Persistent Graves' hyperthyroidism despite rapid negative conversion of thyroid-stimulating hormone-binding inhibitory immunoglobulin assay results: a case report.

BACKGROUND: Graves' disease is an autoimmune thyroid disorder characterized by hyperthyroidism, and patients exhibit thyroid-stimulating hormone receptor antibody. The major methods of measuring circulating thyroid-stimulating hormone receptor antibody include the thyroid-stimulating hormone-binding inhibitory immunoglobulin assays. Although the diagnostic accuracy of these assays has been improved, a minority of patients with Graves' disease test negative even on second-generation and third-generation thyroid-stimulating hormone-binding inhibitory immunoglobulins. We report a rare case of a thyroid-stimulating hormone-binding inhibitory immunoglobulin-positive patient with Graves' disease who showed rapid lowering of thyroid-stimulating hormone-binding inhibitory immunoglobulin levels following administration of the anti-thyroid drug thiamazole, but still experienced Graves' hyperthyroidism. CASE PRESENTATION: A 45-year-old Japanese man presented with severe hyperthyroidism (serum free triiodothyronine >25.0 pg/mL; reference range 1.7 to 3.7 pg/mL) and tested weakly positive for thyroid-stimulating hormone-binding inhibitory immunoglobulins on second-generation tests (2.1 IU/L; reference range <1.0 IU/L). Within 9 months of treatment with oral thiamazole (30 mg/day), his thyroid-stimulating hormone-binding inhibitory immunoglobulin titers had normalized, but he experienced sustained hyperthyroidism for more than 8 years, requiring 15 mg/day of thiamazole to correct. During that period, he tested negative on all first-generation, second-generation, and third-generation thyroid-stimulating hormone-binding inhibitory immunoglobulin assays, but thyroid scintigraphy revealed diffuse and increased uptake, and thyroid ultrasound and color flow Doppler imaging showed typical findings of Graves' hyperthyroidism. CONCLUSIONS: The possible explanations for serial changes in the thyroid-stimulating hormone-binding inhibitory immunoglobulin results in our patient include the presence of thyroid-stimulating hormone receptor antibody, which is bioactive but less reactive on thyroid-stimulating hormone-binding inhibitory immunoglobulin assays, or the effect of reduced levels of circulating thyroid-stimulating hormone receptor antibody upon improvement of thyroid autoimmunity with thiamazole treatment. Physicians should keep in mind that patients with Graves' disease may show thyroid-stimulating hormone-binding inhibitory immunoglobulin assay results that do not reflect the severity of Graves' disease or indicate the outcome of the disease, and that active Graves' disease may persist even after negative results on thyroid-stimulating hormone-binding inhibitory immunoglobulin assays. Timely performance of thyroid function tests in combination with sensitive imaging tests, including thyroid ultrasound and scintigraphy, are necessary to evaluate the severity of Graves' disease and treatment efficacy.

[Stroke in the elderly people with diabetes mellitus].

In Japan, number of elderly people with type 2 diabetes mellitus are increasing. The purpose of care and management for diabetes mellitus is a prevention of chronic complications and maintaining longevity and quality of life. This purpose does not change even in elderly people with diabetes. Diabetes mellitus is an established risk factor for stroke. In this review, we described clinical characteristics of stroke in elderly people with diabetes. There is a possibility that several features in the elderly patients are different from those in the non-elderly subject with diabetes. Stroke strongly affects prognosis of patients including quality of life. It is necessary to understand the characteristics of elderly people with diabetes and the way for the management of diabetes.

Patient perceptions of different lancing sites for self-monitoring of blood glucose: a comparison of fingertip site with palm site using the OneTouch Ultra Blood Glucose Monitoring System.

