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A. Sugut, M.B. B.A.O., M.B.B.Ch., Ph.D.

Assistant Professor, Icahn School of Medicine at Mount Sinai

These were the quality metrics chosen for monitoring, levels between 50 and 79 m/dL were not considered "in range" but were not counted as hypoglycemia. Blood sugar levels were measured before meals and at bedtime or if patients were not allowed to eat or drink, their blood sugar levels were measured every six hours. The sliding-scale protocol was reassessed after two consecutive blood glucose measurements exceeding 150 mg/dL or for two consecutive blood glucose measurements less than 100 mg/dL. The intensive bariatric surgery protocol was initiated after it was noted to be inadequate when reviewed by the system quality improvement committee. It was noted that unlike all other surgical subgroups, bariatric surgery patients demonstrated no significant change in control (based on chosen metrics above) with the standard hospital protocol. A new approach was formulated, and consisted of the same protocol listed in Table 1. However, treatment for all postoperative bariatric surgery patients whose care followed the intensive protocol were initiated at level 2 instead of level 1. Discrete variables were compared using c2 analysis with two degrees of variability. Results Data for a total of 461 postoperative bariatric surgery patients, divided into groups A, B, and C, were reviewed. The mean body mass index values for groups A, B, and C were 51, 58, and 51 kg/m2, respectively. The majority of operations performed in protocol groups B and C were laparoscopic, whereas only open operations were performed in group A. The observed increase in length of stay and incidence of wound infections in group A is likely secondary to changes in surgical technique (Table 2). Both wound infections in group C involved the only two open operations in that group. We found no difference in the incidence of hypoglycemia (blood sugar <50 mg/dL) in group C compared with the other two groups. The "insulin-sensitive" designation is for those patients with a diagnosis of proven disposition to hypoglycemia or previous issues with hypoglycemia under protocol level 1. Group demographics Mean body mass index 51 58 51 Open surgery 169 0 2 Laparoscopic surgery 0 91 199 % Laparoscopic 0 100 99 Length of stay (days) 4. The incidence of mild and major hyperglycemia was significantly lower in group C than in groups A and B (Table 3). The incidence of mild hyperglycemia was 20% in group C, 31% in group A, and 27% in group B; the incidence of major hyperglycemia was 1% in group C, 4% in group A, and 2% in group B. Glycemic control was not adequate in this group with the initial level 1 protocol. Van den Berghe et al reported a reduction in mortality of the critically ill patients with a decrease in both time spent in an intensive care unit and hospital length of stay with even minor improvements in glucose control. This report focuses on bariatric surgery patients, all of whom are morbidly obese. The pandemic of obesity in the United States has led to an increased number of hospitalizations for morbidly obese patients. The work reported here represents sev- 38 the Permanente Journal/ Spring 2007/ Volume 11 No. American College of Endocrinology and American Diabetes Association consensus statement on inpatient diabetes and glycemic control. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized control trials. Effect of intensive glucose management protocol on the mortality of critically ill adult patients. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Those That Survive Great ceramics are not made by putting clay in the sun; they come only from the white heat of the kiln. In the firing process some pieces are broken, but those that survive the heat are transformed from clay into porcelain and are objects of art. And so it is with people, those who, through medical skill, opportunity, work, and courage, survive illness or overcome their handicap and take their places back in the world have a depth of spirit that you and I can hardly measure. Primary care physicians, obstetricians, and cardiologists are now seeing patients in transition to adulthood from the pediatric cardiology clinics.

