Endocrinology

ABSTRACT: Angiotensin-converting enzyme inhibitors and ß-blockers are the cornerstone of heart failure medical therapy; unless contraindicated, start these agents as soon as possible after volume status has been optimized. Aldosterone receptor antagonists, angiotensin-receptor blockers, and a fixed-dose combination of hydralazine and isosorbide dinitrate (the last recommended especially for African Americans) can be used as add-on therapy. Prophylactic implantable cardioverter defibrillators reduce long-term mortality in symptomatic patients with a left ventricular ejection fraction (LVEF) of 35% or less. Cardiac resynchronization therapy improves symptoms and ventricular remodeling in some patients; indications include wide (more than 20 milliseconds) QRS complex on ECG, impaired LVEF (35% or less), and advanced heart failure symptoms (NYHA classes III and IV) despite optimal drug therapy. Measurement of natriuretic peptides and impedance cardiography both show promise for monitoring patients with heart failure and for guiding therapy, but definitive data to justify their routine use are still lacking.

A large right adrenal mass was noted incidentally on an MRI scan of the lumbar spine, which had been performed for other reasons in a 55-year-old non-obese woman. The bright heterogeneous mass (T2-weighted image) measured 6.2 3 6.2 3 4.1 cm and sat like the head of a serpent on the superior pole of the right kidney. Its margins were smooth, but signal intensity was increased on T2 weighting because of high water content. The left adrenal gland was normal.

At a routine blood pressure check, a 63-year-old woman has 2 readings of 165/100 mm Hg. The patient has had essential hypertension since age 41 years. For more than a decade, it was easily controlled with a b-blocker; however, in recent years, her blood pressure has been more variable, with occasional readings of higher than 150/90 mm Hg.

CHICAGO -- A child who has a body mass index in the range of the 85th to 95th percentile for age and sex should be considered overweight, not "at risk of overweight".

SAN DIEGO -- Men older than 50 with androgen deficiency are at a greater risk for all-cause mortality than their peers with age-appropriate testosterone, reported investigators here.

To determine whether a midline neck swelling is caused by a thyroglossal cyst or by enlargement of the thyroid gland, ask the patient to open his or her mouth and move the tongue in and out.

ABSTRACT: Undiagnosed or persistent Helicobacter pylori infection and surreptitious or unrecognized NSAID use are the most common causes of refractory peptic ulcers. The use of antibiotics, bismuth, or proton pump inhibitors (PPIs) suppresses the H pylori bacterial load and may obscure the diagnosis. H pylori infections have also become more difficult to cure because of increased antibiotic resistance. For refractory infection, select an antibiotic based on in vitro susceptibility testing. When this is not available, combination therapy with a PPI, tetracycline, metronidazole, and bismuth is often effective. To detect surreptitious or inadvertent NSAID use, review the drug history in detail. When there is any doubt about such use, check platelet cyclooxygenase function.

Is it necessary to prescribe lipid-lowering therapy for a patient with a mildly elevated total cholesterol level (240 mg/dL), a low-density lipoprotein (LDL) cholesterol level of 120 mg/dL, and a high high-density lipoprotein (HDL) cholesterol level of 100 mg/dL?

I am an adult psychiatric nurse practitioner, and a significant part of my practice has been the treatment of subclinical hypothyroidism. Whenever a patient has depression and low energy, I measure free T4, free T3, and thyroid-stimulating hormone (TSH) levels. In most of the subclinical hypothyroidism I have detected, the TSH level is normal. In many cases, the only level that is low is the free T3. When liothyronine is prescribed for these patients, their symptoms of depression and tiredness decrease and their need for antidepressants has, in a few cases, been eliminated.

ABSTRACT: Many patients with diabetes are anxious or fearful about the disease. These negative emotions stem in part from the fact that the patient is responsible for many facets of diabetes management, such as exercise, dietary modification, and blood glucose measurement. For example, failure to adhere to a regimen may engender guilt. Up to 30% of patients with diabetes are depressed, and hemoglobin A1c levels are higher in such patients. Even patients with good metabolic control may not be doing well psychologically. It is thus essential to ask about patients' concerns and fears, identify their psychosocial needs, and provide emotional support.

ABSTRACT: In addition to appropriate pharmacotherapy and assistance with smoking cessation, a secondary prevention plan should include counseling about a heart-healthy diet, a structured exercise program and/or increased physical activity, and assessment of psychosocial risk factors, such as depression. Advise patients to reduce their intake of salt, sugars, refined carbohydrates, and saturated and trans fats; incorporate more fruits, vegetables, and fish into their diet; and balance caloric intake and physical activity to achieve and maintain a body mass index between 18.5 and 24.9 kg/m2. Cardiorespiratory fitness is the key to cardioprotection; the threshold for improving it in persons with coronary heart disease is about 70% of the mea-sured maximal heart rate. Encourage patients to engage in multiple short bouts of physical activity daily, such as taking the stairs instead of the elevator or walking the dog. Among previously sedentary persons, this approach has effects on cardiorespiratory fitness, body composition, and coronary risk factors similar to those of a structured exercise program.

