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Background: Diabetic ketoacidosis entails a huge health burden among patients with diabetes. Atrial fibrillation (AF) is the most common type of heart arrhythmia. This study aimed to evaluate the impact of AF on clinical outcomes in patients with diabetic ketoacidosis., Methods: Using the 2012-2014 National Inpatient Sample database, we identified adult patients hospitalized with diabetic ketoacidosis as the principal discharge diagnosis. The identified admissions were stratified into 2 cohorts based on the AF presence. We used multivariable regression models and propensity score matching models to evaluate in-hospital mortality, length of stay, comorbidities, and in-hospital complications., Results: The study included 478,890 adult patients who were admitted for diabetic ketoacidosis in the year 2012-2014. A total of 467,780 (97.68%) had no AF and 11,125 (2.32%) had AF. In both multivariable regression models and propensity score matching models, compared with nonatrial fibrillation group, the AF group had higher in-hospital mortality rates (2.36 [1.69-3.32], P < 0.001) and longer length of stay (5.5 versus 3.3 days, P < 0.001). AF was also associated with a significantly higher incidence of complications including septic shock, pulmonary failure, mechanical ventilation, neurological failure, cerebral edema, acute kidney injury, acute hematologic failure, and cardiac arrest., Conclusions: Among patients who were hospitalized for diabetic ketoacidosis, comorbid AF led to increasing in-hospital mortality rates and longer length of stay. A potential explanation was that AF increased the risk of in-hospital complications including respiratory failure with a more frequent requirement for mechanical ventilation, cardiac arrest, and metabolic encephalopathy., (Copyright © 2019 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Interest in nephrology careers continues to decline in the United States. The reasons for this declining interest are not fully understood but it is plausible that inadequate exposure to the full spectrum of what a career in nephrology encompasses may be part of the explanation. Inpatient-based nephrology electives have been a common venue for residents to gain exposure to nephrology but little is known regarding the details of such electives and how often they include outpatient experiences. We carried out a national survey of nephrology fellowship training program directors to obtain data on the content of nephrology elective experiences as well as their ideas on how to promote interest in the field. The survey revealed the majority of elective experiences to be either exclusively or heavily inpatient based, with only a small percentage having a substantial outpatient component, particularly in outpatient dialysis or transplantation. Training program directors felt that providing greater outpatient experiences to residents during elective rotations would be an effective means to promote interest in nephrology, along with structured faculty mentoring. Our findings suggest that current approaches to the nephrology elective experience are heavily inpatient-based and might benefit from incorporating much more of the rich spectrum of activities a career in nephrology entails. Hopefully such efforts can create and enhance interest in careers in nephrology and potentially begin a sustained reversal of an unfortunate and serious decline in interest.

Although many anticipate that there will be an eventual shortage of practicing nephrologists, a complete understanding is lacking regarding the current factors that lead US adult nephrology fellows to choose nephrology as a career and their satisfaction with this choice. It is of great concern that interest in obtaining nephrology fellowship training continues to decline in the United States, especially among US medical graduates, and the reasons for this are unclear. The exposure that students and residents have to nephrology is likely to play an important role in the career choices that they make and their ultimate satisfaction with this career choice is likely influenced by several factors, including job opportunities. Some of the findings presented here suggest that there may be a high percentage of nephrology fellows who are dissatisfied with their career choice. Failure to understand the factors that influence trainees to choose nephrology as a career and those that affect their satisfaction with this choice may impair the ability to graduate a sufficient number of nephrologists to meet projected demand. In this article, a number of variables related to the choice of nephrology as a career and satisfaction with a career in nephrology are discussed. Some steps that the nephrology training community might take to help promote interest in nephrology and optimize the satisfaction that nephrology graduates derive from their careers are also proposed.

Background: The American College of Physicians recommends perioperative use of beta-blockers for certain patients to improve outcomes after surgery. Study of physician behavior with respect to guidelines and recommended practices have shown that beta-blockers have been underutilized after myocardial infarction. We evaluated physician concordance with the perioperative use of beta-blockers along with a specialty-related difference in the frequency of perioperative beta-blocker use., Methods: To determine perioperative use of beta-blockers, we retrospectively analyzed the medical charts of adult patients who underwent open cholecystectomy at a tertiary care medical center from December 1997 through December 2001. Patients met criteria for perioperative beta-blocker use if they had a history of coronary artery disease or if they had the presence of 2 or more of the following risk factors: 65 years or older; history of hypertension, diabetes mellitus, or hypercholesterolemia; or current smoking., Results: Among the 336 cases of cholecystectomy reviewed, criteria for beta-blocker use were met in 146 patients (43%) who did not have emergency operations and/or contraindications to beta-blocker use. Of these 146 patients, 123 (84%) had a documented preoperative medical evaluation by a physician in the medical chart. There were 44 patients (30%) receiving beta-blockers prior to admission, and 102 patients (70%) were not receiving beta-blockers. Of those 102 patients not receiving beta-blockers at admission but who meet criteria for their use, 94 (92%) were not started on beta-blocker therapy preoperatively. Of the 18 patients evaluated by a cardiologist, 4 (22%) were started on beta-blocker therapy compared with 3 (6%) of 47 patients evaluated by a noncardiologist physician (P =.08)., Conclusion: Perioperative beta-blocker therapy is underutilized in patients with risk factors for coronary artery disease despite evidence that its use in appropriate individuals may be lifesaving.

Several reports have suggested that the incidence of hemorrhagic stroke may be greater on hemodialysis as compared with that among the general population and that patients with intracranial hemorrhage should be treated with peritoneal dialysis rather than hemodialysis. However, whether the risk of fatal stroke is greater on hemodialysis versus peritoneal dialysis has not been systematically examined. In this study, the case of a diabetic patient with extensive peripheral vascular disease who, after 7 years on hemodialysis, was changed to peritoneal dialysis and subsequently suffered two strokes over a 5-month period, is reported. Recent data from the United States Renal Data System, which allow a comparison of death rates from stroke in large numbers of hemodialysis versus peritoneal dialysis patients, are reviewed. These data suggest that the risk of death from stroke may actually be greater for patients on peritoneal dialysis versus hemodialysis in spite of their having a lesser prevalence of preexisting cerebrovascular disease. This risk was greatest for elderly diabetic black patients and women, who experienced a nearly twofold-greater odds favoring death from stroke on peritoneal dialysis versus hemodialysis. Selection of a dialysis modality for a patient beginning renal replacement therapy may require the consideration of such data, particularly in those patients with extensive preexisting vascular disease.