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.

COVID-Necessitated Online Radiology Elective Improves Student Imaging Appropriateness in Clinical Case Vignettes

RATIONALE AND OBJECTIVES

The use of imaging in medicine has increased considerably over the previous decades, contributing to significant inefficiency of use. Radiology education varies amongst institutions without standardized learning objectives. Consequently, many physicians and student doctors are unprepared to make appropriate choices regarding imaging. In response to COVID-19-engendered restrictions, we created a fully online, image-intensive radiology curriculum to introduce students to clinical radiology and appropriate imaging usage.

MATERIALS AND METHODS

A 2-week radiology elective curriculum was created that adopted accessible, free, online-based learning to foster student education and patient safety while upholding academic standards. Each unit included an emphasis on imaging appropriateness. Students assembled an elective portfolio including self-assessments and prepared a clinical radiology conference to present as a radiologist in training. Two final assessments were required. One consisted of clinical vignettes based on American College of Radiology (ACR) Appropriateness Criteria (AC). The second was an MRI safety quiz.

RESULTS

Third and fourth year students at five institutions (N = 97) completed the elective. Examination scores on an assessment adapted from the ACR AC were significantly improved compared to previously published scores of medical students who took ACR AC-based assessments without taking a radiology course. The course was published and shared with medical schools worldwide.

CONCLUSION

The elective successfully educated students in radiology through a virtual platform and introduced them to the concept of appropriateness in medical imaging. These goals were accomplished using a free, online, easily accessible curriculum. Incorporation of additional topics within the discipline of radiology should be included in the curriculum in the future.

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.

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.

Adapting Surgical Clerkship Curricula in Response to the COVID-19 Pandemic

BACKGROUND

Coronavirus disease-19 (COVID-19) impacted medical education and led to the significant modification or suspension of clinical clerkships and rotations.

OBJECTIVES

To describe a revised surgery clerkship curriculum, in which we divided in-person clinical teaching into smaller groups of students and adopted online-based learning to foster student and patient safety while upholding program standards.

METHODS

The third-year surgery core clerkship of a 4-year international English-language program at the Medical School for International Health at Ben Gurion University of the Negev, Beer Sheva, Israel, was adapted by dividing students into smaller capsules for in-person learning and incorporating online learning tools. Specifically, students were divided evenly throughout three surgical departments, each of which followed a different clinical schedule.

RESULTS

National Board of Medical Examiners clerkship scores of third-year medical students who were returning to in-person clinical clerkships after transitioning from 8 weeks of online-based learning showed no significant difference from the previous 2 years.

CONCLUSIONS

To manage with the restrictions caused by COVID-19 pandemic, we designed an alternative approach to a traditional surgical clerkship that minimized the risk of exposure and used online learning tools to navigate scheduling challenges. This curriculum enabled students to complete their clinical rotation objectives and outcomes while maintaining program standards. Furthermore, this approach provided a number of benefits, which medical schools should consider adopting the model into practice even in a post-pandemic setting.

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.

Evidence-Based Medicine in Ophthalmic Journals During Covid-19 Pandemic

Background

COVID-19 has erupted into our lives and forced rapid changes in all fields of medicine, causing a rush for publications that inevitably caused a shift away from the paradigm of evidence-based medicine (EBM). The objective of the present report is to assess and quantify this process.

Methods

We compared the levels of EBM of the publications in the ophthalmic literature on COVID-19 at the beginning of the pandemic and compared it to those of articles published the prior year during April 2019 for the three highest ranking journals in the field of comprehensive ophthalmology.

Results

COVID-19 publications ranked significantly lower (p<0.001). Time between submission and acceptance was significantly shorter for the COVID-19 publications (p<0.001), and significantly more publications were accepted without revisions (P<0.001).

Conclusion

Though a shift away from EBM may be unavoidable in the early stages of a pandemic, we suggest that for the benefit of reliable information and informed decision-making, it is time to go back to EBM.

Age, ageing, ageism and "age-itation" in the Age of COVID-19: rights and obligations relating to older persons in Israel as observed through the lens of medical ethics

COVID-19, the illness caused by the SARS-CoV-2 virus, has reached pandemic proportions. Although the virus can cause disease in anyone, it is particularly dangerous for those with various "co-morbidities" such as heart disease, hypertension, diabetes, obesity and others. Furthermore, advancing age (from about 60 on), even in those older persons without any accompanying illnesses, is a strong and independent risk factor for pneumonia, need for an ICU bed and death from the virus. It is therefore essential to find ways to protect all at-risk persons (old or young) from the virus but at the same time not harming, more than absolutely necessary their essential freedoms as well as taking into account their social/psychological needs. Compared with other OECD countries, Israel's population is still relatively young, with only 11.5% being over 65+ with a smaller proportion of older persons in long-term institutions than that found in most other comparable jurisdictions. These factors might explain a part of the country's (so far) relatively low rates of serious disease and mortality compared to those seen in other developed countries. However there are still over a million older citizens at risk and the numbers of infected, hospitalized and seriously ill persons are rising once again. This is no time for complacency.An analysis of the effect of age on the disease as seen through the principles of medical ethics is followed by a proposal as to how best to balance these sometimes conflicting goals. This paper relates mainly to older persons in the community since the Ministry of Health early on in the pandemic initiated an effective program (Magen Avot) meant to protect those older persons in long-term care institutions. Recommendations include the Ministry of Health publishing clear guidelines as to risk factors and offering sensible advice on how to practice physical (not "social") distancing without exacerbating an older person's sense of social isolation. In order to reduce the incidence of influenza (which can clinically be confused with COVID-19) and the potentially disastrous consequences of a "double pandemic" this coming winter, a robust flu vaccination program needs immediate implementation. Persons at all ages (but especially those 60+) should be encouraged and assisted to sign advance directives, especially those who do not wish to undergo invasive therapy. An individual older person's wish to "make way" for younger people should be respected as an expression of his/her autonomy. As we enter the second wave, triage mechanisms and protocols need to be circulated in readiness for and well before a situation in which an acute imbalance develops between the availability for acute resources and the population's need for them. The Ministry of Health, in cooperation with other relevant ministries and NGOs, should take the lead in developing plans, ensuring that they are carried out in an orderly, timely and transparent manner. The blanket is indeed not large enough but we must place it as judiciously as possible in order as much as possible to protect, cover and keep warm the body politic.

