Can a single interactive seminar durably improve knowledge and confidence of hospital diabetes management?

BACKGROUND: Safe and effective diabetes management in the hospital is challenging. Inadequate knowledge has been identified by trainees as a key barrier. In this study we assess both the short-term and long-term impact of an interactive seminar on medical student knowledge and comfort with hospital diabetes management. METHODS: An interactive seminar covering hospital diabetes management and utilizing an audience response system was added to the third-year medical student curriculum. Students were given a multiple choice assessment immediately before and after the seminar to assess their comprehension of the material. Students were also asked to rate their confidence on this topic. Approximately 6 months later, students were given the same assessment to determine if the improvements in hospital diabetes knowledge and confidence were durable over time. Students from the preceding medical school class, who did not have a hospital diabetes seminar as a part of their curriculum, were used as a control. RESULTS: Fifty-three students participated in the short-term assessment immediately before and after the seminar. The mean score (maximum 15) was 7.7 +/- 2.7 (51%) on the pre-test and 11.4 +/- 1.8 (76%) on the post-test (p < 0.01). 75 students who attended the seminar completed the same set of questions 6 months later with mean score of 9.2 ± 2.3 (61%). The control group of 100 students who did not attend seminar had a mean score of 8.8 ± 2.5 (58%). The difference in scores between the students 6-months after the seminar and the control group was not significantly different (p = 0.30). CONCLUSIONS: Despite initial short-term gains, a single seminar on hospital diabetes management did not durably improve trainee knowledge or confidence. Addition of repeated and focused interactions during clinical rotations or other sustained methods of exposure need to be evaluated.

Preprocedure and preoperative management of diabetes mellitus.

Appropriate management of diabetes mellitus before a procedure or operation is important for the prevention of hypo- and hyperglycemia in the periprocedural/perioperative period. This can significantly influence glucose levels after a procedure, which in turn affects outcomes. There is a paucity of prospective trials addressing algorithms to guide adjustment of oral diabetes medications and insulin prior to a procedure. Our institution has developed guidelines that allowed us to standardize the periprocedural process for glucose management across departments. This article describes our experience with guidelines, discusses salient features of medication management, and summarizes prospective trials and expert opinion to provide recommendations for clinicians to effectively manage glucose preprocedurally for their patients with diabetes.

Management of non-islet-cell tumor hypoglycemia: a clinical review.

CONTEXT: Non-islet cell tumor hypoglycemia (NICTH) is a rare but serious paraneoplastic syndrome in which a tumor secretes high molecular weight IGF-II, causing hypoglycemia. Complete tumor resection is curative but is often delayed or unfeasible. There is no clear "standard of care" for managing these patients. EVIDENCE ACQUISITION: PubMed searches were conducted for: "non-islet-cell tumor hypoglycemia," "NICTH," "Doege-Potter," "Doege-Potter syndrome," "high molecular weight IGF-II," and "big IGF-II." Relevant articles were reviewed in detail. We limited our review to English-language articles, focusing on 1988-2013 (corresponding with the elucidation of the pathophysiology of NICTH). EVIDENCE SYNTHESIS: The available literature exists as case reports or small case series, with a void of higher-order treatment studies. Thus, an evidence-based approach to data synthesis was difficult. Nevertheless, the available literature is presented objectively with an attempt to describe clinically useful trends and findings in the management of NICTH. CONCLUSIONS: Appropriate identification of NICTH and prompt and complete tumor resection represents ideal management. However, when prompt resection is not feasible, iv glucose or dextrose often does not suffice to prevent hypoglycemia. In such cases, we suggest consideration of local antitumor therapies for disease control and trial of glucocorticoids alone or in combination with GH. Continuous glucagon infusion can be successful if the patient has a positive response to a glucagon stimulation test, and parenteral nutrition may allow higher glucose delivery, but both are limited by the need for continuous iv infusion. Diazoxide and octreotide have no role in NICTH.

An academic hospitalist model to improve healthcare worker communication and learner education: results from a quasi-experimental study at a Veterans Affairs medical center.

BACKGROUND: Although hospitalists may improve efficiency and quality of inpatient care, their effect on healthcare-worker communication and education has been less well-studied. OBJECTIVE: To test various approaches to improving healthcare-worker communication and learner education within the context of a newly designed academic hospital medicine program. DESIGN: Before-and-after design with concurrent control group. SETTING: A Midwestern Veterans Affairs medical center. INTERVENTION: Multimodal systems redesign of 1 of 4 medical teams (Gold team) that included clinical modifications (change in rounding structure, with inclusion of nurses, a Clinical Care Coordinator, and a pharmacist) and educational interventions (providing explicit expectations of learners and providing a reading list for both learners and attending physicians). MEASUREMENTS: Number of admissions, length of stay, readmissions, house officer and medical student ratings of attendings' teaching, medical student internal medicine National Board of Medical Examiners Subject Examination ("shelf" exam) scores, and clinical staff surveys. RESULTS: Length of stay was reduced by about 0.3 days on all teams after the initiative began (P = 0.004), with no significant differences between Gold and non-Gold teams. The majority of physicians (83%) and nurses (68%) felt that including nurses during rounds improved healthcare-worker communication; significantly more nurses were satisfied with communication with the Gold team than with the other teams (71% vs 53%; P = 0.02). Gold attendings generally received higher teaching scores compared with non-Gold attendings, and third-year medical students on the Gold team scored significantly higher on the shelf exam compared with non-Gold team students (84 vs 82; P = 0.006). CONCLUSIONS: Academic hospitalists working within a systems redesign intervention were able to improve healthcare-worker communication and enhance learner education without increasing patient length of stay or readmission rates.

Linezolid-associated hypoglycemia in a 64-year-old man with type 2 diabetes.

BACKGROUND: Older diabetic patients are at increased risk for skin infections, often with methicillin-resistant Staphylococcus aureus (MRSA). Linezolid offers oral therapy with MRSA coverage. We present a case of linezolid-associated hypoglycemia in a 64-year-old diabetic patient with presumed MRSA cellulitis. CASE SUMMARY: A 64-year-old man with diabetes was treated for cellulitis. Linezolid was started when amoxicillin/clavulanate failed. Within 7 days, he developed frequent diaphoresis and tremulousness, with glucoses of 30 to 60 mg/dL. Hypoglycemia worsened despite decreasing insulin use, discontinuing glyburide, and increasing caloric intake. The day of admission, he awoke with a glucose level of 30 mg/dL. He took no medications, ate a large breakfast, and presented to clinic. He was symptomatic with a glucose level of 35 mg/dL. Hypoglycemia persisted despite IV dextrose. Linezolid was discontinued immediately in favor of vancomycin. Dextrose was weaned and his diabetes medications were resumed without further hypoglycemia. CONCLUSIONS: Linezolid has monoamine oxidase (MAO) inhibitory properties, and MAO inhibitors have been reported to contribute to hypoglycemia. The use of linezolid in older diabetic patients, especially those patients already taking agents with the potential to cause hypoglycemia, represents an area of concern. Increased comorbidities and polypharmacy in geriatric patients adds to this concern.