Introduction: Diabetic ketoacidosis (DKA) is a common complication of diabetes encountered in the acute care setting. Emergent management of DKA is essential as positive outcomes are seen with timely resolution. Some strategies for timely resolution include initial fluid resuscitation, administration of insulin, and management of electrolytes and fluid. Additionally, rebound DKA occurs in patients and may prolong hospitalization and lead to additional complications. The goal of this study was to evaluate the use of a novel protocol suite for the management of DKA in a community hospital setting. Methods: The study design is a pragmatic, retrospective cohort with historical control conducted at a suburban hospital setting. A novel DKA protocol was implemented which included a change to initial volume resuscitation at 250mL/hr, initiation of insulin bolus in the emergency department with repeat dosing if necessary, insulin drip initiation in the ICU with criteria based dosing, and transition to dextrose-containing fluid when blood glucose (BG) is < 250mg/dL. Instead of discontinuing the insulin drip when BG < 100mg/dL, it was continued with dextrose boluses until DKA resolution. Additionally, a weight-based insulin transition protocol was utilized to transition the patient to long-acting insulin with a basal-bolus plus sliding scale approach. The primary objective of the study was incidence of rebound DKA. Secondary outcomes include duration of insulin drip, hospital length of stay, and hypoglycemic events. Results: A total of 165 patients were included in the study, 84 in the pre-implementation group and 81 in the post-implementation group. Baseline demographics were similar between groups in terms of age, sex, ethnicity, type of diabetes, and insulin-dependence. Rebound DKA was seen in 59.5% of patients in the pre-group and 7.7% in the post-group (p< 0.001). Hospital length of stay was similar between groups (4.3 days vs. 3.9 days, p=0.4). Insulin drip duration was shorter in the post-group (27.2 hrs vs. 22.3 hrs, p=0.02). Fewer hypoglycemic events were noted in the post-group as well. Conclusions: The implementation of a novel DKA protocol in a community hospital setting was associated with lower rates of DKA rebound, shorter total duration of insulin drip, and fewer hypoglycemic episodes.

Purpose: Staphylococcus aureus is a leading cause of bacteremia with a 30-day mortality of 20%. This study evaluated outcomes after implementation of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) initiative in a community hospital. Methods: This retrospective cohort analysis compared patients admitted with SAB between May 2015 and April 2018 (intervention group) to those admitted between May 2012 and April 2015 (historical control group). Pharmacists were notified of and responded to blood cultures positive for Staphylococcus aureus by contacting provider(s) with a bundle of recommendations. Components of the SAB bundle included prompt source control, selection of appropriate intravenous antibiotics, appropriate duration of therapy, repeat blood cultures, echocardiography, and infectious diseases consult. Demographics (age, gender, and race) were collected at baseline. Primary outcome was in-hospital mortality. Compliance with bundle components was also assessed. Results: Eighty-three patients in the control group and 110 patients in the intervention group were included in this study. Demographics were similar at baseline. In-hospital mortality was lower in the intervention group (3.6% vs. 15.7%; p = 0.0033). Bundle compliance was greater in the intervention group (69.1% vs. 39.8%; p < 0.0001). Conclusions: We observed a significant reduction in in-hospital mortality and increased treatment bundle compliance in the intervention cohort with implementation of a pharmacist-driven SAB initiative. Pharmacists’ participation in the care of SAB patients in the form of recommending adherence to treatment bundle components drastically improved clinical outcomes. Widespread adoption and implementation of similar practice models at other institutions may reduce in-hospital mortality for this relatively common and life-threatening infection.

Background: Over 8% of the US population have detectable Type I hevea latex IgE antibodies and, upon exposure to natural latex and rubber products, are at risk for potentially dangerous reactions, especially in dental settings where these products meet mucosal membranes. Methods: Extractable antigenic protein levels were quantified in dental dams, examination gloves, and various other dental and rubber products. ASTM standards D6499 (antigenic protein) and D5712 (total protein) were used to quantify protein content. Results: In dental dams, extractable protein content ranged from low/non-sensitizing levels (<3 μg/dm2) to high/ sensitizing levels (130 200 μg/dm2). Also, while examination gloves from Malaysian glove manufacturers consistently exhibited a lower extractable protein content (<9 μg/dm2), than gloves from Thai manufacturers (16-23 μg/dm2) these levels should both still be non-sensitizing. There was no correlation between extractable protein content and the price or thickness of dental dams or examination gloves. Most of the other assorted dental products tested displayed low extractable protein content (<2.5 μg/dm2). Nearly all dental products made from natural rubber contained detectable antigenic Hevea proteins, subjecting previously sensitized patients and providers to risk of severe allergic reaction. A case study describes a female patient, with no previous history of Type I latex allergy, who reacted severely to a dental dam mouth exposure, necessitating her admission to the intensive care unit (ICU) of a local hospital for management of respiratory failure, with discharge after 4 days. Conclusions: Some dental products may pose a significant risk of Type I latex protein allergy sensitization, due to repeated contact, and that a single exposure can induce a severe reaction in a previously sensitized person, even when no prior latex allergy history is known.