Hybrid Telehealth Medical Retina Clinic Due to Provider Exposure and Quarantine During COVID-19 Pandemic

Objective

To present our hybrid telehealth medical retina clinic service with intravitreal injections (IVI) treatment as a safe alternative to in-person visits and examination during COVID-19 pandemic disease.

Methods

Due to exposure to a COVID-19 positive retina fellow, our retina service, in quarantine, evaluated patients’ medical files and retinal scans using a telemedicine approach. A different protocol for patients coming for IVI during the COVID-19 pandemic was established for IVI administration.

Results

During the 14-day quarantine period (between March 18th and March 31st 2020), the hybrid telehealth medical retina clinic performed 523 IVI to 394 patients with a mean age ± SD 70.96 ± 14.4 years. IVI were administered for neovascular age-related macular degeneration in 50.5% of the cases (199 patients), diabetic macular edema in 21.3% (84 patients), retinal vein occlusion in 17.5% (69 patients), and 10.7% for other retinal pathologies (42 patients). No ocular or systemic complications were observed.

Conclusion

During disasters and pandemics, IVI can be provided safely using a hybrid telehealth medical retina clinic approach but only in the appropriate patient and health care system.

Remote pathology education during the COVID-19 era: Crisis converted to opportunity

Context

The COVID-19 pandemic led to shutting of education faculties, including clinical clerkships for medical students.

Objective

To review a selective for a course in diagnostic pathology geared toward undergraduate medical students, including its design, technical implementation, instructor and student evaluations, and suggestions for options for further adjusting and optimizing the selective.

Design

Whole slide images (WSI) were anonymized and students were given remote access to university computers, which were prepared with two freely available WSI viewers. Each topic was taught in a four-part module: Self-assigned reading, lecture via Zoom, quiz based on digital slide sets, and a frontal review of the slides via Zoom. Fifty-nine students participated in the selective. Following the course, students completed an anonymous questionnaire.

Results

Of the 59 participants, 42% (n = 25) responded. None of the respondents had any previous instruction in diagnostic pathology. Overall, the course was rated very favorably: 68% (n = 17) gave at least 3 points on a 4-point scale on questions relating to course interest, improvement in understanding of the covered diseases, and how strongly they would recommend a student take this course if given an option. The most significant disadvantage of the class, as reported by 80% (n = 20) were technical challenges in accessing the slides.

Conclusion

We believe the course was a success and can be a model for future virtual pathology electives. Great effort should be done to provide technical support to the students. The selective demonstrated value for students and provided much-needed exposure to diagnostic pathology in clinical practice.

•

COVID-19 pandemic guidelines partially excluded medical students from their normal training.

•

A new pathology course, utilizing distance learning, was implemented.

•

Digital pathology slides enriched the undergraduate students' education.

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.

The healthcare worker at risk during the COVID-19 pandemic: a Jewish ethical perspective

The current COVID-19 pandemic has raised many questions and dilemmas for modern day ethicists and healthcare providers. Are physicians, nurses and other healthcare workers morally obligated to put themselves in harm's way and treat patients during a pandemic, occurring a great risk to themselves, their families and potentially to other patients? The issue was relevant during the 1918 influenza epidemic and more recently severe acute respiratory syndrome epidemic in 2003. Since the risk to the healthcare workers was great, there was tension between the ethical duty and responsibility to treat and the risk to one's own life. This tension was further noted during the 2014 Ebola outbreak in West Africa that left hundreds of healthcare workers dead. The AMA Code of Ethics states that physicians are to 'provide urgent medical care during disasters…even in the face of greater than usual risk to physicians' own safety, health or life.'1 Classic Jewish sources have dealt with this question as well. There is an obligation 'to not stand by idly when your friends life is in danger'; however, the question arises as to whether there are limits to this obligation? Is one required to risk one's own life to save another's? There is a consensus that one is not required but the question open to debate is whether it is praiseworthy to do so. However, regarding healthcare workers, there is agreement for ethical, professional and societal reasons that they are required to put themselves in harm's way to care for their patients.

Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making.

