Volume 96, Issue 10

A study was undertaken to demonstrate the relationship between known risk factors for coronary artery disease and hyperinsulinemia in both patients without diabetes and patients with non-insulin-dependent diabetes mellitus. Both groups of patients were categorized based on insulin levels in the fasting and 2-hour post glucose challenge state, in relation to the median insulin level for that group. Patients with an insulin level higher than the median value were compared with those with lower insulin levels. Differences in weight; levels of fasting glucose, insulin at 2 hours post glucose challenge, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and very-low-density lipoprotein cholesterol; presence of hypertension; and history of smoking cigarettes-known risk factors for atherosclerosis-were analyzed. An elevated fasting insulin level was found to be strongly associated with a number of atherogenic risk factors in both sets of patients. Weight was the only factor with a consistently positive association with the insulin level in all subgroups. In both groups, the fasting insulin level was associated with more risk factors than the insulin level at 2 hours after administration of 75g of oral glucose.

This article presents rediscovered osteopathic manipulative techniques described by Charles Hazzard in 1905 and ascribed by him to Andrew Taylor Still, the founder of osteopathic medicine. Still refrained from writing about his manipulative techniques in any significant detail, apparently intentionally. The techniques published by Hazzard have both internal consistency and similarity to those less well described by Still, suggesting that the attribution is accurate. The techniques are analyzed and presented as a variant of a direct articulatory technique with axial compression. In honor of their originator, they are being termed the Still techniques.

Nonketotic hyperglycemic hyperosmolar coma is an uncommon, but significant, complication of type n diabetes mellitus with a high overall mortality rate. Treatment of this entity is controversial but mandates aggressive fluid resuscitation and strict control of serum glucose levels. In the patient described, nonketotic hyperglycemic hyperosmolar coma complicated by diabetes insipidus was successfully treated with desmopressin acetate. To the authors' knowledge, this is the first reported case of nonketotic hyperglycemic hyperosmolar coma associated with partial central diabetes insipidus.

A 40-year-old woman had a 10-year history of dermatophyte-related toenail onychomycosis (tinea unguium) and dry-type tinea pedis, which had failed to respond to previous therapy with topical antifungal agents or oral griseofulvin. The patient was successfully treated with four cycles of intermittent itraconazole therapy (that is, 400 mg/d for 1 week per month for 4 months). At the end of this time, the tinea pedis had resolved and the onychomycosis improved significantly after four cycles were completed. Twelve months after the onset of therapy, both conditions had resolved completely according to both clinical and mycologic criteria. Itraconazole was well tolerated, with no side effects reported. These observations suggest that itraconazole intermittent dosing is a highly effective therapy for the treatment of onychomycosis caused by dermatophyte organisms, because it provides a high cure rate after only a short course of therapy.

Primary skeletal lymphoma is an uncommon tumor whose appearance on plainfilm radiographs has been well described. However, few reports have described the appearance of this neoplasm on magnetic resonance imaging. As in the primary skeletal lymphoma described, magnetic resonance imaging can be used to define the extent of the tumor and the degree of soft tissue and bone marrow involvement. It can also help to determine the biopsy site and to monitor the tumor's response to radiation therapy.

Metastatic Sertoti cell tumor is a very rare and deadly disease accounting for approximately 1% of all testicular carcinomas. With fewer than 30 cases reported in the literature, there has not been a uniform treatment regimen with good results. Retroperitoneal lymph node dissection, chemotherapy, and radiation therapy in combination appear to offer the best outcome. This report describes the occurrence of this rare tumor in a 38-year-old man 2 years after left orchiectomy.

An 11-year-old, 25-kg girl with congenital myelomeningocele was scheduled for posterior spinal fusion because of progressive scoliosis. After induction of general anesthesia and administration of a standard dose of intravenous esmolol hydrochloride, her cardiac rhythm progressed to asystole. Although given ephedrine, epinephrine, and atropine sulfate, the patient's normal heart rhythm could not be restored until calcium chloride was administered. A review of the medical literature indicates that the optimal treatment for acute beta-blocker toxicity is intravenous glucagon. Calcium administration should also be considered. Acute esmolol toxicity may be self-limiting because of its extremely short half-life.

The authors review the strengths of traditional osteopathic medical education, identify the principles that managed care organizations have identified as being essential in preparing physicians to succeed in the current medical marketplace, and discuss the advantages of incorporating the best principles of managed care into osteopathic medical education. They present a strategy and outline proposed by the Department of Family Medicine at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific for the integration of these principles into the undergraduate educational process.