Clinical and Prognostic Features of Diabetic Ketoacidosis According to the Trigger of the Syndrome.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute metabolic, life-threatening complication of diabetes mellitus with a mortality rate that now stand at less than 1%. Although mortality is coupled with the etiology of DKA, literature on the influence of DKA etiology on patient outcome is scarce. OBJECTIVES: To study different triggers for DKA and their effect on outcomes. METHODS: We conducted a retrospective study that include 385 DKA patients from 2004 to 2017. The study compared demographics, clinical presentation, and mortality rates by different precipitating factors. RESULTS: Patients with DKA due to infections had a higher risk to develop in-hospital mortality after controlling for age and sex (odds ratio 4.40, 95% confidence interval 1.35-14.30), had a higher Charlson Comorbidity Index score, a higher risk of being mechanical ventilated (14% vs. 3%, P < 0.01), and a longer duration of hospitalization (5 days vs. 3 days, P < 0.001). CONCLUSIONS: It is crucial to find the triggers that precipitate DKA and start the treatment as early as possible in addition to the metabolic aspect of the treatment especially when the trigger is an infectious disease.

Management of diabetic ketoacidosis.

Diabetic ketoacidosis (DKA) is an acute life-threatening emergency in patients with diabetes, it can result in serious morbidity and mortality. Management of DKA requires reversing metabolic derangements, correcting volume depletion, electrolyte imbalances and acidosis while concurrently treating the precipitating illness. There are still controversies regarding certain aspects of DKA management. Different society guidelines have inconsistencies in their recommendations, while some aspects of treatment are not precise enough or have not been thoroughly studied. These controversies may include issues such as optimal fluid resuscitation, rate and type of Insulin therapy, potassium and bicarbonate replacement. Many institutions follow common society guidelines, however, other institutions either develop their own protocols for internal use or do not routinely use any protocols, resulting in inconsistencies in treatment and increased risk of complications and suboptimal outcomes. The objectives of this article are to review knowledge gaps and controversies in the treatment of DKA and provide our perspective on these issues. Moreover, we believe that special patient factors and comorbidities should receive more careful attention and consideration. Factors like pregnancy, renal disease, congestive heart failure, acute coronary syndrome, older age, use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and site of care all impact the treatment approach and require tailored management strategies. However, guidelines often lack sufficient recommendations regarding specific conditions and comorbidities, we aim to address unique circumstances and provide an approach to managing complex patients with specific conditions and co-morbidities. We also sought to examine changes and trends in the treatment of DKA, illuminate on aspects of latest research with a perspective towards future developments and modifications.

The Risk of Rectal Temperature Measurement in Neutropenia.

BACKGROUND: Avoiding rectal thermometry is recommended in patients with neutropenic fever. Permeability of the anal mucosa may result in a higher risk of bacteremia in these patients. Still, this recommendation is based on only a few studies. METHODS: This retrospective study included all individuals admitted to our emergency department during 2014-2017 with afebrile (body temperature <38.3°C) neutropenia (neutrophil count <500 cells/microL) who were over the age of 18. Patients were stratified by the presence or absence of a rectal temperature measurement. The primary outcome was bacteremia during the first five days of index hospitalization; the secondary outcome was in-hospital mortality. RESULTS: The study included 40 patients with rectal temperature measurements and 407 patients whose temperatures were only measured orally. Among patients with oral temperature measurements, 10.6% had bacteremia, compared to 5.1% among patients who had rectal temperature measurements. Rectal temperature measurement was not associated with bacteremia, neither in non-matched (odds ratio [OR] 0.36, 95% confidence interval [CI] 0.07-1.77) nor in matched cohort analyses (OR 0.37, 95% CI 0.04-3.29). In-hospital mortality was also similar between the groups. CONCLUSIONS: Patients with neutropenia who had their temperature taken using a rectal thermometer did not experience a higher frequency of events of documented bacteremia or increased in-hospital mortality.

Community-based serum chloride abnormalities predict mortality risk.

