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.
Immune check point inhibitors have revolutionized the treatment of metastatic malignancies. They are a promising area in oncology and more drugs are likely to be available in the coming years. Along with the promise of better response oncologically, there is an increased incidence of endocrinopathies related to autoimmunity. This case report illustrates the dramatic development of hypothyroidism in a patient with underlying subclinical hyperthyroidism. It also suggests the potential pretreatment predictors of endocrinopathies related to these immune check point inhibitors.
In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.