Ketogenic diet, a very low-carbohydrate diet and high-fat diet, has emerged as a popular approach for weight reduction, particularly in young adults. However, a serious but rare complication of the ketogenic diet is ketoacidosis associated with low carbohydrate intake, which should be cautiously monitored in people with a predisposition to the condition. We report a 22-year-old Thai woman with an unremarkable past medical history who presented with an acute onset of dyspnea of 2 days’ duration. Diabetic ketoacidosis was diagnosed by elevated capillary blood glucose, significant metabolic acidosis, and a high serum beta-hydroxybutyrate level. Low C-peptide level and positive islet autoantibodies confirmed the new diagnosis of type 1 diabetes in this patient. After her conditions were stabilized, the patient revealed that she began a ketogenic diet for weight reduction 4 days before her illness. Other precipitating factors were not identified. This highlights that ketogenic diet may increase diabetic ketoacidosis risk at the presentation of previously unrecognized type 1 diabetes.

Lung ultrasound (LUS) is used for dry weight guidance by assessment of pulmonary congestion in hemodialysis (HD) patients. The aim of this study was to estimate amounts of accumulated fluid by total LUS scores (TLUSS), which were scarcely reported in HD patients who were normal or had a mild functional abnormality. In addition, the correlations between the LUS score of each area and TLUSS were determined to suggest fewer specific areas valuable to shorten the examination time of LUS. Methods: This cohort study was conducted in adult HD patients who have New York Heart Association Classes I-II. LUS and multifrequency bioimpedance (BIA) were performed at baseline and the individual prescribed dry weight was set. Then each LUS was conducted at 28 areas of bilateral intercostal spaces and calculated as TLUSS weekly for eight weeks in which dry weight was adjusted. The second BIA was also measured at week eight. The difference of pre-HD weight and target weight (weight gain; WG) represented the amount of fluid accumulation. Results: Twenty patients with a mean age of 62.2±14.0 years were enrolled. One hundred and sixty-six LUS were performed in which forty episodes of them were simultaneously measured with BIA. Optimum dry weight adjusted by TLUSS which benefited in mean reductions of blood pressure, and cardiothoracic ratios. WG amounts were significantly correlated with TLUSS (r=0.38), and with extracellular fluid (r=0.35) and overhydration fluid (r=0.39) assessed by BIA. Estimations of mean fluid overload were 2.18 (TLUSS ≤15), 2.72 (TLUSS 16-24), 3.17 and 5.03 (TLUSS ≥39) in liters. The cut-off points of sum scores of 12 specific lung areas represented the none-mild were <8, moderate at 8-16, and severe pulmonary congestions were >16. Conclusion: TLUSS estimated accumulated fluid useful for volume and blood pressure controls. Performance of LUS in 12 specific lung areas may reduce spending time and support routine uses of LUS in clinical practice.

Background Serial monitoring of plasma cytomegalovirus (CMV) viral load monitoring with intervals of less than five days or using different assays for monitoring may cause unnecessary budgets for laboratory testing without changes in treatment, morbidity, and mortality. Methods The pre-intervention retrospective study and post-intervention prospective cohort study were performed. In 2021, the inpatient electronic pop-up and telephone interview and feedback were used to limit unnecessary plasma CMV viral load testing. The rate of plasma CMV viral load testing being performed with intervals of less than five days was compared before and after protocol implementation using the Poisson regression model. The cost-effectiveness of plasma CMV viral load testing after protocol implementation was also studied. Results After protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test requests with intervals of less than five days from 11.8% to 6.2% [Incident rate ratio (IRR) 0.50, p-value &lt; 0.001]. Of these, 38.9% was due to unintentional requests. After telephone interviews the rate of plasma CMV viral load test requests with intervals of less than five days decreased further to 4.7% (IRR 0.37, p-value &lt; 0.001). The costs of plasma CMV viral load testing performed with intervals of less than five days and anti-CMV drugs were reduced significantly. (822,500 to 345,000 Thai Baht, p &lt; 0.001 and 12,327,436 to 7,860,187 Thai Baht, p = 0.001) Incidence of plasma CMV viral load testing performed with intervals of less than five days Costs of plasma CMV viral load testing, anti-CMV drug, bronchoscopy, and gastrointestinal endoscopy Conclusion The diagnostic stewardship program is helpful to reduce unnecessary plasma CMV viral load testing and costs without increasing CMV viremia and CMV diseases. This program should be maintained, and an electronic hard stop alert program should be developed. Disclosures All Authors: No reported disclosures.

Background Frequent serial monitoring of plasma cytomegalovirus (CMV) viral load caused unnecessary budgets for laboratory testing without changes in treatment. We aimed to implement diagnostic stewardship to limit CMV viral load testing at appropriate intervals. Methods A quasi-experimental study was performed. To avoid unnecessary plasma CMV viral load testing, the inpatient electronic pop-up reminder was launched in 2021. In cases with plasma CMV viral load testing was ordered in intervals of less than five days, telephone interview and feedback were performed. Pre-post intervention data was compared in terms of clinical and monetary outcomes. The rate of plasma CMV viral load testing performed in intervals of less than five days was compared between 2021 and 2019 using the Poisson regression model. Results After the protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test orders in intervals of less than five days from 17.5% to 8.0% [incidence rate ratio 0.40, p < 0.001]. There was no statistically significant difference in the incidence of CMV DNAemia and CMV disease (p = 0.407 and 0.602, respectively). As a result, the hospital could save the costs of plasma CMV viral load testing per 1,000 patients performed with intervals of less than five days from 2,646,048.11 to 1,360,062.89 Thai Baht. Conclusions The diagnostic stewardship program is safe and helpful in reducing unnecessary plasma CMV viral load testing and costs.