Douglas S. Paauw

Inpatient Management of Adults with Diabetes

H capitalization is more common for people with diabetes than for those without diabetes. In addition, patients with diabetes are more likely to be hospitalized for a longer period of time than those without diabetes. In one report, people with diabetes were hospitalized 2.4 times more frequently than people without diabetes and stayed in the hospital for a longer (30% longer) amount of time (1). In 1992, there were a total of 371,969 hospitalizations accounting for 2.3 million hospital days attributable to diabetes (2). Not surprisingly, most of these hospitalizations are directly due to the complications of the disease, mostly those related to the circulatory system (2,3). In 1987, diabetic complications accounted for 2% of total hospital admissions in the U.S. (3). Because the prevalence of diabetes may be increasing in the U.S. (4), it is likely that an even greater number of patients with diabetes will be admitted to our hospitals in the years to come. Recently, a plethora of reports have been published reviewing outpatient diabetes therapy for both insulindependent diabetes mellitus (IDDM) (516) and non-insulin-dependent diabetes mellitus (NIDDM) (10,17-24). In addition, there is a large body of literature that reviews inpatient therapy as it pertains to perioperative diabetes management. However, there is no major review that examines inpatient diabetes therapy as it relates to the nonsurgical situation. Because of the lack of studies examining this issue and the importance and increasing frequency of hospitalizations for patients with diabetes, it seems appropriate to review this subject.

DIABETES MANAGEMENT IN SPECIAL SITUATIONS

Clinicians are frequently required to manage situations for which few data are available in the literature. Medical therapies for these situations are frequently based on graduate and postgraduate training, community standards, and personal experience. For individuals with diabetes, this would include perioperative diabetes management, the management of diabetes while discontinuing an insulin infusion, and the management of diabetes during treatment with glucocorticoids and TPN. Clinicians may disagree with some of the recommendations for these four situations, and implementation of these suggestions may not be possible at all hospitals. The therapies described herein are based on the pathophysiology of the respective situation and the pharmacokinetic and pharmacodynamic properties of available medications, particularly insulin. The introduction of new insulin analogues and agents to treat insulin resistance may improve our ability to treat diabetes in special situations. Future investigations should focus on how to best use these tools during critical times.

Diagnosing HIV-related disease : Using the CD4 count as a guide

AbstractOBJECTIVE: To summarize current information on the relation between CD4 counts and the risk of different HIV-related diseases. MEASUREMENTS AND MAIN RESULTS: MEDLINE search of English language articles between 1985 and 1996 using the medical subject heading (MeSH) term “CD4 lymphocyte count” and searches using key words of multiple HIV-related diseases were conducted. Some HIV-related diseases can be stratified to different CD4 count levels. Regardless of their CD4 count, HIV-infected patients are susceptible to sinusitis, Kaposi’s sarcoma, community-acquired pneumonia, and oral hairy leukoplakia. In advanced HIV, when CD4 is below 200/mm3, Pneumocystis carinii pneumonia, toxoplasmosis, progressive multifocal leukoencephalopathy, Mycobacterium avium complex, molluscum contagiosum, and bacillary angiomatosis all increase in incidence. In very advanced HIV disease, when CD4 counts are below 50/mm3, patients are at risk of pseudomonas pneumonia, cytomegalovirus retinitis, central nervous system lymphoma, aspergillosis, and disseminated histoplasmosis.SummaryRegardless of their CD4 count, HIV-infected patients are susceptible to sinusitis, community-acquired pneumonia, oral hairy leukoplakia, Kaposi’s sarcoma, and HIV meningitis. Once their CD4 counts drop below 500/mm3, they are at risk of developing tuberculosis, thrush, herpes simplex, and herpes zoster. In advanced HIV, when their CD4 counts are below 200/mm3, PCP, coccidioidomycosis, bacillary angiomatosis, molluscum contagiosum, cryptococcal meningitis, toxoplasmosis, progressive multifocal leukoencephalopathy, Mycobacterium avium complex, and non-Hodgkin’s lymphoma all increase in incidence. In very advanced HIV, when their CD4 counts are below 50/mm3, they are at risk of pseudomonas pneumonia, CMV retinitis, CNS lymphoma, aspergillosis, and histoplasmosis. By appreciating these characteristic changes in disease incidence, and by knowing a patient’s CD4 count, clinicians should be better able to develop differential diagnoses and plans for diagnostic evaluation.

Factors affecting the reliability of ratings of students' clinical skills in a medicine clerkship.

