Epidemiology, microbiology, and diagnosis of infection in diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: A multicenter retrospective observational study.

AIMS: We investigated the characteristics of infection and the utility of inflammatory markers in diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS). METHODS: A multicenter, retrospective observational study in 21 acute-care hospitals was conducted in Japan. This study included adult hospitalized patients with DKA and HHS. We analyzed the diagnostic accuracy of markers including C-reactive protein (CRP) and procalcitonin (PCT) for bacteremia. Multiple regression models were created for estimating bacteremia risk factors. RESULTS: A total of 771 patients, including 545 patients with DKA and 226 patients with HHS, were analyzed. The mean age was 58.2 (SD, 19.3) years. Of these, 70 tested positive for blood culture. The mortality rates of those with and without bacteremia were 14 % and 3.3 % (P-value < 0.001). The area under the curve (AUC) of CRP and PCT for diagnosis of bacteremia was 0.85 (95 %CI, 0.81-0.89) and 0.76 (95 %CI, 0.60-0.92), respectively. Logistic regression models identified older age, altered level of consciousness, hypotension, and higher CRP as risk factors for bacteremia. CONCLUSIONS: The mortality rate was higher in patients with bacteremia than patients without it. CRP, rather than PCT, may be valid for diagnosing bacteremia in hyperglycemic emergencies. TRIAL REGISTRATION: This study is registered in the UMIN clinical trial registration system (UMIN000025393, Registered December 23, 2016).

High versus low chloride load in adult hyperglycemic emergencies with acute kidney injury: a multicenter retrospective cohort study.

Hyperglycemic emergencies frequently lead to acute kidney injury (AKI) and require treatment with large amount of intravenous fluids. However, the effects of chloride loading on this population have not yet been investigated. We conducted a multicenter, retrospective, cohort study in 21 acute-care hospitals in Japan. The study included hospitalized adult patients with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) who had AKI upon arrival. The patients were classified into high and low chloride groups based on the amount of chloride administered within the first 48 h of their arrival. The primary outcome was recovery from AKI; secondary outcome was major adverse kidney events within 30 days (MAKE30), including mortality and prolonged renal failure. A total of 390 patients with AKI, including 268 (69%) with DKA and 122 (31%) with HHS, were included in the study. Using the criteria of Kidney Disease Improving Global Outcomes, the severity of AKI in the patients was Stage 1 (n = 159, 41%), Stage 2 (n = 121, 31%), and Stage 3 (n = 110, 28%). The analysis showed no significant difference between the two groups in recovery from AKI (adjusted hazard ratio, 0.96; 95% CI 0.72-1.28; P = 0.78) and in MAKE30 (adjusted odds ratio, 0.91; 95% CI 0.45-1.76; P = 0.80). Chloride loading with fluid administration had no significant impact on recovery from AKI in patients with hyperglycemic emergencies.Trial Registration This study was registered in the UMIN clinical trial registration system (UMIN000025393, registered December 23, 2016).

Clinical profile of patients with diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome in Japan: a multicenter retrospective cohort study.

INTRODUCTION: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. Their clinical profiles have not been fully investigated. METHODS: A multicenter retrospective cohort study was conducted in 21 acute care hospitals in Japan. Patients included were adults aged 18 or older who had been hospitalized from January 1, 2012, to December 31, 2016 due to DKA or HHS. The data were extracted from patient medical records. A four-group comparison (mild DKA, moderate DKA, severe DKA, and HHS) was performed to evaluate outcomes. RESULTS: A total of 771 patients including 545 patients with DKA and 226 patients with HHS were identified during the study period. The major precipitating factors of disease episodes were poor medication compliance, infectious diseases, and excessive drinking of sugar-sweetened beverages. The median hospital stay was 16 days [IQR 10-26 days]. The intensive care unit (ICU) admission rate was 44.4% (mean) and the rate at each hospital ranged from 0 to 100%. The in-hospital mortality rate was 2.8% in patients with DKA and 7.1% in the HHS group. No significant difference in mortality was seen among the three DKA groups. CONCLUSIONS: The mortality rate of patients with DKA in Japan is similar to other studies, while that of HHS was lower. The ICU admission rate varied among institutions. There was no significant association between the severity of DKA and mortality in the study population. TRIAL REGISTRATION: This study is registered in the UMIN clinical Trial Registration System (UMIN000025393, Registered 23th December 2016).

Association between intrarenal venous flow from Doppler ultrasonography and acute kidney injury in patients with sepsis in critical care: a prospective, exploratory observational study.

