Faculty Bibliography

BACKGROUND:Diabetic ketoacidosis (DKA) is commonly complicated by mixed acid-base disorders. Therefore, patients with DKA can present with pH > 7.3 or bicarbonate > 18 mmol/L, which falls outside the values defined by the current traditional DKA criteria (pH ≤ 7.3 or bicarbonate ≤ 18 mmol/L). OBJECTIVE:We aimed to study the spectrum of acid-base clinical presentations of DKA and the prevalence of diabetic ketoalkalosis. METHODS:This study included all adult patients at a single institution admitted in 2018-2020 with diabetes, positive beta-hydroxybutyric acid, and increased anion gap ≥ 16 mmol/L. Mixed acid-base disorders were analyzed to determine the spectrum of presentation of DKA. RESULTS:There were 259 encounters identified under the inclusion criteria. Acid-base analysis was available in 227 cases. Traditional acidemic DKA (pH ≤ 7.3), DKA with mild acidemia (7.3 < pH ≤ 7.4), and diabetic ketoalkalosis (pH > 7.4) account for 48.9% (111/227), 27.8% (63/227), and 23.3% (53/227) of cases, respectively. Of the 53 cases with diabetic ketoalkalosis, increased anion gap metabolic acidosis was present in all, and concurrent metabolic alkalosis, respiratory alkalosis, and respiratory acidosis were present in 47.2% (25/53), 81.1% (43/53), and 11.3% (6/53) encounters, respectively. In addition, 34.0% (18/53) of those with diabetic ketoalkalosis were found to have severe ketoacidosis, defined by beta-hydroxybutyric acid ≥ 3 mmol/L. CONCLUSIONS:DKA can present as traditional acidemic DKA, DKA with mild acidemia, and diabetic ketoalkalosis. Diabetic ketoalkalosis is a common yet easily overlooked alkalemic variant of DKA associated with mixed acid-base disorders, and a high proportion of these presentations have severe ketoacidosis and thus, require the same treatment as traditional DKA.

Purpose: Trimethoprim-sulfamethoxazole (TMP-SMX) is the preferred agent for pneumocystis jirovecii pneumonia (PJP) prophylaxis in solid organ transplant (SOT) and bone marrow transplant (BMT); however, adverse effects may lead to the use of alternative agents. We sought to characterize the rate and reason for using alternative agents for PJP prophylaxis in SOT and BMT recipients over an 18-month period at a single institution to guide stewardship.
Method(s): SOT and BMT patients between 2/1/2018 and 8/1/2019 were included. 455 SOT and 126 BMT patients were identified and included in the final analysis; 1 SOT and 2 BMT patients were excluded due to expiration prior to initiation of PJP prophylaxis. Electronic medical records were retrospectively reviewed for initial PJP prophylaxis choice, change of initial prophylaxis, and reason for change.
Result(s): Among 454 SOT and 124 BMT recipients, most (90.1%) patients received initial prophylaxis with TMP-SMX, followed by atovaquone (9.9%). In SOT recipients, the primary reason for an initial or subsequent switch to an alternative regimen was elevated creatinine or potassium. In BMT recipients, the primary reason was cytopenias. Among patients who were switched to an alternate regimen, 34 (41%) SOT recipients and 3 (12%) BMP recipients were switched back to TMP-SMX. Among patients who were initiated on an alternate regimen, 28 (59.6%) SOT recipients and 1 (9.1%) BMT recipient were switched to TMP-SMX. Mean number of days to TMP-SMX regimen interruption was 42 days in SOT recipients and 107 days in BMT recipients (p=0.005).
Conclusion(s): While most SOT and BMT recipients received TMP-SMX for PJP prophylaxis, alternate agents were used primarily in the setting of concern for renal and hematologic adverse effects. Patients should be monitored for recovery of renal function and cell counts to evaluate the appropriateness of switching back to TMP-SMX

Previous research supports the link among malnutrition, cognitive dysfunction, and behavioral outcomes; however, less research has focused on micronutrient deficiencies. This study investigates whether micronutrient deficiencies, specifically blood zinc and iron levels, will be associated with increased behavior problem scores, including internalizing and externalizing behaviors. 1314 Children (55% boys and 45% girls) from the Jintan Preschool Cohort in China participated in this study. Venous blood samples were collected and analyzed for zinc and iron when the children were 3-5 years old. Behavior problems were measured with the Child Behavior Checklist (CBCL), which was completed by the parents when children were in their last months of preschool (mean age 5.6 years). General linear multivariate modeling was used, with adjustment for important sociodemographic variables. The results indicate that low zinc levels alone (p = 0.024) and combined low zinc and iron levels (p = 0.022) are significantly associated with increased reports of total behavior problems. We did not find an association between low iron and behavior problems. With regards to sociodemographics, living in the suburbs is associated with increased internalizing problems, while higher mother's education and being female were associated with decreased externalizing problems. This study suggests that micronutrient deficiencies and sociodemographic facts are associated with behavior problems in preschoolers.