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1.
Medicine (Baltimore) ; 98(5): e14347, 2019 Feb.
Article in English | MEDLINE | ID: mdl-30702621

ABSTRACT

RATIONALE: Spontaneous anterior cervical or mediastinal hemorrhage is a rare presentation of parathyroid adenoma. PATIENT CONCERNS: A 69-year-old woman presented with neck hematoma and dysphagia and was found to have a soft tissue mass adjacent to her thyroid gland as seen on MRI and neck ultrasound. DIAGNOSIS: Laboratory testing demonstrated elevated calcium and parathyroid hormone supporting diagnosis of parathyroid adenoma. INTERVENTIONS: She underwent right inferior parathyroidectomy and en bloc right hemithyroidectomy due to significant fibrosis. OUTCOMES: Pathology confirmed hypercellular parathyroid and normal thyroid tissue. Postoperatively, patient's calcium and parathyroid hormone levels had normalized. LESSONS: In conclusion, imaging may not always be specific in identifying the source of neck hematoma and so laboratory studies should be done to rule out parathyroid adenoma as the underlying etiology.


Subject(s)
Adenoma/complications , Adenoma/diagnosis , Hematoma/etiology , Mediastinal Diseases/etiology , Parathyroid Neoplasms/complications , Parathyroid Neoplasms/diagnosis , Adenoma/surgery , Aged , Female , Humans , Neck , Parathyroid Neoplasms/surgery , Parathyroidectomy , Thyroidectomy
2.
Metabolism ; 78: 155-166, 2018 01.
Article in English | MEDLINE | ID: mdl-28986164

ABSTRACT

OBJECTIVE: Insulin resistance is a major risk factor for type 2 diabetes. ApolipoproteinJ (ApoJ) has been implicated in altered pathophysiologic states including cardiovascular and Alzheimer's disease. However, the function of ApoJ in regulation of glucose homeostasis remains unclear. This study sought to determine whether serum ApoJ levels are associated with insulin resistance in human subjects and if they change after interventions that improve insulin sensitivity. METHODS: Serum ApoJ levels and insulin resistance status were assessed in nondiabetic (ND) and type 2 diabetic (T2D) subjects. The impacts of rosiglitazone or metformin therapy on serum ApoJ levels and glucose disposal rate (GDR) during a hyperinsulinemic/euglycemic clamp were evaluated in a separate cohort of T2D subjects. Total ApoJ protein or that associated with the HDL and LDL fractions was measured by immunoblotting or ELISA. RESULTS: Fasting serum ApoJ levels were greatly elevated in T2D subjects (ND vs T2D; 100±8.3 vs. 150.6±8.5AU, P<0.0001). Circulating ApoJ levels strongly correlated with fasting glucose, fasting insulin, HOMA-IR, and BMI. ApoJ levels were significantly and independently associated with HOMA-IR, even after adjustment for age, sex, and BMI. Rosiglitazone treatment in T2D subjects resulted in a reduction in serum ApoJ levels (before vs. after treatment; 100±13.9 vs. 77±15.2AU, P=0.015), whereas metformin had no effect on ApoJ levels. The change in ApoJ levels during treatment was inversely associated with the change in GDR. Interestingly, ApoJ content in the LDL fraction was inversely associated with HOMA-IR. CONCLUSION: Serum ApoJ levels are closely correlated with the magnitude of insulin resistance regardless of obesity, and decrease along with improvement of insulin resistance in response only to rosiglitazone in type 2 diabetes.


Subject(s)
Clusterin/blood , Insulin Resistance/physiology , Blood Glucose/drug effects , Blood Glucose/metabolism , Diabetes Mellitus, Type 2/blood , Diabetes Mellitus, Type 2/drug therapy , Diabetes Mellitus, Type 2/metabolism , Diabetes Mellitus, Type 2/physiopathology , Female , Glucose/metabolism , Glucose Clamp Technique/methods , Homeostasis/drug effects , Homeostasis/physiology , Humans , Hyperinsulinism/blood , Hyperinsulinism/drug therapy , Hyperinsulinism/metabolism , Hyperinsulinism/physiopathology , Hypoglycemic Agents/therapeutic use , Insulin/metabolism , Male , Metformin/therapeutic use , Middle Aged , Risk Factors , Rosiglitazone , Thiazolidinediones/therapeutic use
3.
Endocr Pract ; 21(4): 355-67, 2015 Apr.
Article in English | MEDLINE | ID: mdl-25536971

