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Jul 7, 2017

Running low

The story

You're no stranger to extremes, but dosing Lantus for that clinic patient with an A1c of 12 and AM fingersticks in the 60s is tricky. A different long-acting insulin may help.

The background

A cup of soft serve cures your low blood sugar when rounds drag past lunch in the ICU. But it's not so simple for diabetic patients: an estimated 10% of deaths are due to hypoglycemia in patients under 40. Traditionally, docs have compensated by raising hemoglobin A1c targets to prevent hypoglycemia episodes. And while it's well-known that higher A1c's make patients more prone to diabetes complications, recent data suggests that patients with type 1 (DM1) and type 2 diabetes (DM2) continue to have episodes of hypoglycemia even when A1c's are high.

The study

The SWITCH trials looked at the impact of basal insulins on hypoglycemia rates in DM1 and DM2. Long-acting insulin degludec (Tresiba), with a half life of 25 hours, was less likely to cause hypoglycemia than insulin glargine (Lantus and other brand names) and its 12.5-hour half-life. Patients on degludec had a 10% lower event rate for symptomatic hypoglycemia in 500 DM1 patients and a 30% lower event rate in 700 DM2 patients, all thought to be secondary to less variability in insulin levels with the longer-acting drug. Enrolled patients acted as their own controls by completing 16-weeks of both forms of insulin.

The takeaway

SWITCH is industry-funded, but the study has been praised for its crossover design. Consider using insulin degludec for your clinic patients with sugars that are all over the place, though insurance coverage may vary.

Say it on rounds

When your clinic patient sneezes, then demands antibiotics

We don't give Z-Paks for everything...yet. But a 400-patient Australian RCT found that adult patients with persistent symptomatic asthma had significantly fewer exacerbations per year when treated with azithromycin 500 mg three times a week compared to placebo. The macrolide group also reported significant improvements in quality-of-life. The trial used higher azithromycin doses and a longer duration of treatment compared to prior studies that failed to show similar benefits.

When there's only one patient left to discuss on rounds

The end is in sight! And while you'd be thrilled if it came a little early, pregnant women would prefer to end on schedule. An RCT of 1600 women identified as high-risk for preterm preeclampsia on first trimester screening found that those given 150 mg of aspirin per day from weeks 11 - 36 of gestation were one-third as likely to have preterm preeclampsia as those given placebo (1.6 vs. 4.3%, respectively). Adverse effects were similar between groups.

When your inservice exam looks nothing like what you've seen on the wards

Apparently it's a trend. A formal study of the American Board of Internal Medicine's Maintenance of Certification exam (the recertification boards) found a 31% discordance between exam questions and the frequency of medical conditions seen in routine practice. And while the examiners have for now decided against making test questions that exclusively cover heart failure and COPD exacerbations and therefore match your hospital experience, they are working on making shorter, more frequent, and hopefully more tolerable exams beginning in 2018.

Brush up

Rarefied air

It's hard to tell if the neuropsychological effects of chronic hypoxia are similar to gen med induced sleep deprivation, but neither are promising. Both visitors and permanent residents of high altitude areas (think 3500+ meters) experience difficulty concentrating and have a tendency to make arithmetic errors. On a chronic basis, the world's high-altitude dwellers and COPD patients are also prone to protein synthesis that promotes abnormal angiogenesis and pulmonary hypertension. Small concentrations of inspired oxygen can go a long way towards preventing harmful effects.

What's the evidence

For the cognitive effects of chronic hypoxia in kids? A 2016 study of children from low and high altitude sites saw marked impairment in executive functioning, memory, and processing in low-altitude residents with short-term high altitude exposure. Even more severe deficits were seen in those permanently living at high altitudes. Results like these have prompted oxygen enrichment initiatives across the world.

Survival guide

Been there, done that, (almost) as wide-eyed for fellowship. Your fresh-from-residency Scope writers have pooled together our favorite tips for getting over the hump. This week we have lifestyle tips for new interns getting used to the job. We’ll give the PGY-2s our favorite hospital tricks next week, and finish the week after with our tips for fellowship interviews for PGY-3s.

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