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Bujawansa S, Thondam SK, Steele C, Cuthbertson DJ, Gilkes CE, Noonan C, Bleaney CW, Macfarlane IA, Javadpour M, Daousi C. Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom. Clin Endocrinol (Oxf) 2014; 80:419-24. [PMID: 23909507 DOI: 10.1111/cen.12307] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 06/14/2013] [Accepted: 07/30/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy. DESIGN Retrospective analysis of casenotes at a single neurosurgical centre in Liverpool, UK. RESULTS Fifty-five patients [mean age, 52·4 years; median duration of follow-up, 7 years] were identified; 45 of 55 (81%) had nonfunctioning adenomas, four acromegaly and six prolactinomas. Commonest presenting features were acute headache (87%), diplopia (47·2%) and visual field (VF) defects (36%). The most frequent ocular palsy involved the 3rd nerve (81%), followed by 6th nerve (34·6%) and multiple palsies (19%). Twenty-three patients were treated conservatively, and the rest had surgery either within 7 days of presentation or delayed elective surgery. Indications for surgery were deteriorating visual acuity and persistent field defects. Patients presenting with VF defects (n = 20) were more likely to undergo surgery (75%) than to be managed expectantly (25%). There was no difference in the rates of complete/near-complete resolution of VF deficits and cranial nerve palsies between those treated conservatively and those who underwent surgery. Endocrine outcomes were also similar. We were able to calculate the PAS for 46 patients: for the group treated with early surgery mean, PAS was 3·8 and for those managed conservatively or with delayed surgery was 1·8. CONCLUSIONS Patients without VF deficits or whose visual deficits are stable or improving can be managed expectantly without negative impact on outcomes. Clinical severity based on a PAS ≥ 4 appeared to influence management towards emergency surgical intervention.
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Affiliation(s)
- S Bujawansa
- Department of Endocrinology & Diabetes, University Hospital Aintree, Liverpool, UK
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Thondam SK, Cuthbertson DJ, Aditya BS, Macfarlane IA, Wilding JP, Daousi C. A glucagon-like peptide-1 (GLP-1) receptor agonist in the treatment for hypothalamic obesity complicated by type 2 diabetes mellitus. Clin Endocrinol (Oxf) 2012; 77:635-7. [PMID: 22356092 DOI: 10.1111/j.1365-2265.2012.04368.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
AIMS To determine the long-term (20 years from presentation) outcome of brittle type 1 diabetes characterized by recurrent episodes of ketoacidosis (DKA). METHODS The cohort studied was a group of brittle diabetic patients from various parts of UK originally identified between 1979 and 1985. Patients were traced, where possible, via their diabetic clinics and/or general practitioners. Data on survival or otherwise were obtained from hospital case notes and information from diabetes care team members. For survivors, clinical and demographic information obtained included complication status and whether they still had brittle characteristics. They were also compared with a matched case-control group of type 1 patients with no history of brittle behaviour. RESULTS The original cohort comprised 33 patients- all female and mean ± SD, aged 18 ± 5 years and diabetes duration 8 ± 4 years. Thirteen were not traceable and 10 of the remaining 20 (50%) had died during the mean 22 years of follow-up. Deaths occurred evenly throughout the period, and causes were chronic renal failure (3), DKA (3), hypoglycaemia (2), subarachnoid haemorrhage (1) and uncertain (1). Age at death ranged from 27 to 45 years. Of the 10 survivors, none remained brittle, but they had a substantial burden of complications. Compared with the non-brittle control group, there was a significant excess of nephropathy and autonomic neuropathy. CONCLUSION We conclude that brittle diabetes characterized by recurrent DKA has high long-term outcome mortality. These deaths were premature and almost all diabetes related. Those who survived had resolution of brittleness, but suffered a significant complication burden.
