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In the United States (US), the risk of hepatotoxicity linked to the widespread use of certain herbal products has gained increased attention among regulatory scientists. Based on current US law, all dietary supplements sold domestically, including botanical supplements, are regulated by the Food and Drug Administration (FDA) as a special category of foods. Under this designation, regulatory scientists do not routinely evaluate the efficacy of these products prior to their marketing, despite the content variability and phytochemical complexity that often characterizes them. Nonetheless, there has been notable progress in the development of advanced scientific methods to qualitatively and quantitatively measure ingredients and screen for contaminants and adulterants in botanical products when hepatotoxicity is recognized.

Background: Dietary supplements, such as herbal or complementary nutritional products and micronutrients (vitamins and minerals), are commonly used in the United States, yet national data on adverse effects are limited., Methods: We used nationally representative surveillance data from 63 emergency departments obtained from 2004 through 2013 to describe visits to U.S. emergency departments because of adverse events related to dietary supplements., Results: On the basis of 3667 cases, we estimated that 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year were attributed to adverse events related to dietary supplements. These visits resulted in an estimated 2154 hospitalizations (95% CI, 1342 to 2967) annually. Such visits frequently involved young adults between the ages of 20 and 34 years (28.0% of visits; 95% CI, 25.1 to 30.8) and unsupervised children (21.2% of visits; 95% CI, 18.4 to 24.0). After the exclusion of unsupervised ingestion of dietary supplements by children, 65.9% (95% CI, 63.2 to 68.5) of emergency department visits for single-supplement-related adverse events involved herbal or complementary nutritional products; 31.8% (95% CI, 29.2 to 34.3) involved micronutrients. Herbal or complementary nutritional products for weight loss (25.5%; 95% CI, 23.1 to 27.9) and increased energy (10.0%; 95% CI, 8.0 to 11.9) were commonly implicated. Weight-loss or energy products caused 71.8% (95% CI, 67.6 to 76.1) of supplement-related adverse events involving palpitations, chest pain, or tachycardia, and 58.0% (95% CI, 52.2 to 63.7) involved persons 20 to 34 years of age. Among adults 65 years of age or older, choking or pill-induced dysphagia or globus caused 37.6% (95% CI, 29.1 to 46.2) of all emergency department visits for supplement-related adverse events; micronutrients were implicated in 83.1% (95% CI, 73.3 to 92.9) of these visits., Conclusions: An estimated 23,000 emergency department visits in the United States every year are attributed to adverse events related to dietary supplements. Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults. (Funded by the Department of Health and Human Services.).

As companies, including large pharmaceutical houses, try to market supplemental nutrients and herbal products to ever-increasing numbers of consumers, diabetics will start to approach their physicians about these alternative remedies. A whole new industry know as "neutraceuticals" has evolved. This new industry is a combination of the vitamin supplement and herbal industries trying to work with regulatory agents to develop good manufacturing processes to ensure that consumers obtain good products. In fact, some diabetics may be taking herbal or nutritional supplements without their physician's knowledge. Therefore, it is important to query diabetic patients at least once a year as to whether they are using any herbal or nutritional products. Once it is determined that a patient is using these products, physicians must decide if they or someone else should address the issue of taking these products. Physicians who have a good comfort level with herbal products by all means should recommend them to their patients. If such a comfort level is lacking or low, patients can be referred for a consultation on the use of supplements or told that information will be forwarded to them after contact is made with someone who has knowledge of diabetes and use of appropriate supplements. This article reviews nine nutrient and herbal remedies commonly used for diabetes to facilitate such patient education.

This article emphasizes to primary care physicians the importance of maintaining a diabetic patient's blood sugar level within the normal range. Additionally, it aims to impress on those who care for diabetic patients some of the adverse consequences of surgical and dental procedures that can be avoided by proper precautionary measures taken before the procedures.

Objective: To present the first documented case of malignant nonfunctioning pheochromocytoma occurring in a mixed multiple endocrine neoplasia (MEN) syndrome., Methods: We describe the personal and family history of a 34-year-old man with headaches, increased serum prolactin levels, and hyperparathyroidism and review the details of his clinical course and treatment., Results: After diagnosis of a prolactinoma, bromocriptine therapy was implemented but eventually discontinued by the patient when severe headaches recurred. A transsphenoidal resection of a prolactinoma was performed; the patient continued to have abnormally high serum prolactin levels. Subsequent left lower flank pain prompted an exploratory laparotomy, and a left nephroad-renalectomy was performed. Pathologic examination disclosed a 1-cm tumor, consistent with malignant pheochromocytoma. Electron microscopy demonstrated neurosecretory granules. A hypercoagulable state complicated the course postoperatively. Despite chemotherapy, extensive metastatic disease ensued, and the patient died., Conclusion: Although pheochromocytomas are usually associated with MEN type IIA and type IIB, this patient had a malignant pheochromocytoma, without the usual clinical and biochemical manifestations, in the setting of MEN type I.

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 75 g of oral glucose.

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 II diabetes mellitus during a 1-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 A1c of more than 0.5%. At 12 months, 50% 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, 50% of the patients showed a 21.4% reduction in their daily insulin dose.

Diabetes insipidus together with acute myelogenous leukemia has rarely been seen. Still rarer is the occurrence of monosomy 7 with the two diseases (only six cases reported). A patient who had diabetes insipidus develop before the diagnosis of acute myelogenous leukemia was found at karyotyping to have monosomy 7. Although a specific mechanism whereby monosomy 7 would cause diabetes insipidus has been proposed, some have suggested that monosomy 7 may have its effect by altering cell wall membranes. Others have suggested that acute myelogenous leukemia causes diabetes insipidus by causing infiltrates in the hypothalamus or posterior lobe of the pituitary gland. Magnetic resonance imaging of the patient's brain showed no abnormalities of the hypothalamus or pituitary gland. Lumbar puncture revealed no leukocytes in the cerebrospinal fluid. The authors believe that the cause of diabetes insipidus can be explained in patients with acute myelogenous leukemia by checking for monosomy 7 during karyotyping. Because karyotyping is now more frequently performed in evaluation of patients for chemotherapy or bone marrow transplantation, genetic abnormalities such as monosomy 7 will become increasingly apparent.

The differential diagnosis of fasting hyperglycemia in type I diabetes includes the Somogyi effect, the dawn phenomenon, and insufficient insulin administration. To determine the causes of fasting hyperglycemia and their effect on subsequent daytime blood glucose control, the authors retrospectively reviewed blood glucose profiles of 126 patients with type I diabetes. The Somogyi effect accounted for 12.6% of all instances of fasting hyperglycemia, the dawn phenomenon, 24.1%, and poor control, 63.3%. Measurement of 3 AM and 5 AM blood glucose values is the key to making a correct diagnosis. Once a patient's fasting hyperglycemia is placed in one of these groups, appropriate treatment can be started.