Severe Hypercalcemia and Acute Renal Failure: An Unusual Presentation of Sarcoidosis

Although hypercalcemia is a known metabolic complication of sarcoidosis, it is rarely a presenting manifestation. Long-standing hypercalcemia and hypercalciuria can cause nephrocalcinosis and chronic renal failure. Acute renal failure, although described, is also a rare presentation of patients with sarcoidosis. We describe two patients with sarcoidosis, who presented with severe hypercalcemia and worsening renal function. Parathyroid hormone levels were appropriately suppressed. This led to an extensive search for the cause of hypercalcemia. Finally, after a lymph node biopsy in both cases, a diagnosis of sarcoidosis was established, hypercalcemia resolved, and renal function improved in both cases after administration of prednisone

Comparison of the Adherence to the American Diabetes Association Guidelines of Diabetes Care in Primary Care and Subspecialty Clinics

Abstract Background Diabetes mellitus is a major public health problem with significant morbidity and mortality. Evidence based guidelines have been proposed to reduce the micro and macrovascular complications, but studies have shown that these goals are not being met. We sought to compare the adherence to the American Diabetes Association guidelines for measurement and control of glycohemoglobin (A1c), blood pressure (BP), lipids (LDL) and microalbuminuria (MA) by subspecialty and primary care clinics in an academic medical center. Methods 390 random charts of patients with diabetes from Family Practice (FP), Internal Medicine (IM) and Diabetes (DM) clinics at Michigan State University were reviewed. Results We reviewed 131, 134 and 125 charts from the FP, IM and DM clinics, respectively. DM clinic had a higher percentage of patients with type 1 diabetes 43/125 (34.4%) compared with 7/131 (5.3%) in FP and 7/134 (5.2%) in IM clinics. A1c was measured in 99%, 97.8% and 100% subjects in FP, IM and DM clinics respectively. B.P. was measured in all subjects in all three clinics. Lipids were checked in 97.7%, 95.5% and 92% patients in FP, IM and DM clinics respectively. MA was measured at least once during the year preceding the office visit in 85.5%, 82.8% and 76.8% patients in FP, IM and DM clinics respectively. A1C was controlled (<7%) in 38.9, 43.3, 28.8% of patients in the FP, IM and DM clinics, respectively (p = 0.034). LDL was controlled (<100 mg/dl or 2.586 mmol/l) in 71.8, 64.9, 64% of patients in the FP, IM and DM clinics, respectively. MA was controlled (<30 mg/gm creatinine) in 60.3%, 51.5% and 60% patients in FP, IM and DM clinics respectively (P = 0.032). BP was controlled (<130/80) in 59.5, 67.2 and 52.8% patients in the FP, IM and DM clinics, respectively. Conclusion Testing rates for A1C, LDL, and MA were high, in both subspecialty and primary care clinics. However, the degree of control was not optimal. Significantly fewer patients in the DM clinic had A1c <7%, the cause of which may be multifactorial.http://deepblue.lib.umich.edu/bitstream/2027.42/111055/1/40200_2015_Article_158.pd

Contemporary Adult Diabetes Mellitus Management Perceptions

Background: Over 180 million people have been diagnosed with diabetes mellitus worldwide, with this number expected to more than double by 2030. Due to the increasing mortality and morbidity associated with this epidemic, the improved primary-care management of diabetes during routine office visits remains an emerging international challenge. Objective: To report the results of a series of exploratory semi-structured group interview sessions with a sample of 44 American adults with type 2 diabetes, concerning their diabetes management perceptions and office-based diabetes care processes. Methods: A total of 44 adults from a Midwest Internal Medicine Clinic were interviewed during 2004 and 2005 before starting a larger, quantitative, shared decision-making intervention study. During group interviews, participants offered their perceptions of their self-management practices, interactions with office clinicians, and diabetes-related health outcomes to date. A total of 178 audio-taped interview comments (across 44 participants) were transcribed and analyzed for core themes and sub-themes. Results: Many participants reported frustrating experiences regarding the relationship between their personal diabetes self-management practices and typical office visit interactions with clinicians. Most participants perceived these diabetes management processes as inherently different from each other. Many participants were intrigued with the proposed shared decision-making management approach of the larger intervention study. Conclusions: Primary-care clinicians should assess how patients may perceive their self-management strategies relate to office-based diabetes care processes. Patients' self-management beliefs and practices should be routinely evaluated since they frequently affect the nature of key diabetes care office visit decisions. These qualitative results suggest that clinicians should convey the increasing interdependence between their patients' daily diabetes self-management practices and contemporary office visit decision-making discussions.Decision-making, Diabetes-mellitus, treatment, Disease-management-programmes, Patient-preference