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Affiliation(s)
- A Cartwright
- Department of Diabetes/Endocrinology, University of Liverpool, Liverpool L9 1AE, UK
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Wallymahmed ME, Morgan C, Gill GV, Macfarlane IA. Nurse-led cardiovascular risk factor intervention leads to improvements in cardiovascular risk targets and glycaemic control in people with Type 1 diabetes when compared with routine diabetes clinic attendance. Diabet Med 2011; 28:373-9. [PMID: 21204963 DOI: 10.1111/j.1464-5491.2010.03224.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To compare the effects of a dedicated cardiovascular risk factor clinic run by a nurse consultant with routine diabetes clinic attendance in achieving glycaemic and cardiovascular risk targets in patients with Type 1 diabetes. METHODS Eighty-one patients (45 male, mean age 34.6 years, mean duration of diabetes 15 years) with an HbA(1c) ≥ 8% (64 mmol/mol) and at least one other risk factor for the development of cardiovascular disease were randomized to receive either routine care or intensive nurse-led cardiovascular risk factor intervention. HbA(1c) , non-fasting lipid profile, blood pressure, weight, BMI and insulin dose were recorded at baseline, 6, 12 and 24 months. RESULTS At baseline there were no differences between the groups. At 12 months, there were significant improvements in the nurse-led cardiovascular risk factor group: HbA(1c) [10.1% (87 mmol/mol) vs. 9.3% (78 mmol/mol), P < 0.001], total cholesterol (5.8 vs. 4.3 mmol/l, P < 0.001), systolic blood pressure (127 vs. 115 mmHg, P < 0.001) and diastolic blood pressure (71 vs. 65 mmHg, P < 0.05). Improvements were maintained in all variables at 24 months except diastolic blood pressure. In the routine group, only total cholesterol improved significantly (5.8 vs. 5.2 mmol/l, P < 0.01) after 12 months and this was maintained at 24 months. CONCLUSION A nurse consultant cardiovascular risk factor clinic has a beneficial effect on cardiovascular risk targets in Type 1 diabetes, probably attributable to the increased use of lipid-lowering and anti-hypertensive agents and this was maintained at 24 months. Glycaemic control also improved.
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Affiliation(s)
- M E Wallymahmed
- University Department of Diabetes and Endocrinology, Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
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Gardner CJ, Javadpour M, Morgan C, Daousi C, Macfarlane IA, Cuthbertson DJ. Hypopituitarism – a late consequence of aneurysmal subarachnoid haemorrhage? Br J Neurosurg 2011; 25:337-8. [DOI: 10.3109/02688697.2010.546900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gardner CJ, Wieshmann H, Gosney J, Carr HM, Macfarlane IA, Cuthbertson DJ. Localization of metastatic parathyroid carcinoma by 18F FDG PET scanning. J Clin Endocrinol Metab 2010; 95:4844-5. [PMID: 21051579 DOI: 10.1210/jc.2010-1479] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Deepak D, Daousi C, Javadpour M, Clark D, Perry Y, Pinkney J, Macfarlane IA. The influence of growth hormone replacement on peripheral inflammatory and cardiovascular risk markers in adults with severe growth hormone deficiency. Growth Horm IGF Res 2010; 20:220-225. [PMID: 20185347 DOI: 10.1016/j.ghir.2010.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 01/27/2010] [Accepted: 02/01/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Adult GHD syndrome is associated with clustering of adverse cardiovascular (CV) risk factors such as abnormal body composition, dyslipidemia, insulin resistance and abnormal haemostatic factors. There is a wealth of evidence linking CV events with elevated levels of inflammatory markers (hs-CRP and IL-6) in the general population; however data on their abnormalities in GHD and specially the effects of GH replacement (GHR) on these inflammatory markers are limited. OBJECTIVE To study the effects of GHR on inflammatory markers, glucose homeostasis and body composition in a cohort of adults with recently diagnosed severe GHD due to hypothalamic pituitary disease. DESIGN Fifteen hypopituitary adults (11 males, mean age 48.5 years) with recently diagnosed, severe GHD were recruited. Patients received GHR (in addition to other pituitary hormone replacements) titrated to clinical response and to normalize age and gender adjusted IGF-1 levels. Weight, waist hip ratio (WHR), body composition, fasting plasma glucose and insulin, insulin resistance index (HOMA-IR), fasting