INTRODUCTION: This population-based study aimed to investigate the prognostic value of ambulatory serum chloride abnormalities, often ignored by physicians. METHODS: The study population included all non-hospitalized adult patients, insured by "Clalit" Health Services in Israel's southern district, who underwent at least 3 serum chloride tests in community-based clinics during 2005-2016. For each patient, each period with low (≤97 mmol/l), high (≥107 mmol/l) or normal chloride levels were recorded. A Cox proportional hazards model was used to estimate the mortality risk of hypochloremia and hyperchloremia periods. RESULTS: 664,253 serum chloride tests from 105,655 subjects were analyzed. During a median follow up of 10.8 years, 11,694 patients died. Hypochloremia (≤ 97 mmol/l) was independently associated with elevated all-cause mortality risk after adjusting for age, co-morbidities, hyponatremia and eGFR (HR 2.41, 95%CI 2.16-2.69, p<0.001). Crude hyperchloremia (≥107 mmol/L) was not associated with all-cause mortality (HR 1.03, 95%CI 0.98-1.09 p = 0.231); as opposed to hyperchloremia ≥108 mmol/l (HR 1.14, 95%CI 1.06-1.21 p<0.001). Secondary analysis revealed a dose-dependent elevated mortality risk for chloride levels of 105 mmol/l and below, well within the "normal" range. CONCLUSION: In the outpatient setting, hypochloremia is independently associated with an increased mortality risk. This risk is dose-dependent where the lower the chloride level, the higher is the risk.

Diagnostic utility of clinical characteristics, laboratory tests, and serum ferritin in diagnosis of adult-onset Still disease.

The diagnosis of adult-onset Still disease (AOSD) is challenging with ambiguous clinical presentation and no specific serological markers. We aim to evaluate the diagnostic utility of clinical, laboratory and serum ferritin features in established AOSD patients. We included all patients >18 years who were admitted to 2 tertiary medical centers (2003-2019) with serum ferritin above 1000 ng/mL. AOSD patients and non-AOSD controls were matched in 1:4 ratio for age and sex. The primary outcomes were sensitivity, specificity, positive/negative likelihood ratio and area under the curve (AUC) using clinical and laboratory characteristics based on the Yamaguchi classification criteria, in addition to serum ferritin. We identified 2658 patients with serum ferritin above 1000 ng/m, of whom 36 diagnosed with AOSD and 144 non-AOSD matched controls. Presence of arthralgia/arthritis showed the highest sensitivity (0.74), specificity (0.93), positive likelihood ratio (10.69), negative likelihood ratio (0.27) and AUC (0.83, 95% confidence interval 0.74-0.92) to the diagnosis of AOSD. On the other hand, serum ferritin showed variation and poorer results, depends on the chosen ferritin cutoff. Joint involvement showed the best diagnostic utility to establish the diagnosis of AOSD. Although clinicians use often elevated ferritin levels as an anchor to AOSD, the final diagnosis should be based on thorough clinical evaluation.

Point of Care Lung Ultrasound Injury Score-A simple and reliable assessment tool in COVID-19 patients (PLIS I): A retrospective study.

BACKGROUND: In COVID-19 patients, lung ultrasound is superior to chest radiograph and has good agreement with computerized tomography to diagnose lung pathologies. Most lung ultrasound protocols published to date are complex and time-consuming. We describe a new illustrative Point-of-care ultrasound Lung Injury Score (PLIS) to help guide the care of patients with COVID-19 and assess if the PLIS would be able to predict COVID-19 patients' clinical course. METHODS: This retrospective study describing the novel PLIS was conducted in a large tertiary-level hospital. COVID-19 patients were included if they required any form of respiratory support and had at least one PLIS study during hospitalization. Data collected included PLIS on admission, demographics, Sequential Organ Failure Assessment (SOFA) scores, and patient outcomes. The primary outcome was the need for intensive care unit (ICU) admission. RESULTS: A total of 109 patients and 293 PLIS studies were included in our analysis. The mean age was 60.9, and overall mortality was 18.3%. Median PLIS score was 5.0 (3.0-6.0) vs. 2.0 (1.0-3.0) in ICU and non-ICU patients respectively (p<0.001). Total PLIS scores were directly associated with SOFA scores (inter-class correlation 0.63, p<0.001), and multivariate analysis showed that every increase in one PLIS point was associated with a higher risk for ICU admission (O.R 2.09, 95% C.I 1.59-2.75) and in-hospital mortality (O.R 1.54, 95% C.I 1.10-2.16). CONCLUSIONS: The PLIS for COVID-19 patients is simple and associated with SOFA score, ICU admission, and in-hospital mortality. Further studies are needed to demonstrate whether the PLIS can improve outcomes and become an integral part of the management of COVID-19 patients.