Clinical and Epidemiological Characteristics of Diabetic Ketoacidosis in Older Adults

OBJECTIVES

Much of the research previously done on diabetic ketoacidosis (DKA) was based on a young population with type 1 diabetes mellitus (type 1 DM). But substantial numbers of DKA episodes occur in patients with a prior history of type 2 diabetes mellitus (type 2 DM). There is a lack of Data are lacking about DKA in older adults. The aims of this study were to analyze the clinical characteristics and outcomes of older adult patients with DKA.

DESIGN

Retrospective matched cohort study of adult patients hospitalized with DKA between 2004 and 2017.

SETTING

Soroka University Medical Center, Be'er Sheva, Israel.

PARTICIPANTS

The clinical characteristics of DKA patients 65 years and older were compared with patients younger than 65 years.

MEASUREMENTS

The primary outcome was in-hospital mortality.

RESULTS

The study cohort included 385 consecutive patients for whom the admission diagnosis was DKA: 307 patients (79.7%) younger than 65 years (group 1), and 78 patients (20.3%) older than 65 years (group 2). Patients in group 2 compared with group 1 had a significantly higher Charlson index (6 [6-6] vs 6 [6-7]; P < .0001) and DM with target organ damage (24.4% vs 6.2%; P < .0001). Patients in group 2 compared with group 1 had more serious disease according to results of laboratory investigations. The total in-hospital mortality rate of patients in group 2 was 16.7% compared with 1.6% in patients in group 1 in a sex and co-morbidities matched analysis (P = .001).

CONCLUSIONS

DKA in older adults is a common problem. The serious co-morbidities and precipitating factors such as infection/sepsis, myocardial infarction, and cerebrovascular accidents, may explain the severity of the problem of DKA in older adults and the high rate of mortality of these patients. DKA appears to be a lifethreatening condition in older adults. The alertness of physicians to DKA in older adults, timely diagnosis, proper treatment, and prevention are cornerstones of care. J Am Geriatr Soc 68:1256-1261, 2020.

High prevalence of fibromyalgia syndrome among Israeli nurses

OBJECTIVES

Stress has extensively been shown to trigger fibromyalgia syndrome (FM). Nursing is associated with high levels of stress. Our hypothesis was that nurses suffer from an increased prevalence of FM symptoms, and that these symptoms correlate with the levels of stress to which they are exposed in the course of their occupation.

METHODS

The study was conducted as a targeted survey distributed to nursing staff in Soroka University Medical Centre, Beer-Sheva, Israel. Participants were asked to answer a questionnaire evaluating symptoms of FM, based on the current diagnostic criteria, which include the widespread pain index (WPI) and the symptom severity scale (SSS). Participants were further questioned regarding stressful experiences during their work and about post-traumatic symptoms as well as regarding work performance and motivation.

RESULTS

206 participants completed the study questionnaire (84.5% females and 15.5% males). Twenty (9.7%) participants of the sample fulfilled criteria for diagnosis of FM reaching rates among females and males of 10.9% and 3.1% respectively. The prevalence of FM in our study was related to age with the highest prevalence in the older age groups (p=0.012). FM symptoms were strongly correlated with work related stress and were strongly correlated with Post Traumatic Stress Disorder (PTSD)-related symptoms. Work-performance parameters did not show a significant correlation with FM parameters.

CONCLUSIONS

FM is highly prevalent among nursing staff. Our findings point towards the possibility that work-related stress and traumatic events may play a major role in the development of FM symptoms among nurses. With aging this association is more significant.

Takotsubo cardiomyopathy triggered by wasabi consumption: can sushi break your heart?

Takotsubo cardiomyopathy is a left ventricular dysfunction that typically occurs after sudden intense emotional or physical stress and mimics myocardial infarction. We describe a case of a 60-year-old woman that presented to the emergency department with chest pain after she attended a wedding and ate a large amount of wasabi, assuming it to be an avocado. To the best of our knowledge, this is the first report of takotsubo cardiomyopathy triggered by wasabi consumption.

Recurrent diabetic ketoacidosis

OBJECTIVE

The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions.

MATERIALS AND METHODS

Review article.

RESULTS

Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients.

CONCLUSIONS

Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Withholding Treatment From the Dying Patient: The Influence of Medical School on Students' Attitudes

PURPOSE

To determine motives and attitudes towards life-sustaining treatments (LSTs) by clinical and preclinical medical students.

METHODS

This was a scenario-based questionnaire that presented patients with a limited life expectancy. The survey was distributed among 455 medical students in preclinical and clinical years. Students were asked to rate their willingness to perform LSTs and rank the motives for doing so. The effect of medical education was then investigated after adjustment for age, gender, religion, religiosity, country of origin, and marital status.

RESULTS

Preclinical students had a significantly higher willingness to perform LSTs in all cases. This was observed in all treatments offered in cases of a metastatic oncologic patient and an otherwise healthy man after a traumatic brain injury (TBI). In the case of an elderly woman on long-term care, preclinical students had higher willingness to supply vasopressors but not perform an intubation, feed with a nasogastric tube, or treat with a continuous positive air-pressure ventilator. Both preclinical and clinical students had high willingness to perform resuscitation on a twelve-year-old boy with a TBI. Differences in motivation factors were also seen.

DISCUSSION

Preclinical students had a greater willingness to treat compared to clinical students in all cases and with most medical treatments offered. This is attributed mainly to changes along the medical curriculum. Changes in reasons for supplying LSTs were also documented.

