Recent clinical observations and animal experiments 1 have shown that prolonged administration of cortisone produces adrenal atrophy. According to the adaptation syndrome of Selye,2 adrenal atrophy in turn may lessen the body's ability to withstand trauma and stress. One might suspect that patients receiving cortisone would not normally withstand major surgery; yet every day patients are successfully undergoing surgery while regularly taking cortisone in both the preoperative and postoperative periods.We wish to present the record of a patient who, while receiving a prolonged course of cortisone therapy, underwent a major operation, cup arthroplasty of the hip, and died of immediate postoperative shock, in spite of normally adequate, aggressive antishock therapy. Postmortem examination revealed marked bilateral adrenal atrophy and other conditions consistent with shock. REPORT OF A CASEA 34-year-old man had had rheumatoid arthritis for a period of seven years. Almost every joint of his body was involved, particularly the hips, where there was a marked flexion contracture. The patient had been receiving cortisone for eight months. He first received 1,200 mg. of cortisone over a period of 10 days and then 100 mg. three times weekly. For two months prior to the present examination the patient had been taking 25 mg. of cortisone twice a day. Because of the pain in the right hip and flexion deformity, a cup arthroplasty in the right hip was advised.Past History.-The patient had the usual childhood diseases, including smallpox, and had hay fever. Several episodes of mild skin petechiae were diagnosed as allergic purpura; the latest occurred after his use of cortisone. Bleeding, clotting, and prothrombin times were normal. The platelet count was normal.Physical Findings.-Physical examination revealed a chronically ill-appearing, deformed man of 34 years, who was able to walk about in a stooped position with the use of crutches. He did not appear to be in acute pain. There was pronounced evidence of generalized rheumatoid arthritis. The heart and lungs were normal. Laboratory Data.-X-ray studies revealed an essentially normal chest. The heart measured nearly 50% of the transverse diameter of the chest and was not enlarged in any one region. The red blood cell count was 4,220,000 and hemoglobin 13 gm. I per 100 cc. Urinalysis disclosed no abnormalities. Serologie studies revealed nothing essentially abnormal. The white cell count was 11,000, with 72% neutrophils, 19% lymphocytes, 8% monocytes, 1 basophil, and no eosinophils.Course in the Hospital.-The patient received cortisone up to the time of admission and two days later was taken to the operating room. Spinal anesthesia was employed, with tetracaine (pontocaine®) hydrochloride supplemented with thiopental sodium. The blood pressure at the beginning of the operation was 140/80 and the pulse rate 72. A routine cup arthroplasty of the right hip was performed. During the course of surgery the patient received one blood transfusion. His blood pressure did not fall below 11...

Diabetic patients treated with insulin, whether for type 1 or type 2 diabetes, are prone to often unexplained swings in their blood glucose. These swings can vary from dangerously low to persistently high levels. Most diabetic patients, and most physicians, will adjust insulin regimens so as to avoid hypoglycemia at the expense of hyperglycemia. Among the "textbook" reasons for variable glucose responses to any given insulin regimen are 1) site of administration, 2) exercise, 3) bottles not adequately mixed before drawing the insulin (for NPH, Lente, or Ultralente), and 4) duration of treatment with insulin (1).A new insulin was marketed by Aventis Pharmaceuticals about 1 year ago, insulin glargine (Lantus). The manufacturer seemed to stress that patients not use a started bottle of this insulin for Ͼ28 days (2). Two patients of mine highlighted this point.L.K. is a 76-year-old woman with type 2 diabetes, diagnosed at 55 years of age, and treated with insulin since age 56. Her insulin regimen was changed to Lantus at night together with Novolog before meals. She monitors her blood glucose four times a day. She used a bottle of Lantus until it ran out; therefore, a bottle lasted for 2 months. Her recent HbA 1c was 7.6%. I retrospectively analyzed her home glucose readings by averaging her fasting blood glucose levels for the first 15 days of a new bottle and the last 15 days of that same bottle. The results were 137 Ϯ 20 and 187 Ϯ 13 mg/dl, respectively. E.T. is a 77-year-old man with type 1 diabetes since 29 years of age. His regimen was changed from Humulin N plus Lispro to Lantus at bedtime and Lispro before meals. He checks his blood glucose levels four times a day. He observed on his own that the last 25% of his Lantus bottle didn't seem as potent as the first 75% and questioned me about this. I asked him how long a bottle of Lantus insulin lasts for him. He told me 40 days (consistent with his dose of 25 U/day). Simple math revealed that his last 25% was past the recommended 28 days.I set out to review the available literature on insulin storage. Lilly recommends using an opened bottle of Humulin R for 4 weeks, Humalog for 4 weeks, and Humulin N for only 1 week, whether refrigerated or at room temperature. Humalog Mix 75/25, Humulin 70/ 30, and Humulin N cartridges can be used for 7-10 days (3). Novo Nordisk states that vials or cartridges of Novolog can be used for 28 days at room temperature but says nothing about how long it will last if refrigerated (4). In a private communication with a staff pharmacist at Novo Nordisk, I received the following message: "If human insulin vials that are stored under refrigeration are used beyond 30 days, the stability of human insulin vials is dependent upon a number of factors in addition to temperature [sic]. These factors include the number of injections per day, volume of insulin remaining in the vial, exposure to light, agitation, and technique used for dose preparation. The impact of these factors is difficult to measure and the health professional should advise p...

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In patients with chronic renal failure, blood samples for laboratory analysis are often taken via dialysis catheters. This report describes a case of gross spurious hypernatraemia in a blood sample collected from a patient undergoing haemodialysis. After centrifugation of the blood sample in question, the separator gel formed the topmost layer, with the serum in the middle and the clot at the bottom. Subsequent analysis of the serum showed severe hypernatraemia (serum sodium, 744 mmol/litre). It was established that the blood sample had been taken from the patient’s dialysis catheter into which 3 ml of Citra-Lock™ (46.7% trisodium citrate) had been instilled previously as a “catheter locking” solution. The hypernatraemia seen in this case was recognised immediately as an artefact, but it was found that even minimal contamination of blood samples with Citra-Lock may significantly affect sodium concentrations. This contamination may be missed, with potentially adverse consequences for patient management.