Diabetic ketoacidosis in pregnancy - Case series, pathophysiology, and review of the literature.

OBJECTIVE: Diabetic ketoacidosis (DKA) during pregnancy is a life-threatening emergency for both the mother and the fetus. The pathophysiology of DKA in pregnancy has its own characteristics due to multiple factors, such as insulin resistance, accelerated starvation and respiratory alkalosis, thus creating ketosis-prone state, with DKA occurring at milder degrees of hyperglycemia, even in normoglycemic levels, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences. STUDY DESIGN: In this article, we presented 8 clinical cases of DKA during pregnancy. We discuss the spectrum of the clinical picture, the entity of euglycemic DKA vs hyperglycemic DKA, the period of pregnancy in appearance of episode of DKA and triggers of DKA. CONCLUSION: The treatment of DKA in pregnant women must be started immediately and must be accentuated on intravenous fluids, insulin and electrolyte replacement. DKA in pregnancy may be euglycemic. Prevention, early recognition, immediate hospitalization, and aggressive management remain the cornerstones in DKA management in pregnancy.

Secondary organizing pneumonia after recovery of mild COVID-19 infection.

A 36-year-old male with diffuse large B-cell lymphoma on maintenance rituximab therapy presented to the emergency department with high fever and fatigue. A chest X-ray showed a lobar infiltrate, 40 days before admission the patient suffered from a mild coronavirus disease 2019 (COVID-19) infection and fully recovered. PCR nasopharyngeal swab was negative for COVID-19. Comprehensive biochemical, radiological, and pathological evaluation including 18-fluorodeoxyglucose positron emission tomography with computed tomography and transbronchial lung biopsy found no pathogen or lymphoma recurrence. Treatment for pneumonia with antibiotic and antifungal agents was nonbeneficial. A diagnosis of secondary organizing pneumonia (OP) was made after pneumonia migration and a rapid response to corticosteroids. OP secondary to a viral respiratory infection has been well described. Raising awareness for post-COVID-19 OP has therapeutic and prognostic importance because those patients benefit from steroid therapy. We believe the condition described here is underdiagnosed and undertreated by doctors worldwide. Because of the ongoing global pandemic we are now encountering a new kind of patient, patients that have recovered from COVID-19. We hope that this case may contribute to gaining more knowledge about this growing patient population.

[COMMUNITY ACQUIRED KLEBSIELLA PNEUMONIAE LIVER ABSCESS - REPORT FROM ISRAEL].

INTRODUCTION: Klebsiella pneumoniae is facultative anaerobic bacilli gram-negative bacteria. Klebsiella pneumoniae often causes urinary tract infections and sometimes causes community acquired pneumonia. During the past two decades, a distinct syndrome of Klebsiella pneumoniae with a pyogenic liver abscess was noted. The incidence is higher among patients with diabetes mellitus, and can cause serious complications, including bacteremia, meningitis, endophthalmitis and necrotizing fasciitis. The first cases were reported from Taiwan, but later, more cases emerged in other Asian countries. During recent years the incidence of Klebsiella pneumoniae liver abscess has increased globally, with cases also reported in Australia, New Zealand, West Europe and the United States. To the best of our knowledge, these are the first 2 cases described in Israel.

Predictors and outcomes of recurrent diabetic ketoacidosis in Israeli adults.

