Volume 96, Issue 6

In this retrospective study, the authors assess the efficacy of combined insulin and oral hypoglycemic agents (OHAs) in controlling glycemic levels, as well as lipid levels and insulin requirements, in 48 patients with type IT diabetes mellitus during a I-year period. Thirty-two of these patients had secondary failure to an OHA (group 1). Sixteen patients (group 2) were taking high doses of insulin alone. Overall, 64.6% of all the patients responded to the combination therapy and insulin at 6 months. Response was defined as a decrease in hemoglobin Ale of more than 0.5%. At 12 months, 500/0 of these patients continued to respond to this regimen. No significant differences were seen in the patients' total cholesterol and triglyceride levels between responders and nonresponders in each group. After 1 year of combination OHA and insulin therapy, 500/0 of the patients showed a 21.4% reduction in their daily insulin dose.

Astemizole was released in 1988. In late 1992, a new warning label was added in response to reports of syncope and death from arrhythmia. Records of patients given new prescriptions for astemizole were reviewed to assess compliance with the warnings in a large multispecialty practice. The indication was appropriate in 89% of cases. Excessive doses were used in 4% of cases. Two percent of prescriptions were given to patients with contraindications. Only two complications were documented. Despite carrying a drug warning, astemizole continues to be used inappropriately and is a medicolegal concern. Education and drug evaluations can be used to enhance compliance and decrease the risk associated with the use of astemizole.

With Republicans and Democrats agreeing to strategies that move the resources and responsibilities for healthcare reform to the states, the Employee Retirement Income Security Act of 1974 (ERISA) presents even greater barriers than surfaced in federal planning. The single most formidable obstacle to state healthcare reforms, ERISA's preemption clause supersedes all state laws that ''relate to" employee benefit plans. The authors trace the history of pension legislation that led to the strong ERISA protections and explain the interpretations of the law which affect healthcare. They explain the history of the Hawaii plan's waiver; the continual refinement of the law through legislation; and the growing body of case law that interprets ERISA's application through the "relate to" requirement, the "savings" clause, and the "deemer" clause. Finally, they point out that the political solutions being acted out in Congress are leading to poor healthcare policy. Overriding or waiving ERISA would not lead to national health policy solutions and could endanger millions of workers' pension and benefit plans. Meanwhile, the only relief for states comes in slow and incremental steps through the court system.

Pneumoscrotum occurred in a 53-year-old man as a complication after pulmonary resection for carcinoma. Recognition of this entity and its conservative management are crucial to a positive outcome and prevention of unnecessary interventions based on the differential diagnosis. A review of the literature is included with this description of an unusual complication.

Massive hemoperitoneum seen without an obvious precipitating event is rare. A 21-year-old man was seen with diffuse abdominal pain of 48 hours' duration. He had no fever, nausea, or vomiting, and most laboratory values were normal. Exploration of the abdomen revealed free intraperitoneal blood with clotting but failed to reveal a source. The patient could recall no trauma or other inciting event. The only abnormalities found during laparotomy were multiple adhesions of the omentum to the lateral abdominal wall and localization of most of the clot within the greater omentum. The author cautions that a high index of suspicion followed by laparotomy are the management tools for controlling spontaneous hemoperitoneum. Conservative management produces a high mortality rate.

Sweet's syndrome is defined as acute febrile neutrophilic dermatosis. Characteristic features are fever; peripheral neutrophilia; and painful cutaneous nodules and plaques on the face, neck, trunk, and limbs. Biopsy specimens of these lesions show a mature neutrophilic infiltrate of the dermis. Vasculitis is absent. Sweet's syndrome is associated with malignancy in approximately 20% of reported cases. The pathogenesis is unknown. The authors describe Sweet's syndrome in a 39year-old man 5 weeks after splenic irradiation for chronic myelogenous leukemia. Treatment with parenteral corticosteroids resulted in dramatic improvement of the patient's condition. The authors discuss the diagnosis of Sweet's syndrome and the fact that it is thought to be cytokine-induced.

A small but growing number of radiation-induced sarcomas after breast-conserving surgery for carcinoma have been reported. Because breast-conserving surgery followed by irradiation is becoming increasingly popular, the potential for the emergence of these sarcomas is growing. Unfortunately, because of postirradiation changes in the affected breast, detection of a new lesion can be difficult, resulting in a delay in diagnosis. This case history describes a 48-year-old woman in whom a malignant fibrous histiocytoma was discovered 5 years after she had had a lumpectomy followed by radiation therapy for infiltrating ductal carcinoma. Although the exact mechanism of radiation-induced carcinogenesis is unclear, one theory is discussed. Also discussed are the histologic composition of the malignant fibrous histiocytoma, its latency period, and the best treatment modality for radiation-induced sarcomas.

The patient described, a 51-yearold woman, had diplopia and cephalgia of two weeks' duration. On admission, the radiologic evaluation revealed a mass in the sphenoid sinus, multiple lesions in the calvarium and a solitary lung mass. Biopsy of the lung mass revealed an atypical plasmacytic infiltration. Laboratory findings confirmed the diagnosis of light-chain myeloma presenting with a pulmonary plasmacytoma and cranial nerve involvement.