ABSTRACT

OBJECTIVE: Uncontrolled hyperglycemia and iatrogenic hypoglycemia represent common and frequently preventable quality and safety issues. We sought to demonstrate the effectiveness of a hypoglycemia reduction bundle, proactive surveillance of glycemic outliers, and an interdisciplinary data-driven approach to glycemic management. POPULATION: all hospitalized adult non-intensive care unit (non-ICU) patients with hyperglycemia and/or a diagnosis of diabetes admitted to our 550-bed academic center across 5 calendar years (CYs). INTERVENTIONS: hypoglycemia reduction bundle targeting most common remediable contributors to iatrogenic hypoglycemia; clinical decision support in standardized order sets and glucose management pages; measure-vention (daily measurement of glycemic outliers with concurrent intervention by the inpatient diabetes team); educational programs. MEASURES AND ANALYSIS: Pearson chi-square value with relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare glycemic control, hypoglycemia, and hypoglycemia management parameters across the baseline time period (TP1, CY 2009-2010), transitional (TP2, CY 2011-2012), and mature postintervention phase (TP3, CY 2013). Hypoglycemia defined as blood glucose <70 mg/dL, severe hypoglycemia as <40 mg/dL, and severe hyperglycemia >299 mg/dL. RESULTS: A total of 22,990 non-ICU patients, representing 94,900 patient-days of observation were included over the 5-year study. The RR TP3:TP1 for glycemic excursions was reduced significantly: hypoglycemic stay, 0.71 (95% CI, 0.65 to 0.79); severe hypoglycemic stay, 0.44 (95% CI, 0.34 to 0.58); recurrent hypoglycemic day during stay, 0.78 (95% CI, 0.64 to 0.94); severe hypoglycemic day, 0.48 (95% CI, 0.37 to 0.62); severe hyperglycemic day (>299 mg/dL), 0.76 (95% CI, 0.73 to 0.80). CONCLUSION: Hyperglycemia and hypoglycemia event rates were both improved, with the most marked effect on severe hypoglycemic events. Most of these interventions should be portable to other hospitals.


Subject(s)
Hyperglycemia/therapy , Hypoglycemia/prevention & control , Adult , Aged , Blood Glucose/analysis , Female , Humans , Hyperglycemia/blood , Inpatients , Male , Middle Aged
4.
Jt Comm J Qual Patient Saf ; 40(5): 228-34, 2014 May.
Article in English | MEDLINE | ID: mdl-24919254

ABSTRACT

BACKGROUND: Nearly 2 million osteoporosis-related fractures occur yearly in the United States, with more than 400,000 requiring hospital admissions. Fewer than 30% receive proper evaluation and care for osteoporosis, representing a large opportunity to enhance secondary prevention of fractures. Methods to improve identification and triage of hospitalized fragility-fracture patients are desirable. METHODS: A multidisciplinary team was created, and definitions were established for an evidence-based best-practice protocol to assess, treat, and document an osteoporosis diagnosis and triage patients with hip-fragility fractures on the basis of the best-practice recommendations from The Joint Commission and the National Osteoporosis Foundation. The team initiated a preauthorized osteoporosis consultation from the endocrinology service for hip-fracture patients, "triggered" via a brief query in admission orders or by the orthopedic service nurse practitioner. Osteoporosis consultations used a consultation template reflecting the protocol. RESULTS: Data were analyzed for 71 baseline patients and 61 intervention patients. The groups possessed similar age, gender, race, and body mass index characteristics. The baseline (on-demand consultation) group suffered from poor performance, with only 3%-21% of patients receiving the desired evaluation, documentation, treatment, or outpatient follow-up. Intervention (triggered-consultation) patients improved markedly postintervention, With performance increasing by 52%-76% on all parameters except outpatient follow-up, which changed insignificantly (6%-15%). CONCLUSION: Although triggered consultation was effective, multimodal layered interventions may achieve even better results and address several identified barriers.


