Euglycemic Diabetic Ketoacidosis in Concurrent Very Low-carbohydrate Diet and Sodium-glucose Transporter-2 Inhibitor Use: A Case Report.

INTRODUCTION: With the incredibly high incidence of Type 2 Diabetes in the current population of emergency department patients, it is critical for clinicians to understand the possible complications of the treatment of this disease. Medication like canagliflozin are more common to encounter on patient's home medication lists and clinicians should be aware of how these medications, alone or combined with dietary modifications, can result in significant pathology and even mortality if not appropriately treated. CASE REPORT: We report a case of a patient with type II diabetes mellitus who presented with euglycemic diabetic ketoacidosis in the setting of concurrent use of canagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, and strict adherence to a low-carbohydrate ketogenic diet for weight control. DISCUSSION: Euglycemic ketoacidosis has previously been observed in both diabetic and non-diabetic patients following strict ketogenic diets, as well as in diabetic patients being treated with SGLT-2 inhibitors. CONCLUSION: As more patients choose ketogenic diets for weight control and diabetes management, clinicians should be aware of this potentially life-threatening complication in patients concurrently taking SGLT-2 inhibitors.

Osteopathic manipulative treatment use in the emergency department: a retrospective medical record review.

CONTEXT: Although the use of osteopathic manipulative treatment (OMT) appears to be declining, data on the use of OMT in the emergency department (ED) are not available. OBJECTIVE: To determine the quantity and characteristics of OMT performed in a single, community academic ED that houses an osteopathic emergency medicine residency. DESIGN: Retrospective medical record review. SETTING: A single large community academic ED with an osteopathic emergency medicine residency from July 14, 2005, to March 4, 2013. PARTICIPANTS: Patients in the ED who received OMT (N=2076). MAIN OUTCOME MEASURES: Medical record data were analyzed to determine patient demographics; treatment characteristics including number of procedures and patients per physician, OMT techniques used, night vs day procedure variation, and financial implication of future billing for OMT; chief complaints; primary discharge diagnoses; and length of stay in the ED. RESULTS: Patients were aged 0 to 95 years (mean, 39 years) and were predominately female (1260 [60.69%]) and white (1300 [62.62%]). A mean of 0.74 patients received OMT per day, and a mean of 29.65 procedures were performed per physician. When data for residents were looked at separately, the mean was higher at 40.32 procedures per physician. The top 3 discharge diagnoses were low back pain (189 patients [9.10%]), muscle spasm (106 patients [5.11%]), and spasm: muscle, back (93 patients [4.48%]). Eleven different OMT techniques were recorded, with myofascial release being used most frequently (1150 of 2868 procedures [40.09%]), followed by muscle energy (672 [23.43%]). The average length of stay in the ED was 206 minutes. A total of 1663 OMT procedures (80%) were performed during the day, whereas 413 (20%) were performed at night. Potential procedural billing for all OMT performed during the study period was $33.09 per day. CONCLUSION: In contrast to perceptions that OMT use is declining, the authors found that OMT is being performed on a near daily basis in the ED. Additional research is needed to fully understand the impact of OMT in the ED.

The use of tissue models for vascular access training. Phase I of the procedural patient safety initiative.

INTRODUCTION: Following the Institute of Medicine report "To Err is Human," the Agency for Healthcare Research and Quality identified proper central venous catheter (CVC) insertion techniques and wide sterile barriers (WSB) as 2 major quality indicators for patient safety. However, no standard currently exists to teach proper procedural techniques to physicians. AIM: To determine whether our nonhuman tissue model is an effective tool for teaching physicians proper wide sterile barrier technique, ultrasound guidance for CVC placement, and sharps safety. PARTICIPANTS: Educational sessions were organized for physicians at Cedars-Sinai Medical Center. Participants had a hands-on opportunity to practice procedural skills using a nonhuman tissue model, under the direct supervision of experienced proceduralists. PROGRAM EVALUATION: An anonymous survey was distributed to participants both before and after training, measuring their reactions to all aspects of the educational sessions relative to their prior experience level. DISCUSSION: The sessions were rated highly worthwhile, and statistically significant improvements were seen in comfort levels with ultrasound-guided vascular access and WSB (P<.001). Given the revitalized importance of patient safety and the emphasis on reducing medical errors, further studies on the utility of nonhuman tissue models for procedural training should be enthusiastically pursued.

Percutaneous dilatational tracheostomy for emergent airway access.

The study objective of this article was to evaluate percutaneous dilatational tracheostomy (PDT) for emergent airway access. This is a case series of 9 patients who presented over a 58-month period. All patients were in severe respiratory difficulty where intubation by conventional means was unsuccessful. All 9 patients were successfully intubated using PDT technique. No technical complications were noted, specifically bleeding, extratracheal placement, or prolonged procedure time. Six patients ultimately died, 2 from anoxic encephalopathy due to failed resuscitation and 4 from comorbid illness. Three patients ultimately survived to hospital discharge. The authors conclude that PDT can effectively establish a surgical airway in an emergent setting. The major advantage of this technique is the ability to gain and maintain competence in an elective, controlled environment. The authors believe that PDT may play a role in the management of the emergent surgical airway.

Effects of excitatory amino acid receptor antagonists on a capsaicin-evoked nociceptive reflex: a comparison with morphine, clonidine and baclofen.

The rat isolated spinal cord-tail preparation has been employed to examine the effects of several antinociceptive drugs and excitatory amino acid (EAA) receptor antagonists on nociceptive reflexes (recorded in ventral roots) stimulated by peripheral application of capsaicin (CAP). Non-nociceptive monosynaptic and polysynaptic dorsal root-evoked ventral root potentials (DR-VRPs) were also examined. Morphine (0.01-3 microM) and clonidine (0.03-1 microM) inhibited CAP-stimulated activity, but not the non-nociceptive dorsal root-evoked monosynaptic reflex (MSR) or polysynaptic (PSR) activity. These effects were antagonized by naloxone and efaroxan, respectively. The AMPA/KA receptor antagonists CNQX (0.1-100 microM) and DNQX (0.1-30 microM) blocked nociceptive activity and were 4-fold selective for CAP-evoked potentials compared to the monosynaptic reflex. Kynurenate (1-300 microM), DL-AP-4 (3-300 microM), L-AP-4 (3-300 microM), and the GABAB receptor agonist baclofen (0.1-10 microM), inhibited all evoked potentials with relatively little selectivity between nociceptive and non-nociceptive responses. NMDA receptor antagonism by AP-5 (100 microM) reduced nociceptive and non-nociceptive potentials by a maximum of 30-33%. These data indicate that AMPA/KA receptor-mediated synapses are involved in acute spinal nociceptive transmission and suggest that AMPA/KA receptor subtypes could provide novel analgesic targets.