Liddle's syndrome: A case report.

Liddle's syndrome or pseudoaldosteronism is a rare autosomal dominant disease mimicking primary hyperaldosteronism, characterized by early-onset hypertension, hypokalemia and hypoaldosteronism, caused by excessive salt and water reabsorption in the distal nephron. As of 2008, there are <30 pedigrees or isolated cases that have been reported worldwide. We present an isolated case of a Liddle's syndrome in a 48-year-old female. A 48-year-old female presented to the clinic with palpitation and a three to four-year history of low potassium level and hypertension. She was initially treated with a high potassium diet and potassium supplements. Her cardiac work-up including echocardiography, stress test and Holter monitoring were all negative. After a few months, she was admitted to the hospital with an acute hypertensive episode and hypokalemia. On evaluation, she was found to have low renin and aldosterone levels. Liddle's syndrome was considered with the clinical picture of hypokalemia, hypertension and low renin/ aldosterone level. The patient was successfully treated with a high potassium diet, triamterene and atenolol. Liddle's syndrome should be considered as the differential diagnosis in patients presenting with the clinical picture of hypokalemia, hypertension and low renin/aldosterone level.

Vitamin D insufficiency/deficiency management.

OBJECTIVES: In recent years, vitamin D deficiency has been recognized increasingly often in patients, and different supplement regimens have been prescribed to treat it. There has been no consensus on treatment regimens. This study was conducted to determine the management of vitamin D deficiency/insufficiency in outpatient adults in northeast Tennessee. METHODS: A retrospective record review was conducted in an internal medicine teaching clinic for patients seen from July 2007-July 2008 in Johnson City, Tennessee. A total of 626 nonelectronic charts listed with vitamin D measurements were used in the analysis. Data regarding the level of vitamin D, whether treatment was prescribed, dose and duration of treatment prescribed, and repeat levels of vitamin D, if any were ordered, were collected. Vitamin D deficiency was defined as levels <20 ng/mL; vitamin D insufficiency was defined as levels ranging from 20 to 29.9 ng/mL. RESULTS: Of the 626 patients, 325 (52%) were vitamin D deficient or insufficient. Of these 325 patients, 184 were given a low-dose supplement and 54 received a high-dose supplement. Eighty-seven were either not prescribed any replacement or the dose was unknown (not documented in the chart). The mean change in serum vitamin D levels was significantly different for the high dose compared with the low dose prescribed. There was no significant sex difference in response to the dose given. On average, those who were vitamin D deficient experienced a greater change than those who were insufficient and a greater change, on average, was observed in those who received a higher dose. CONCLUSIONS: Vitamin D deficiency and insufficiency are highly prevalent. Clinicians tended to prescribe a high dose of treatment for lower levels of serum vitamin D. The response is higher in high-dose treatment. Documentation regarding whether vitamin D supplements were given or the dose of supplements was given and followed up with repeat levels of vitamin D after treatment was poor.

The relationship of vitamin D status to cardiovascular risk factors and amputation risk in veterans with peripheral arterial disease.

OBJECTIVES: Peripheral arterial disease (PAD) is a common and often overlooked entity responsible for considerable morbidity and mortality. Recent evidence suggests that nontraditional risk factors such as vitamin D may contribute to atherosclerosis. We hypothesized that vitamin D status was associated with cardiovascular risk factors and that vitamin D deficiency (25(OH)D <20 ng/mL) enhanced the risk of amputation. DESIGN: We reviewed medical records of 1435 veterans between 2000 and 2008 in Tennessee via retrospective chart analysis using correlations, logistic regressions, t tests, and χ(2) analyses. RESULTS: Vitamin D status was significantly and inversely correlated with body mass index (BMI), glucose, and triglyceride values. Hypertension and diabetes but not smoking also emerged as significantly associated. Of the sample population, 5.2% (n = 75) had an amputation performed. Those individuals who were vitamin D deficient had a significantly higher amputation rate (6.7%) compared with patients who were nondeficient (4.2%). BMI, triglyceride, total cholesterol, hypertension, and diabetes were found to account for 5.7% of the variation in amputation status. Vitamin D concentration and deficiency status accounted for a nonsignificant amount of additional variance. CONCLUSIONS: We conclude that vitamin D deficiency is closely linked to increased adiposity, triglyceride, and glucose measurements. Vitamin D deficiency was associated with an increased amputation risk in veterans with PAD and appears to mediate its effects through traditional risk factors.

Vitamin D deficiency: an increasing concern in peripheral arterial disease.

Peripheral arterial disease is a common and often overlooked entity responsible for considerable morbidity and mortality. Recent evidence suggests that nontraditional risk factors such as vitamin D deficiency may contribute to atherosclerosis and increased cardiovascular morbidity and mortality, hence monitoring of vitamin D status is essential. This review tries to examine this entity.

Testing for vitamin D deficiency in veterans-is there a seasonal bias?

OBJECTIVE: The present study was undertaken to determine if a seasonal bias was present for vitamin D testing among Northeast Tennessee veterans, in whom vitamin D deficiency is common. DESIGN: Medical chart review. SETTING: VA Medical Center. PARTICIPANTS: Participants were 9447 patients with initial 25(OH) vitamin D levels obtained over a 3-year period. MEASUREMENT: Serum 25-hydroxyvitamin D (25[OH]D) level, date of testing, patient background factors. RESULTS: Vitamin D testing occurred more frequently in September, October, November, and December, whereas the lowest levels of 25(OH) vitamin D levels were found in January, February, and March. Similar results were observed in quarterly data with the greatest number of tests noted in the last quarter of the year, yet the lowest 25(OH) vitamin D levels were noted in the first quarter. The average monthly 25(OH) vitamin D levels were below 30 ng/mL throughout the year in the study population, consistent with highly prevalent vitamin D deficiency. CONCLUSION: Clinicians may have a seasonal bias, favoring testing for vitamin D status in the latter part of the year even though the lowest vitamin D levels are observed in the first part of the year. Although an argument could be made to check for peak 25(OH) vitamin D levels in September and trough levels in March, the seasonal contribution to vitamin D deficiency is overshadowed by ongoing vitamin D deficiency throughout the year. Thus, it may be prudent to test for vitamin D deficiency in patients presenting with fatigue, myalgias, and arthralgias regardless of the season of presentation.

Prevalence of vitamin D deficiency and insufficiency in northeast Tennessee.

BACKGROUND: Vitamin D deficiency is increasingly being recognized as a highly prevalent and undertreated problem. This study was conducted to determine the prevalence of vitamin D deficiency/insufficiency in hospitalized adults in northeast Tennessee. METHODS: A prospective cohort study was conducted on 99 inpatients admitted to an internal medicine teaching service from July through October 2006 at a single private hospital in Johnson City, Tennessee. A single measurement of 25-hydroxyvitamin D was performed on all patients. RESULTS: Of the 99 patients, 53% were vitamin D deficient or insufficient (30% deficient with a level of <20 ng/mL and 23% insufficient with a level between 20-29.9 ng/mL). The highest frequency of deficiency was in females <50 years. CONCLUSION: Vitamin D deficiency is highly prevalent in all age groups and in both females and males in this population. Clinicians should consider measuring the vitamin D level of all inpatients on a routine basis.