Bicarbonate as a predictor of successful insulin transition in critically ill patients with diabetic ketoacidosis: A retrospective cohort study.

BACKGROUND: Treatment of diabetic ketoacidosis with intravenous insulin is effective but resource intensive. Treatment guidelines recommend transitioning to subcutaneous insulin when the anion gap closes, but transition failures due to recrudescent ketoacidosis are common despite adherence to treatment protocols following such guidance. STUDY OBJECTIVE: The primary objective of our study was to evaluate the ability of serum bicarbonate levels of ≤16 mEq/L to predict intravenous to subcutaneous transition failures among those with a normal anion gap at the time of transition. DESIGN AND SETTING: This retrospective cohort study evaluated critically ill adult patients with a primary diagnosis of diabetic ketoacidosis. Historical patient data were obtained by manual chart review. The primary outcome was transition failure, defined as the re-initiation of intravenous insulin within 24 h of transitioning to subcutaneous insulin. Odds ratios were calculated using generalized estimating equations with a logit link and weighted by standardized inverse probability weights to assess the predictive value of serum bicarbonate levels. MAIN RESULTS: The primary analysis included 93 patients with a total of 118 distinct transitions. In the adjusted analysis, patients whose anion gap had normalized but had a serum bicarbonate of ≤16 mEq/L were significantly more likely to experience a transition failure (odds ratio = 4.74, 95% confidence interval: 1.24-18.1, p = 0.02). The results of the unadjusted analysis were similar. CONCLUSIONS: In patients with a normal anion gap at the time of insulin transition, serum bicarbonate levels of ≤16 mEq/L were associated with significantly increased odds of transition failure.

Reducing Diabetic Ketoacidosis Intensive Care Unit Admissions Through an Electronic Health Record-Driven, Standardized Care Pathway.

Diabetic ketoacidosis (DKA) is a common condition, with wide variation in admission location and clinical practice. We aimed to decrease intensive care unit (ICU) admission for DKA by implementing a standardized, electronic health record-driven clinical care pathway that used subcutaneous insulin, rather than a continuous insulin infusion, for patients with nonsevere DKA. This is a retrospective, observational preintervention to postintervention study of 214 hospital admissions for DKA that evaluated the effect of our intervention on clinical, safety, and cost outcomes. The primary outcome was ICU admission, which decreased from 67.0% to 41.7% (p < .001). Diabetes nurse educator consultation increased from 45.3% to 63.9% (p = .006), and 30-day Emergency Department (ED) return visit decreased from 12.3% to 2.8% (p = .008). Time to initiation of basal insulin increased from 18.19 ± 1.25 hours to 22.47 ± 1.76 hours (p = .05) and reopening of the anion gap increased from 4.7% to 13.9% (p = .02). No changes in ED length of stay (LOS), hospital LOS, hypoglycemia, treatment-induced hypokalemia, 30-day hospital readmission, or inpatient mortality were observed. The implementation of a standardized DKA care pathway using subcutaneous insulin for nonsevere DKA resulted in decreased ICU use and increased diabetes education, without affecting patient safety.

Decreased serum linezolid levels in a critically ill patient receiving concomitant linezolid and rifampin.

Serious gram-positive infections present an increasingly common therapeutic dilemma. Combination antimicrobial regimens (e.g., linezolid with rifampin) aimed at improving bacterial eradication and preventing resistance are often used; however, most data supporting this treatment strategy are not from randomized controlled trials. We describe a patient with disseminated community-acquired methicillin-resistant Staphylococcus aureus infection who experienced a possible drug interaction between linezolid and rifampin that resulted in decreased serum linezolid levels. To our knowledge, this is the first published report of a possible drug interaction in a critically ill patient receiving concomitant linezolid and rifampin. Although we hypothesize that the reaction was caused by P-glycoprotein expression, further study is warranted.

Benefit of ribose in a patient with fibromyalgia.

Ribose was added to the existing treatment regimen of a woman with fibromyalgia, resulting in a decrease in symptoms. It has been postulated that patients with fibromyalgia may have an alteration in muscle adenine nucleotide metabolism, leading to depleted energy reserves and an imbalance in cellular adenosine 5'-triphosphate:adenosine 5'-diphosphate:adenosine 5'-monophosphate (ATP:ADP:AMP) ratios with an abnormal energy charge. As a key component in adenine nucleotide synthesis, ribose supplementation may be useful in such patients.

Organ pipe radiant modes of periodic micromachined silicon surfaces.

In recent studies on small pyroelectric thermal anemometers with roughened surfaces we showed that one of the most widely used heat transfer models1,2 yielded calculated anemometer responses for flow and geometric behaviour that agreed functionally with observations, but were significantly smaller than the experimental data3-5. As the first stage in investigating the role of small structures in heat transfer, we initiated a study of emittance from deep gratings. Here we report measurements at 400 °C of infrared (3 µm⩽λ⩽14 µm), normal, s- and p-polarized spectral emittances of 45 µm deep, near square-wave gratings of heavily phosphorus doped (110) silicon (P content ∼5 × 1019 cm-3). The grating surface repeat scales, Λ, were 10, 14, 18 and 22µm, yielding a range of Λ/λ from 0.14 to 7.33. The s-polarization vector was parallel to the grating slots. Both s and p spectral emittances had pronounced resonant periodicities with a characteristic length of ∼42 µm. A reasonable explanation for this behaviour is the presence of standing waves in the air slots perpendicular to the silicon surface similar to those in an organ pipe. While the resonant amplitude of the s polarization does not depend significantly on Λ it does for the p polarization. No explanation for the Λ dependence of the p polarization is known.