Euglycemic diabetic ketoacidosis

Euglycemic DKA (eu-DKA) is a life-threatening emergency. It may occur in patients with both type 1 and type 2 DM, and characterized by milder degrees of hyperglycemia with blood glucose level < 200 mg/dl, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences. Following the wide introduction of the sodium glucose transporter 2 inhibitors (SGLT2i) in therapeutic practice for DM type 2 treatment the amount of eu-DKA increased and therefore, interest to this entity rose. Other causes associated with eu-DKA include pregnancy, decreased caloric intake, heavy alcohol use, insulin use prior to hospital admission, cocaine abuse, pancreatitis, sepsis, chronic liver disease and liver cirrhosis. Patients with eu-DKA as well as with DKA need immediate referral for emergency evaluation and treatment. The treatment includes rapid correction of dehydration, correction electrolyte abnormalities, and use of insulin drip until the anion gap, and bicarbonate levels normalize. Increased glucose administration using higher percentages of dextrose (10 or 20%) are required to facilitate the concomitant administration of the relatively large amounts of insulin that are needed to correct the severe acidosis in these patients.

Placebos in the era of open-label trials: An update for clinicians

Placebos have been used extensively by vast numbers of physicians, in a majority of clinical trials. Placebo effects involve behavioural, psychological and genetic factors and have been subject to ethical controversies stemming from the use of deception in treating patients. The patient-physician encounter, endogenous pharmacological pathways, personality traits and genetic diversity have all been reported to be key players in placebo responses. In the last decade, a new methodological paradigm of placebo research has emerged, using open-label placebos to investigate their effects which showed promising results for various common medical conditions. In this review, we will summarize the current body of evidence on placebos in clinical practice, with a view to open-label placebo trials in particular. It is our view that future larger-scale randomized blinded open placebo trials will benefit physicians and improve patient outcomes.

Clinical, Epidemiological, and Etiological Changes in Erythema Nodosum

BACKGROUND

Erythema nodosum (EN) is the most common type of panniculitis, commonly secondary to infectious diseases.

OBJECTIVES

To elucidate the causative factors and the clinical presentation of patients with EN (2004-2014) and to compare their data to those reported in a previous study.

METHODS

A retrospective study was conducted of all patients diagnosed with EN who were hospitalized at Soroka University Medical Center (2004-2014). The clinical, demographic, and laboratory characteristics of the patients were compared to those in a cohort of patients diagnosed with EN from 1973-1982.

RESULTS

The study comprised 45 patients with a diagnosis of EN. The most common symptoms of patients hospitalized with EN were arthritis or arthralgia (27% of patients). Patients with EN, compared to those reported in 1987, has significantly lower rates of fever (18% vs. 62% P < 0.001), streptococcal infection (16% vs. 44%, P = 0.003), and joint involvement (27% vs. 66%, P < 0.001). In addition, fewer patients had idiopathic causes of EN (9% vs. 32%, P = 0.006).

CONCLUSIONS

In the past decades, clinical, epidemiological, and etiological changes have occurred in EN patients. The lowering in rate of fever, streptococcal infection, and joint involvement in patients with EN are probably explained by improvements in socioeconomic conditions. The significantly decreasing rate of idiopathic causes of EN is possibly due to the greater diagnostic accuracy of modern medicine. The results of the present study demonstrate the impact of improvements in socioeconomic conditions and access to healthcare on disease presentation.

Dabigatran-induced nephropathy and its successful treatment with Idarucizumab - case report and literature review

BACKGROUND

Anticoagulant induced renal injury has been previously described with Warfarin treatment. In the last decade direct oral anticoagulants (DOAC) were introduced. They include direct inhibitors of factor Xa (Rivaroxaban, Apixaban, Edoxaban) and a thrombin inhibitor (Dabigatran). There are isolated reports describing acute kidney injury (AKI) due to the use of DOACs.

CASE REPORT

We report a clinical case of an 80-year-old patient recently started on Dabigatran for new onset atrial fibrillation. She presented with AKI and hematuria, urine specimen showed RBC casts, and a working diagnosis of anticoagulant nephropathy due to Dabigatran was made. During hospitalization she was treated with Idarucizumab with a full recovery of renal function. To the best of our knowledge, there are 4 published case reports describing kidney injury produced by Dabigatran.

CONCLUSION

The use of DOACs is increasing rapidly, with increasing concern about its safety profile and, in particular, its potential harmful effect on renal function. As described in our case, treatment with Praxbind for Dabigatran induced kidney injury may be an acceptable management strategy that may obviate the need for urgent dialysis in selected cases by complete reversal of the AKI.

Ethical issues in medical cannabis use

The increasing use of medical cannabis (MC) in the past decade raises several ethical considerations for the clinician. Regulatory issues stem from a gap between MC registration and certification in each country. Professional issues derive from the lack of sufficient knowledge of MC characteristics and the intersection between the physician, the patient and commercial interests. Finally, there are medical and psychological implications which are related to the use of MC regimens. We will discuss these issues in the light of the current era, in which policy has rapidly shifted toward legalization of cannabis, which influences the decisions of both clinicians and patients.

