ADDRESSING PITFALLS IN MANAGEMENT OF DIABETIC KETOACIDOSIS WITH A STANDARDIZED PROTOCOL.

Objective: To determine the efficacy and safety of a diabetic ketoacidosis (DKA)-Power Plan (PP) for guiding intravenous (IV) insulin infusions prior to anion gap (AG) closure and administering subcutaneous (SC) insulin ≥1 hour before discontinuing IV insulin. Methods: Retrospective chart review of patients with DKA before (pre-PP) (n = 60) and following (post-PP) (n = 60) implementation of a DKA-PP. Groups were compared for percentage of patients for whom IV insulin therapy was continued until AG closure, the percentage of patients receiving SC insulin ≥1 hour before discontinuation of IV insulin, and percentage of patients with rebound DKA during the index hospitalization. Results: Admission plasma glucose (514 mg/dL vs. 500 mg/dL; P = .36) and venous pH (7.2 vs. 7.2; P = .57) were similar in pre- and post-PP groups. Inappropriate discontinuation of IV insulin occurred less frequently in post-PP patients (28% vs. 7%; P = .007), with a lower frequency of rebound DKA (40% vs. 8%; P = .001) following acute management. More post-PP patients received SC insulin ≥1 hour before discontinuation of IV insulin (65% vs. 78%; P = .05). Conclusion: Implementation of a DKA-PP was associated with appropriate discontinuation of IV insulin in more patients, more frequent administration of SC insulin ≥1 hour prior to discontinuation of IV insulin, and fewer episodes of rebound DKA. Abbreviations: ADA = American Diabetes Association; AG = anion gap; BG = blood glucose; DKA = diabetic ketoacidosis; DKA-PP = DKA-Power Plan; ICU = intensive care unit; IQR = interquartile range; IV = intravenous; IVF = IV fluid; LOS = length of stay; SC = subcutaneous.

Identification of multiple endocrine neoplasia type 1 in patients with apparent sporadic primary hyperparathyroidism.

BACKGROUND: In the evaluation of patients with primary hyperparathyroidism (PHP), specific query for a personal or family history of MEN1 (Hx) is recommended widely, but responses are rarely positiv. We instituted a 6-question panel (6Q) to routinely screen for MEN1 preoperatively. METHODS: The clinical database entries of 939 patients explored for apparent sporadic PHP from June 1992 to November 2007 were examined for presenting diagnosis, demographics, anatomic findings, MEN1 analysis, and final diagnosis. To directly compare the results of 6Q and Hx, we also reviewed the charts of 654/939 PHP patients screened systematically from January 2000 to November 2007. RESULTS: MEN1 was undiagnosed until the preoperative evaluation in 1.6% of patients referred with apparent sporadic PHP. To date, MEN1 has been diagnosed in 42 of 939 (4.5%) PHP patients. Compared with those who have sporadic PHP, MEN1 patients were often male (38.1% vs 20.2%; P = .005) and young (mean, 38 +/- 17 years vs 60 +/- 13 years; P < .001). When hyperplasia was present at initial parathyroid exploration, the likelihood of MEN1 was 26% (32/123). For the 15 patients diagnosed by a surgeon to have MEN1, Hx was positive in 3 patients (20%) and 6Q in 13 (87%) (P = .0002). In a multivariate analysis of 635 patients with negative Hx, the likelihood of MEN1 increased with (1) younger age at initial parathyroid exploration and (2) number of positive 6Q responses. CONCLUSION: MEN1 occurs relatively often and can be missed. Systematic use of a simple 6-question panel helps to identify MEN1 prior to parathyroid exploration. Young male patients with parathyroid hyperplasia and positive 6Q results should be evaluated for MEN1.