Recommended Citation Longcore, Travis; Almaleh, Lindsay; Chetty, Brittany; Francis, Kathryn; Freidin, Robert; Huang, Ching-Sheng; Pickett, Brooke; Schreck, Diane; Scruggs, Brooke; Shulman, Elise; Swauger, Alissa; Tashnek, Alison; Wright, Michael; and Boydston, Erin E. (2011) "Wildlife Underpass Use and Environmental Impact Assessment: A Southern California Case Study," Cities and the Environment (CATE): Vol. 11: Iss. 1, Article 4. Available at: http://digitalcommons.lmu.edu/cate/vol11/iss1/4

Pain and agitation may be difficult to assess in a critically ill patient. Pain is best assessed by self-reporting pain scales; but in patients who are unable to communicate, behavioral pain scales seem to have benefit. Patients' sedation level should be assessed each shift and preferably by a validated ICU tool, such as the RASS or SAS scale. Pain is most appropriately treated with the use of opiates, and careful consideration should be given to the pharmacokinetic and pharmacodynamic properties of various analgesics to determine the optimal agent for each individual patient. Sedation levels should preferably remain light or with the use of a daily awakening trial. Preferred treatment of agitation is analgosedation with the addition of nonbenzodiazepine sedatives if necessary. There are risks associated with each agent used in the treatment of pain and agitation, and it is important to monitor patients for effectiveness, signs of toxicity, and adverse drug reactions.

The recent synthesis of a wide variety of cyanate ester monomers that may be derived from renewable resources has created a newly available set of chemical structures that, due to a wide range of chemical features, provide a unique opportunity for the development of quantitative structure-property relationships for dicyanate esters and their polymerized networks. Specific structure-property relationships for monomer melting point, glass transition temperature at full conversion, and char yields at 600 degrees C under nitrogen and air have been developed with the aid of partial least squares methods. The predictions inherent in these structure-property relationships are examined and compared to predictions based on ordinary least squares methods. Specific predictions for the properties of two as-yet unsynthesized dicyanate ester monomers derived from renewable resources are also presented.

Background: Epinephrine (adrenaline) autoinjectors are increasingly prescribed for the emergency management of severe allergic reactions.There is an increasing incidence of unintentional administration of these devices, typically into a digit.Digital epinephrine has theoretical dangers of ischemia and gangrene and multiple interventions have been advocated in the treatment of these unintentional administrations of epinephrine.Objective: This systematic literature review examines available evidence about unintentional epinephrine digital injections, in order to advise appropriate treatment.Methods: Systematic searches were made of electronic databases (Medline, EMBASE, Scopus), reference screening and forward citation searching.Application of inclusion and exclusion criteria: Findings of included articles were summarized and data analyzed.Results: This literature review found limited published material on the topic.Four observational studies (retrospective cohort studies) and seven case series have been published, along with a number of single case reports.The data described complete recovery of almost all (greater than 99%) patients exposed to a digital epinephrine injection by autoinjector-regardless of treatment.Most patients received no pharmacological treatment.Case reports suggest that recovery may be quicker with use of subcutaneous phentolamine or terbutaline than with observation or conservative treatment.A small number of patients (from one database and one case series) suffered long term or severe effects from the digital epinephrine injection. Conclusion:There is a growing body of evidence suggesting that accidental injection with epinephrine autoinjector may be managed conservatively in most cases.Evidence to date suggests conservative treatment (observation and/or local heat) will result in full recovery in the vast majority of patients.Treatment with locally injected phentolamine or terbutaline appears to rapidly reverse vasconstriction.There have been a small number of reports of incomplete recovery.This limited evidence needs to be interpreted with caution due to potential selection bias and misclassification.Further observational and randomized experimental research is needed to determine when pharmacological treatment is indicated and if it improves patient outcomes.Patient and carer education about proper use of individual autoinjector devices is the best prevention for these events.

CONTEXTThe role at admission of nasal polymerase chain reaction (PCR) for patients with methicillin-resistant Staphylococcus aureus (MRSA) in guiding antibiotic therapy for lower respiratory tract infection is unknown.OBJECTIVETo determine whether nasal MRSA PCR at admission can predict the absence of MRSA in lower respiratory tract secretions.DESIGNWe performed a retrospective study of adult patients admitted to a large urban hospital. Patients had a nasal MRSA PCR test and a lower respiratory tract culture obtained within 48 hours of admission and the culture yielded S aureus.MAIN OUTCOME MEASURESSensitivity, specificity, and positive and negative predictive values.RESULTSOur results showed high sensitivity (93.3%) and negative predictive value (95.2%) of nasal PCR for MRSA in the lower respiratory tract.CONCLUSIONWith its high sensitivity and negative predictive value, a nasal MRSA PCR test performed within 48 hours of hospital admission could help guide the discontinuation of MRSA-directed empiric antibiotic therapy in patients who are unlikely to be infected with this organism. A prospective study is needed to confirm these findings.

Decreases of up to 50% in the moisture uptake of polycyanurate networks based on 2,2-bis(4-cyanatophenyl)propane (BADCy) and 1,1-bis(4-cyanatophenyl)ethane (LECy) were observed when analogous networks containing a single methyl group ortho- to each arylcyanurate linkage were prepared by reduction and acid-catalyzed coupling of salicylic acid followed by treatment with cyanogen bromide and subsequent cyclotrimerization. The differences in water uptake were observed despite similar decreases in packing fraction as conversion proceeded in all networks studied. Conversely, the presence or absence of methyl groups at arylene bridges, remote from the cyanurate oxygen, had no influence on water uptake. Vitrification during cure had little effect on either free volume development or moisture uptake. These results confirm that steric hindrance from ortho-methyl groups inhibits absorption of water presumably by decreasing the thermodynamic favorability of sterically permitted interaction with the cyanurate oxygen. A further examination of the effect of two different catalysts, 2 parts per hundred of a 30:1 by weight mixture of nonylphenol and copper(II) acetylacetonate and 500 ppm of dibutyltin dilaurate (DBTDL), compared to analogous uncatalyzed networks, showed that hydrolytic stability was dramatically affected by catalyst choice, while thermochemical stability was also impacted. These results provide important insights into the mechanisms that determine structureproperty relationships in polycyanurate networks.