The Use of SGLT-2 Inhibitors Coupled With a Strict Low-Carbohydrate Diet: A Set-Up for Inducing Severe Diabetic Ketoacidosis.

A 58-year-old male with a history of hypertension and non-insulin dependent type 2 diabetes mellitus (DM) was brought in by ambulance and admitted to the intensive care unit for weakness, lethargy, and altered mental status and was found to be hypotensive and subsequently diagnosed with severe diabetic ketoacidosis (DKA). A thorough investigation into precipitating factors for his DKA was largely unrevealing; an extensive infectious work- up was negative and the patient's history was otherwise only significant for starting a ketogenic diet 1 month prior while simultaneously being on a sodium-glucose transport protein 2 (SGLT-2) inhibitor, namely empagliflozin. Literature investigation revealed that a strict low carbohydrate diet can rarely lead to DKA in the setting of SLGT-2 inhibitor use.

Can emergency physicians perform extended compression ultrasound for the diagnosis of lower extremity deep vein thrombosis?

BACKGROUND: Current point-of-care ultrasound protocols in the evaluation of lower extremity deep vein thrombosis (DVT) can miss isolated femoral vein clots. Extended compression ultrasound (ECUS) includes evaluation of the femoral vein from the femoral vein/deep femoral vein bifurcation to the adductor canal. Our objective is to determine if emergency physicians (EPs) can learn ECUS for lower extremity DVT evaluation after a focused training session. METHODS: Prospective study at an urban academic center. Participants with varied ultrasound experience received instruction in ECUS prior to evaluation. Two live models with varied levels of difficult sonographic anatomy were intentionally chosen for the evaluation. Each participant scanned both models. Pre- and post-study surveys were completed. RESULTS: A total of 96 ultrasound examinations were performed by 48 participants (11 attendings and 37 residents). Participants' assessment scores averaged 95.8% (95% CI 93.3%-98.3%) on the easier anatomy live model and averaged 92.3% (95% CI 88.4%-96.2%) on the difficult anatomy model. There were no statistically significant differences between attendings and residents. On the model with easier anatomy, all but 1 participant identified and compressed the proximal femoral vein successfully, and all participants identified and compressed the mid and distal femoral vein. With the difficult anatomy, 97.9% (95% CI 93.8%-102%) identified and compressed the proximal femoral vein, whereas 93.8% (95% CI 86.9%-100.6%) identified and compressed the mid femoral vein, and 91.7% (95% CI 83.9%-99.5%) identified and compressed the distal femoral vein. CONCLUSION: EPs at our institution were able to perform ECUS with good reproducibility after a focused training session.

Real-time patient experience surveys of hospitalized medical patients.

BACKGROUND: Real-time feedback about patients' perceptions of the quality of the care they are receiving could provide physicians the opportunity to address concerns and improve these perceptions as they occur, but physicians rarely if ever receive feedback from patients in real time. OBJECTIVE: To evaluate if real-time patient feedback to physicians improves patient experience. DESIGN: Prospective, randomized, quality-improvement initiative. SETTING: University-affiliated, public safety net hospital. PARTICIPANTS: Patients and hospitalist physicians on general internal medicine units. INTERVENTION: Real-time daily patient feedback to providers along with provider coaching and revisits of patients not reporting optimal satisfaction with their care. MEASUREMENTS: Patient experience scores on 3 provider-specific questions from daily surveys on all patients and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and percentiles on randomly selected patients. RESULTS: Changes in HCAHPS percentile ranks were substantial (communication from doctors: 60th percentile versus 39th, courtesy and respect of doctors: 88th percentile versus 23rd, doctors listening carefully to patients: 95th percentile versus 57th, and overall hospital rating: 87th percentile versus 6th (P = 0.02 for overall differences in percentiles), but we found no statistically significant difference in the top box proportions for the daily surveys or the HCAHPS survey. The median [interquartile range] top box score for the overall hospital rating question on the HCAHPS survey was higher in the intervention group than in the control group (10 [9, 10] vs 9 [8, 10], P = 0.04). CONCLUSIONS: Real-time feedback, followed by coaching and patient revisits, seem to improve patient experience.