Jun 29, 2018

Self control

The story

A wave of new interns are getting their first pages about insulin orders this week. But what if new delivery systems could make sliding scales obsolete?   

The loop

Between orders, injections, and gathering fingersticks around the clock, managing Type 2 diabetes (T2DM) puts a huge strain on hospital resources. Automated delivery systems promise help: the FDA approved the first artificial pancreas, or closed-loop insulin delivery system, in 2016 for use in Type 1 diabetes (T1DM). A sensor and insulin pump, both implanted subcutaneously, work together via an algorithm controller (often a smartphone app) to keep glucose levels in target range. The early evidence suggests that closed-loop systems control glucose more effectively than humans.

The wards

Automated insulin delivery systems outperformed conventional therapy in non-critically ill hospitalized patients with T2DM, says a 140-patient open label trial from Switzerland and the UK. Patients in the automated arm were hooked up to closed-loop systems by study investigators. They spent 66% of their inpatient time with glucose in the target range compared to the control group mark of 42%. Average glucose was 150 mg / dL compared to 188 mg / dL, and no differences were found in duration of hypoglycemia or amount of insulin delivered.

The takeaway

Important things (read: costs) need to be worked out before closed-loop insulin is ready for your wards. But the promise of automated insulin delivery looks too compelling for this technology to fail.

Say it on rounds

When you're frightened by what you see on the news

We feel you. A mash-up of the Mapping Police Violence database and a nationwide CDC survey on behavioral risk factors found that police killings of unarmed black Americans adversely impacted the mental health of uninvolved black Americans in the surrounding state. For each police killing in the 3 months prior to being surveyed, blacks were more likely to self-report poor mental health days and frequent mental distress. The findings feel like the tip of the iceberg and should prompt further study on the clinical impact of police violence. 

When 400 pages of outside records prop your monitor to the perfect height

The key is to make things useful, and it turns out that poliovirus may be best suited for treatment of glioma. A phase I study of 60 patients with recurrent grade IV malignant glioma found that intratumoral injection of a nonpathogenic recombinant polio-rhinovirus led to durable responses (> 3 years) in 20% of patients. Survival with conventional therapy is typically < 1 year. Polio and glioma are paired through an upregulated cell surface marker that helps the virus hone in on glioma cells. The scan results for responders are striking.

When what's in your fridge is tied to how hard you're working

It's a wide world of associations, and the latest is between Type 2 diabetes (T2DM) and Parkinson' Disease (PD). A UK record-linkage cohort study of over 8 million patients found that those with T2DM were 30% more likely to develop PD than matched controls. And while overall incidence of PD was low, young patients (ages 25 - 44 years) with T2DM were 4x as likely to develop PD than their peers. Researchers don't yet know whether the association stems from shared genetic pathways or long-term complications of hyperglycemia.

Brush up

Legionnaires' disease

Sooner or later one of those urine antigens you send is going to come back positive. Suspect Legionella in patients who present with pneumonia and GI symptoms including nausea, vomiting, or diarrhea. Hyponatremia and elevated liver enzymes serve as important laboratory clues. Cases most often appear in the context of broader outbreaks, classically due to contaminated water supplies in hospitals, hotels, or apartment buildings. The immunocompromised are at especially high risk.

What's the evidence

For initial antibiotic choice in Legionnaires' disease? Levofloxacin and azithromycin are both appropriate picks for confirmed infection. A 2017 multi-center retrospective cohort found no meaningful difference in outcomes between patients treated with either antibiotic. Keep in mind that affected patients can remain febrile for 2 - 5 days after initiation of antibiotics, so be wary of your urge to broaden or change therapy.

What your emergency med friends are talking about

Looking for pointers on your CPR technique? Don't ask Poncho, a police dog in Madrid trained to perform chest compressions on unresponsive bystanders. He gets an A for effort, but is still kind of working things out

Spread the word

Send your interns something to look forward to


We're off next week for July 4th. Enjoy the fireworks and barbecues – we'll return on July 13th

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