Nov 22 - Inpatient DM management

The topic of the day - optimizing inpatient management of hyperglycemia.  Linked here are the guidelines for management of diabetes per the American Association of Clinical Endocrinologists.  The section on hospital mamagement is below.  The full document covers how to dx and tx diabetes in the outpatient setting, as well as optimum strategies to manage risk factors such as HTN and hyperlipidemia.  Regardless of the regimen used, the plan should be reviewed and modified on a daily basis of the glucose remains uncontrolled or if hypoglycemia events occur.

Some adverse events reviewed on AHRQ's Web m&M are linked here and here.  The second link goes into more detail about hypoglycemia prevention and pitfalls even when optimum order sets are available.  As with any complex treatment algorithm in medicine these days, a multidisciplinary approach is key.

Finally - the Society of Hospital Medicine has an extensive and well resourced toolkit to enable rapid adoption of current best practices.

From AACE Guidelines:

• If appropriate for the patient, use intravenous insulin infusion (grade A)

• If hyperglycemia is reproducibly present and intravenous insulin infusion is not necessary, order scheduled subcutaneous insulin (grade B)

• For subcutaneous management, order amounts of insulin sufficient to cover basal and nutritional needs (grade B)

• Plan the patterns of glucose monitoring and delivery of insulin to match carbohydrate exposure (grade B)

• Revise the amounts of scheduled insulin daily or more frequently based on patient response (grade B)

• For patients receiving scheduled insulin, order an as needed correction dose of subcutaneous insulin with dosing that is: (a) proportionate to blood glucose elevation and insulin sensitivity of the patient and (b) appropriate to time of day; specify the times or mealtimes to which the order applies (grade B)

19 Nov - Syncope with funky neurological symptoms on recovery

Today's case was a previously healthy 71 y/o male who sustained a witnessed syncopal attach where he fell and hit is face on the ground.  He rapidly regained consciousness, but when he awakened he could not use his hands or feet and had bilateral upper and lower extremity numbness.  Distal muscle weakness was more prononced than proximal muscle weakness.  On arrival to the hospital he was bradycardic with normal blood pressure and denied light headedness.  ECG revealed sinus bradycardia, rate ~48 with an LBBB.  Due to his neurologic signs and symptoms MRI of the cervical spine was performed which revealed cord contusion with siginificant canal stenosis and osteophytes.

Spinal cord contusions are typically seen in contact sports injuries and motor vehicle crashes.  Such an injury from a low velocity fall is unusual.  An ovid search turned up no articles reporting this occurence. 

Steroid treatment is controversial but may be effective if started within a few hours of injury.  This article reviewed current recommendations - SPINE Volume 28, Number 9, pp 941–947 and is available on Ovid full text.

As far as the bradycardia goes - he is felt to need permanent pacemaker - the AHA and ACC recently revised guidelines for permanent caridiac pacing and antiarrhythmia devices and it would be useful to be familiar with these gudelines (especially class I indications) for board purposes.

18 Nov - Graves

Today's case was a 33 y/o F that presented with symptoms of emotional lability and weight loss over two months.  The symptoms began shortly following a flu like illness.  Family members had noted increased tearfulness that had progressively worsened.  There was no previous history of depression.  She did have a history of low back pain managed with prescription opiates, but no recent changes in pain or med dosages were noted.  Family members had noted neck swelling.  On examination she had marked nodular thyromegaly with an audible bruit.  There was no evidence of exophthalmos.  She was tremulous.  Heart rate was 120's to 130's.  TSH was 0.02 and T4 was 4.  She was hypercalcemic.  She was diagnosed with Grave's disease with thyrotoxicosis and started on beta blockers and PTU.

Clinical Pearls:

- Imaging and antibody tests are not necessary to establish the diagnosis in typical cases such as this.
- methimazole is more convenient and probably superior to PTU in terms of effectiveness.
- PTU is the drug of choice in pregnancy
- agranulocytosis and hepatotoxicity are potential side effects of PTU
- elderly patietns with graves can present with "apathetic hyperthyroidism" with wt loss and depression.

This Clinical Practice article reviews a case remarkably similar to the one discussed in MR and provides a good diagnostic stragety for cases that are not as typical in presentation.

Hypercalcemia in graves has been linked to PTHrP (usually seen in hypercalcemia of malignancy) as a cause of non-PTH dependent hypercalcemia. 

Graves ophthalmopathy has been reviewed here and here.  It is clinically evident in ~1/3 of Graves patients, but can be seen in imaging in 70-80% of cases.  Treatment involves immunosuppressive therapy with steroids and potentially TNF inhibitors among other treatments.

17 Nov Septic Arthritis

Long break from posting for a thousand reasons - but wanted to add some info from today's discussion on septic arthritis.  The case was a pt with previous history of total knee arthroplasty (bilateral) and diabetes mellitus.  He as admitted with fevers with swelling and tenderness of his knee.  Arthrocentesis revealed bloody synovial fluid with ~ 50 000 leukocytes.  Only 50% or so were polys.  Cultures of blood and synovial fluid were both noted to be positive for group G streptococcus.

Acute monoarthritis must be evaluated rapidly.  Arthrocentesis is quick, easy, and safe and is the key to differentiating septic arthritis from other causes of monoarthritis.  Do not rely on elevated uric acid levels in serum analysis to make a diagnosis of gout.  Gout and septic arthritis can and often do coexist.  Hematogenous infections of prosthetic joints usually result in loss of the joint.  In some cases of acute postoperative prosthetic joint infection the prosthesis can be salvaged with joint washout and prolonged (6 months) antibiotic therapy.

Linked here is the seminal article from NEJM on the approach to monoarthritis.  Still the ideal approach to this situation.

Also - diabetes mellitus is a significant risk factor for invasive streptococcal infections, and there seems to be an increasing indicence of Groups B, C, and G streptococcus.  These organisms are exquisitely susceptible to penicillin.