serum lipid levels, hs-CRP, IL-6 and TNF-alpha were measured at baseline and following a minimum 6 months of stable maintenance GHR. RESULTS GHR resulted in a physiological increase in IGF-1 SDS [median -0.6 to +0.39, P<0.0001], improved quality of life (mean pre-treatment AGHDA score 16 vs. post-treatment score 7, P<0.0001) and reduction in WHR (0.94 vs. 0.92, P=0.01). There were no significant changes in body weight and composition. Levels of hs-CRP (log transformed, mean (SD)) were significantly reduced following GHR (pre 1.21 (0.9) vs. post 0.27 (0.9), P<0.0001) but TNF-alpha and IL-6 levels remained unchanged. Fasting glucose (mmol/L) [4.6 (0.1) vs. 5.1 (0.1), P=0.003], fasting insulin (muU/mL) [9.4 (8.1) vs. 12.1 (9.2), P=0.03] and HOMA-IR [1.2 (1.0) vs. 1.5 (1.1) P=0.02] (all pre-GHR vs. post-GHR and mean (SD)) significantly increased following GHR indicating increased insulin resistance. Significant improvements were noted in fasting LDL-cholesterol (LDL-C) and HDL-cholesterol (HDL-C) levels following GHR [3.4 (0.9) vs. 2.9 (0.7), P=0.03 and 1.2 (0.2) vs. 1.3 (0.2), P=0.02, respectively] (all pre-GHR vs. post-GHR and mean (SD)). Levels of total cholesterol and triglycerides did not change following GHR. CONCLUSIONS Physiological GHR for at least 6 months in hypopituitary adults with recently diagnosed severe GHD resulted in favourable changes in hs-CRP, WHR, fasting LDL-C and HDL-C levels all of which are recognised CV risk markers. However, there remains a high prevalence of obesity in this population and given the worsening of insulin sensitivity in the short term with GHR, monitoring and aggressive treatment of established CV risk factors is essential to reduce premature atherosclerotic CVD in this patient population.
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Affiliation(s)
- D Deepak
- Diabetes and Endocrinology Research Group, Clinical Sciences Centre, Aintree University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK.
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Saunders SA, Wallymhamed M, Macfarlane IA. Improvements in glycaemic control and cardiovascular risk factors in a cohort of patients with type 1 diabetes over a 5-year period. QJM 2009; 102:29-34. [PMID: 18829712 DOI: 10.1093/qjmed/hcn125] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Management of patients with type 1 diabetes in the UK has changed over the past 20 years. The targets for glycaemic control, blood pressure and cholesterol are lower. We examined a cohort of patients with type 1 diabetes who have been through these changes to assess their effects. DESIGN AND METHODS A cohort of patients with type 1 diabetes who attended a secondary care outpatient diabetes clinic between 1991 and 1996 were reviewed in 2001 and 2006. Comparison is made between current biophysical markers and those obtained in 2001. RESULTS Only 81.9% (n = 214) of the original cohort attended in 2006. These patients had an average duration of diabetes of 23.46 (SD +/- 8.06) years. There were 134 male patients (62.62%). In these patients HbA1c had reduced by 0.4% (absolute reduction); a relative reduction of 4.41% (P = 0.0001). Statistically significant reductions in diastolic blood pressure (74-68 mmHg) and total cholesterol (5.37-4.62 mmol/l) occurred. However, weight (75.04-82.31 kg) and BMI (25.32-27.72 kg/m(2)) significantly increased. There was no statistically significant change in insulin dose (units/kg), serum creatinine, urinary ACR or systolic blood pressure. CONCLUSION An urban setting, mobile population and patient non-attendance can complicate modern diabetes care. Despite these difficulties, input by the diabetes team working with the patients can achieve small improvements in Hba1c and cardiovascular risk factors by increased use of long acting insulins, metformin, statins and blood pressure medication.
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Affiliation(s)
- S A Saunders
- St. Helens and Knowsley NHS Trust, Whiston Hospital, Warrington Road, Prescot, Merseyside L355DR, UK.
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Deepak DS, Woodcock BE, Macfarlane IA. A thyroid mass composed of Langerhans' cell histiocytosis and auto-immune thyroiditis associated with progressive hypothalamic-pituitary failure. Int J Clin Pract 2007; 61:2130-1. [PMID: 17997812 DOI: 10.1111/j.1742-1241.2005.00749.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- D S Deepak
- University Department of Endocrinology & Diabetes, University Hospital Aintree, Liverpool, UK.