AIMS: To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies. METHODS: Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2). RESULTS: 385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112-3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04-0.742; p = 0.018). CONCLUSION: High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.

[ETHNIC DIVERSITY AND CLINICAL CHARACTERISTICS OF HOSPITALIZED PATIENTS WITH ACUTE PANCREATITIS].

BACKGROUND: Previous studies have shown a correlation between acute pancreatitis and several different risk factors that vary in different countries and ethnic groups. The aims of this study are to examine the clinical characteristics and outcomes of acute pancreatitis in patients of Jewish and Bedouin origin. METHODS: We performed a retrospective cohort study of patients hospitalized with acute pancreatitis in the Soroka University Medical Center between the years 2012 and 2016 and compared two groups of patients: patients of Jewish and Bedouin origin. The primary outcome was a composite outcome consisting of 30-days mortality, ICU admission, complications (defined as necrotizing pancreatitis or pseudocyst formation), surgery due to these complications and 30-days re-admission due to pancreatitis. RESULTS: A total of 560 patients were included, 483 patients (86.3%) of Jewish origin and 77 patients (13.7%) of Bedouin origin. The most common cause in both groups was biliary pancreatitis: 49.7% among Jewish, 61% among Bedouin. In our study alcohol consumption, the most common worldwide risk factor of pancreatitis, accounts for only a small percentage of the disease in the Jewish population (5.6%) and does not exist in the Bedouin population. We found no significant differences in outcomes between the two groups. CONCLUSIONS: Biliary pancreatitis was the most common cause in both groups of patients. The important finding of our study is that alcohol use is a minor cause of acute pancreatitis in the Negev. Moreover, it is uncommon in the Jewish population and is completely non-existent among Bedouins. No differences were found in the primary outcomes between the two groups.

Clinical Characteristics and Prognosis of Idiopathic Acute Pancreatitis.

OBJECTIVE: Acute pancreatitis is a serious diagnosis with an increasing incidence in the Western world. In this study we sought to investigate the incidence of idiopathic AP and to compare clinical and prognostic characteristics of idiopathic cases with cases of AP with known etiology. METHODS: In this retrospective study of adult hospitalized patients diagnosed with acute pancreatitis between 2012 and 2015, a comparison was made between admissions of patients with known etiology and those for whom no cause was found. Primary outcome was defined as composite outcome of 30-day mortality and complications. RESULTS: Among 560 admissions of 437 patients with a primary diagnosis of acute pancreatitis, the main factors identified were gallstones (51.2%) and idiopathic pancreatitis (35.9%), with alcohol ranked third at only 4.8%. Mortality rate within 30 days of hospitalization was 2.9% and within one year was 7.1%. Use of lipid-lowering, anti-hypertensive, and anti-diabetic medications was more frequent among patients with "idiopathic" disease (70%, 68%, and 33% versus 59%, 56%, and 27%, respectively). Patients admitted with idiopathic AP, in comparison to patients with known AP etiology, had milder disease with shorter hospital stay (3 days versus 4, respectively), and less re-admission in 30 days (7.5% versus 21.2%). Idiopathic AP patients had better prognosis in terms of 30-day death and complication (HR 0.33, 95% CI 0.08-0.40, P<0.001). CONCLUSION: Idiopathic disease is common among acute pancreatitis patients; the two study groups differed in severity of disease and prognosis. Common use of medications with doubtful value suggests possible under-diagnosis of drug-induced acute idiopathic pancreatitis.

Nonhepatic hyperammonemic encephalopathy complications following bariatric surgery: a case report and review of the literature.

