Waterhouse–Friderichsen syndrome—massive adrenal haemorrhage in the setting of overwhelming clinical sepsis—is usually taken at necropsy to indicate meningococcal infection, and may be the only evidence of this pathogen. This report describes three fatal cases of the syndrome in which the causative organism proved to be a streptococcus. The organisms were detected during routine coroners’ autopsies with histology and microbiological investigations. In two cases, the syndrome followedStreptococcus pneumoniaeinfection and in a third β haemolytic streptococcus group A. Thus, adrenal haemorrhage alone cannot be taken to indicate meningococcal disease and other pathogens, particularly streptococcus, must be considered.
Any chronic disease is associated with an increased prevalence of mood disorders and depression. Diabetes is unique in that it places the burdens of invasive blood glucose monitoring, regimentation of diet and exercise, and often multiple daily insulin injections into the hands of the individual. Therefore, it is not surprising that depression may be three times more prevalent in the diabetic population when compared with nondiabetic individuals. Depressed patients with diabetes have been shown to have poorer glycemic control and a higher incidence of microvascular and macrovascular complications. Treatment of the depression associated with diabetes with either pharmacologic therapy or behavioral intervention has been shown to result in improved glycemic control and quality of life. Specific side effects of commonly used antidepressant medications, which have particular bearing on the diabetic state, are discussed. Future research into the causal relationship of depression to the onset on diabetes, longitudinal studies looking at depression and the rate of occurrence of diabetic complications, and the impact of the early development of healthy coping mechanisms and the treatment of depression on the natural history of diabetes are needed.
Eight normal subjects were studied twice for 360 min after the subcutaneous injection of unmodified insulin (0.15 U kg-1) during euglycaemic clamps. Insulin absorption was assessed by both the area under the insulin-time curve above baseline (AUC) and time course of absorption (time to 25% and 50% of total AUC). Insulin action was measured as the amount of glucose infused. The maximal serum insulin concentration was 0.27 +/- 0.02 (+/- SE) nmol l-1 at 112 +/- 10 min. Fifty percent of total glucose infused occurred at 218 +/- 7 min. The maximal glucose infusion rate was 5.11 +/- 0.70 mg kg-1 min-1 and occurred at 256 +/- 12 min. Intrasubject coefficients of variation (CV) for total insulin AUC (11.2%), time to 25% of maximum AUC (12.1%) and time to 50% of maximum AUC (10.2%) were considerably lower than that for total insulin action (22.6%). Total insulin AUC did not correlate with total glucose utilization (r = 0.06, NS). We conclude that when glucose concentrations are maintained by euglycaemic clamps the peak of unmodified insulin action is later and the duration longer than traditionally recognized, insulin AUC does not predict insulin action, and the higher variability of insulin action compared with the indices of absorption suggests that day-to-day changes in tissue insulin sensitivity contribute more to the variability in insulin action than changes in absorption.
Our algorithm for automatic quantification of LVEF and relative end-systolic and end-diastolic volumes from gated 99mTc sestamibi myocardial perfusion SPECT is repeatable. When performed in the prone position, values of ejection fractions and ventricular volumes are essentially identical to those obtained in the supine position.
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