Subject(s)
Endocrinology/organization & administration , Hip Fractures , Osteoporosis/therapy , Quality Improvement , Referral and Consultation , Aged , Evidence-Based Medicine , Female , Humans , Male , Osteoporosis/diagnosis , Patient Care Team , Practice Guidelines as Topic
5.
Physiol Rep ; 1(7): e00157, 2013 Dec 01.
Article in English | MEDLINE | ID: mdl-24744851

ABSTRACT

Intermittent pneumatic compression of the calf and foot increases inflow to the popliteal artery and skin. We hypothesize that mild, continuous pneumatic compression of the lower extremities of type 2 diabetic patients increases microvascular blood flow to skin (SBF) and muscle (MBF) and improves sensation in feet. Data were collected on 19 healthy volunteers and 16 type 2 diabetic patients. Baseline values of SBF, MBF, and foot sensation were recorded in one leg. The lower extremity was then subjected to 30 mmHg of continuous external air pressure for 30 min, whereas SBF and MBF were continuously monitored. Sensation was reassessed after pressure was released. During 30 mmHg continuous external compression, the healthy control group significantly increased MBF by 39.8% (P < 0.01). Sensation of the foot in this group improved significantly by 49.8% (P < 0.01). In the diabetic group, there was a significant increase in MBF of 17.7% (P = 0.03). Also sensation improved statistically by 40.2% (P = 0.03). Importantly and counterintuitively, MBF and foot sensation both increase after 30 min of leg compression at 30 mmHg. Therefore, mild, continuous pneumatic compression may be a new approach for treating diabetic patients with compromised leg perfusion and sensation.

6.
Am J Physiol Endocrinol Metab ; 297(3): E767-73, 2009 Sep.
Article in English | MEDLINE | ID: mdl-19622782

ABSTRACT

Adiponectin, an insulin-sensitizing factor secreted from adipose tissue, is decreased in individuals with type 2 diabetes (T2D) and increased in response to thiazolidinedione (TZD) therapy. Changes in its secretion and assembly into higher-order forms affect insulin sensitivity. To determine the relative potency of TZDs on intra-adipocyte multimerization and secretion of adiponectin, we assessed the impact of in vivo low- or high-dose rosiglitazone treatment alone or combined with metformin in subjects with T2D. T2D subjects received high-dose rosiglitazone (8 mg/day), high-dose metformin (2,000 mg/day), or low-dose combination rosiglitazone-metformin therapy (4 mg + 1,000 mg/day) for 4 mo. All subjects were then switched to high-dose rosiglitazone-metformin combination therapy (8 mg + 2,000 mg/day) for another 4 mo. Low-dose rosiglitazone increased serum adiponectin, whereas the high dose increased both adipocyte content and serum adiponectin levels. TZDs selectively increased the percentage of circulating adiponectin in the potent, high-molecular-weight (HMW) form. No TZD effects were evident on multimer distribution in the cell. Expression of the chaperone protein ERp44, which retains adiponectin within the cell, was decreased by TZD treatment. No changes occurred in Ero1-Lalpha expression. Metformin had no effect on any of these measures. Increases in adiponectin correlated with improvements in insulin sensitivity. In vivo, TZDs have apparent dose-dependent effects on cellular and secreted adiponectin. TZD-mediated improvements in whole body insulin sensitivity are associated with increases in circulating but not cellular levels of the HMW adiponectin multimer. Finally, TZDs promote the selective secretion of HMW adiponectin, potentially, in part, through decreasing the expression of the adiponectin-retaining protein ERp44.


Subject(s)
Diabetes Mellitus, Type 2/drug therapy , Diabetes Mellitus, Type 2/metabolism , Hypoglycemic Agents/pharmacology , Intracellular Space/metabolism , Protein Multimerization/drug effects , Adiponectin/blood , Adiponectin/chemistry , Adiponectin/metabolism , Adult , Aged , Diabetes Mellitus, Type 2/blood , Dose-Response Relationship, Drug , Double-Blind Method , Female , Humans , Hypoglycemic Agents/administration & dosage , Hypoglycemic Agents/therapeutic use , Intracellular Space/drug effects , Male , Metformin/administration & dosage , Middle Aged , Molecular Weight , Protein Isoforms/blood , Protein Isoforms/chemistry , Protein Isoforms/metabolism , Rosiglitazone , Substrate Specificity , Thiazolidinediones/administration & dosage , Thiazolidinediones/pharmacology , Thiazolidinediones/therapeutic use , Young Adult
7.
South Med J ; 100(11): 1123-31, 2007 Nov.
Article in English | MEDLINE | ID: mdl-17984745

ABSTRACT

Intensive treatment has been shown to improve glycemic control and reduce the risk of diabetic complications in controlled clinical trials; however, glycemic control has substantial room for improvement in the diabetic population. Management strategies have traditionally focused on achieving A1c targets, with fasting glucose levels serving as the primary measure of day-to-day glycemic control. Considerable evidence indicates that postchallenge plasma glucose, a surrogate for postprandial hyperglycemia, is an independent cardiovascular risk factor, highlighting the fact that optimal glycemic control requires management of both fasting and postprandial glucose levels. Self-monitoring of blood glucose (SMBG) is an important adjunct for optimizing glycemic control, owing to its ability to differentiate between fasting and postprandial hyperglycemia and to provide feedback on the effects of food choices, medications, and exercise. New and emerging medications specifically targeting postprandial hyperglycemia offer the ability to customize pharmacologic therapy to address specific glycemic defects. Periodic glucose profiles and regular SMBG will remain an important tool for both patients and healthcare professionals when using these newer approaches.