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Bohnen JM, Christou NV, Maclean LD, Meakins JL, Pollock AV, Almgren B, Watkins RM, Watkin EM, Mansfield AO, Bradley JWP, Cooperberg P, Stoller JL, McKay AJ, Macfarlane IA, Howat JMT, Hodgson WJB, Nicholls RJ, Poston GJ, Pickering BN, Rahamim J, Millar AW, Brennan SS, Smith GMR, Evans M, Rampen FHJ, Everett WG, Jurewicz WA, Buffet C, Turner K, Pelletier G, Etienne JP, Keohane PP, Silk DBA, Mitchell A, Kettlewell MGW, McMahon MJ, Collins REC, Spittlehourse K. Correspondence. Br J Surg 2005. [DOI: 10.1002/bjs.1800700225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- J M Bohnen
- Department of Surgery and Microbiology, Royal Victoria Hospital and McGill University, Montreal, Quebec, Canada H3A 1A1
| | - N V Christou
- Department of Surgery and Microbiology, Royal Victoria Hospital and McGill University, Montreal, Quebec, Canada H3A 1A1
| | - L D Maclean
- Department of Surgery and Microbiology, Royal Victoria Hospital and McGill University, Montreal, Quebec, Canada H3A 1A1
| | - J L Meakins
- Department of Surgery and Microbiology, Royal Victoria Hospital and McGill University, Montreal, Quebec, Canada H3A 1A1
| | - A V Pollock
- Scarborough Hospital, North Yorkshire YO12 6QL
| | - B Almgren
- Department of Surgery, University Hospital, S-752 14 Uppsala, Sweden
| | - R M Watkins
- Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU
| | - E M Watkin
- Department of Radiology, Leicester General Hospital, Gwendolen Road, Leicester
| | | | | | - P Cooperberg
- Depts of Radiology and Suergery, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, Canada V5Z IM9
| | - J L Stoller
- Depts of Radiology and Suergery, University of British Columbia, 855 West 12th Avenue, Vancouver, British Columbia, Canada V5Z IM9
| | - A J McKay
- Level 5, Gartnavel General Hospital, Glasgow
| | - I A Macfarlane
- The Diabetic Clinic, The General Hospital, Steelhouse Lane, Birmingham B46 NH
| | - J M T Howat
- The Diabetic Clinic, The General Hospital, Steelhouse Lane, Birmingham B46 NH
| | - W J B Hodgson
- New York Medical College, Munager Pavilion, Valhalla, New York 10595, USA
| | | | - G J Poston
- Derriford Hospital, Derriford Road, Plymouth PL6 8DH
| | - B N Pickering
- Derriford Hospital, Derriford Road, Plymouth PL6 8DH
| | - J Rahamim
- Derriford Hospital, Derriford Road, Plymouth PL6 8DH
| | - A W Millar
- Surgical SHO, Derby City Hospital, Uttoxeter Road, Derby DE3 3NE
| | - S S Brennan
- Department of Surgery, North Manchester General Hospital, Crumpsall, Manchester M8 6RB
| | - G M R Smith
- Scarborough Hospital, North Yorkshire YO12 6QL
| | - Mary Evans
- Scarborough Hospital, North Yorkshire YO12 6QL
| | - F H J Rampen
- Department of Dermatology, Academisch Medisch Centrum, 1105 AZ Amsterdam, The Netherlands
| | | | | | - C Buffet
- Service des Maladies du Foie et de l'Appareil Digestif, 78 Avenue du General Leclerc, 94270 Le Kremlin Bicetre, France
| | - K Turner
- Service des Maladies du Foie et de l'Appareil Digestif, 78 Avenue du General Leclerc, 94270 Le Kremlin Bicetre, France
| | - G Pelletier
- Service des Maladies du Foie et de l'Appareil Digestif, 78 Avenue du General Leclerc, 94270 Le Kremlin Bicetre, France
| | - J P Etienne
- Service des Maladies du Foie et de l'Appareil Digestif, 78 Avenue du General Leclerc, 94270 Le Kremlin Bicetre, France
| | - P P Keohane
- Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London NW10 7NS
| | - D B A Silk
- Department of Gastroenterology and Nutrition, Central Middlesex Hospital, Acton Lane, London NW10 7NS
| | - Andrew Mitchell
- Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU
| | | | - M J McMahon
- University Department of Surgery, The General Infirmary, Leeds LS1 3EX
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Wallymahmed ME, Littler P, Clegg C, Haqqani MT, Macfarlane IA. Nodules of fibrocollagenous scar tissue induced by subcutaneous insulin injections: a cause of poor diabetic control. Postgrad Med J 2005; 80:732-3. [PMID: 15579616 PMCID: PMC1743164 DOI: 10.1136/pgmj.2004.019547] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A 46 year old man with longstanding type 1 diabetes developed major weight loss and marked deterioration in diabetic control. He had been persistently injecting insulin into areas of abdominal lipohypertrophy within which hard collagenised fibrous tissue nodules had developed. Injecting insulin at different sites dramatically improved blood glucose control. Fibrocollagenous nodules induced by insulin injections have not been previously described. Examination of a further 73 type 1 patients revealed lipohypertrophy in 44% and hard subcutaneous nodules on two.
