Sex, Sleep, Steroids, and Lifestyle: Unraveling the Coronavirus Disease 2019 Conundrum.

Coronavirus disease 2019 (COVID-19) has wreaked havoc and distressed economies worldwide. Countries have gone on lockdown of their economies to prevent the spread of the disease. This obviously led to collateral damage in the form of worsening healthcare for non-COVID-related conditions and is playing havoc with the world economy. Herein, we suggest novel strategies to prevent COVID-19 related complications, keeping in view the pathophysiology of the disease.

Clinical Conundrums in the Management of Diabetic Ketoacidosis in the Elderly.

One of the dreaded life-threatening complications of diabetes mellitus (DM) is diabetic ketoacidosis (DKA). American Diabetic Association (ADA) came out with 2018 guidelines on the management of DM and its complications, but these are woefully silent on the clinical conundrums that accompany DKA in elderly patients. In elderly patients, DKA is often complicated by sepsis, atrial fibrillation, polypharmacy, nonketotic hyperosmolar states, atypical clinical presentations, acute kidney injury (AKI), dementia, and noncompliance with medications. Here in we highlight these conundrums that need to be addressed to improve morbidity and mortality in elderly patients.

Temporal occurrences and recurrence patterns of hypoglycemia during hospitalization.

OBJECTIVE: To describe the temporal distribution of hypoglycemia and its rate of recurrence during hospitalization to aid in the development of strategies to prevent hypoglycemia in hospitalized patients. METHODS: Retrospective review of hypoglycemia (blood glucose <50 mg/dL) audit data in adult hospitalized patients at 2 academic hospitals. Demographics, timing, and blood glucose values were recorded. Antihyperglycemic medications, number of recurrent events, and change in basal insulin dose following the hypoglycemic event were also extracted. RESULTS: A total of 274 index occurrences of hypoglycemia were analyzed. The mean age of the patients was 53.8 years, with roughly equal gender distributions. Twenty-eight percent of the events occurred in the absence of antihyperglycemic therapy. The incidence of hypoglycemia peaked between midnight and 6 AM. There were 36 instances of recurrent hypoglycemia associated with antihyperglycemic therapy, with 78% (n = 28) cases involving basal insulin. Patients on basal insulin who developed hypoglycemia did not have their dose changed prior to the time of the next administration in 75% of the cases. CONCLUSION: Hypoglycemia in hospitalized patients may occur with greater frequency overnight. Although cumbersome, routine nocturnal glycemic testing should be considered. Education regarding insulin management in the hospital and improved communication between night and day staff may aid in decreasing subsequent hypoglycemic events.

Technical performance of colonoscopy in patients sedated with nurse-administered propofol.

OBJECTIVES: Nurse-administered propofol has gained attention as a safe and effective means of sedation for patients undergoing endoscopic procedures. However, little is known about the effect of propofol on the technical performance of colonoscopy. METHODS: Three separate studies were conducted. In the first study, we reviewed procedure notes from consecutive colonoscopies performed by a single experienced endoscopist at our hospital endoscopy unit on patients sedated with either nurse-administered propofol (n = 162) or midazolam/narcotic (n = 164). In the second study, 100 eligible colonoscopy outpatients were randomized to receive either nurse-administered propofol (n = 50) or midazolam/fentanyl (n = 50). In both studies, the measured parameters included visualization of the cecum, time required to reach the cecum, repositioning of the patient, and the application of abdominal counterpressure. In a third study, we reviewed the rate of cecal intubation and colonic perforation in the first 2357 patients in our unit receiving nurse-administered propofol. RESULTS: In the retrospective comparative study, there was no difference in the cecal intubation rate in those receiving propofol (99.4%) compared to those receiving midazolam/narcotic (97%; p= 0.1), and three of five failed cecal intubations in the latter group resulted from obstructing masses. Patients sedated with propofol were repositioned less frequently compared to those receiving midazolam/narcotic (3.7%vs 26.2%) (p < 0.0001). Abdominal pressure was employed in 9.9% of patients sedated with propofol compared to 19.5% (p= 0.01) of those given midazolam/narcotic. The mean time to reach the cecum was lower in the propofol group than in the midazolam/narcotic group (4.6 min vs 6.0 min, p= 0.002). In the prospective randomized study, the endoscopist intubated the cecum in all 100 patients. Patients in the propofol group were repositioned less frequently than those in the midazolam/fentanyl group (2%vs 24%, respectively, p= 0.001). The number of cases requiring abdominal counterpressure was not significantly different between the propofol and midazolam/fentanyl groups (12%vs 24%, respectively, p= 0.1). The mean time to reach the cecum in the propofol group (3.2 min) was similar to that in the midazolam/fentanyl group (3.8 min, p= 0.08). Among the first 2357 patients in our unit undergoing colonoscopy with nurse-administered propofol, the rate of complete colonoscopy was 99.2% and there were no perforations. CONCLUSION: Nurse-administered propofol sedation is safe and simplifies the technical performance of colonoscopy compared to midazolam/narcotic sedation.

Predictors and implications of severe hypersplenism in patients with cirrhosis.

BACKGROUND AND OBJECTIVES: Hypersplenism is frequently seen in patients with cirrhosis. However, it is unclear why some patients with cirrhosis develop marked hypersplenism and others do not. Additionally, the implications of severe hypersplenism are unknown. Therefore, we conducted a study to evaluate the predictors and implications of severe hypersplenism in patients with cirrhosis. SUBJECTS AND METHODS: All subjects with cirrhosis who were referred to Indiana University over a 53-month period for liver transplantation were studied. Severe hypersplenism was defined as platelet count < 75,000 per mm3 and/or white blood cell count < 2,000 per mm3 in the presence of splenomegaly. The outcomes of interest were development of spontaneous bacterial peritonitis (SBP), variceal bleeding, and death. Patients were observed until death, transplantation, or study closure. RESULTS: The study group comprised 329 subjects with cirrhosis and their median follow-up time was 450 days (0.25-42 months). The prevalence of severe hypersplenism was 33%. Decompensated liver disease [odds ratio (OR), 2.0; 95% confidence interval (CI), 1.1-3.7] and a history of alcohol consumption (OR 2.3; 95% CI, 1.4-3.8) were independent predictors of severe hypersplenism. The presence of severe hypersplenism independently predicted the development of variceal bleeding [hazard ratio (HR) 4.1; 95% CI, 1.7-10], SBP (HR 8.0; 95% CI, 3.1-20.5), and death (HR 2.0; 95% CI 1.2-3.4). CONCLUSIONS: This study suggests that severe hypersplenism is an independent risk factor for developing variceal bleeding, SBP, and death in patients with cirrhosis. If these observations are confirmed, severe hypersplenism can be considered as an indication for prophylactic measures against variceal bleeding and SBP.

Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists.

BACKGROUND & AIMS: Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy. METHODS: One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications. RESULTS: The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5). CONCLUSIONS: Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.