Insulin therapy in the elderly patient with diabetes.

BACKGROUND: Most elderly patients with type 2 diabetes require, or will eventually require, insulin to achieve or maintain their glycemic goals. However, insulin therapy remains underused in this population. OBJECTIVE: The goal of this review is to evaluate the role of insulin therapy in elderly patients and identify strategies to improve its use in this patient population. METHODS: Searches of the MEDLINE and EMBASE databases were conducted to identify papers published in English between January 1990 and March 2010. The following search terms were used: diabetes mellitus, insulin, elderly, geriatric, analog, premix, pen device, and human insulin. Papers selected for review included meta-analyses, randomized controlled trials of insulin therapy, or evidence-based reviews and/or expert opinion regarding the use of insulin in elderly patients with diabetes. RESULTS: Insulin therapy is the most effective antidiabetic agent when appropriately dosed; however, only a minority of elderly patients with diabetes uses it. Although there are few randomized controlled studies on insulin use in the elderly, an individualized approach to insulin therapy is recommended to account for varying clinical and practical factors that affect diabetes care in this patient population. Therapy with insulin analogs offers several advantages compared with human insulin regimens, including a more physiologic pharmacologic profile, increased convenience, and a reduced risk of hypoglycemia, which may make them particularly attractive in older adults. Premixed insulin analog therapy may provide added convenience, as well as improved glycemic control. Insulin pen devices are also recommended to facilitate insulin dosing and help patients maintain their independence. CONCLUSIONS: The improved clinical profiles of insulin analogs and the ease of use of newer insulin delivery devices may be advantageous in elderly patients with diabetes; however, additional research on the efficacy and safety of insulin regimens is urgently needed.

Diagnostic challenges in Creutzfeldt-Jakob disease: case report.

Sporadic Creutzfeldt-Jakob disease (CJD) is the most common prion disease. The diagnosis can be confirmed only by histological examination of brain tissue obtained at biopsy or at autopsy. Because of the transmissible nature of the disease, autopsy or brain biopsy cannot be performed at many institutions, which poses numerous challenges in confirming the diagnosis. We report the case of a patient with CJD in which autopsy to confirm the diagnosis was performed after overcoming numerous obstacles and advocating with hospital leadership. This case illustrates the numerous challenges that exist in achieving a definitive diagnosis of CJD and in postmortem disposition of the body, and we provide recommendations to clinicians who face similar challenges.

A case of gonadal dysgenesis, breast development, Graves' disease, and low bone mass.

OBJECTIVE: To describe a case of XY gonadal dysgenesis with Tanner stage 4 breast development in the absence of a hormone-producing gonadal neoplasm and with Graves' disease and low bone mass. METHODS: The clinical features, laboratory results, and cytogenetic findings in the patient are presented, and the potential mechanisms of breast development are discussed. A MEDLINE search was performed, and related articles in the English-language literature published between 1955 and 2001 were reviewed. RESULTS: A 23-year-old African American woman was referred to the University of Louisville Hospital for evaluation of hyperthyroidism. About 4 months before this referral, hyperthyroidism was diagnosed, and treatment with methimazole was initiated. She continued to have thyrotoxicosis. Additionally, systemic review disclosed a history of primary amenorrhea. Physical examination revealed a tall phenotypic female patient with Tanner stage 4 breast development. Pelvic examination showed normal findings except for sparse pubic hair. Laboratory evaluation confirmed the diagnosis of Graves' disease as well as primary gonadal failure. Pelvic ultrasonography revealed a small uterus and bilateral adnexal masses (0.9 by 0.6 cm). On chromosomal analysis, a 46,XY karyotype was found. Further analysis of Y-DNA by polymerase chain reaction confirmed the presence of an intact Y chromosome, and no microdeletions were identified. Dual-energy x-ray absorptiometry demonstrated a Z-score of -4.7 and -4.2 at the lumbar spine and right hip, respectively. Graves' disease was successfully treated with (131)I. Laparoscopy was performed to resect streak gonads. On histologic examination, no typical ovarian, testicular, or neoplastic tissue was identified. The breast development in this patient remains unexplained. CONCLUSION: To the best of our knowledge, this is the first case report of a tall XY female patient with breast development in the absence of a hormone-producing gonadal neoplasm and without clearly identifiable gonads. Breast development was most likely related to estrogens, possibly produced by either streak gonads at the time of puberty or peripheral conversion of androgens, or to increased sensitivity of breast tissue to estrogens. Graves' disease is likely coincidental and could contribute to bone loss in such subjects.

Lipodystrophy, insulin resistance, diabetes mellitus, dyslipidemia, and cardiovascular disease in human immunodeficiency virus infection.

The introduction of highly active antiretroviral therapy has significantly reduced morbidity and mortality in patients infected with the human immunodeficiency virus. Treatment with antiretroviral agents--protease inhibitors in particular--has uncovered a syndrome of abnormal fat redistribution, dyslipidemia, and impaired glucose metabolism, collectively termed lipodystrophy syndrome. The cause of the syndrome seems to be multifactorial; however, its exact mechanisms have yet to be elucidated. Accelerated risk for cardiovascular disease is likely to be a major concern in these patients in the future. At this time, no clinical guidelines are available for the prevention and/or the treatment of lipodystrophy syndrome. The available treatment options range from switching the different antiretroviral drugs and lifestyle modifications to the use of pharmacologic agents to treat patients with dyslipidemia, impaired glucose tolerance and/or diabetes, and changes in body composition. This review emphasizes the clinical features, potential molecular mechanisms, and treatment options for patients infected with human immunodeficiency virus who have lipodystrophy syndrome.

Minimal change nephropathy and graves' disease: report of a case and review of the literature.

OBJECTIVE: To describe a possible association between Graves' disease and nephrotic syndrome attributable to minimal change nephropathy and to review the literature related to renal diseases in patients with Graves' disease. METHODS: The clinical, laboratory, and renal biopsy findings in a patient with Graves' disease and minimal change nephropathy are discussed. In addition, the pertinent English-language literature published from 1966 to 2001, determined by means of a MEDLINE search, is reviewed. RESULTS: A 29-year-old woman underwent assessment by her primary-care physician because of palpitations, sweating, and a 4.5-kg weight loss. Physical examination revealed a diffuse goiter and tremors of the extremities but no ophthalmologic signs. Laboratory tests confirmed a diagnosis of thyrotoxicosis. Treatment was initiated with propylthiouracil and propranolol. Four weeks later, she presented to the University of Louisville Hospital with increasing swelling of her legs and periorbital puffiness. Examination revealed generalized edema, ascites, and pleural effusion. She continued to have features of thyrotoxicosis. Laboratory tests showed undetectable thyroid-stimulating hormone (<0.03 mIU/mL) and homogeneously increased 123I thyroid uptake and scan. A 24-hour urine collection revealed urinary protein excretion of 6.75 g. Antinuclear antibodies, serum complement levels, hepatitis, and human immunodeficiency virus (HIV) screen were normal. A kidney biopsy specimen revealed features consistent with minimal change disease on light, immunofluorescence, and electron microscopy. The patient had an excellent clinical and laboratory response to treatment with radioactive iodine and corticosteroids, and she was asymptomatic at 6-month follow-up. CONCLUSION: To the best of our knowledge, this is the first report of the concomitant occurrence of Graves' disease and minimal change disease in the absence of any other immunologic disorder known to be associated with minimal change nephropathy.