Evaluation of a Computerized Insulin Dosing Tool for the Treatment of Diabetic Ketoacidosis.

PURPOSE: Computerized insulin dosing tools (CIDT) have been shown to improve the care of critically ill patients with hyperglycemia. Application of a CIDT in addition to a diabetic ketoacidosis (DKA) order set for the treatment of DKA has not been evaluated. Our goal was to determine the effects the CIDT would have on the treatment of a patient with DKA. METHODS: In this retrospective, pre-post chart review, a provider-driven insulin dosing strategy (pregroup) was compared to the CIDT (postgroup) with 24-hour pharmacist monitoring. The CIDT utilized an equation that incorporated a patient's most recent blood glucose (BG) value and recommended a rate of insulin (units/hour) every hour. RESULTS: All baseline characterizes were similar between the 2 groups. There were no significant differences in average time to anion gap closure (≤ 12 mEq/L) or intensive care unit length of stay between the pregroup and postgroup (12.5 [6] hours vs 10.5 [7] hours, P = 0.235; 40.6 [24] hours vs 40.8 [24] hours, P = 0.945). Although not statistically significant, 17 hypoglycemic events (BG < 70 mg/dL) occurred in the pregroup with 4 being severe (BG < 50 mg/dL) while 5 hypoglycemic events occurred in the postgroup, none of which were severe. CONCLUSION: This study suggests, when compared to a provider-driven insulin dosing strategy, the CIDT with 24-hour pharmacist monitoring is efficacious and safe for treatment of patients with a primary diagnosis of DKA.

Pain, delirium, and physical function in skilled nursing home patients with dementia.

OBJECTIVE: Skilled nursing facilities (SNFs) are major sites of postacute care for patients with dementia. A recent Office of the Inspector General report indicated that outcomes in SNFs are suboptimal because of poor-quality treatment, including the failure to provide needed care. Pain is frequently unrecognized and untreated in patients with dementia. The aim of this exploratory study was to examine the effect daily pain has on delirium and physical function in patients with dementia in SNFs. The association of daily pain with discharge disposition was also examined. DESIGN: Secondary analysis of data from an on-going randomized clinical trial. SETTING: Eight SNFs located in central and northeast Pennsylvania. PARTICIPANTS: A total of 103 SNF patients with adjudicated dementia and delirium diagnoses and a mean age of 86 (±6.8) years; most were women (66%) and white (98%). MEASUREMENTS: Measures of pain (Pain Assessment in Advanced Dementia), delirium (Confusion Assessment Method), and physical function (Barthel Index) were taken daily for 30 days or until discharge. RESULTS: On days when participants experienced greater than their average level of pain, they also experienced more delirium symptoms (P < .001) and lower physical function (P < .001). Participants with higher levels of average daily pain were more likely to die (odds ratio [OR] 6.306, 95% confidence interval [CI] 1.914-20.771, P = .003) or be placed in a nursing home (OR 4.77, 95% CI 1.7-13.2, P = .003) compared with returning to the community at 3-month follow-up. CONCLUSION: Greater attention to pain in patients with dementia may be a potential solution to some of the quality problems and high costs of care in SNFs.

Do patients at risk of sleep apnea have an increased risk of cardio-respiratory complications during endoscopy procedures?

BACKGROUND: Patients with sleep apnea (OSA) have an increased risk of perioperative complications. AIM: The purpose of this study is to assess whether OSA increases the risk of cardio-respiratory complications in patients undergoing endoscopic procedures with conscious sedation. METHODS: A prospective study over a 7-month period was performed. All patients undergoing upper, lower, or combined endoscopy were asked to fill in the Berlin questionnaire. The questionnaire was scored, and patients were classified as high or low risk for sleep apnea based on the suggested scoring criteria. Patients who had previously undergone a sleep study were excluded. Demographics and co-morbidities were identified from the electronic medical record. Procedure type, amount of sedation, and minor and major complications were identified from the endoscopy flow sheet. The minor complications were defined as hypertension, hypotension, bradycardia, tachycardia, hypoxemia, and bradypnea (respiratory rate <8 breaths/min). Major complications included chest pain, arrhythmia, altered mental status, respiratory distress, and a minor complication that required a significant intervention, such as use of a reversal agent, atropine, up-titration of oxygen for hypoxemia, or prolonged observation. RESULTS: Procedures were performed in 904 patients: colonoscopies, 68.0%; upper endoscopies, 22.8%; and combined procedures, 9.2%. Five hundred fifty-three patients were identified as low risk (61.2%), and 351 were identified as high risk (38.8%). The mean age was 59.5 ± 10.5 years, mean body mass index was 28.9 ± 6.6, mean neck circumference was 16.2 ± 6.3 in., and 91.4% were males. The median Charlson co-morbidity index was 1 (25-75% percentage range 0-2). All patients received midazolam and fentanyl during endoscopy. The median and 25-75% range for midazolam and fentanyl dosages were 5 mg, 4-6 mg and 100 µg, 75-125 µg, respectively. Minor complications were observed in 10.56% of low-risk patients and 10.63% of high-risk patients (p = not significant (NS); odds ratio, 1.01; 95% confidence interval 0.65-1.56). Major complications were observed in 3.25% of low-risk patients and 1.9% of high-risk patients (p = ns; odds ratio, 0.6; 95% confidence interval 0.26-1.46). CONCLUSION: For patients undergoing endoscopy procedures under conscious sedation, the presence of OSA does not clearly increase the risk of cardiopulmonary complications.

Effects of pulmonary rehabilitation on activity levels in patients with chronic obstructive pulmonary disease.

