could be associated with systemic effects including suppression of the hypothalamic-pituitary-adrenal axis. There are nearly no reports on the effect of IACI of betamethasone at the knee joint on the hypothalamic-pituitary-adrenal axis. METHOD: Consecutive patients attending the rheumatology or orthopedic clinic with osteoarthritic knee pain who were not responding satisfactorily to medical and physical therapy were allocated to group 1 after consent and given IACI of 6 mg of betamethasone acetate/betamethasone sodium phosphate. After completion of this part, consecutive age- and sex-matched patients were allocated to group 2 and given intra-articular injection of 60 mg of sodium hyaluronate. Demographic, clinical, laboratory, and radiographic variables were documented. Just before the knee injection and 1, 2, 3, 4, and 8 weeks later, patients had 1-µg adrenocorticotropin hormone (ACTH) stimulation test. Secondary adrenal insufficiency (SAI) was defined as levels of less than 18 µg/dL and lack of a rise of more than 6 µg/dL in serum cortisol level, 30 minutes after the ACTH stimulation test.Patients were blinded to the injected material, and all injections were ultrasound guided. RESULTS: Twenty patients were enrolled in each group and equally divided between the 2 sexes. The mean age of the patients was approximately 54 years in both groups. No significant difference in any variable was seen between the 2 groups. One patient only from group 1 (the betamethasone group) had SAI 3 weeks after the IACI compared to none in the control group (P > 0.9999). His serum cortisol level 30 minutes after the ACTH stimulation was 17 µg/dL, with a rise of 3 µg/dL from baseline. CONCLUSION: Intra-articular corticosteroid injection of 6 mg of betamethasone acetate/betamethasone sodium phosphate at the knee joint was not significantly associated with SAI at the time points tested.

[Acute eosinophilic pneumonia: a potentially fatal disease under a mask of acute community-acquired bacterial pneumonia].

Acute eosinophilic pneumonia (AEP) is a rare and sometimes fatal disease. Diagnosis of AEP may be especially difficult in its early stages, before development of peripheral eosinophilia. This is a case study of AEP in a 27 years old female, reviewing etiologic factors, clinical presentation, diagnostic procedures and current treatment strategies. An important feature is that an early presentation of AEP may mimic the onset of bacterial pneumonia. Misdiagnosis and delay of appropriate treatment may result in development of respiratory failure and even death. Therefore, it is important that the relevant information regarding AEP presented in this article is disseminated to a wide forum of physicians.

Effects of hyperoxia on local and remote microcirculatory inflammatory response after splanchnic ischemia and reperfusion.

Splanchnic ischemia-reperfusion (I/R) causes tissue hypoxia that triggers local and systemic microcirculatory inflammatory responses. We evaluated the effects of hyperoxia in I/R induced by 40-min superior mesenteric artery (SMA) occlusion and 120-min reperfusion in four groups of rats: 1) control (anesthesia only), 2) sham operated (all surgical procedures without vascular occlusion; air ventilation), 3) SMA I/R and air, 4) SMA I/R and 100% oxygen ventilation started 10 min before reperfusion. Leukocyte rolling and adhesion in mesenteric microvessels, pulmonary microvascular blood flow velocity (BFV), and macromolecular (FITC-albumin) flux into lungs were monitored by intravital videomicroscopy. We also determined pulmonary leukocyte infiltration. SMA I/R caused marked decreases in mean arterial blood pressure (MABP) and blood flow to the splanchnic and hindquarters vascular beds and pulmonary BFV and shear rates, followed by extensive increase in leukocyte rolling and adhesion and plugging of >50% of the mesenteric microvasculature. SMA I/R also caused marked increase in pulmonary sequestration of leukocytes and macromolecular leak with concomitant decrease in circulating leukocytes. Inhalation of 100% oxygen maintained MABP at significantly higher values (P < 0.001) but did not change regional blood flows. Oxygen therapy attenuated the increase in mesenteric leukocyte rolling and adherence (P < 0.0001) and maintained microvascular patency at values not significantly different from sham-operated animals. Hyperoxia also attenuated the decrease in pulmonary capillary BFV and shear rates, reduced leukocyte infiltration in the lungs (P < 0.001), and prevented the increase in pulmonary macromolecular leak (P < 0.001), maintaining it at values not different from sham-operated animals. The data suggest that beneficial effects of normobaric hyperoxia in splanchnic I/R are mediated by attenuation of both local and remote inflammatory microvascular responses.