Subject(s)
Blood Glucose Self-Monitoring/methods , Blood Glucose/analysis , Diabetes Mellitus/blood , Hyperglycemia/drug therapy , Hypoglycemic Agents/therapeutic use , Postprandial Period , Humans , Risk Factors
8.
J Natl Med Assoc ; 99(4): 357-60, 363-7, 2007 Apr.
Article in English | MEDLINE | ID: mdl-17444424

ABSTRACT

There is a growing consensus that blood glucose control, and postprandial control in particular, must become more aggressive if we are to stem the growing tide of diabetes-related complications and mortality. For most patients, this means that insulin therapy must begin earlier and that insulin must be titrated sufficiently to achieve tighter glycemic targets. The limitations of traditional treatment regimens, delivery devices and conventional insulin formulations, in conjunction with patient factors, have prevented the majority of people with type-2 diabetes from realizing the potential benefits of insulin therapy and achieving recommended glycemic targets. Fortunately, modern insulin analog formulations, new treatment regimens, and advanced delivery devices are now available. This review will discuss features of these new tools, and compare the benefits of using premixed insulin versus a basal-only approach to initiating insulin therapy. Once physicians become familiar with these tools and incorporate them into daily practice, they will be able to better tailor diabetes self-management programs to the needs of individual patients. The result will be that more patients should be able to reach recommended glycemic targets with greater convenience and safety than has previously been available.


Subject(s)
Blood Glucose/drug effects , Diabetes Mellitus, Type 2/drug therapy , Insulin/therapeutic use , Humans , Insulin/administration & dosage , Insulin/analogs & derivatives , Titrimetry
9.
Obes Res ; 13(8): 1321-9, 2005 Aug.
Article in English | MEDLINE | ID: mdl-16129713

ABSTRACT

OBJECTIVE: To determine whether adipocyte differentiation-related protein (ADRP), a lipid droplet-associated protein that binds to and sequesters intracellular fatty acids, is 1) expressed in human skeletal muscle and 2) differentially regulated in human skeletal muscle obtained from obese non-diabetic (OND) and obese diabetic (OD) subjects. RESEARCH METHODS AND PROCEDURES: Ten OND subjects and 15 OD subjects underwent a weight loss or pharmacological intervention program to improve insulin sensitivity. Anthropometric data, hemoglobin A(1C), fasting glucose, lipids, and glucose disposal rate were determined at baseline and at completion of studies. Biopsies of the vastus lateralis muscle (SkM) were obtained in the fasting state from OND and OD subjects. Protein expression was determined by Western blotting. RESULTS: ADRP was highly expressed in SkM from OND (4.4 +/- 1.54 AU/10 microg, protein, n = 10) and OD (5.02 +/- 1.33 AU/10 microg, n = 12) subjects. OND subjects undergoing weight loss had decreased triglyceride levels and improved insulin action. SkM ADRP content increased with weight loss from 5.14 +/- 2.15 AU/10 microg to 9.92 +/- 1.57 AU/10 microg (p < 0.025). OD subjects were treated with either troglitazone or metformin, together with glyburide, for 3 to 4 months. Both treatments attained similar levels of glycemic control. OD subjects with lower baseline ADRP content (2.85 +/- 1.07 AU/10 microg, n = 6) displayed up-regulation of ADRP expression (to 9.27 +/- 2.76 AU/10 microg, p < 0.025). DISCUSSION: ADRP is the predominant lipid droplet-associated protein in SkM, and low ADRP expression is up-regulated in circumstances of improved glucose tolerance. Up-regulation of ADRP may act to sequester fatty acids as triglycerides in discrete lipid droplets that could protect muscle from the detrimental effects of fatty acids on insulin action and glucose tolerance.


Subject(s)
Adipocytes/metabolism , Insulin Resistance/physiology , Membrane Proteins/metabolism , Muscle, Skeletal/metabolism , Adult , Aged , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/metabolism , Female , Humans , Lipid Metabolism , Male , Middle Aged , Obesity/complications , Obesity/metabolism , Perilipin-2
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