BACKGROUND: Intrarenal venous flow (IRVF) patterns assessed using Doppler renal ultrasonography are real-time bedside visualizations of renal vein hemodynamics. Although this technique has the potential to detect renal congestion during sepsis resuscitation, there have been few studies on this method. We aimed to examine the relationship between IRVF patterns, clinical parameters, and outcomes in critically ill adult patients with sepsis. We hypothesized that discontinuous IRVF was associated with elevated central venous pressure (CVP) and subsequent acute kidney injury (AKI) or death. METHODS: We conducted a prospective observational study in two tertiary-care hospitals, enrolling adult patients with sepsis who stayed in the intensive care unit for at least 24 h, had central venous catheters placed, and received invasive mechanical ventilation. Renal ultrasonography was performed at a single time point at the bedside after sepsis resuscitation, and IRVF patterns (discontinuous vs. continuous) were confirmed by a blinded assessor. The primary outcome was CVP obtained at the time of renal ultrasonography. We also repeatedly assessed a composite of Kidney Disease Improving Global Outcomes of Stage 3 AKI or death over the course of a week as a secondary outcome. The association of IRVF patterns with CVP was examined using Student's t-test (primary analysis) and that with composite outcomes was assessed using a generalized estimating equation analysis, to account for intra-individual correlations. A sample size of 32 was set in order to detect a 5-mmHg difference in CVP between IRVF patterns. RESULTS: Of the 38 patients who met the eligibility criteria, 22 (57.9%) showed discontinuous IRVF patterns that suggested blunted renal venous flow. IRVF patterns were not associated with CVP (discontinuous flow group: mean 9.24 cm H2O [standard deviation: 3.19], continuous flow group: 10.65 cm H2O [standard deviation: 2.53], p = 0.154). By contrast, the composite outcome incidence was significantly higher in the discontinuous IRVF pattern group (odds ratio: 9.67; 95% confidence interval: 2.13-44.03, p = 0.003). CONCLUSIONS: IRVF patterns were not associated with CVP but were associated with subsequent AKI in critically ill adult patients with sepsis. IRVF may be useful for capturing renal congestion at the bedside that is related to clinical patient outcomes.

Association of intranasal desmopressin therapy with overcorrection of severe hyponatremia: A retrospective, propensity score-based, single-center cohort study.

PURPOSE: Severe hyponatremia, defined as serum sodium concentration ([sNa]) ≤ 120 mEq/L, requires aggressive treatment to prevent potentially fatal cerebral edema, seizures, and other sequelae, but overcorrection can also result in life-threatening cerebral hemorrhage and demyelination. We compared the safety and efficacy of nasal desmopressin to conventional management for the prevention of [sNa] overcorrection. MATERIAL AND METHODS: This retrospective analysis compared 47 patients treated with desmopressin to 17 patients treated conventionally at a university hospital ICU in Japan between 2013 and 2018 using propensity score-based approaches. The primary outcome was safe [sNa] correction, defined as a ≤ 8 mEq/L difference between baseline and follow-up [sNa] at any time within 24h of diagnosis. RESULTS: The 24-h safe correction rate was significantly greater in the desmopressin group than the conventional treatment group (68% [32/47] vs. 41% [7/17], P = 0.039), and dose-response analysis indicated a positive association between cumulative 24-h desmopressin dose and safe correction at 24 h (P = 0.003). Few overcorrections precluded reliable assessment at 48 h. Exacerbation of hyponatremia was comparable in the two treatment groups. CONCLUSIONS: Intranasal desmopressin therapy increased the safe correction of severe hyponatremia. Large prospective trials are warranted to confirm this result.

Mobility and mortality of 340 patients with fragility fracture of the pelvis.

PURPOSE: To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan. METHODS: We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated. RESULTS: According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%. CONCLUSION: According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.

Synchronous reversible cerebral vasoconstriction syndrome following thyrotoxicosis in a postpartum woman.

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) typically manifests with acute-onset, recursive, severe headache that continues for a month; it rarely manifests as seizures. Development of RCVS following thyrotoxicosis has not been previously reported in detail. CASE PRESENTATION: A 30-year-old postpartum woman with thyrotoxicosis developed a generalized seizure refractory to anticonvulsants. Magnetic resonance angiography demonstrated cerebral artery stenosis in the right anterior cerebral artery and the right middle cerebral artery. These findings were compatible with RCVS. Reversible cerebral vasoconstriction syndrome was treated successfully with i.v. nicardipine and conventional management was undertaken for thyrotoxicosis. CONCLUSION: This is the first well-documented case of a postpartum woman with synchronous RCVS following thyrotoxicosis. Reversible cerebral vasoconstriction syndrome and thyrotoxicosis can coincidentally occur in postpartum women and manifest with postpartum seizures.

Multiple limb compartment syndrome as a manifestation of capillary leak syndrome secondary to metformin and dipeptidyl peptidase IV inhibitor overdose: A case report.