PURPOSE: The purpose of this study was to determine whether patients with chronic obstructive pulmonary disease (COPD) increase physical activity immediately after a short course (8 weeks) of pulmonary rehabilitation (PR). Activity levels in patients with COPD were also compared with those in healthy controls. METHODS: Consecutive patients with COPD (n = 24, aged 71.9 ± 7.7 years, forced expiratory ventilation in 1 second 44.1 ± 17.9% predicted, who completed PR) and 8 aged-matched controls (aged 66.6 ± 7.2 years) were studied. Activity was monitored with a triaxial accelerometer for 5 days before and after PR. Activity was expressed as vector magnitude units (VMU) per minute and time spent at VMU above 250 and 500, respectively. RESULTS: Overall activity was significantly less in patients with COPD compared with that in controls (117 ± 63 compared with 242 ± 103 VMU/min, P = .0003). Time spent at VMU above 250 and 500 was also less in patients with COPD (166 ± 71 vs 227 ± 37 min, P = .028 and 39 ± 43 vs 124 ± 26 min, P < .0001, respectively). After PR, overall VMU activity was not significantly increased (117 ± 63 vs 120 ± 63 VMU/min). Time spent at VMU above 250 and 500 was also not significantly increased after PR. Increases in activity levels after PR did not correlate with improvements in exercise performance, quality of life, or quadriceps strength. CONCLUSIONS: Despite significant improvements in exercise capacity and quality of life after PR, this did not translate into a significant increase in activity level. Improving function in patients with copd may not translate into behavioral change.

Incidence of postpartum thrombosis and preterm delivery in women with antiphospholipid antibodies and recurrent pregnancy loss.

OBJECTIVE: To determine the frequency of preterm deliveries and postpartum thrombotic events (TE) in pregnancies resulting in live birth in women with antiphospholipid antibodies (aPL) and a history of recurrent pregnancy loss (RPL) but without prior TE. METHODS: We reviewed the pregnancy outcomes of women referred to our clinic with a history of RPL. Prepregnancy investigation of RPL included history of TE and aPL positivity (anticardiolipin IgG and lupus anticoagulant). We recorded use of anticoagulation therapy during and after pregnancy, obstetric outcome, gestational age at delivery, and postpartum course. Included in our study were women with unexplained RPL with no history of TE attending our clinic who subsequently had pregnancies that resulted in a live birth. RESULTS: Over a 5-year period, 260 women with RPL and no history of TE had a live birth at our clinic. Eighty-seven (33.5%) were positive for aPL and 173 (66.5%) were negative for aPL. Twenty-four percent of deliveries in the aPL-positive group occurred before 37 weeks' gestation compared to 9.8% of deliveries in the aPL-negative group (p = 0.004; 95% CI 0.052-0.234). There were no antepartum TE in either group. One woman in the aPL-positive group (1.1%) had a deep vein thrombosis 3.5 weeks postpartum while receiving prophylactic anticoagulant therapy, compared to none in the aPL-negative group. CONCLUSION: A significantly higher proportion of aPL-positive patients had preterm deliveries compared to aPL-negative patients, but pregnancy-related TE was infrequent: 99.0% of aPL-positive women with a history of RPL and no prior TE who had a live birth at our clinic had an uneventful pregnancy, delivery, and postpartum course.

Preterm deliveries in women with systemic lupus erythematosus.

OBJECTIVE: To compare the clinical, laboratory, and demographic variables of women in our clinic with systemic lupus erythematosus (SLE) who have had a pregnancy resulting in a live birth and identify any correlations with either term or preterm delivery. METHODS: Pregnancies in women with SLE from 1999 to 2001 were retrospectively reviewed. We recorded demographic data, disease activity (SLE Disease Activity Index, SLEDAI), obstetric history, prednisone dosage, other medications taken during pregnancy, history of renal disease, and autoantibody status [including antinuclear antibody, anti-DNA, anticardiolipin IgG (aCL), and lupus anticoagulant (LAC)]. Preterm delivery was defined as gestational age at delivery < 37 weeks. We performed a literature survey using PubMed and the key words SLE, pregnancy, and outcome. RESULTS: Of the 72 pregnancies, 28 (38.9%) resulted in preterm deliveries. There were no significant differences in any demographic or disease variables measured comparing term versus preterm delivery groups. More women in the preterm group were taking > or = 10 mg/day prednisone during their pregnancy (50.0% vs 22.2%; p = 0.028), and the mean dose was significantly higher than the term group taking > or = 10 mg/day (24.8 vs 16.7 mg/day; p = 0.047). There was a higher prevalence of women with aCL IgG in the preterm group (p = 0.023). The mean weeks gestation was shorter for women positive for aCL IgG compared to the group negative for aCL (34.9 +/- 4.4 vs 37.5 +/- 3.2 weeks, respectively; p = 0.032). There was no difference in second trimester disease activity between the term and preterm groups (33.3% and 36.4% of each group had a SLEDAI of 0). However, significantly more women in the term group received no medication during their pregnancies compared to women in the preterm group (20.0% vs 0.0%; p = 0.031). CONCLUSION: The rates of preterm deliveries, premature rupture of membranes, intrauterine growth restriction, and aPL in SLE pregnancies vary considerably in published reports, most of which are retrospective analyses. Our rates closely approximate the median values for all measures. We found preterm deliveries to be associated with disease activity (as determined by the use of any medication throughout pregnancy vs no medication, and prednisone dose > or = 10 mg/day) and the presence of aCL IgG but not LAC. Our results suggest that inactive disease rather than controlled disease at the onset of pregnancy may be the determining factor in extending SLE pregnancies to full term, thereby decreasing maternal and fetal morbidity.