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Affiliation(s)
- M E Wallymahmed
- University Department of Diabetes and Endocrinology, University Hospital Aintree, Liverpool, UK.
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Abstract
AIMS To determine the morbidity, mortality and healthcare costs of intravenous drug-abusing patients with Type 1 diabetes (IVDA-DM), who are admitted to hospital. METHODS Retrospective case note analysis of admissions, complications and cost estimation over a 6-year period. Each drug-abusing patient (IVDA-DM) (n = 9) was compared with two controls (n = 18) with Type 1 diabetes but without a history of intravenous drug abuse (DM-controls). Admissions were also analysed for patients with intravenous drug abuse, but without Type 1 diabetes (IVDA-controls) (n = 198). Admissions were at a University teaching hospital in Liverpool, UK. DM-controls were drawn from a population attending diabetes outpatient clinics between 1997 and 2002 at the same hospital. The main outcome measures were: the duration and healthcare costs of hospital admissions per year, outpatient attendances per year, glycated haemoglobin (HbA(1c)), weight, micro- and macrovascular complications and mortality. RESULTS Multiple admissions, mainly related to ketoacidosis, led to marked differences in mean (95% CI) inpatient days per year per patient [IVDA-DM 28.1 (13.6-42.7) vs. DM-control 1.1 (0.2-1.9); P < 0.0001], mean inpatient days per year per patient in critical care bed (IVDA-DM 1.7 (-0.7-4.2) vs. DM-control 0; P < 0.02) and mean costs of admission, per patient per year (pound sterling 7320 vs. pound sterling 230). The IVDA-DM group frequently omitted insulin, were underweight, failed to attend as outpatients and five had died by the end of 2002. The IVDA-controls spent considerably less time in hospital [3.4 (2.8-3.9) days per patient per year]. CONCLUSION IVDA-DM patients have higher rates of diabetes complications, are admitted more frequently and have a high mortality compared with DM and IVDA-controls. The cost of inpatient care of this small group of patients was considerable.
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Affiliation(s)
- S A Saunders
- University Hospitals Aintree NHS Trust, Liverpool, UK
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Li Voon Chong JS, Burrows CT, Cave-Bigley D, Macfarlane IA. A hard thyroid mass due to plasma cell granuloma. Int J Clin Pract 2001; 55:335-6. [PMID: 11452684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
Plasma cell granuloma involving the thyroid is very rare. A 29-year-old man with type 1 diabetes mellitus presented with a one-week history of fever, sore throat, neck tenderness and dysphagia. Antibiotics were given but over the next two weeks a hard 8 cm mass in the left lobe of the thyroid developed. Fine needle aspiration was not diagnostic and surgical exploration revealed an inflammatory process arising from the left lobe of the thyroid involving the left sternothyroid muscle and parapharyngeal spaces. Histology of multiple biopsies showed plasma cell granuloma. Immunoperoxidase staining demonstrated the presence of IgG, IgM and IgA with predominance of IgG. The residual mass resolved and was impalpable after four weeks. Plasma cell granuloma should be suspected when there is a rapidly developing hard thyroid mass. Open biopsy/removal and histological confirmation are mandatory and residual disease may resolve within weeks.
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Li Voon Chong JS, Lecky BR, Macfarlane IA. Recurrent encephalopathy and generalised seizures associated with relapses of thyrotoxicosis. Int J Clin Pract 2000; 54:621-2. [PMID: 11220993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Seizures or encephalopathy associated with thyrotoxicosis are very rare. A 30-year-old man with thyrotoxicosis and strongly positive thyroid antibodies presented with generalised seizures preceded by an encephalopathic illness of a few days duration. CSF protein was raised and EEG showed bilateral slowing of activity. Antithyroid drug treatment rendered him biochemically euthyroid, his cognitive state returned to normal and his seizures stopped. Subsequently he had a recurrence of both encephalopathy and seizures on two occasions, coinciding with relapses of the thyrotoxicosis. This supports the view that the hyperthyroid state caused this serious neurological condition. Treatment with 131I caused hypothyroidism and he has remained seizure free and well for six years on thyroxine replacement. Corticosteroids may have been helpful in the management of his encephalopathy.