Altruism and Religion: A New Paradigm for Organ Donation

Activity of NGO's supporting living donor kidney donations can affect the shortage of kidneys. Matnat Chaim is a Jewish orthodox organization active in Israel since 2009. This is a voluntary organization with aims to shorten and eliminate the waiting list for kidneys. Since the beginning of its activity, it has said to play a key role in 379 kidney transplantations. In 2015, out of 174 live donor kidney transplantations that took place in Israel, Matnat Chaim had a key role in 88 of them (50.6%). We found some ethical issues concerning the organization's activity. The donor can restrict his or her donation to specific characteristics of recipient which can result in organs transplanted in a homogeneous group of the population. Another issue is the question of whether nudging people to kidney donation takes place and whether it is valid to do so. We found that Matnat Chaim does a great deal for promotion and intermediation of kidney donations in Israel. This form of promotion can be implemented by other organizations and countries.

Basal insulin for the management of diabetic ketoacidosis

Due to its pharmacokinetic properties, it has been suggested that long-acting insulin analogues may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA for prevention of rebound hyperglycemia, particularly if there are high insulin requirements. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia. Several studies have investigated the use of basal insulin in the management of DKA. Studies have been instituted on pediatric patients and adult patients. These studies reveal that co-administration of basal insulin in combination with an insulin infusion in the acute management of DKA is feasible. Basal insulin co-administration with regular insulin infusion was well tolerated, associated with faster resolution of acidosis without any adverse effects; patients required a shorter duration of intravenous insulin infusion and had a lower total dose of intravenous insulin and significantly decreased hyperglycemia after discontinuation of the intravenous insulin. This could potentially lead to a shorter ICU length of stay and reduced costs in the treatment of DKA. However, this approach may be associated with an increased risk of hypokalemia. The current literature on this management approach is incomplete, due to its many limitations (retrospective nature, small sample size, nonrandomized design). Additional prospective randomized studies are needed on this new therapeutic approach in the management patients with DKA.

The Patient-Psychiatrist Relationship on the Axis of the Other and the Same

The patient-psychiatrist relationship is a cornerstone of psychiatric professionalism and ethics. We discuss this topic along the axis of the Other and the Same, concepts defined by continental philosophy. The self of Anglo-American philosophy is typically described in individualistic terms. Individualism, autonomy and ideal self are valorized within the current model of care. These characteristics belong to the Lacanian Imaginary Order, which is the core of narcissism. Patients may yearn for another model of interaction. For Levinas, ethics should not involve a search for perfectionism and accomplishment but responsibility toward others. Ethics is, according to him, rooted in the calling into question of one's Sameness by the other's Otherness. The question of hospitality and of the welcoming of Otherness is central to his thought. Derrida further asks whether hospitality is not an interruption of the self. Hospitality may thus become a fundamental way of re-thinking clinical practices. A relationship to the Other as an-other is characterized as of Euclidian-type, establishing borders between the self and the Other, whereas a relationship to the Other as same is characterized as of fractal-type, emphasizing similarities between self and other as same and obliterating boundaries. Winnicott's object-relating versus use of object and Buber's I-you and I-it relations are also examined along the axis of Sameness and Otherness. Since psychiatric clinical practice requires to our view adequate and adaptive to and fro movements along this axis, the two forms of relating to the Other are discussed both theoretically and through a clinical case presentation.

Impact of a 3-Day Introductory Oncology Course on First-Year International Medical Students

Although only some medical students will choose cancer as their specialty, it is essential that all students have a basic understanding of cancer and its treatment. The purpose of this study was to evaluate the impact of an introductory clinical oncology course on first-year international medical students. Evaluation of the course involved a quantitative survey designed for this study that was given pre- and post-course completion. Participants included 29 first-year international medical students. Students reported that the course affected them emotionally more than they anticipated it would prior to beginning the course. By the end of the course, students felt more comfortable focusing on how to live with cancer, felt less afraid of dealing with death, and were better able to cope with uncomfortable emotional situations. The course had no significant effect on students' interest in specializing in oncology in the future. Our study provides evidence that an introductory oncology course can increase student comfort with issues related to living with cancer, with confronting and dealing with death and dying, and with coping with uncomfortable emotional situations as related to cancer care. In anticipation of growing shortages in oncology specialists in the coming years, the ability of an early course in oncology to attract more students to the field is of interest. Future research should examine ethnic and cultural differences in uptake of the clinical oncology courses across continents and should use direct observation in addition to self-report in evaluating outcomes.

Response to: 'Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies' by Schuklenk and Smalling

The recent essay by Schuklenk and Smalling opposing respect for physicians' conscientious objections to providing patients with medical services that are legally permitted in liberal democracies is based on several erroneous assumptions. Acting in this manner would have serious harmful effects on the ethos of medicine and of bioethics. A much more nuanced and balanced position is critical in order to respect physicians' conscience with minimal damage to patients' rights.

Reflections on Cultural Preferences and Internal Medicine: The Case of Jehovah's Witnesses and the Changing Thresholds for Blood Transfusions

Jehovah's witnesses oppose receiving blood transfusions based on religious grounds. This refusal raises complex medical, legal and ethical issues for the treating medical staff. In the past physicians attempted to force patients and children to accept transfusions when deemed medically necessary through the use of court orders. However, in recent years the threshold for blood transfusion has been gradually raised by medical experts as expressed in consensus guidelines, which means that Jehovah's witnesses' aversion to transfusion would have been partially justified medically. This article will further discuss these current trends.

