Awareness of diabetes complications in an Irish population.

BACKGROUND: Patients' awareness of the increased cardiovascular risk associated with their diabetes is poorly documented. AIM: The aim of this study was to assess the awareness of diabetes complications among patients with diabetes in Ireland. METHODS: Patients attending diabetes outpatient clinics in two teaching hospitals in different regions of the country were invited to complete a questionnaire. RESULTS: A total of 258 (59.3% male) patients completed the questionnaire; mean age 57.8 years. On questioning, 53.5% reported cardiovascular disease as a potential complication of diabetes, with awareness rates of 61.2, 17.1, 16.3 and 12% for retinopathy, stroke, peripheral vascular disease and amputation, respectively. Disappointingly, less than half of respondents felt that improvements in diet and exercise could potentially reduce their cardiovascular risk. CONCLUSIONS: Awareness of cardiovascular risk and knowledge of effective measures to reduce this were low in our study and an alternative means of education may need to be considered.

Declining prevalence of diabetes mellitus in hereditary haemochromatosis--the result of earlier diagnosis.

AIMS: The aims of this study were to describe the prevalence and clinical features of diabetes in hereditary haemochromatosis (HH), with particular emphasis to how this has changed since the introduction of genetic testing in 1996. SUBJECTS AND METHODS: Two hundred and thirty-seven patients were diagnosed with HH (based on elevated iron indices and liver biopsy or genetic testing) by a single physician, and all biochemical and clinical data recorded from diagnosis to the end of the study. RESULTS: The prevalence of diabetes (21.9%) was lower than most previously published studies. There was a significantly greater prevalence of diabetes and cirrhosis in those diagnosed before the introduction of genetic testing, p<0.001. The type of genetic mutation for HH, degree of ferritin elevation at diagnosis, or the presence of cirrhosis was not predictive for the development of diabetes. Iron depletion did not result in an improvement in glycaemic control or reduction in insulin requirements in the majority of patients. CONCLUSIONS: This is one of the largest published series of diabetes in HH. Because the occurrence of diabetes in patients with HH reduces life expectancy, our finding of a lower prevalence of diabetes is expected to translate into a greater survival rate in these patients.

A dog's detection of low blood sugar: a case report.

One of the life threatening complications of diabetes is hypoglycaemia. It is a common complication, with times of greatest risk being before meals and during the night. Symptoms usually develop when the blood glucose level falls below 3.5 mmol/l. Many patients with long-standing diabetes report loss of warning symptoms. Prevention of such hypoglycaemic attacks is highly desirable. Recently a dog's ability to detect hypoglycaemia in diabetic patients has been recorded. This is the first recorded case of hypoglycaemia in a non-diabetic patient being detected by a dog and also we believe it to be the first report of hypoglycaemia being detected by a dog in this country (Ireland).

Celiac disease presenting as resistant hypothyroidism.

The high prevalence of celiac disease in patients with autoimmune hypothyroidism, compared to the general population, has been well documented but screening for celiac disease is not recommended as yet in otherwise asymptomatic hypothyroid patients. In recent years the high prevalence of undiagnosed celiac disease in the general population, largely as a result of the many atypical manifestations of the disease, has become apparent. We report the case of a 58-year-old woman with autoimmune hypothyroidism who was initially suspected of having celiac disease on the basis of apparent resistance to levothyroxine therapy, and who had no other clinical or laboratory clues to suggest the diagnosis. Cases of undiagnosed celiac disease causing levothyroxine malabsorbtion have previously been described, but all previous cases had other obvious manifestations of the disease. We believe that this atypical presentation of celiac disease warrants further attention, and that the diagnosis of celiac disease should always be considered in patients requiring higher than expected doses of thyroid hormone replacement, even in patients with normal bowel habit, and no other apparent manifestations of the disease.

Hypogonadism in hereditary hemochromatosis.