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Leese GP, Tesfaye S, Dengler-Harles M, Laws F, Clark DI, Gill GV, Macfarlane IA. Screening for diabetic eye disease by optometrists using slit lamps. J R Coll Physicians Lond 1997; 31:65-9. [PMID: 9044202 PMCID: PMC5420835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Diabetic patients were screened for diabetic eye disease by hospital-based optometrists using a slit lamp with a 78-dioptres Volk lens. Visual acuity and intraocular pressure were also measured. Of 622 patients screened, 149 (24.0%) had background and 32 (5.1%) advanced retinopathy/maculopathy. The fundus was inadequately visualised in four (0.6%) patients. Following screening, 86 (13.8%) patients were referred to the ophthalmology clinic for appropriate treatment and follow up. Hospital-based optometrists using a slit lamp offer a useful new method for screening for diabetic eye disease. They can identify previously unrecognised sight-threatening diabetic eye disease and important non-diabetic eye disease requiring intervention, and are relatively cheap. This method is ideally suited for rapid referral to the specialist. The results merit larger-scale studies both to confirm the effectiveness of this method and to assess whether hospital trained optometrists could perform screening in the community.
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Affiliation(s)
- G P Leese
- Department of Diabetes and Ophthalmology, Walton Hospital, Liverpool
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Abstract
OBJECTIVE To assess whether the development of plantar foot ulceration could be predicted from the mean plantar foot temperature (MFT), as assessed by liquid-crystal contact thermography (LCT), in patients with peripheral neuropathy. RESEARCH DESIGN AND METHODS Fifty patients with painful diabetic sensorimotor neuropathy were studied prospectively. Initially, 30 patients had no significant peripheral vascular disease (PVD) (ankle:brachial systolic blood pressure ratio > 1.0). LCT was used to assess the MFT from eight standard plantar sites. RESULTS Initial MFT was higher in the patients without PVD (28.2 +/- 2.9 degrees C, mean +/- SD) than in patients with PVD (25.6 +/- 1.9 degrees C, P < 0.001) and in nondiabetic control subjects (25.7 +/- 2.1 degrees C, P < 0.001). At review, on average 3.6 (range 3.0-4.1) years later, 11 patients had died (6 of whom had PVD), and one was lost to follow-up. Six patients (seven feet) from the group without PVD had developed neuropathic plantar foot ulcers. The initial MFT was significantly higher in these seven feet (30.5 +/- 2.6 degrees C) than in the 38 feet of the 19 survivors in this group (27.8 +/- 2.3 degrees C, P < 0.01). Only one patient with PVD developed a plantar ulcer, although four required foot surgery for ischemic feet. CONCLUSIONS LCT is a simple, inexpensive, and noninvasive method of identifying the neuropathic foot at increased risk of ulceration. Patients with high plantar foot temperatures are at increased risk of neuropathic foot ulceration. A normal or low MFT in the neuropathic foot is a marker of PVD, which confers an increased risk of ischemic foot disease.
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Affiliation(s)
- S J Benbow
- Department of Medicine, University of Liverpool, U.K
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Abstract
CSF methionine and leucine enkephalins were measured by high performance liquid chromatography and radioimmunoassay in diabetic patients with painful neuropathy (n = 22) and painless neuropathy (n = 5), and non-diabetic subjects with low back pain (n = 11). Wide variations in CSF enkephalin levels were found and they were often below the limit of detection (less than 0.1 pmol/l) in the diabetic and non-diabetic groups. The origin of CSF enkephalins is unknown and CSF levels may not reflect tissue concentrations. In conclusion, CSF enkephalin levels are difficult to interpret and do not provide useful information on the function of enkephalinergic pathways.
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Affiliation(s)
- A W Chan
- Diabetes Centre, Walton Hospital, Liverpool, U.K
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Moore AP, Macfarlane IA, Blumhardt LD. Polyneuropathy in lithium intoxication. Muscle Nerve 1991; 14:578. [PMID: 1649400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
Two patients with primary hypothyroidism who developed neuroleptic malignant syndrome (NMS) are described. Thyroid disease might predispose to NMS by altering brain dopamine metabolism.