BACKGROUND: Alternate-site testing (AST) for self-monitoring of blood glucose leads to improved glycemic control for treatment of diabetes mellitus. The aim of this randomized, open-label, two-period, crossover study was to compare the comfort of two different lancing sites, fingertip and palm sites, for AST in diabetes patients. METHODS: Patients injected insulin four times a day. Self-monitoring of blood glucose was carried out more than thrice daily with fingertip measurements for at least three months using apparatuses except the OneTouch Ultra Blood Glucose Monitoring System (OneTouch) before examination. The comfort of two lancing sites using OneTouch were compared. In two randomized groups that used one fingertip lancing site for one week followed by the alternate lancing site for another week, patients completed 11-item questionnaires assessing usability of the site before and after each week. Each item was scored on a visual analogue scale from -100 (most negative) to +100 (most positive). RESULTS: Most patients desired to continue AST, which was insignificantly different between the two lancing sites (fingertip and palm AST) in 43 diabetes patients aged 57.3 +/- 13.8 years, body mass index of 23.1 +/- 2.5 kg/m(2), diabetes duration of 19.6 +/- 9.7 years, and hemoglobin A1c of 7.4 +/- 1.1%. However, patients were less (p < .01) satisfied with using the palm lancing site as compared to the fingertip lancing site because of difficulties in inserting the needle, drawing blood samples, and applying enough blood into the test strip. CONCLUSIONS: These results suggest that patients desire to use the palm for AST, but more technological advances in AST of a palm site is required to reduce patient discomfort.

Usefulness of home blood pressure measurement in the morning in patients with type 2 diabetes: long-term results of a prospective longitudinal study.

Previous cross-sectional studies have demonstrated that blood pressure measurements at home (HBP) in the morning display stronger predictive power for micro- and macrovascular complications in type 1 and 2 diabetic patients than casual/clinic blood pressure (CBP) measurements. This longitudinal study investigated which of these measurements offers stronger predictive power for outcomes over 6 years. At baseline, 400 Japanese patients with type 2 diabetes were classified as hypertensive or normotensive based on HBP and CBP measurements. Mean (+/-SD) survey duration of all patients was 42.1 +/- 20.0 months (range, 3-72 months). Primary and secondary endpoints were death and new, worsened, or improved micro- and macrovascular events, respectively. Differences in outcomes for each endpoint between hypertensive and normotensive patients in each group were analyzed using survival curves from Kaplan-Meier analysis and log-rank testing. Associated risk factors related to outcomes were assessed using Cox proportional hazards modeling. On the basis of HBP, cumulative events of death and new or worsened microvascular diseases were significantly higher in hypertensive patients than in normotensive patients. On the basis of CBP, no significant differences were identified. New or worsened macrovascular events were significantly higher in hypertensive patients than in normotensive patients on the basis of both HBP and CBP. One associated risk factor was morning hypertension. A longitudinal study of type 2 diabetic patients demonstrated that elevated HBP in the morning is predictive of micro- and macrovascular complications.

Fulminant type 1 diabetes mellitus acutely emerged during pregnancy.

A pregnant woman at 32 weeks of gestation was emergently admitted to our hospital with symptoms of nausea, vomiting, and uterine contraction. Cardiotocogram demonstrated a loss of variability and late deceleration in fetal heart rate pattern. Emergency cesarean section was performed, and a male infant weighing 1750 g was born with Apgar scores of 1 at 1 min, and 3 at 5 min after delivery. After cesarean section, the patient developed an acetone breath odor, and blood examination demonstrated remarkable acidemia and an extremely high level of blood glucose. The patient was diagnosed with ketoacidosis with acute onset of fulminant type 1 diabetes mellitus. Intensive care was applied due to the severe diabetes mellitus conditions. The patient's general condition ameliorated during the postoperative period, although there was a possibility of neurological complications in the infant.

GH-releasing peptide-2 does not stimulate arginine vasopressin secretion in healthy men.

Ghrelin has a stimulating effect on arginine vasopressin (AVP). However, it is not known whether GHRP-2, a synthetic ghrelin receptor agonist, also has a stimulating effect on AVP release in men. To determine whether the GHRP-2 test is useful for assessing AVP secretion, blood ACTH, GH, FSH, LH, PRL, TSH and AVP levels, as well as glucose, osmolality, sodium and hematocrit, were measured before and 15, 30, 45 and 60 min after an intravenous bolus of 100 microg GHRP-2 in 10 healthy men with and without fasting. Blood pressure was measured at 15-min intervals. AVP secretion was not stimulated by the GHRP-2 test with and without fasting. There were no significant differences in hematocrit, blood pressure and plasma osmolality before and after GFRP-2 injection, although significant (p<0.001) peak blood GH, and ACTH and PRL levels were observed 30 and 15 min after GHRP-2 injection with and without fasting, respectively, and the maximal peaks were significantly (p<0.05) higher with fasting than without fasting. These results suggest that AVP secretion is not stimulated by the GHRP-2 test both with and without fasting, though GH, ACTH and PRL levels were higher with than without fasting.