Hypogonadism, usually hypogonadotropic in origin, is the most common nondiabetic endocrinopathy in hereditary hemochromatosis (HH). Early studies, usually evaluating small numbers of patients with advanced HH, report prevalence rates of 10-100%. The clinical presentation of HH has changed in recent years as a result of increased awareness and screening. We assessed the prevalence of hypogonadism in a large group of patients with HH diagnosed in a single center over the past 20 yr, the period of follow-up spanning the time before and after widespread screening was introduced and the HFE gene was recognized. Abnormally low plasma testosterone levels, with low LH and FSH levels, were found in nine of 141 (6.4%) male patients tested. Eight of nine (89%) had associated hepatic cirrhosis; three of nine (33%) had diabetes. Inappropriately low LH and FSH levels were found in two of 38 females (5.2%) in whom the pituitary-gonadal axis could be assessed. This is the largest detailed study of hypogonadism reported in HH. The lower prevalence of hypogonadism compared with other reported series reflects the earlier diagnosis of HH in an unselected group of patients attending a single center. Patients with lesser degrees of hepatic siderosis at diagnosis are unlikely to develop hypogonadism.

Concurrent hereditary haemochromatosis and idiopathic Parkinson's disease: a case report series.

Hereditary haemochromatosis (HH) is a genetic disorder in which abnormal iron handling leads to excessive iron accumulation in systemic tissues. Magnetic resonance imaging studies suggest excess iron deposition in the basal ganglia of patients with HH. The symptoms of neurological complications of HH include cognitive decline, gait difficulties, cerebellar ataxia, and extrapyramidal dysfunction, but idiopathic Parkinson's disease, in which brain iron deposition is normal, has not been reported. We describe four patients with concurrent HH and IPD. Although three of the cases had risk factors for cerebrovascular and cardiovascular disease, computed tomography did not show ischaemic changes in the basal ganglia. We speculate that in these cases, abnormal deposition of iron in the basal ganglia induced the symptoms of IPD.

Thyroid function in haemochromatosis.

BACKGROUND: In hereditary haemochromatosis (HH), the thyroid gland is the site of substantial iron deposition. However, there have been relatively few reported cases of thyroid dysfunction in HH. AIM: To evaluate the prevalence of thyroid disorders in a large group of patients with HH. METHODS: A variety of endocrine investigations were undertaken including thyroid function tests and thyroid antibody studies. RESULTS: A total of 154 consecutive patients (123 male, 31 female) were studied. One case of primary hypothyroidism was identified, giving a prevalence of 0.6%. Subclinical hypothyroidism was identified in two females, giving a prevalence of 1.3%. Iatrogenic hypothyroidism was identified in two other cases. No case of hyperthyroidism was identified. CONCLUSION: Thyroid dysfunction is an uncommon occurrence in patients with HH.

Coeliac disease and autoimmune Addison's disease: a clinical pitfall.

BACKGROUND: Coeliac disease has an increased prevalence in a number of autoimmune endocrine conditions. An association between coeliac disease and Addison's disease has been proposed in isolated case reports, but has not been formally studied. AIM: To investigate the extent of this association. DESIGN: Prospective screening of patients with confirmed Addison's disease. METHODS: From central computerized records, we identified all living patients with a diagnosis of autoimmune Addison's disease in the past 30 years and presently attending our affiliated hospitals. After exclusions, 44 were invited to attend for screening. RESULTS: Of 41 patients screened, five (12.2%) had coeliac disease: Three were previously diagnosed coeliacs and this was confirmed on review, including examination of biopsy material. A further two had positive IgA-endomysial antibodies. Histological confirmation was obtained in both cases. Neither had laboratory or clinical evidence of malabsorption. DISCUSSION: In this series of patients with Addison's disease, a higher co-morbidity with coeliac disease was observed than in any previously studied endocrine condition. We recommend that coeliac serology (anti-endomysial and tissue transglutaminase antibody) testing be incorporated routinely into the autoimmune screen for other conditions in patients with Addison's disease.

Mineralocorticoid and glucocorticoid status in idiopathic haemochromatosis.