BACKGROUND: Hyperammonemic encephalopathy, a rare but fatal condition, is increasingly being reported as a possible complication of bariatric surgery. Here, we present a case of hyperammonemic encephalopathy, focusing on the clinical presentation, diagnostic measures, and our treatment methods, which resulted in a rare favorable outcome, emphasizing the unique role of renal replacement treatment. We also provide a detailed discussion of the mechanism through which hyperammonemia occurs secondarily to bariatric surgery. CASE PRESENTATION: A 44-year-old Moroccan Jew woman with a history of obesity presented in the hospital with urea cycle disorder that manifested after bariatric surgery. A rapid diagnostic process, together with conservative treatment with lactulose, nutritional supplementation, dietary protein restriction, and ammonia scavengers did not result in adequate improvement. Therefore, hemofiltration was performed, which yielded a favorable outcome. CONCLUSIONS: The case findings indicate an association between hyperammonemic encephalopathy and bariatric surgery, and support early treatment with ammonia scavengers, as currently accepted. Nevertheless, if rapid improvement is not seen, it is advisable to consider hemodialysis or hemofiltration as early invasive strategies.

[COMMUNITY ACQUIRED KLEBSIELLA PNEUMONIAE LIVER ABSCESS - REPORT FROM ISRAEL].

BACKGROUND: Klebsiella pneumoniae is facultative anaerobic bacilli gram-negative bacteria. Klebsiella pneumoniae, often causes urinary tract infections and sometimes causes community acquired pneumonia. During the past two decades, a distinct syndrome of Klebsiella pneumoniae with a pyogenic liver abscess was noted. The incidence is higher among patients with diabetes mellitus, and can cause serious complications, including bacteremia, meningitis, endophthalmitis and necrotizing fasciitis. The first cases were reported from Taiwan, but later, more cases emerged in other Asian countries. During recent years the incidence of Klebsiella pneumoniae liver abscess has increased globally, with cases also reported in Australia, New Zealand, West Europe and the United States. To the best to our knowledge, these are the first 2 cases described in Israel.

Outcomes of diabetic ketoacidosis in a tertiary centre with restricted intensive care unit bed capacity.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute metabolic condition, sometimes requiring admission to an intensive care unit (ICU). AIMS: To investigate the outcomes of DKA patients admitted to a hospital with restricted ICU capacity. METHODS: We included all DKA patients above age 18 who were admitted to a tertiary hospital during 2004-2017. We conducted multivariate logistic regression analysis adjusted for ICU bed availability to analyse parameters associated with ICU admission, and a composite outcome of mortality, DKA recurrence and mechanical ventilation. RESULTS: Among 382 DKA patients in our cohort, 94 (24.6%) were admitted to the ICU. The in-hospital mortality was 4.7%. Low bicarbonate (<10 mmoL/L) and pH (<7) levels at presentation were associated with ICU admission (P < 0.001 for both). In multivariate models availability of beds in the ICU was not associated with ICU admission, mortality or DKA recurrence of any type. CONCLUSION: In a setting of limited ICU capacity, DKA treatment does not necessarily require admission to the ICU. When the rising rates of diabetes mellitus and the associated elevated rates of DKA are taken into account, our results highlight the importance of including step-down units when devising local protocols for care of these patients.

Sex Differences in Infective Endocarditis.

BACKGROUND: The impact of sex on the presentation, etiology, and outcomes of infective endocarditis (IE) has not been adequately studied. The aim of the present research was to analyze the impact of sex on the presentation, etiology, and outcomes of IE. METHODS: We performed a retrospective study of 214 adult patients (131 male and 83 female) with IE. All cases of IE were reviewed by two investigators- both senior physicians in internal medicine. Two groups of patients were compared: male and female patients with IE. The primary outcome was in-hospital mortality. RESULTS: We found significant differences in etiologic factors of IE in male and female patients. Microbiologic etiology differences between male and female groups of patients were in coagulase negative staphylococcus (15.0% in male vs 3.8% in female groups, P = 0.011), and culture negative endocarditis (8.7% in male vs 23.8% in female groups, P = 0.004). We did not find a difference in the primary outcome between the two groups; however, all-cause mortality was significantly higher in the female group as compared to the male group (26 [31.3] vs 22 [16.8], P = 0.018). CONCLUSIONS: We found that sex may have important role in both the microbial profile and the patient's outcome with IE.

Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes.

Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams. Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an "any symptoms of delirium" group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records. Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records. Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.