Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists
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Review Case Reports
Persistent tumor-induced osteomalacia confirmed by elevated postoperative levels of serum fibroblast growth factor-23 and 5-year follow-up of bone density changes.
To describe a case of persistent tumor-induced osteomalacia, determine whether serum fibroblast growth factor-23 (FGF-23) levels postoperatively indicate incomplete tumor resection, and report lumbar spine and forearm bone mineral density (BMD) changes during 5 years of follow-up. ⋯ The serum FGF-23 level is high in a substantial proportion of patients with tumor-induced osteomalacia. The postoperative above normal levels of serum FGF-23 correlated with known persistence of tumor in our study patient. In a patient with normal renal function, such as our study patient, levels of serum FGF-23 studied with use of the C-terminal enzyme-linked immunosorbent assay reached their nadir within 24 hours postoperatively. This result suggests that this assay can provide clinicians with rapid prognostic information in patients with known or suspected residual tumor. BMD should be assessed at both appendicular and axial sites in patients with persistent tumor-induced osteomalacia.
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To discuss the initial clinical manifestations and management of 8 obese African American children and adolescents who presented with a severe hyper-osmolar hyperglycemic state (HHS) and were newly diagnosed with type 2 diabetes mellitus (DM), except for one who most likely had type 1 DM. ⋯ The incidence of obesity and type 2 DM in children and adolescents is increasing at an alarming rate. Many patients previously undiagnosed with type 2 DM may indeed present with HHS. Because experience and published literature regarding HHS in pediatric patients are meager, this is a new challenge for physicians. Mortality and morbidity are high in this group of patients, and a high index of suspicion and awareness of this condition by physicians are warranted.
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To summarize the novel evidence for maintaining normoglycemia with intensive insulin therapy during intensive care in critically ill patients, with or without diabetes, in the surgical intensive-care unit. ⋯ The available evidence favors targeting normoglycemia (blood glucose levels of less than 110 mg/dL or 6.1 mmol/L) by insulin infusion in all adult surgical intensive-care patients. Whether these findings are applicable to nonsurgical intensive-care or to pediatric patients in the intensive care unit remains unclear.
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To describe indications for intravenous (IV) insulin infusion therapy and glycemic thresholds, discuss methods and protocols, and promote use of and access to IV insulin infusion therapy for all appropriate patients in the hospital setting. ⋯ The threshold for initiation of IV insulin infusion is 110 mg/dL for critically ill surgical patients, 140 mg/dL for other medical or surgical patients, 180 mg/dL for patients in whom subcutaneous insulin regimens fail, and 100 mg/dL for pregnant women. The blood glucose target range is 80 to 110 mg/dL for selected critically ill surgical patients, 70 to 100 mg/dL for pregnant women, and 90 to 140 mg/dL for all other patients. Hospitals should develop procedures to make IV insulin infusion therapy available to all appropriate patients.
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Clinical Trial Controlled Clinical Trial
Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project.
To describe the main findings of the Portland Diabetic Project, which elucidates the adverse relationship between hyperglycemia and outcomes of cardiac surgical procedures in patients with diabetes and delineates the protective effects of intravenous insulin therapy in reducing those adverse outcomes. ⋯ Perioperative hyperglycemia in patients undergoing a cardiac surgical procedure affects biochemical and physiologic functions, which, in turn, adversely alter mortality, LOS, and infection rates. The Portland CII Protocol is a cost-efficient method that effectively eliminates hyperglycemia and reduces postoperative morbidity and mortality in patients with diabetes undergoing an open-heart operation. CII protocols should be the standard care for glycometabolic control in all patients undergoing cardiac surgical procedures.