[HEALTH SCARES: A CHRONICLE UNNECESSARY ANXIETY]

A health scare is an event characterized by fear of catastrophic consequences with little actual results. Regardless of these negligible results, the health, social and economic impacts of such events may be significant. Health scares are spread throughout four major groups: the media, relevant medical experts, policy makers and the public at large. In this review, we described two recent cases in Israel: the case of Eltroxin exchange that occurred in Israel as well as other countries, in addition to the polio virus spread in sewage, in the context of health scares. Furthermore, we summarized the interaction between these groups, focusing on their functioning in selected health scares from the previous two decades. There is increased need for creating a priori coordinating methods, in order to deal efficiently with such events in the future. In that way, the implications of health scares can be reduce to minimum.

Effectiveness of Inferior Vena Cava Filters without Anticoagulation Therapy for Prophylaxis of Recurrent Pulmonary Embolism

OBJECTIVE

The optimal treatment of deep vein thrombosis (DVT) is anticoagulation therapy. Inferior vena cava filter (IVC) placement is another option for the prevention of pulmonary embolism (PE) in patients with deep vein thrombosis. This is used mostly in patients with a contraindication to anticoagulant therapy. The purpose of the present study was to compare the two options.

METHODS

A retrospective cohort study of two groups of patients with DVT: patients who received an IVC filter and did not receive anticoagulation due to contraindications; and patients with DVT and similar burden of comorbidity treated with anticoagulation without IVC insertion. To adjust for a potential misbalance in baseline characteristics between the two groups, we performed matching for age, gender, and Charlson's index, which is used to compute the burden of comorbid conditions. The primary outcome was an occurrence of a PE.

RESULTS

We studied 1,742 patients hospitalized with the diagnosis of DVT in our hospital;93 patients from this population received IVC filters. Charlson's score index was significantly higher in the IVC filter group compared with the anticoagulation group. After matching of the groups of patients according to Charlson's score index there were no significant differences in primary outcomes.

CONCLUSION

Inferior vena cava filter without anticoagulation may be an alternative option for prevention of PE in patients with contraindications to anticoagulant therapy.

Computerized Tomography Scanning and Magnetic Resonance Imaging Will Terminate the Era of the Autopsy - A Hypothesis

Background: Reports on a marked reduction of the number of autopsies performed worldwide to less than 5% of hospital deaths remain without a satisfactory explanation. The premature disappearance of the autopsy might represent a medical tragedy of a major order. One of the causes for the decrease in autopsies is poorly documented: we suspect that the attending physician might show some reluctance when requesting a consent for an autopsy from the bereaved family. Moreover, this officer might consider that the post mortem will add little information to that already obtained from the computerized tomography scanner or the magnetic resonance imaging.

Methods: In order to confirm our hypothesis, we carried out a review of 300 articles indexed as "radiologic-histologic correlation", 118 of which were selected for a significant correlation. From the abstracts, we retrieved the type of the article, the degree of correlation as assessed by the authors and the form of imaging employed, and we computed them.

Results & conclusions: The most striking correlation was observed in the small prospective series. An additional search for the "radiologic-autopsy correlation" supported a marked reduction in the number of post-mortems, especially those related with prospective studies. Based on the present study, we cannot determine precisely the role of the house officer in this tragedy. We may have demonstrated, however, that the modern radiologic methods have not yet reached a high enough performance quality to achieve the status of a candidate substitute for the autopsy.

The Ethics of Public Health Laws, and the Special Case of the New "Model Law"

The "model law" in Israel forbids underweight models (BMI below 18.5) to work. The stated goal of the law is to prevent eating disorders among the general audience of the models. Most public health laws that aim to encourage healthy lifestyles target issues related to unhealthy products, for instance taxes and limitations on advertisements. A law that aims to prevent the imitation of an unhealthy lifestyle is unique. A similar law against showing movies with smoking actors has previously passed in India. Notwithstanding the good intentions, these new laws and other similar legislation raise significant ethical issues, such as limitations on personal freedom and the potential for discrimination.

Thromboembolic events in patients with severe pandemic influenza A/H1N1

BACKGROUND

The 2009 pandemic influenza A/H1N1 developed as a novel swine influenza which caused more diseases among younger age groups than in the elderly. Severe hypoxemic respiratory failure from A/H1N1 pneumonia resulted in an increased need for ICU beds. Several risk groups were identified that were at a higher risk for adverse outcomes. Pregnant women were a particularly vulnerable group of patients The CDC reported on the first ten patients with severe illness and acute hypoxemic respiratory failure associated with A/H1N1 infection, none of whom were pregnant, but they noticed that half of the patients had a pulmonary embolism.

METHODS

During a four-month period from September to December 2009, 252 patients were admitted to our hospital with confirmed pandemic influenza H1N1 by real-time reverse transcriptase-polymerase chain reaction test (rRT-PCR). We cared for twenty patients (7.9%) admitted to MICU with severe A/H1N1. Results on Thrombotic events were identified in five (25%) of our critically ill patients.

CONCLUSIONS

We recommend that patients with severe influenza A/H1N1 pneumonitis and respiratory failure be administered DVT prophylaxis in particular if there are additional risk factors for TVE. Further prospective studies on the relationship of influenza A/H1N1 and VTE are needed.

