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Diabetic ketoacidosis (DKA) is a severe and too-common complication of uncontrolled diabetes mellitus. Acidosis is one of the fundamental disruptions stemming from the disease process, the complications of which are potentially lethal. Hydration and insulin administration have been the cornerstones of DKA therapy; however, adjunctive treatments such as the use of sodium bicarbonate and protocols that include serial monitoring with blood gas analysis have been much more controversial. There is substantial literature available regarding the use of exogenous sodium bicarbonate in mild to moderately severe acidosis; the bulk of the data argue against significant benefit in important clinical outcomes and suggest possible adverse effects with the use of bicarbonate. However, there is scant data to support or refute the role of bicarbonate therapy in very severe acidosis. Arterial blood gas (ABG) assessment is an element of some treatment protocols, including society guidelines, for DKA. We review the evidence supporting these recommendations. In addition, we review the data supporting some less cumbersome tests, including venous blood gas assessment and routine chemistries. It remains unclear that measurement of blood gas pH, via arterial or venous sampling, impacts management of the patient substantially enough to warrant the testing, especially if sodium bicarbonate administration is not being considered. There are special circumstances when serial ABG monitoring and/or sodium bicarbonate infusion are necessary, which we also review. Additional studies are needed to determine the utility of these interventions in patients with severe DKA and pH less than 7.0.

BACKGROUNDAluminum phosphide (AlP) is an insecticide and rodenticide used to protect stored grains from rodents and other household pests. This substance is highly toxic to humans and has been the cause of many accidental and intentional deaths due in part to poor regulation of sales and distribution in many countries.OBJECTIVESDescribe poisonings reported to the Ministry of Health in Saudi Arabia in terms of demographic variables and by time and geographic distribution.DESIGNRetrospective medical record review.SETTINGMinistry of Health hospitals nationwide.PATIENTS AND METHODSUsing a semi-structured checklist, data was collected from patient records that contained sociodemographic variables and the outcome (died or discharged).MAIN OUTCOME MEASURESAggregated data, summary statistics and statistical comparisons.SAMPLE SIZE68 patients.RESULTSThirty-eight (56%) were female and the mean (SD) age of patients was 18.6 (1.86) years. Eighteen of 22 (82%) patients who died were younger than 20 years old. Mortality in patients younger than 20 years of age was greater than in adults (P=.043). Mortality was highest in patients younger than 7 years of age (P=.006). The cases were reported by the Islamic years 1427–1435, corresponding approximately to Gregorian years 2006 to 2017. Fifty-six cases (83%) were reported from Jeddah. Most cases were due to accidental exposure to phosphine gas during fumigation.CONCLUSIONMortality due to AlP poisoning was highest in children and most commonly occurred during fumigation of households. Delays in medical attention and diagnosis may have contributed to mortality.LIMITATIONSRetrospective data collection and relatively small sample size. Data on exact amount and route of phosphide ingestion or exposure not available.

Background: Sinus tachycardia in cancer reflects a significant multi-system organ stressor and disease, with sparse literature describing its clinical significance. We assessed cardiovascular (CV) and mortality prognostic implications of sinus tachycardia in cancer patients. Methods: We conducted a case-control study of 622 cancer patients at a U.S. urban medical center from 2008 to 2016. Cases had ECG-confirmed sinus tachycardia [heart rate (HR) ≥100 bpm] in ≥3 different clinic visits within 1 year of cancer diagnosis excluding a history of pulmonary embolism, thyroid dysfunction, left ventricular ejection fraction <50%, atrial fibrillation/flutter, HR >180 bpm. Adverse CV outcomes (ACVO) were heart failure with preserved ejection fraction (HFpEF), HF with reduced EF (HFrEF), hospital admissions for HF exacerbation (AHFE), acute coronary syndrome (ACS). Regression analyses were conducted to examine the effect of sinus tachycardia on overall ACVO and survival. Results: There were 51 cases, age and sex-matched with 571 controls (mean age 70±10, 60.5% women, 76.4% Caucasian). In multivariate analysis over a 10-year follow-up period, sinus tachycardia (HR ≥100 vs.

An 86-year-old male with a history of metastatic castrate sensitive prostate cancer received a single dose of Denosumab for his bony metastases. Two weeks later, he presented to the hospital due to left foot cellulitis and was incidentally found to have profound hypocalcemia whereas his serum calcium was normal at the time of Denosumab injection. A thorough workup was undertaken which showed severe Vitamin D deficiency. He was diagnosed with Denosumab induced hypocalcemia with underlying Vitamin D deficiency which was refractory to supplemental calcium and Vitamin D. This case demonstrates the potential of Denosumab to cause profound hypocalcemia which can be resistant to therapy. Bone metastasis is a common clinical encounter and Denosumab is an effective therapy to prevent skeletal related events (SRE). Therefore, given its widespread use, it is extremely important to identify and treat risk factors that may aggravate hypocalcemia when treated with Denosumab.