Objective:To determine the overall reliability and factors that might affect the reliability of ratings of students’ clinical skills in a medicine clerkship.Design:A nine-item instrument was used to evaluate students’ clinical skills. Raters were also asked to provide a grade of each student’s overall clinical performance. Generalizability studies were performed to estimate the reliability of the ratings. The effects of rater experience and clerkship setting were investigated by regression analysis.Setting:Teaching hospitals and community-based sites in three Northwestern states.Participants:All students (328) who had completed the 12-week clerkship in internal medicine at one medical school during the academic years 1987–1989. Raters included attending physicians, chief residents, and other residents.Results:Seven observations were needed to provide a reliable rating of the overall clinical grade. More observations were needed to obtain reliable ratings for individual items, ranging from seven observations needed for the rating of data gathering skills to 27 observations needed for the rating of interpersonal relationships with patients. Rater experience and clerkship setting (i.e., teaching hospitals vs. community-based clinics) were found, in general, not to affect significantly the ratings received by students.Conclusions:Reliable ratings of students’ overall clinical skills, including overall clinical grades, can be achieved by collecting a minimum of seven observations. More observations are needed to measure reliably the interpersonal aspects of clinical performance. These findings support the use of performance ratings to evaluate clinical skills and knowledge of students in clerkship settings.

Do primary care physicians screen patients about alcohol intake using the CAGE questions

The performances of 134 primary care physicians at initial screening about alcohol use and screening with the CAGE questions were assessed using 17 standardized patients. For three-fourths of the standardized patients, more than 50% of the physicians asked an initial alcohol screening question. However, use of the CAGE questions with six patients who reported drinking more than one drink per day was less consistent; for most of these patients, few physicians asked any CAGE questions. Fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for three of four patients who drank four or more drinks per day. Methods are needed to incorporate the CAGE questions into primary care practices in a more systematic manner.

Apotemnophilia masquerading as medical morbidity

We report a case of apotemnophilia, or “love of amputation,” in a man in his mid-20s. Apotemnophilia is defined as self-desired amputation driven by the patients erotic fantasy of possessing an amputated limb and overachieving despite being handicapped. The desire of a patient with apotemnophilia for amputation is obsessive, and a history of repeated, unexplained injuries to the same segment of the body is common among these patients. Patients with apotemnophilia secretly harm themselves to necessitate amputation of an injured limb, which creates a diagnostic challenge for the health care provider because of the atypical presentation of self-inflicted medical morbidity caused by apotemnophilia.

Appropriate prescribing and important drug interactions in older adults.

Polypharmacy, specifically the overuse and misuse of medications, is associated with adverse health events, increased disability, hospitalizations, and mortality. Mechanisms through which polypharmacy may increase adverse health outcomes include decreased adherence, increased drug side effects, higher use of potentially inappropriate medications, and more frequent drug-drug interactions. This article reviews clinical problems associated with polypharmacy and presents a framework to optimize prescribing for older adults.

Ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP.

Pilot study of a ‘RIME’‐based tool for giving feedback in a multi‐specialty longitudinal clerkship

Context  The Reporter–Interpreter–Manager–Educator (RIME) evaluation framework is intuitive and reliable. Our preceptors’ frustration with using summative tools for formative feedback and the hypothesis that the RIME vocabulary might improve students’ and preceptors’ experiences with feedback prompted us to develop and pilot a RIME‐based feedback tool.

Ophthalmologic emergencies in the patient with diabetes

Diabetes is associated with many emergent ophthalmologic conditions. The management of patients with diabetes requires careful monitoring for visual symptoms and frequent physical examination for signs of retinopathy. Randomized studies have documented a significant reduction in the development of new retinopathy and the progression of existing retinopathy with tight control of diabetes. Photocoagulation laser therapy is helpful in preserving vision in severe nonproliferative retinopathy, for proliferative retinopathy, and for clinically significant macular edema. Vascular events include arterial and venous occlusions and cranial nerve palsies; important diagnostic clues are visual symptoms and the findings of ocular and neurologic examinations. Life-threatening infections associated with diabetes include endophthalmitis and mucormycosis, which require prompt diagnosis to prevent blindness or systemic infection. Herpes zoster infection, which is common in older patients and in patients with immunosuppression, may affect the trigeminal nerve and cause anterior uveitis and keratitis. Patients with zoster and skin vesicles on the face need emergent ophthalmologic evaluation and treatment because untreated ocular infection and inflammation may lead to scarring and synechiae formation in the anterior chamber, resulting in vision loss.