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Affiliation(s)
- A P Moore
- Department of Neurological Science, University of Liverpool, Walton Hospital, Liverpool, United Kingdom
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Ardron M, Macfarlane IA, Martin P, Walton C, Day J, Robinson C, Calverly P. Urinary excretion of albumin, alpha-1-microglobulin, and N-acetyl-B-D-glucosaminidase in relation to smoking habits in diabetic and nondiabetic subjects. J Diabet Complications 1989; 3:154-7. [PMID: 2476455 DOI: 10.1016/0891-6632(89)90038-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Smoking may be a risk factor for the development of diabetic nephropathy. Therefore, the urinary excretion of albumin, alpha-1-microglobulin, and N-acetyl-BD glucosaminidase was studied in 24 young adult diabetic patients who smoked. None of these patients had urine samples positive for albumin as determined by the Albustix method (i.e., a urinary concentration of albumin of less than 0.5 g in 24 hr). Control groups were nonsmoking diabetic patients (matched for age and duration of diabetes) and nondiabetic subjects (smokers and nonsmokers). Expired breath carbon monoxide and the urinary nicotine metabolite cotinine were measured as objective markers of smoking load. No significant differences in concentrations of urinary proteins were found among any of the four groups. Therefore, smoking is not associated with the development of an increased urinary excretion of albumin within the "microalbuminuria" range. However, further studies are required to determine whether smoking is a risk factor for the progression of established microalbuminuria to Albustix positive proteinuria in diabetic patients.
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Affiliation(s)
- M Ardron
- Diabetic Clinic, Walton Hospital, Liverpool, United Kingdom
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Macfarlane IA, Shalet SM, Beardwell CG, Applegate G, Robinson EL, Sutton ML. External pituitary irradiation as a cause of TRH deficiency in patients with pituitary adenomas. Clin Endocrinol (Oxf) 1983; 18:201-9. [PMID: 6406112 DOI: 10.1111/j.1365-2265.1983.tb03203.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The influence of external pituitary irradiation (XRT) on thyrotroph function and PRL secretion was studied in twenty-five patients with pituitary adenomas, of whom eight had acromegaly. Twenty-one patients had undergone subtotal operative removal of their adenomas 8-190 weeks (median 12 weeks) before XRT. Following irradiation there was a significant reduction in peak serum TSH levels in response to i.v. TRH (P less than 0.05, compared with before XRT). Peak TSH levels returned to normal at 3 months. Similarly a transient reduction in TRH-stimulated beta-TSH release was observed. Serum T3 and T4 concentrations also fell after XRT, the levels at 3 months being significantly lower than control values (P less than 0.02), though no difference was seen at 6 and 12 months. A delayed (hypothalamic) serum TSH response to TRH (60 greater than 20-min level) developed at 6 months. In contrast, PRL concentrations (basal and TRH stimulated) were not altered during the 12 months following XRT. These findings demonstrate that thyrotroph function can be transiently impaired following external pituitary irradiation. None of the patients studied required T4 replacement therapy. The development of a delayed TSH response to i.v. TRH may indicate endogenous TRH deficiency. It was not associated with supra-sellar tumour enlargement in our patients and may be due to hypothalamic damage by irradiation.
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Macfarlane IA, Beardwell CG, Shalet SM, Darbyshire PJ, Hayward E, Sutton ML. Glycoprotein hormone alpha subunit secretion by pituitary adenomas: influence of external irradiation. Clin Endocrinol (Oxf) 1980; 13:215-22. [PMID: 6163576 DOI: 10.1111/j.1365-2265.1980.tb01045.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
In ninety-nine patients with pituitary adenomas, forty-six with acromegaly, the serum level of the glycoprotein hormone alpha subunit was elevated in eighteen cases. Thirteen of these were acromegalic and one had an FSH-producing tumour. Alpha levels varied little during the day, from one day to the next and over a 6 month period. In twenty-five patients with a variety of other hypothalamic-pituitary disorders examined, one patient with a craniopharyngioma had a mildly elevated alpha level. External pituitary irradiation was followed by an acute and often transient fall in alpha level in several of these patients. Of the fifty-four patients with pituitary adenomas who had received external irradiation before testing, only five had elevated alpha subunit levels compared with thirteen patients of the forty-five who had not been irradiated. This difference in incidence of elevated alpha level was statistically significant (P less than 0.025). We conclude that external irradiation may reduce alpha subunit level chronically in many patients with pituitary adenoma.
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