Impact of mass media on public behavior and physicians: an ecological study of the H1N1 influenza pandemic

BACKGROUND

The mass media plays an important role in public health behavior.

PURPOSE

The objective of the present study was to investigate the effect of mass media coverage of the H1N1 pandemic on the number of emergency department (ED) visits and hospital admission rates.

METHODS

An ecological study of ED visits to 8 general Israeli hospitals due to influenza-like illness during the period June-October 2009 was performed. Data on the number of visits per day for children and adults and daily hospitalization rates were analyzed. Associations with the estimated value of H1N1-related publications and weekly reports from nationwide sentinel clinics were assessed. The analysis was performed in 2012-2013.

RESULTS

There were 55,070 ED visits due to influenza-like illness during the study period. The overall number of media reports was 1,812 (14.3% radio broadcasts, 9.8% television broadcasts, 27.5% newspaper articles, and 48.5% major website reports). The overall estimated value of advertising of publications was $16,399,000, excluding the Internet. While H1N1 incidence recorded by Israeli sentinel clinics showed no association with mass media publications, peaks of media reports were followed by an increase in the number of ED visits, usually with a delay of 3 days (P = .005). This association was noted in children (P < .001) but not in adults (P > .1), with a corresponding decrease in hospital admission rates. Publications' framing had no association with ED visits.

CONCLUSIONS

During the 2009 H1N1 influenza outbreak in Israel, an increase in mass media coverage was associated with an increase in pediatric ED visits.

The use of narrative in Jewish medical ethics

Anne Jones has pointed out that over the last three decades, stories have been important to medical ethics in at least three ways: (1). Stories as cases for teaching principle-based medical ethics (2). Narratives for moral guides on what is considered living a good life (3). Stories as testimonials written by both patients and physicians. A pioneer in this effort, particularly in regard to using narratives as moral guides, has been the ethicist and philosopher Stanley Hauerwas. Heavily influenced by virtue ethics, Hauerwas believes that it is a person's particular narrative tradition that provides one with convictions that form the basis of one's morality. Befitting a Protestant theologian, he is particularly concerned with the Christian narrative. From a Jewish perspective, there has been much less written on the use of narrative in medical ethics. However, it is a mistake to think that narrative has little, if any, role in Rabbinic ethical decision making. The purpose of this article is to demonstrate the centrality of narrative in the thought of Orthodox Jewish decisors and the problems inherent in this methodology.

New approaches to the use of insulin in patients with diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is one of the most common and serious acute complications of diabetes and is a significant cause of morbidity and mortality. In the last decade the mortality rate from DKA has declined because of greater recognition and improvements in its management. The current available guidelines state that the most effective means of insulin delivery during DKA is a continuous infusion of regular insulin, usually referred to as continuous low-dose insulin infusion. However, the cost of this treatment is usually quite high, because patients are required to be admitted to an intensive care unit in order to be monitored closely. New analogs of human insulin that have a rapid onset of action have become available in the past decade and represent potential alternatives to the use of regular insulin in the treatment of DKA. In several trials it has been demonstrated that the use of subcutaneous rapid-acting insulin analogs represents a safe, cost-effective and technically simpler treatment that precludes intensive care unit admission without significant differences in outcome in the management of patients with mild to moderate, uncomplicated DKA. The long-acting insulin analog may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA. This avoids rebound hyperglycaemia and ketogenesis when intravenous insulin is stopped and may avoid excess length of stay.

Medical navigation in Israel: description, advantages and ethical considerations

Throughout history religious figures have been intimately involved in caring for the sick. Not only have they prayed for the welfare of the sick and arranged for their care but in many instances provided medical care as well. With the advent of scientific medicine, the responsibility for medical care was transferred to trained physicians. A new phenomenon has recently emerged in Israel that has threatened this 'division of labor' between physicians and rabbis, namely, the establishment of medical navigation organizations. Medical navigation can improve access to highly specialized care and help build trust between doctors and patients. However, this system is accompanied by numerous ethical and professional difficulties. For example, it is not clear how referrals are made and to what extent the system should be regulated. The phenomenon needs to be further studied to determine its prevalence in Israeli society as well as its impact on the practice of medicine from the perspective of both physicians and patients.

Willingness to treat infectious diseases: what do students think?

INTRODUCTION

Outbreaks of serious communicable infectious diseases remain a major global medical problem and force healthcare workers to make hard choices with limited information, resources and time. While information regarding physicians' opinions about such dilemmas is available, research discussing students' opinions is more limited.

METHODS

Medical students were surveyed about their willingness to perform medical procedures on patients with communicable diseases as students and as physicians. Students were asked about their opinions regarding the duty to treat in such cases.

RESULTS

74% of respondents felt that by deciding to enter medical school they were morally obliged to treat any patient despite the risks. Students' willingness to treat as physicians is significantly higher than their willingness to treat as students. HIV was significantly the most tolerated disease with respect to performing mouth to mouth resuscitation. Among preclinical students, we found that willingness to treat during the later years is significantly greater than during the earlier years. Among clinical students, the opposite was observed.

