Cefcapene pivoxil-induced hypocarnitinemic hypoglycemia in elderly man with subclinical ACTH deficiency: a case report.

BACKGROUND: Drug-induced hypocarnitinemia has been noted as a cause of hypoglycemia in children. However, adult cases are extremely rare and pre-existing conditions (including endocrine disorders and frailty) have been suggested to be involved. Hypoglycemia due to drug-induced hypocarnitinemia is quite rare, and there were few reports of pivoxil-containing cephalosporin (PCC)-induced hypocarnitinemia in adults. CASE PRESENTATION: We present a case of an 87-year-old man with malnutrition, and frailty. He developed severe hypoglycemia with unconsciousness after taking cefcapene pivoxil hydrochloride, one of PCC, and hypocarnitinemia was diagnosed. Despite levocarnitine administration, asymptomatic mild hypoglycemia had persisted. Subsequent investigation revealed subclinical ACTH deficiency due to empty sella, which played a key role to maintain mild hypoglycemia as underlying disorder, and PCC-induced hypocarnitinemia triggered severe hypoglycemia. The patient responded to hydrocortisone therapy. CONCLUSIONS: We need to be aware of the facts that PCC can induce severe hypocarnitinemic hypoglycemia in elderly adults associated with frailty, malnutrition, and subclinical ACTH syndrome.

Semaglutide is effective in type 2 diabetes and obesity with schizophrenia.

Background: Prevention and treatment of type 2 diabetes and obesity are problematic for individuals with schizophrenia partly because atypical antipsychotics and mental distress themselves increase appetite, thus promoting subsequent body weight gain and deterioration of glycemic control. Glucagon-like peptide-1 (GLP-1) receptor agonists have been gaining attention for their glucose-lowering and body weight-reducing effects in obese individuals with type 2 diabetes generally, but their effects in those also having schizophrenia have not been adequately addressed. Case presentation: This case was a 50-year-old obese woman having type 2 diabetes and schizophrenia. Although she was receiving oral anti-diabetes treatment, her HbA1c remained inadequately controlled (8.0-9.0%) partly due her difficulty in following instructions on heathy diet and exercise. In addition, she was repeatedly hospitalized due to suicide attempts by overdosing on her anti-psychotic and anti-diabetes drugs. Her HbA1c was elevated to as high as 10.2% despite the use of multiple anti-diabetes drugs including the GLP-1 receptor agonist dulaglutide, and she was hospitalized in our department. We chose the GLP-1 receptor agonist semaglutide to replace dulaglutide along with a multidisciplinary team approach that included a cognitive-behavioral therapist. The patient perceived that her hunger was suppressed when she started receiving semaglutide 0.5 mg. After discharge, semaglutide was remarkably more effective than dulaglutide in that it reduced and maintained the patient's HbA1c and body weight for 6 months after initiation of the drug. Conclusion: The GLP-1 receptor agonist semaglutide can be effective in maintaining appropriate control of glycemia and body weight in diabetes and obesity with schizophrenia.

[A retrospective study in spinal anesthesia for sumo-wrestlers].

BACKGROUND: Spinal anesthesia for the Sumo-wrestler is thought to be difficult because of following reasons. 1. Sumo-wrestlers are so fatty and weighty that piercing spinal needle into the subarachnoid space is technically difficult. 2. The relationship between volume of local anesthetics and attained spinal anesthesia level is difficult to detect. 3. Upper airway can be easily obstructed during sedation. METHODS: Retrospectively, we compared 30 Sumo-wrestler patients (group S) with normal body weight patients (group N) concerning 17 items. RESULTS: While all patients in group N were approached from L 3 and L 4 interspinal space using 25 gauge spinal needles, 13 patients in group S were approached from another interspinal space, for example L 2 and L 3 or L 4 and L 5 and 40% of patients in group S needed 23 gauge spinal needles. The time intervals from the entrance into the operating room till the end of intrathecal administration of local anesthetics in group S and group N were 34 and 24 minutes, respectively (P < 0.05). The distances from the surface of the skin to subarachnoid space in group S and group N were 80 mm and 49 mm, respectively (P < 0.05). CONCLUSIONS: These results indicate that subarachnoid puncture in Sumo-wrestler patients is difficult and we should understand the specificities of spinal anesthesia for these patients.