Cushing’s syndrome with no clinical stigmata – a variant of glucocorticoid resistance syndrome

Abstract Background Cortisol resistance syndrome is a very rare condition characterized by high cortisol levels, but without any clinical features of Cushing’s syndrome. Our objective is to present such a case. Case presentation A 41 year old female presented with mild hirsutism and elevated urinary cortisol levels. Plasma cortisol levels were elevated and were not suppressed by conventional doses of dexamethasone on multiple occasions, but decreased following administration of higher doses of dexamethasone. Adrenocorticotropic hormone (ACTH) levels were inappropriately elevated. Despite significantly elevated cortisol levels, she did not develop any clinical signs or symptoms of Cushing’s syndrome. Pituitary and adrenal imaging did not reveal any abnormalities. Genetic testing for human glucocorticoid receptor did not reveal any mutations. Conclusions Although we were not able to identify any new mutations, we believe that our patient has a variant of cortisol resistance syndrome. This syndrome should be considered in the differential diagnosis of patients who present with high levels of cortisol but have no clinical features of Cushing’s syndrome

Adherence to thyroid hormone replacement therapy: a retrospective, claims database analysis

<p><b>Objective:</b> The objective of this analysis was to compare adherence at 6 months and 12 months across levothyroxine formulations for patients with hypothyroidism.</p> <p><b>Methods:</b> This retrospective analysis utilized insurance claims data from a commercially insured population from January 1, 2000 through March 31, 2016. Patients were included if they were diagnosed with hypothyroidism and initiated treatment with generic levothyroxine, Levoxyl, Synthroid, Unithroid, or Tirosint. Patients were excluded if they were younger than age 18, were diagnosed with thyroid cancer, received a prescription for liothyronine, or did not have continuous insurance coverage over the study period. Adherence, defined by the proportion of days covered (PDC) ≥ 80%, was examined using multivariable analyses for both 6 and 12 months post-initiation on therapy</p> <p><b>Results:</b> The study identified 580,331 patients who fit the study criteria. At 6 months, 40.3% of patients were found to be non-adherent, while 51.9% were non-adherent at 12 months. Synthroid was associated with significantly higher adherence compared to all other levothyroxine formulations at both 6 and 12 months. Compared to generic levothyroxine, the likelihood of being adherent at 12 months was highest for Synthroid (OR = 1.44; 95% CI = 1.43–1.46), followed by Levoxyl (OR = 1.20 95% CI = 1.17–1.23). Tirosint and Unithroid were associated with significantly lower adherence at 12 months compared to generic levothyroxine (OR = 0.65; 95% CI = 0.57–0.75 and OR = 0.79; 95% CI = 0.71–0.89, respectively).</p> <p><b>Conclusions:</b> This large, retrospective real-world study demonstrated that adherence to levothyroxine remains a concern among patients with hypothyroidism, and that differences in adherence may exist across levothyroxine formulations.</p

COMPARISON OF MIDDLE-AGED WOMEN WITH AND WITHOUT TYPE 2 DIABETES ON DEMOGRAPHIC, CLINICAL, AND SOCIAL-COGNITIVE FACTORS ASSOCIATED WITH MODERATE- TO VIGOROUS-INTENSITY PHYSICAL ACTIVITY

Aims: The purpose of this cross-sectional, exploratory study was to compare demographic, clinical, and social cognitive factors associated with minutes per day of moderate- to vigorous-intensity physical activity (MVPA) in middle-aged women with and without Type 2 diabetes. Methods: The theoretical framework was based on both the Social Cognitive Theory and the Theory of Planned Behavior used to depict the demographic, clinical, and social-cognitive factors shown to be associated with physical activity. Forty-two middle-aged women with Type 2 diabetes and 67 without diabetes met inclusion criteria at four urban primary care clinics.. Enrolled women received an accelerometer to wear for seven consecutive days and completed a survey including questions exploring various demographic, clinical, and social-cognitive factors. Height and weight were measured to calculate body mass index (BMI). After the one week of wear-time, women returned the accelerometer and completed the International Physical Activity Questionnaire (IPAQ) short-form. Data were analyzed using independent t-tests and chi-squared tests. Results: Ninety-three (86.1%) of the women were overweight or obese. A higher proportion of non-Whites was noted for women with Type 2 diabetes, compared to women without diabetes. The mean values for women with Type 2 diabetes were higher for BMI and comorbidity index, lower for perceived benefits and self-efficacy related to physical activity, and fewer for minutes per day of vigorous-intensity physical activity. Conclusions: Tailored nursing interventions are needed to enhance perceived benefits and self-efficacy of physical activity, especially in middle-aged women with Type 2 diabetes, as a means for increasing MVPA