Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present — ‘D’, either elevated blood glucose levels or a family history of diabetes mellitus; ‘K’, the presence of high urinary or blood ketoacids; and ‘A’, a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children

Is There a July Phenomenon?: The Effect of July Admission on Intensive Care Mortality and LOS in Teaching Hospitals

BACKGROUND: It has been suggested that inexperience of new housestaff early in an academic year may worsen patient outcomes. Yet, few studies have evaluated the “July Phenomenon,” and no studies have investigated its effect in intensive care patients, a group that may be particularly susceptible to deficiencies in management stemming from housestaff inexperience. OBJECTIVE: Compare hospital mortality and length of stay (LOS) in intensive care unit (ICU) admissions from July to September to admissions during other months, and compare that relationship in teaching and nonteaching hospitals, and in surgical and nonsurgical patients. DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of 156,136 consecutive eligible patients admitted to 38 ICUs in 28 hospitals in Northeast Ohio from 1991 to 1997. RESULTS: Adjusting for admission severity of illness using the APACHE III methodology, the odds of death was similar for admissions from July through September, relative to the mean for all months, in major (odds ratio [OR], 0.96; 95% confidence interval [95% CI], 0.91 to 1.02; P = .18), minor (OR, 1.02; 95% CI, 0.93 to 1.10; P = .66), and nonteaching hospitals (OR, 0.96; 95% CI, 0.91 to 1.01; P = .09). The adjusted difference in ICU LOS was similar for admissions from July through September in major (0.3%; 95% CI, −0.7% to 1.2%; P = .61) and minor (0.2%; 95% CI, −0.9% to 1.4%; P = .69) teaching hospitals, but was somewhat shorter in nonteaching hospitals (−0.8%; 95% CI, −1.4% to −0.1%; P = .03). Results were similar when individual months and academic years were examined separately, and in stratified analyses of surgical and nonsurgical patients. CONCLUSIONS: We found no evidence to support the existence of a July phenomenon in ICU patients. Future studies should examine organizational factors that allow hospitals and residency programs to compensate for inexperience of new housestaff early in the academic year

Caprylic Triglyceride as a Novel Therapeutic Approach to Effectively Improve the Performance and Attenuate the Symptoms Due to the Motor Neuron Loss in ALS Disease

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder of motor neurons causing progressive muscle weakness, paralysis, and finally death. ALS patients suffer from asthenia and their progressive weakness negatively impacts quality of life, limiting their daily activities. They have impaired energy balance linked to lower activity of mitochondrial electron transport chain enzymes in ALS spinal cord, suggesting that improving mitochondrial function may present a therapeutic approach for ALS. When fed a ketogenic diet, the G93A ALS mouse shows a significant increase in serum ketones as well as a significantly slower progression of weakness and lower mortality rate. In this study, we treated SOD1-G93A mice with caprylic triglyceride, a medium chain triglyceride that is metabolized into ketone bodies and can serve as an alternate energy substrate for neuronal metabolism. Treatment with caprylic triglyceride attenuated progression of weakness and protected spinal cord motor neuron loss in SOD1-G93A transgenic animals, significantly improving their performance even though there was no significant benefit regarding the survival of the ALS transgenic animals. We found that caprylic triglyceride significantly promoted the mitochondrial oxygen consumption rate in vivo. Our results demonstrated that caprylic triglyceride alleviates ALS-type motor impairment through restoration of energy metabolism in SOD1-G93A ALS mice, especially during the overt stage of the disease. These data indicate the feasibility of using caprylic acid as an easily administered treatment with a high impact on the quality of life of ALS patients