Ongoing assessment of health status in patients with diabetes mellitus.

In 1990, the Division of Endocrinology and Metabolism of Henry Ford Hospital established an Outcomes Management data base for patients with Type I and Type II diabetes. A first cohort of 117 patients completed a baseline and 6-month follow-up assessment; a second cohort of 116 patients completed the baseline assessment. Assessment at each time point includes: the Short Form--36 Questions (SF-36) health status instrument; a set of clinical variables known as the Diabetes TyPE scale Form 2.2 abstracted from the medical record; and the physicians' ratings of patient's health status along the major dimensions of the SF-36. Success with both face-to-face and mailed administration of the SF-36 has been good, with response rates of over 85% using both methods. Comparison of patient and physician ratings of patient health status indicated a significant discrepancy on ratings of general health status, with physicians' ratings higher than those of patients themselves. "Tight" glycemic control (as measured by glycosylated hemoglobin) was associated with somewhat lower ratings on the various SF-36 dimensions for all patients in the first cohort and for Type I patients in the second cohort. However, this effect did not seem to be attributable to those features of a complex regimen used to achieve tight control, but rather reflected a complex combination of age, education level, and number of daily injections associated with achieving good control.

An ambulatory approach to self-care of diabetes.

Managing the insulin-requiring diabetic patient in an ambulatory setting includes metabolic regulation of the diabetes and education in its self-care. Means of achieving these goals include structured group or one-on-one individualized sessions. Third party policies relating to ambulatory care are challenged and their need for fiscal support emphasized. During the coming decade, diabetic patients should 1) have access to ambulatory care programs for metabolic regulation and education in self-care, 2) expect third party support of these programs, and 3) heighten their own priorities on diabetes care to ensure quality management of their diabetes.

Disturbances in lipid metabolism associated with chylothorax and its management.

Changes in circulating lipid status were studied in a 70-year-old woman during management of chylothorax that included chest drainage, pleuroperitoneal shunting, and a successful thoracic duct ligation. Hypolipidemia with a relative decline in high-density lipoprotein (HDL) cholesterol was apparent at presentation. Following recovery, serum HDL cholesterol rose to the upper limit of normal. Apolipoprotein A-1 (Apo A-1) was discordantly raised during the period of pleuroperitoneal shunting. We speculate that diversion of chylomicrons to the liver with subsequent hydrolysis accounted for a release of Apo A-1 particles into the circulation at a time when the formation of HDL was compromised by a state of starvation.

Effect of glyburide on metabolic control and insulin binding in insulin-dependent diabetes mellitus.

The extrapancreatic effects of the sulfonylurea drug glyburide in insulin-dependent diabetes mellitus were examined in a double-blind, prospective study involving 28 patients. Administration of glyburide in addition to the usual diet and insulin dose for 6 mo led to a minimal and transient decrease in hemoglobin A1c and total glycosylated hemoglobin. Insulin receptors of peripheral monocytes were initially normal in both number and affinity in this group of insulin-dependent diabetic patients, but, after 6 mo of glyburide therapy, binding to insulin receptors declined at the lower insulin concentration range without falling out of the normal range. No changes could be demonstrated in plasma triglycerides, cholesterol, or lipoprotein-cholesterol fractions. We conclude that the extrapancreatic effects of the sulfonylurea glyburide in insulin-deficient diabetic subjects are small. These effects may be mediated through a postinsulin receptor mechanism.

Outpatient regulation of the insulin-requiring person with diabetes (an alternative to hospitalization).

One hundred and six insulin-requiring diabetic patients were randomly recruited to a pilot out-patient diabetes regulation and self-care program. The program was designed to offer an alternative to hospitalization. 89 patients completed the 5-day program. Fasting plasma glucose values at 5 days were significantly lower than initial levels (263 +/- 73 mg/dl vs 156 +/- 60 mg/dl; p-value less than 0.001). Long-term diabetic control was similarly improved at 6 months after entry when total glycosylated hemoglobin levels were significantly lower than initial values (13.8 +/- 2.8% vs 11.1 +/- 2.4%; p-value less than 0.0005). 17 patients failed to complete the program. Only four patients of the 89 were subsequently hospitalized with diabetes-related conditions. 445 hospital days were saved during the study period with calculated total dollar savings over $90,000. It is suggested that a structured out-patient program for diabetes regulation and self-care can be successfully developed and carried out at a significantly lower cost than hospitalization. Third party payors should take cognizance of these programs and appropriately include them in their health care coverage.

Pituitary carcinoma mimics the ectopic adrenocorticotropin syndrome.

A middle-aged man presented with weight loss, hypokalemic alkalosis, diabetes, hypertension, and generalized melanosis. Marked elevation of urinary free cortisol (655 micrograms/24 h) and plasma ACTH (2445 PG/ML) SUGGESTED THE DIAGNOSIS OF ECTOPIC ACTH syndrome. The plasma concentrations of cortisol and urinary 17-hydroxycorticosteroids increased paradoxically during the administration of dexamethasone without a corresponding change in the plasma ACTH level. Metyrapone administered over 24 h also markedly incrased both urinary free cortisol and 17-hydroxycorticosteroids. Selective venous sampling of plasma ACTH did not reveal a gradient between jugular vein and peripheral venous blood. The laboratory findings supported the diagnosis of ectopic ACTH syndrome. However, belated occurrence of visual changes necessitated surgical exploration, resulting in the diagnosis of pituitary carcinoma. A fluorescent antibody to ACTH reacted strongly with the atypical pituitary cells. This rare case documents that severe melanosis in Cushing's disease can occur without prior adrenalectomy and is consistent with the diagnosis of pituitary carcinoma. Furthermore, melanosis observed in patients with pituitary carcinoma is associated with ACTH levels similar to those occurrring in the ectopic ACTH or Nelson's syndrome.