Two-year outcomes on bone density and fracture incidence in patients with T2DM randomized to bariatric surgery versus intensive medical therapy.

OBJECTIVE: To determine the 2-year outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) vs. intensive medical therapy (IMT) on lean body mass, total bone mass, and bone mineral density (BMD) measures from the STAMPEDE trial. METHODS: 54 subjects (BMI: 36 ± 1 kg/m(2) , age: 48 ± 4 years) with type 2 diabetes (T2DM) (HbA1c : 9.7 ± 2%) were randomized to IMT, RYGB, or SG and underwent DXA at baseline and at 1 and 2 years. RESULTS: At 2 years, the reduction in BMI was similar after RYGB and SG and was greater than IMT (P < 0.001). Lean mass was reduced by ∼10%, total bone mineral content reduced by ∼8%, and hip BMD reduced by ∼9% in both surgical groups and was significantly greater than IMT despite increases in vitamin D intake in all groups. The change in hip BMD correlated with weight loss (r = 0.84, P < 0.0001) and changes in lean mass (r = 0.74, P < 0.0001) and leptin (r = 0.53, P < 0.0001). Peripheral fractures were self-reported in RYGB (4/18 patients), SG (2/19 patients), and IMT (4/16 patients). CONCLUSIONS: Surgically induced weight loss is associated with modest reductions in lean mass, bone mineral content, and BMD, despite calcium and vitamin D supplementation in patients with T2DM. Awareness for bone loss is indicated for patients undergoing bariatric procedures.

Challenges in the diagnostic work-up and management of patients with subclinical Cushing's syndrome and bilateral adrenal masses.

OBJECTIVE: To review the challenges encountered in the diagnostic work-up and management of patients with subclinical Cushing's syndrome (SCS) and bilateral adrenal masses to aid in the case description of a patient with SCS and adrenocorticotropic hormone (ACTH)-independent macronodular adrenal hyperplasia (AIMAH). METHODS: We describe our experience managing a patient with AIMAH and SCS. This case report is followed by an extensive review of the literature regarding differential diagnoses, work-up including adrenal venous sampling (AVS), and treatment of SCS with bilateral adrenal masses. RESULTS: A 51-year-old female who was diagnosed with recent onset hypertension and diabetes mellitus type 2 was evaluated for adrenal masses discovered incidentally on computed tomography (CT). She did not have any Cushingoid features. Magnetic resonance imaging (MRI) of abdomen was performed for further evaluation. Hormonal evaluation came back consistent with SCS. The AVS results were consistent with bilateral autonomous cortisol hypersecretion without lateralization. Collectively, the findings favored the diagnosis of bilateral AIMAH. A left adrenalectomy was performed, and the patient's clinical response was favorable with improvement in blood pressure (BP) accompanied by significant weight loss. Follow-up hormonal testing for autonomous cortisol hypersecretion was within the target range. CONCLUSIONS: AIMAH is a rare cause of SCS. AVS is a useful diagnostic tool that helps localize the source of autonomous cortisol hypersecretion in ACTH-independent SCS with bilateral adrenal masses, especially if radiological features are inconclusive. Patients undergoing unilateral adrenalectomy should be followed for monitoring of clinical response, as well as progression of AIMAH in the contralateral adrenal gland.

Safety and efficacy of an algorithm-based protocol in the management of diabetic ketoacidosis.

OBJECTIVE: To determine the efficacy of an algorithm-based protocol to manage diabetic ketoacidosis (DKA). METHODS: Our study is a retrospective chart review of patients with DKA managed before and after implementation of an algorithm-based DKA protocol at a tertiary care hospital. RESULTS: There were 88 patients managed 1 year prior (control group) and 70 patients managed one year after (study group) implementation of the algorithm-based DKA protocol. The DKA resolution time was significantly shorter (11.5 [8.1 to 17.1] hours versus 8.5 [5.8 to 12] hours; P = 0.008) and the hypoglycemic events were significantly less (P = 0.042) in the study group in comparison with the control group. There was no difference in the potassium abnormalities and rate of decline of glucose. A survey on a scale of 1 to 10 found the majority of physicians and nurses rated the protocol as safe (83%) and effective (96%). Fifty-four percent of the nurses, however, found the protocol difficult to follow. CONCLUSION: Our study showed that implementation of an algorithm-based protocol reduced the DKA resolution time and hypoglycemic events without compromising electrolyte imbalance, and was associated with improved clinical measures of DKA management.