OBJECTIVE: A number of studies have suggested that both primary (Addison's disease) and secondary adrenal failure may be caused by idiopathic haemochromatosis. There is little information on mineralocorticoid secretion. We have assessed the mineralocorticoid and glucocorticoid status of patients with idiopathic haemochromatosis. DESIGN: Cross-sectional study. PATIENTS: Eighteen males and one female with confirmed idiopathic haemochromatosis were investigated. Seven of the subjects had hepatic cirrhosis and three had hypogonadotrophic hypogonadism. MEASUREMENTS: A short Synacthen (tetracosactrin) test was undertaken in addition to an overnight metyrapone test and an insulin stress test. In addition, plasma aldosterone (PA) and plasma renin activity (PRA) were measured in a group of patients in the basal state and again in the upright position. RESULTS: The short Synacthen test, overnight metyrapone test and insulin stress test were normal in all subjects. The PA, PRA, and PA/PRA ratios in the upright position were not significantly different in the patients with idiopathic haemochromatosis compared to control subjects. CONCLUSION: In this patient population, no abnormality of either the pituitary adrenal axis or mineralocorticoid status was detected. Adrenocortical dysfunction is likely to be exceptionally rare in idiopathic haemochromatosis.

Hyperthyroidism associated with acute suppurative thyroiditis.

Acute suppurative thyroiditis is a rare condition with potentially serious complications. It has been suggested that hyperthyroidism may be a feature in occasional cases but this has been poorly documented. We describe a patient in whom acute suppurative thyroiditis caused transient hyperthyroidism.

Pinacidil, a new vasodilator, in the treatment of mild to moderate essential hypertension.

Twenty three patients with essential hypertension who were uncontrolled on diuretic and/or beta-receptor antagonist therapy were treated additionally with the vasodilator, pinacidil, in an open study. Significant reduction in mean blood pressure was achieved. Supine and erect systolic and diastolic blood pressure fell by 44/25 mmHg and 37/24 mmHg respectively over the study period of 12 weeks. Side-effects such as dizziness, headache, facial flushing and mild oedema were experienced by 10 patients during the study, all of which were mild and transient and did not require withdrawal from pinacidil therapy. Pinacidil is an effective and well tolerated agent in the treatment of essential hypertension.

Low-dose insulin treatment of hyperosmolar diabetic coma.

The effect of low-dose hourly i.m. injections of insulin has been studied in the treatment of 17 episodes of hyperosmolar non-ketoacidotic diabetic coma compared with 26 episode of hyperosmolar ketoacidosis occurring in patients over 40 years of age. The fall in blood sugar was satisfactory in the majority of episodes of both types of coma and there was no evidence that patients with hyperosmolar non-ketoacidotic coma were more sensitive to insulin. The excess mortality in the non-ketotic group (47%) compared with the ketoacidotic group (16%) was not due to uncontrolled diabetes.

GIP and insulin responses to oral glucose in coeliac patients before and after treatment.

The responses of plasma gastric inhibitory polypeptide (GIP) and insulin to oral glucose were studied in five patients with untreated coeliac disease. These patients were restudied after one year on a gluten-free diet. In the untreated patients, the blood glucose, serum insulin, and GIP levels were significantly lower than in the controls. After gluten withdrawal there was an improvement towards normality in the responses of blood glucose, serum insulin, and GIP. The results show that untreated coeliac disease is associated with abnormalities of intestinal and pancreatic hormone secretion and that these abnormalities are improved by gluten withdrawal.

Plasma arginine vasopressin in diabetic ketoacidosis.

Plasma Arginine Vasopressin (AVP) was measured serially in 10 patients during the first 24 hours of treatment of diabetic ketoacidosis. AVP was elevated in all cases initially, ranging from 4.0--122.0 pmol/l, the basal level in healthy hydrated subjects being 1.57 +/- 0.59 pmol/l (+/- 1 SD). The levels fell progressively during the course of treatment. While there was no evidence that the massive increases in AVP noted in this study were associated with water overload it remains to be determined whether the high levels observed have any significant metabolic or haemodynamic role in this disorder.