Muehrcke's Lines

A 29-year-old woman with no significant medical history developed anasarca over the course of approximately 2 weeks. On the basis of renal biopsy, a diagnosis of minimal change disease was made. Her nephrotic syndrome was poorly responsive to steroid therapy, and despite high doses of prednisone of up to 120 mg/d, her serum albumin and proteinuria remained 1 g/dL and 10 g/d, respectively. Approximately 1 month after the onset of her symptoms, she developed transverse, nonpalpable, white lines on all her fingernails (Figure). These nail changes are consistent with a diagnosis of Muehrcke's lines.

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-- Nicholas Short, BA, Chirayu Shah, MD

This article originally appeared in the November 2010 issue of The American Journal of Medicine.

Managing Myocardial Infarction in the Elderly: What Should the Clinician Do?

As the American population progressively ages, the number of elderly who suffer an acute myocardial infarction (MI) is increasing. These days, it is not uncommon for me to be caring for a number of patients 80 years old or more in our coronary care unit. The evident and potential frailty of these individuals can make their care complex. Recent publications have focused on the presentation and results of therapy in these elderly patients, as well as pathophysiologic differences between older and younger patients with acute MI.

Not surprisingly, elderly patients with acute MI have a worse prognosis as compared with younger individuals.

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-- Joseph S. Alpert, MD
Editor-in-Chief, The American Journal of Medicine

This article originally appeared in the November 2010 issue of The American Journal of Medicine.

Lactation and Maternal Risk of Type 2 Diabetes: A Population-based Study

Risk of type 2 diabetes increases when childbirth is followed by less than one month of breastfeeding. This effect is independent of physical activity and body mass index later in life. Physicians should encourage breastfeeding.

Abstract

Background
Lactation has been associated with improvements in maternal glucose metabolism.

Methods
We explored the relationships between lactation and risk of type 2 diabetes in a well-characterized, population-representative cohort of women, aged 40-78 years, who were members of a large integrated health care delivery organization in California and enrolled in the Reproductive Risk factors for Incontinence Study at Kaiser (RRISK), between 2003 and 2008. Multivariable logistic regression was used to control for age, parity, race, education, hysterectomy, physical activity, tobacco and alcohol use, family history of diabetes, and body mass index while examining the impact of duration, exclusivity, and consistency of lactation on risk of having developed type 2 diabetes.

Results
Of 2233 women studied, 1828 were mothers; 56% had breastfed an infant for ≥1 month. In fully adjusted models, the risk of type 2 diabetes among women who consistently breastfed all of their children for ≥1 month remained similar to that of women who had never given birth (odds ratio [OR] 1.01; 95% confidence interval [CI], 0.56-1.81). In contrast, mothers who had never breastfed an infant were more likely to have developed type 2 diabetes than nulliparous women (OR 1.92; 95% CI, 1.14-3.27). Mothers who never exclusively breastfed were more likely to have developed type 2 diabetes than mothers who exclusively breastfed for 1-3 months (OR 1.52; 95% CI, 1.11-2.10).

Conclusions
Risk of type 2 diabetes increases when term pregnancy is followed by <1 month of lactation, independent of physical activity and body mass index in later life. Mothers should be encouraged to exclusively breastfeed all of their infants for at least 1 month.

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-- Eleanor Bimla Schwarz, MD, MS, Jeanette S. Brown, MD, Jennifer M. Creasman, MPH, Alison Stuebe, MD, MS, Candace K. McClure, PhD, Stephen K. Van Den Eeden, PhD, David Thom, MD, PhD

This article originally appeared in the September 2010 issue of The American Journal of Medicine.

Inhaled Corticosteroids and the Risks of Diabetes Onset and Progression

In patients with respiratory disease, inhaled corticosteroid use is associated with modest increases in the risks of diabetes onset and diabetes progression. The risks are more pronounced at the higher doses currently prescribed in the treatment of chronic obstructive pulmonary disease.

Abstract

Background

Systemic corticosteroids are known to increase diabetes risk, but the effects of high-dose inhaled corticosteroids are unknown. We assessed whether the use and dose of inhaled corticosteroids increase the risk of diabetes onset and progression.

Methods

We formed a new-user cohort of patients treated for respiratory disease during 1990-2005, identified using the Quebec health insurance databases and followed through 2007 or until diabetes onset. The subcohort treated with oral hypoglycemics was followed until diabetes progression. A nested case-control analysis was used to estimate the rate ratios of diabetes onset and progression associated with current inhaled corticosteroid use, adjusted for age, sex, respiratory disease severity, and co-morbidity.

Results

The cohort included 388,584 patients, of whom 30,167 had diabetes onset during 5.5 years of follow-up (incidence rate 14.2/1000/year), and 2099 subsequently progressed from oral hypoglycemic treatment to insulin (incidence rate 19.8/1000/year). Current use of inhaled corticosteroids was associated with a 34% increase in the rate of diabetes (rate ratio [RR] 1.34; 95% confidence interval [CI], 1.29-1.39) and in the rate of diabetes progression (RR 1.34; 95% CI, 1.17-1.53). The risk increases were greatest with the highest inhaled corticosteroid doses, equivalent to fluticasone 1000 μg per day or more (RR 1.64; 95% CI, 1.52-1.76 and RR 1.54; 95% CI, 1.18-2.02; respectively).

Conclusions

In patients with respiratory disease, inhaled corticosteroid use is associated with modest increases in the risks of diabetes onset and diabetes progression. The risks are more pronounced at the higher doses currently prescribed in the treatment of chronic obstructive pulmonary disease.

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-- Samy Suissa, PhD, Abbas Kezouh, PhD, Pierre Ernst, MD, MSc

This article originally appeared in the November 2010 issue of The American Journal of Medicine.