Brain stem: Cranial nerve deficits, double vision, dysarthria, dysphagia, nystagmus. Visual pathway: Distinguishing monocular from binocular defects is key to localization within the cerebral hemisphere and eyes (see Figure 13. Coma Exam the term coma refers to a condition in which patients are unresponsive, show no purposeful movement, and do not open their eyes to painful stimuli. It requires the impairment of either both cerebral hemispheres or the reticular activating system of the brain stem. Generally caused by one of three processes: A structural problem affecting the brain stem. An electrical problem (ongoing seizure activity even if not clinically apparent-e. Central scotoma caused by inflammation of the optic disk (optic neuritis) or optic nerve (retrobulbar neuritis). Bitemporal hemianopia caused by pressure exerted on the optic chiasm by a pituitary tumor. Right homonymous inferior quadrantanopia caused by partial involvement of the optic radiation by a lesion in the left parietal lobe. Right homonymous hemianopia from a complete lesion of the left optic radiation with or without macular sparing resulting from a lesion such as a posterior cerebral artery occlusion. Motor response to central and peripheral pain is also critical, as asymmetric responses suggest a focal intracranial lesion. Patients with coma caused by a structural problem generally have abnormal brain stem reflexes, as their coma is caused by direct compression of the brain stem. Most often performed in the L3 or L4 interspaces (at the level of the superior iliac crests). Opening pressure should be measured but is valid only when obtained with the patient in the lateral decubitus position. Also useful for preoperative evaluation of vascular supply to intracranial tumors. They are useful for studying and differentiating radiculopathies (spinal root injuries), motor neuron disease, neuropathies, neuromuscular junction diseases, and myopathies. A delay in response suggests that the conduction velocity along the visual pathway is slow, often a sign of demyelination. Sx/Exam: the following findings in patients with headache should prompt further investigation. Subtypes are as follows: Classic migraine (migraine with aura): Occurs in 20% of patients. The most common auras are visual, including "fortification spectra" and scotomas (blind spots). In patients with headache and focal neurologic deficits, a migraine variant remains a diagnosis of exclusion. Tension headache is usually a nonthrobbing, bilateral head pain that is not usually associated with nausea, vomiting, or prodromal visual disturbances. Ergotamines: Also to be avoided in patients with vascular disease and in pregnant women. Others: Acetaminophen/butalbital/caffeine (Fioricet): Butalbital is a barbiturate and has addictive properties. Headaches occur many times daily at distinct times over several weeks; onset with sleep is especially characteristic. Clusters spontaneously remit for months to years before recurring, typically at the same time of year as previous attacks. Prophylactic medications are started once cluster headaches begin but are not used during remissions given that months to years may elapse between clusters. Such medications include verapamil (first-line prophylactic treatment for cluster headache), prednisone (a taper of oral steroids is often used at the beginning of a cluster), lithium, valproate, and methysergide.

Gastric First-pass Metabolism the majority of oral ethanol is rapidly absorbed by passive diffusion from the stomach and the duodenum. Acetaldehyde binds with phospholipids, amino acid residues, and sulphydryl groups and thus becomes reactive and toxic. It affects the plasma membranes by depolymerising proteins and altering surface antigens. Fatty liver: Fatty liver is defined as the presence of more than 5 gm of fat/100 gm of liver tissue. In the more severely affected conditions, fatty change is diffuse (usually fat accumulates in zones 3 and 2). The formation of the nodules is often slow, because of a presumed inhibitory effect of alcohol on hepatic regeneration. Transaminases are increased Hypoalbuminaemia Prothrombin time is prolonged the other features are leukopenia, thrombocytopenia and anaemia. The patients are usually asymptomatic, the diagnosis being made when an enlarged, smooth, firm liver is present. Nausea and vomiting with periumbilical, epigastric or right upper quadrant pain with jaundice are present in severe fatty liver. Prognosis the levels of prothrombin time and bilirubin are used to determine the discriminant function, which estimates prognosis in alcoholic hepatitis. Hepatic transplantation is indicated in selected cases of acute alcoholic hepatitis and alcoholic cirrhosis. The usual symptoms are anorexia, nausea, malaise, weakness, vague abdominal pain, icterus, weight loss, or fever. It directly and indirectly interferes with gamma aminobutyric acid receptor function and predominantly affects frontal cortical control. The clinical feature is mild to diffuse global dementia due to atrophy of the cerebral cortex and enlargement of the ventricles. The other features are antisocial behaviour, dysarthric speech, tremor, ataxic gait and peripheral neuropathy. Marchiafava-Bignami Syndrome It is described in Italian drinkers of crude red wine and other alcoholics. It presents as a subacute dementing illness, and later progresses rapidly to fits, rigidity, paralysis, coma and death. It is due to demyelination and axonal damage in the corpus callosum, cerebral white matter, optic chiasma and middle cerebellar peduncle. Cerebrovascular Disease Consumption of large quantity of alcohol is the most common cause of stroke in the young. The increased risk of stroke is thought to be due to factors like increased viscosity of blood, coagulation defects and dysrhythmias. The possible consequences of high alcohol consumption are intracerebral haemorrhage, cerebral infarction, or subarachnoid haemorrhage. Alcoholics are also prone to develop subdural haematoma as a consequence to head injury while in an intoxicated state. Alcoholic Cerebellar Degeneration It is due to degeneration of cerebellar cortex (Purkinje cells) and superior and anterior part of the vermis. The clinical features are ataxia, progressive unsteadiness of gait with more involvement of the lower limbs than the upper limbs. Central Pontine Myelinosis It is a rare disorder occurring in alcoholics and a number of other disorders (liver, renal, metabolic disorders). It is characterised by rapid onset of flaccid or spastic quadriplegia with involvement of bulbar muscles (dysarthria, dysphagia). Peripheral Neuropathy It is due to predominant axonal neuropathy of the dying back type, affecting the somatic and autonomic nervous system. Alcohol consumption in the later stage of pregnancy results in intellectual deficit, auditory and visual deficits, and hyperkinetic syndromes in the offspring.