DISCUSSION

Students' greater willingness to treat as physicians is mostly attributed to perceptions of higher obligations as a qualified doctor. There is greater but not total willingness to perform resuscitation on patients with HIV relative to other diseases. The increased willingness of preclinical students and the decreased willingness of clinical students both emphasise the importance of patient-physician communication and ethics studies during medical school.

Primary biliary cirrhosis in Southern Israel: a 20 year follow up study

BACKGROUND

The epidemiology of primary biliary cirrhosis (PBC) in Israel is unknown. We aimed to determine the epidemiology, long-term survival and outcomes of PBC in Southern Israel from 1990 to 2010.

METHODS

Case-finding methods and population-based administrative data were used to estimate and evaluate the incidence, prevalence and prognostic factors of outcome in our PBC cohort.

RESULTS

138 cases of PBC were identified. The average annual prevalence of PBC was 255 cases per million. The overall age/sex-adjusted annual incidence of PBC was 10 cases per million from 1990 through 1999 and 20 cases per million from 2000 to 2010. Among 138 incident cases with a total follow-up of 960 persons-years from diagnosis, 30 patients (21.7%) died. Survival in PBC patients was significantly lower than that of the age/sex-matched Israeli population. Mortality was significantly increased in patients with an initial MELD score greater than 8 (P<0.001), with portal hypertension (P<0.001), and in non-responders to ursodeoxycholic acid (UDCA) therapy according to Barcelona criteria (P=0.005). Out of 138 patients, 95 patients (68.0%) responded to UDCA therapy according to Barcelona and Paris criteria. None of the responders died during the follow-up period as opposed to 30 out of 43 (69.8%) of non-responders. In multivariate analysis the factors associated with response to UDCA were: albumin levels above 3.5 g/dL (P<0.001) and lower degree of fibrosis per liver biopsy (P=0.003).

CONCLUSIONS

This study addresses the increasing burden of PBC in Israel and confirms the importance of some clinical and therapeutic factors as predictors of long-term prognosis.

Effect of beta blocker therapy on survival of patients with heart failure and preserved systolic function following hospitalization with acute decompensated heart failure

BACKGROUND

The importance of heart failure with preserved ejection fraction is being increasingly recognized. However, there is a paucity of data about effective treatment for this condition. The present study investigated the impact of beta blocker therapy for 3 months before admission on the two-year survival of patients with heart failure and preserved systolic function hospitalized due to decompensated heart failure.

METHODS

We performed a retrospective cohort analysis of 345 consecutive patients with heart failure with preserved systolic function older than 18 years hospitalized due to decompensated heart failure. Two groups of patients were compared: those who received beta blockers within 3 months before admission (BB) and those who did not (NBB). The primary outcome was two year all cause mortality (maximal follow-up available in all subjects). To adjust for a potential misbalance between BB and NBB groups in baseline characteristics, a propensity score for beta blocker therapy was incorporated into the survival model.

RESULTS

154 patients (44.6%) received beta blockers prior to admission. Overall two year mortality rate in the BB group was 50% vs. 62.8% in the NBB group, log-rank test p = 0.016. Beta blockers showed protective effect on two-year survival after adjustment for comorbidities and propensity score (hazard ratio [HR], 0.69; 95% CI 0.47-0.99).

CONCLUSIONS

Therapy with beta blockers may have protective effect on survival of patients with heart failure with preserved systolic function.

Diabetic ketoacidosis: clinical characteristics, precipitating factors and outcomes of care

BACKGROUND

Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes mellitus (DM).

OBJECTIVES

To evaluate the clinical characteristics, hospital management and outcomes of patients with DKA.

METHODS

We performed a retrospective cohort study of patients hospitalized with DKA during the period 1 January 2003 to 1 January 2010. Three groups were compared: patients with mild DKA, with moderate DKA, and with severe DKA. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30 days all-cause mortality, length of hospital stay, and complication rate.

RESULTS

The study population comprised 220 patients with DKA. In the mild (78 patients) and moderate (116 patients) groups there was a higher proportion of patients with type 1 DM (75.6%, 79.3%) compared with 57.7% in the severe group (26 patients, P = 0.08). HbA1c levels prior to admission were high in all three groups, without significant difference (10.9 +/- 2.2, 10.7 +/- 1.9, and 10.6 +/- 2.4 respectively, P = 0.9). In all groups the most frequent precipitating factors were related to insulin therapy and infections. The patients with severe DKA had more electrolyte abnormalities (hypokalemia, hypomagnesemia, hypophosphatemia) compared with the mild and moderate forms of the disease. While 72.7% of the entire cohort was hospitalized in the general medical ward, 80.8% of those with severe DKA were admitted to the intensive care unit. The in-hospital mortality rate for the entire cohort was 4.1%, comparable with previous data from experienced centers. Advanced age, mechanical ventilation and bedridden state were independent predictors associated with 30 day mortality: hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02-1.11; HR 6.8, 95% CI 2.03-23.1; and HR 3.8, 95% CI 1.13-12.7, respectively.

CONCLUSIONS

Patients with DKA in our study were generally poorly controlled prior to their admission, as reflected by high HbA1c levels. Type 2 DM is frequently associated with DKA including the severe form of the disease. The most common precipitating factors for the development of DKA were related to insulin therapy and infections. Advanced age, mechanical ventilation and bedridden state wer independent predictors of 30 day mortality.