The importance of hyperosmolarity in diabetic ketoacidosis.

AIM: Diabetic ketoacidosis is a hyperglycaemic emergency that is often treated in intensive care units (ICUs) despite having a low mortality and good prognosis. Current risk stratification is based primarily on acidosis, but it has been suggested that hyperosmolarity may also be an important marker of increased severity. Our aim was to evaluate the relationship between raised serum osmolarity and adverse clinical outcomes in ICU admissions for ketoacidosis. METHODS: Retrospective review of prospectively collected data for adult admissions with ketoacidosis in the Australian and New Zealand Intensive Care Society Adult Patient Database over a 15-year period (2004-2018). Exclusions were readmissions and records with critical missing data. Serum hyperosmolarity was defined as > 320 mosm/l. The primary outcome was hospital mortality; secondary outcomes were ICU mortality and other adverse clinical events. RESULTS: Some 17 379 admissions were included in the study population. People with hyperosmolarity had fourfold increased mortality, a higher incidence of renal failure and need for mechanical ventilation, and prolonged ICU and hospital length of stay. The relationship with mortality remained highly significant even after adjusting for severity of acidosis, hospital type, year of admission, time to ICU, and a modified Australia and New Zealand Risk of Death propensity score. CONCLUSIONS: Although adults with ketoacidosis have a good prognosis overall, hyperosmolarity was independently associated with a significantly higher incidence of multiple adverse outcomes including mortality. Whether or not this is directly causal, it may have practical applications to improve risk stratification and identify individuals at risk of adverse outcomes.

An audit of perioperative blood transfusions in a regional hospital to rationalise a maximum surgical blood ordering schedule.

Appropriate preoperative blood typing and cross-matching is an important quality improvement target to minimise costs and rationalise the use of blood bank resources. This can be facilitated using a maximum surgical blood ordering schedule (MSBOS) for specific operations. It is recommended that individual hospitals develop a site-specific MSBOS based on institutional data, but this is challenging in non-tertiary centres without electronic databases. Our aim was to audit our perioperative blood transfusions to develop a site-specific MSBOS. A retrospective audit of blood transfusions in surgical patients in our regional referral hospital was conducted using five years' coded administrative data. Procedures with higher transfusion rates warranting preoperative testing (type and screen with or without subsequent cross-matching) were identified. There were about 15,000 eligible surgical procedures performed in our institution over the audit period. The need for preoperative testing was identified for only a few procedures, namely laparotomy, bowel resection, major amputation, joint arthroplasty, hip/femur fracture and humerus surgery, and procedures for obstetric complications. We observed a reduction in transfusion rates over time for total joint arthroplasty. The use of coding data represents an efficient method by which centres without electronic anaesthesia information management systems can conduct large-scale audits to develop a site-specific MSBOS. This would represent a significant improvement for hospitals that currently base preoperative testing recommendations on expert opinion alone. As many procedures in regional centres have very low transfusion rates, hospitals with a similar case mix to ours could consider selectively auditing higher-risk operations where local data is most likely to alter testing recommendations.

State abortion rates. The impact of policies, providers, politics, demographics, and economic environment.

This paper uses data on abortion rates by state from 1974-1988 to estimate two-stage least squares models with fixed state and year effects. Restrictions on Medicaid funding for abortion are correlated with lower abortion rates in-state and higher rates among nearby states. A maximal estimate suggests that 19-25% of the abortions among low-income women that are publicly funded do not take place after funding is eliminated. Parental notification laws for teen abortions do not significantly affect aggregate abortion rates. A larger number of abortion providers in a state increases the abortion rate, primarily through inducing cross-state travel.

Changes in inequality and unemployment over the 1980s: comparative cross-national responses.

PIP: The steep recession in the early 1980s was followed by a recovery in nations of the Organization for Economic Cooperation and Development (OECD), but in western European countries unemployment rates remained high. On the other hand, the United States economy after 1983 revived and unemployment dropped rapidly. However, a new problem arose in the late 1980s: rising inequality in the wage rates of more and less skilled workers. The widening wage inequality in the US is proven by the fact that among male high school dropouts real wages fell by 13% between 1979-1989, while among male college graduates real wages rose by 11%. The wage inequality was modest in the Netherlands, no noticeable change occurred in France, Germany, and Italy; there was a modest rise in Canada, Japan, and Sweden; and a large rise in the United Kingdom and US in the 1980s. One hypothesis suggests the growing international competition faced by US firms; another credits the changing demand for more skilled workers driven by the technological shift in computer-intensive industries. The consequences of this wage inequality in the US has been increasing poverty: from 15.6% of households in 1979 to 18.1% in 1986, especially in younger households. In contrast, the respective percentages for Germany were 5.5 in 1979 and 6.8 in 1986. It is likely that both in the US and Europe this rising inequality is caused by international shifts in trade, employment, and technology. Policy responses are utilized by OECD countries: 1) income transfer programs, unemployment benefits, and welfare payments, which have become means-tested because of tight public budgets; 2) public sector job creation programs, with the disadvantage of high cost; 3) job placement and training programs, which are also expensive to operate; 4) wage subsidies, as tried in 1993 in the US by expanding the Earned Income Tax Credit; and 5) hiring subsidies, which encourage the private sector to increase employment.^ieng

N-phenyl-2-pyridinecarbothioamides as gastric mucosal protectants.

A series of substituted 2-pyridinecarbothioamides was synthesized and evaluated for gastric mucosal protectant activity in the rat. Out of this investigation N-(3,5-difluorophenyl)-2- pyridinecarbothioamide (23, AY-31,574) was identified. This compound was much more potent than sucralfate and ranitidine against ethanol-induced lesions. Compound 23 was equipotent with ranitidine against gastric injury caused by stress. Unlike ranitidine, 23 was found to be devoid of antisecretory activity in the pylorus-ligated rat model, making it a selective mucosal protectant. Such a potent selective mucosal protectant may provide a novel clinical approach in treating ulcers.