RATIONALE: Capillary leak syndrome is a condition that increases systemic capillary permeability and causes characteristic manifestations such as recurrent hypovolemia, systemic edema, and hemoconcentration. Acute limb compartment syndrome is a possible complication of severe capillary leak syndrome. However, timely diagnosis and prompt treatment are challenging because of atypical presentation. PATIENT CONCERNS: An 18-year-old woman with a history of clinical depression was admitted to our intensive care unit (ICU) because of metformin and vildagliptin overdose. She developed marked vasodilatory shock with recurrent severe hypovolemia and disseminated intravascular coagulation. After urgent hemodialysis and plasma exchange, she started to stabilize hemodynamically. However, her limbs became stone-hard with massive edema. Her serum creatinine kinase level increased to an extremely high level. DIAGNOSIS: Extremities were distended, and her skin developed pallor with blistering. Intramuscular pressure in both forearms and lower legs was significantly elevated. INTERVENTIONS: Decompressive fasciotomy was performed. Hemodialysis was continued because of rhabdomyolyses-induced acute kidney injury. OUTCOMES: The patient was finally able to walk by herself at the time of hospital discharge on day 109. LESSONS: The possibility of acute compartment syndrome should be considered in patients with marked capillary leakage, especially after aggressive fluid resuscitation. It is important to be aware of the compartment syndrome in an ICU setting because communication barriers often mask typical symptoms and make diagnosis difficult.

Primary bipolar hemiarthroplasty as a treatment option for unstable intertrochanteric fractures.

OBJECTIVES: Management of unstable intertrochanteric fractures is challenging, especially in patients with osteoporosis. Comminuted unstable intertrochanteric fractures require postoperative immobilization. Several recent reports have recommended hemiarthroplasty for treatment of unstable intertrochanteric fractures to avoid various immobilization-associated complications. The purpose of this study was to evaluate the functional and clinical outcomes of bipolar hemiarthroplasty for unstable intertrochanteric fractures in older persons. METHODS: Sixty patients aged over 75 years underwent hemiarthroplasty to treat unstable intertrochanteric fractures and were followed up over 12 months. All surgeries were performed by the same surgical team using the standard posterolateral approach. Wires, cables, and plates were used as required. Use of cemented protheses was considered when the lesser trochanter had been displaced. All patients were allowed full weight-bearing as tolerated. Clinical evaluation was based on Harris Hip Scores. RESULTS: The cohort comprised 16 men and 44 women (aged 75-96 years). According to the Jensen classification, 24 fractures were type III, 14 type IV, and 22 type V. Cement was used in 24 patients. At 12 months follow-up, Harris Hip Scores were excellent in 18%, good in 42%, fair in 25%, and poor in 15%. No radiological abnormalities were detected. CONCLUSIONS: Primary bipolar hemiarthroplasty for treating unstable intertrochanteric fractures eliminates the need for prolonged immobilization and permits early ambulation. As reported by others, hip hemiarthroplasty is an effective treatment choice for unstable intertrochanteric femoral fracture in older patients.

Maximum Norepinephrine Dosage Within 24 Hours as an Indicator of Refractory Septic Shock: A Retrospective Study.

BACKGROUND: The management of refractory septic shock remains a major challenge in critical care and its early indicators are not fully understood. We hypothesized that the maximum norepinephrine dosage within 24 hours of intensive care unit (ICU) admission may be a useful indicator of early mortality in patients with septic shock. METHODS: In this retrospective single-center observational study, patients with septic shock admitted to the emergency ICU of an academic medical center between April 2011 and March 2017 were included. Individuals with cardiac arrest and those with do-not-resuscitate orders before admission were excluded. We analyzed if the maximum norepinephrine dosage within 24 hours of ICU admission (MD24) was associated with 7-day mortality. RESULTS: Among 152 patients with septic shock, 20 (15%) did not survive by day 7. The receiver operating characteristic curve analysis for predicting 7-day mortality revealed a cutoff of MD24 of 0.6 µg/kg/min (sensitivity 47%, specificity 93%). In the multivariable regression analysis, a higher MD24 was significantly associated with 7-day mortality (odds ratio: 7.20; 95% confidence interval [CI]: 2.02-25.7; P = .002) but not with 30-day mortality. Using the inverse probability of treatment weighting method in a propensity scoring analysis, a higher MD24 was significantly associated with 7-day (hazard ratio [HR]: 8.9; 95% CI: 3.2-25.0; P < .001) and 30-day mortality (HR: 2.7; 95% CI: 1.2-5.8; P = .012). CONCLUSIONS: An MD24 ≥0.6 µg/kg/min was significantly associated with 7-day mortality in patients with septic shock and may therefore be a useful indicator of refractory septic shock.

A fatal case of infective endocarditis caused by an unusual suspect: Serratia marcescens.

Serratia marcescens has been reported to cause infective endocarditis among intravenous drug users, but it is extremely rare in non-intravenous drug users in Japan. In this article, we report an 85-year-old woman with diabetes mellitus who presented with low-grade fever and general fatigue. She was administered intravenous prednisolone under a diagnosis of right Bell's palsy before this admission. Blood cultures revealed positive Serratia marcescens, which was complicated by multiple cerebral infarctions after admission. Transthoracic echocardiography on day 5 revealed vegetation on the mitral valve, which was diagnosed as infective endocarditis. An operation could not be performed because of the presence of multiple cerebral infarctions. She died on day 65 because of uncontrolled heart failure.