ABSTRACT: Patients who experience an acute myocardial infarction (MI) are at very high risk for recurrent cardiovascular events. Both site-supervised and home-based cardiac rehabilitation programs can effectively reduce all-cause and cardiovascular mortality. Start risk factor reduction as soon as possible; pharmacotherapy is best initiated while patients are still in the hospital. All patients who have had an MI should receive aspirin, an angiotensin-converting enzyme inhibitor, and a ß-blocker, unless these agents are contraindicated or are not tolerated. Prescribe aggressive lipid-lowering therapy to bring patients' low-density lipoprotein cholesterol levels to below 70 mg/dL. For smokers, quitting is the single most important change they can make to reduce future risk of MI.

This lesion had erupted on the back of an elderly man with diabetes mellitus. The inflammatory process involved contiguous follicles with pus evident at several openings.

SEATTLE -- Human growth hormone is useful in adult patients for correction of endocrine deficiencies but not as a fountain of youth, reported investigators here.

A 24-year-old woman presents to the emergency department (ED) withgeneralized weakness, headache, and muscle cramping that have progressivelyworsened over the past week. Recently, she has also had nauseaand vomiting. She denies chest pain, palpitations, dyspnea, cough, fever,chills, diarrhea, and urinary symptoms. She has a history of type 1 renaltubular acidosis.

RIBEIRÃO PRETO, Brazil -- In a pilot study of stem cell therapy for newly diagnosed type 1 diabetes, nearly all patients remained free of exogenous insulin for extended periods , one for as long as three years, researchers here reported.

SUTTON, England -- Halting ovarian function by suppression or ablation offers little further benefit for most women already getting adjuvant tamoxifen with or without chemotherapy for early breast cancer, researchers here found.

SACRAMENTO, Calif. -- So-called triple-negative breast cancers -- tumors that do not express the major prognostic markers -- are particularly aggressive, according to researchers here.

ABSTRACT: A 4-pronged approach that includes patient education, skin and nail care, appropriate footwear, and proactive surgeries can effectively prevent diabetic foot problems. Teach patients with diabetes to examine their feet daily to detect new onset of redness, swelling, breaks in the integrity of the skin, blisters, calluses, and macerated areas. Have them follow a daily foot care regimen that includes warm water soaks and lubrication, and have them keep toenails properly trimmed. Recommend that patients select shoes that fit properly and have sufficient padding and toe box space; have them use inserts, lifts, orthoses, or braces--as recommended-to correct abnormal gait patterns. Finally, if deformities develop, simple proactive surgical procedures can correct these problems before they result in the development of wounds.

A 43-year-old woman presented withuncontrolled type 2 diabetes mellitus.Her hemoglobin A1c level was 12%,and self-measured glucose levels hadbeen above 400 mg/dL for 3 months.She was taking insulin 70/30,70 units twice daily.

HOUSTON -- For establishing the tumor status of women with breast cancer, a gene-expression microarray appears to have accuracy approaching standard tests, researchers found here.

DALLAS -- Galvus (vidagliptin), an investigational oral dipeptidyl peptidase IV-blocker (DPP-4) for type 2 diabetes, was as effective as a rosiglitazone at glycemic control, without associated weight gain, reported researchers here.

A 75-year-old woman had undergone a total thyroidectomy, with histologic evidence of poorly differentiated follicular thyroid cancer. She subsequently received an ablative dose of iodine-131. After a disease-free interval of about 2 years, she presented with evidence of recurrence in the thyroid bed. She had enlarged cervical lymph nodes and complained of dyspnea on exertion.

In his recent editorial Putting Guidelines for Chronic Kidney Disease IntoPractice (CONSULTANT, October 2006, page 1295), Dr Gregory Ruteckidiscussed the results of a study that shows many clinicians fail to follow evidence-based guidelines for the management of chronic kidney disease(CKD), such as when to consult a nephrologist.1 A sampling of the feedbackwe received appears below, along with Dr Rutecki's responses.

During a routine diabetes follow-up visit, a 55-year-old man complains of increasing pain in his right groin and hip. He is also being treated for hypertension, and his body mass index is 28.

DENVER -- Three cases of prepubertal gynecomastia have raised red flags about the estrogenic-like and anti-androgen effects of tea tree oil and lavender, two popular additives in soaps and lotions.

A 63-year-old man presented for his annual eye examination. He has had type 2 diabetes for the past 20 years and takes glipizide.

FREIBURG, Germany -- Long-acting release Sandostatin (octreotide) seems to have no benefit for hepatocellular carcinoma either in clinical outcomes or quality of life, German researchers discovered.

A 54-year-old woman reported a red jagged area of new onset in her right eye, along with many dark red spots and streaks in that eye. She also felt that her vision had become blurrier in that eye.

I very much appreciated Dr Douglas Ross's article, Subclinical Hypothyroidism: When to Treat, When to Watch (CONSULTANT, September 1, 2006, page 1121), and I have several questions for him.