Faculty Bibliography

Learning Objective #1: Recognize risks of hypoglycemia associated with sulfonylureas and thiazolidinediones Learning Objective #2: Apply evidence-based guidelines for appropriate management of diabetes in elderly patients CASE: A 72 year-old Spanish-speaking man with poorly controlled type 2 diabetes, hypertension, and newly diagnosed prostate cancer was bought by ambulance with confusion and weakness. He was found to have a fingerstick glucose of 30 mg/dl. Additional workup was unremarkable and symptoms resolved with 50% dextrose. He was admitted for symptomatic hypoglycemia. The patient reported taking multiple oral hypoglycemic agents, including glipizide twice daily, pioglitazone, metformin, and sitagliptan. Four months prior, pioglitazone was tripled due to A1c 10.4%. He also revealed unintentional weight loss (possibly due to his cancer), and multiple home fingersticks in the 60s. Repeat A1c was 6.7%. The sulfo-nylurea and pioglitazone were discontinued. The patient was educated on his medications, glucose targets, and symptoms of hypoglycemia. He was discharged with advice to follow with his primary physician. IMPACT/DISCUSSION: Nearly 25% of patients over age 65 have diabetes. Elderly diabetics are uniquely vulnerable, with higher risks of symptomatic hypoglycemia, increased hospitalizations, and higher overall associated morbidity and mortality. Polypharmacy, low health literacy, and language barriers contribute to their complex medical management. Recent studies have shown that tighter A1c control (< 7.0%) is associated with additional harms in geriatric patients, including a higher mortality rate. As a result, medical organizations have revised their glycemic control guidelines towards more personalized, patient-centered management. These guidelines include differential A1c goals (from 7.0-9.0%) based on overall health, comorbidities, and life expectancy. Guidelines for geriatric diabetes care were updated in 2018 to include recommendations that overtreatment of diabetes should be avoided, medication classes at low risk of hypoglycemia are preferred, and complex medication regimens should be simplified to reduce hypoglycemia. Our patient illustrates the importance of each of these guidelines. With his age and comorbid-ities, including newly diagnosed cancer, he had indications for looser A1c goals. He was also at high-risk for medication-related adverse events, given his polypharmacy and limited health literacy. Metformin and sitagliptin would have been favored agents. Education on symptoms of hypoglycemia, as well as interpreting fingersticks, was crucial to prevent rehospitalization and improve health literacy.
Conclusion(s): Geriatric patients with diabetes represent a unique and vulnerable population. Guidelines for diabetes management in these patients are evolving, with increased emphasis on personalized, patient-centered management, including looser A1c goals for those with comorbidities or shorter life expectancy. Providers are encouraged to simplify medications and avoid polypharmacy to improve outcomes and save lives

Learning Objective #1: Recognize the incidence of posterior circulation stroke after cardiac catheterization Learning Objective #2: Recognize how cognitive biases affect clinical decision making CASE: A 57 year old man with hypertension, type 2 diabetes, depression, coronary artery disease s/p PCI and 4-vessel CABG presented with nausea, vomiting, and syncope. He was found to be in complete heart block and underwent emergent pacemaker placement and cardiac catheterization with stent placement to the left circumflex artery. After catheterization, patient reported lightheadedness and cloudiness when walking. He was transferred to the medicine service with sign-out to follow up with physical therapy given "deconditioning" after his acute illness. PT sessions were limited by his hesitancy to walk beyond a few steps. Four days after downgrade, patient reported left sided visual changes. Physical exam was notable for left homon-ymous hemianopia without somatosensory deficits. A non-contrast head CT revealed a new acute to sub-acute right posterior cerebral artery infarction. He was determined to have had an embolic ischemic stroke secondary to cardiac catheterization. His lightheadedness and cloudiness were believed to be secondary to hemianopia. He was medically managed and discharged to SAR. IMPACT: This case involves a common post-catheterization complication as an unusual presentation described as lightheadedness and cloudiness. We attributed the symptoms to overall deconditioning secondary to diagnostic momentum. Furthermore, visual fields were not accurately assessed in this post-procedure patient. Our personal practice now includes exam maneuvers to evaluate posterior circulation on patients post-cardiac catheterization given the high incidence of these strokes in cardiac patients. DISCUSSION: Post-cardiac catheterization strokes are common, with most occurring within 24 hours of the procedure. Of these, approximately 25% involve the posterior circulation often leading to visual field deficits without gross somatosensory deficits. As a result, neurological deficits may often go unnoticed if visual fields are not accurately assessed. Furthermore, patients may not realize a true visual field deficit as they can compensate with neck rotation; initial descriptors may be vague such as lightheadedness or cloudiness. Our case was further complicated by cognitive biases that influenced our decision making; namely, the case was framed as overall deconditioning. As a result, we anchored to a single diagnosis and did not consider neurological deficit as an explanation for our patient's symptoms. We encourage all medical professionals to be cognizant of variability in presentation of visual field deficits and also be keen to their own cognitive biases

Cannabinoid hyperemesis syndrome (CHS) is a rare constellation of clinical findings that includes a history of chronic heavy marijuana use, severe abdominal pain, unrelenting nausea, and intractable vomiting. A striking component of this history includes the use of hot showers or long baths that help to alleviate these symptoms. This is an underrecognized syndrome that can lead to expensive and unrevealing workups and can leave patients self-medicating their nausea and vomiting with the very substance that is causing their symptoms. Long-term treatment of CHS is abstinence from marijuana use-but the acute symptomatic treatment of CHS has been a struggle for many clinicians. Many standard medications used for the symptomatic treatment of CHS (including ondansetron, promethazine, and morphine) have repeatedly been shown to be ineffective. Here we present the use of lorazepam as an agent that successfully and safely treats the tenacious symptoms of CHS. Additionally, we build upon existing hypotheses for the pathogenesis of CHS to try to explain why a substance that has been used for thousands of years is only now beginning to cause this paradoxical hyperemesis syndrome.

Albumin, transferrin, and total protein concentrations were measured in the mesenteric tissue, peritoneal fluid, and plasma of 12 ketamine-Nembutal-anesthetized Sprague-Dawley rats. Tissue samples were obtained with an 8-mm trephine; tissue water content was determined by a microgravimetric method to be 5.2 +/- 0.3 microgram water/microgram dry wt. Peritoneal fluid was collected by capillary action in hematocrit tubes, and blood samples were taken from a femoral artery catheter. Total protein concentrations of plasma (5.8 +/- 0.3 g/dl) and peritoneal fluid (2.6 +/- 0.1 g/dl) were determined by Lowry assay. Ratios of peritoneal fluid and tissue densitogram areas to plasma area were used to calculate total protein content of peritoneal fluid (2.5 +/- 0.1 g/dl) and tissue (1.8 +/- 0.2 g/dl). Albumin concentrations were 1.1 +/- 0.1 g/dl for tissue, 1.4 +/- 0.1 g/dl for peritoneal fluid, and 2.8 +/- 0.1 g/dl for plasma. Transferrin concentrations were 0.09 +/- 0.01 g/dl for tissue, 0.13 +/- 0.01 g/dl for peritoneal fluid, and 0.28 +/- 0.01 g/dl for plasma. Peritoneal fluid protein concentrations were similar to values found for lymph in previous studies. Protein concentration in the tissue buttons was significantly less than that of peritoneal fluid. This contradicts the widely held assumption that the protein concentration of fluid outside the matrix is representative of a well-mixed interstitial matrix fluid protein concentration.