ObjectiveWe compared the conventional ‘one-bag protocol’ of management of diabetic ketoacidosis (DKA) with the ‘two-bag protocol’ which utilizes two bags of fluids, one containing saline and supplemental electrolytes and the other containing the same solution with the addition of 10% dextrose.Research design and methodsA retrospective chart review and analysis was done on adult patients admitted for DKA to the Riverside University Health System Medical Center from 2008 to 2015. There were 249 cases of DKA managed by the one-bag system and 134 cases managed by the two-bag system.ResultsThe baseline patient characteristics were similar in both groups. The anion gap closed in 13.56 hours in the one-bag group versus 10.94 hours in the two-bag group (p value <0.0002). None of the individual factors significantly influenced the anion gap closure time; only the two-bag system favored earlier closure of the anion gap. Plasma glucose levels improved to <250 mg/dL earlier with two-bag protocol (9.14 vs 7.82 hours, p=0.0241). The incidence of hypoglycemic events was significantly less frequent with the two-bag protocol compared with the standard one-bag system (1.49% vs 8.43%, p=0.0064). Neither the time to improve serum HCO3 level >18 mg/dL nor the hospital length of stay differed between the two groups.ConclusionsOur study indicates that the two-bag protocol closes the anion gap earlier than the one-bag protocol in adult patients with DKA. Blood glucose levels improved faster with the two-bag protocol compared with the one-bag protocol with fewer associated episodes of hypoglycemia. Prospective studies are needed to evaluate the clinical significance of these findings.

Subclinical pericardial effusions are common in patients with untreated hypothyroidism and usually resolve with thyroid replacement therapy, but cardiac tamponade is a rare presentation of prolonged untreated hypothyroidism. We report the first case of cardiac tamponade due to hypothyroidism produced by administration of amiodarone. KEYWORDS: Cardiac tamponade, hypothyroidism, amiodarone therapyAccumulation of proteinaceous fluid in vital body cavities of patients with hypothyroidism is widely documented. The most common sites for fluid accumulation are the pericardial, pleural, and peritoneal cavities. 1 The reported incidence of pericardial effusion in hypothyroid patients is 3% in an early mild stages to 80% when myxedema is present, 2,3 but cardiac tamponade is very rare and happens in prolonged untreated hypothyroisim. 4 Hypothyroidism is common in patients receiving amiodarone, but cardiac tamponade secondary to this has not been reported to our knowledge. [5][6][7] We report the first case of cardiac tamponade caused by hypothyroidism produced by administration of amiodarone. CASE REPORTA 69-year-old Caucasian man with medical history of hypertensive cardiomyopathy, colon cancer, and atrial fibrillation presented with progressive dyspnea on exertion and fatigue over a period of weeks. He was on longterm amiodarone therapy; 200 mg twice a day for several years. Physical examination revealed blood pressure of 95/54 mm Hg and heart rate of 67 beats per minute with distended jugular veins and distant heart sounds.The chest X-ray revealed massive cardiomegaly (Fig. 1A). Chest computed tomography scan performed to evaluate the metastatic cancer revealed a large pericardial effusion (Fig. 1B). Echocardiography confirmed the diagnosis of massive pericardial effusion with tamponade physiology consisting of markedly dilated inferior vena cava and respirophasic variations in transvalvular flows (Fig. 1C). The clinical suspicion of hypothyroidism was supported by an elevated thyroid stimulating hormone level of 77.7 mIU/mL (normal 0.4 to 4.0 mIU/mL) and decreased plasma-free thyroxine level of 0.62 ng/dL (normal 0.8 to 2.0 ng/dL).The patient underwent emergent echocardiographically guided pericardiocentesis with drainage of 1.4 L of straw-colored fluid. The patient had marked improvement in symptoms and blood pressure with pericardiocentesis. The protein content of the fluid was 2.5 g/dL and cytology was negative for malignant cells. Follow-up chest X-ray showed a dramatic reduction in

End-stage renal disease (ESRD) patients have extraordinarily high cardiovascular risk and mortality, yet the benefit of statins in this population remains unclear based on the randomized trials. We investigated the prognostic value of statins in a large, pure cohort of prospectively recruited patients with ESRD awaiting renal transplantation, and being followed up in a dedicated cardiac clinic. We prospectively collected demographic, clinical, laboratory, and pharmacological data on 423 consecutive ESRD patients on hemodialysis awaiting renal transplantation. Survival analysis was performed as a function of statin therapy. The baseline characteristics were as follows: age 57 ± 11 years, males 64%, diabetes mellitus in 68%, known coronary artery disease in 30%, left ventricular (LV) ejection fraction 61 ± 11%. Over a mean follow-up of 2 years, there were 43 deaths. Adjusted for age, gender, hypertension, body mass index, diabetes mellitus, coronary artery disease, smoking, and treatment with angiotensin converting enzyme inhibitor, β blocker, and antiplatelet medications, statin use was a predictor of lower mortality (hazard ratio 0.30, 95% confidence interval 0.11-0.79, p = 0.01). This beneficial effect of statin was supported by propensity score analysis (p = 0.02) and was consistent across all clinical subgroups. The benefit of statins seemed to be greater in those with LV hypertrophy and smoking. Statin therapy in hemodialysis patients awaiting renal transplant is independently associated with better survival supporting its use in this high-risk population.

Background: Residents frequently experience burnout. Multiple interventions to decrease the risk of burnout have had inconsistent results. In non-medical settings, improving optimism promotes a positive outlook and enhances well-being. Thus, psychological interventions that improve optimism could have potential to decrease the risk for burnout. Objective: Using Lazarus' Ways of Coping as an organizational framework, this intervention sought to evaluate the impact of an optimism curriculum on residents' burnout. Methods: Thirty-six Internal Medicine residents participated in an optimism improvement program from November 2019 to April 2020. We determined pre-and post-curriculum measures of optimism, happiness, and burnout with validated surveys. The Optimism Curriculum was comprised of three one-hour long sessions, which included lectures, group and self-reflective exercises. A post -curriculum evaluation rating the effectiveness of the program was administered separately. Results: Thirty-four out of thirty-six residents completed the post curricular surveys. Individuals with low optimism scores had a higher score for burnout compared to those with higher optimism scores. The post-intervention survey showed numerical improvement in optimism, happiness and burnout, although these changes were not statistically significant. The post-intervention survey showed a decrease in the measure of burnout; however, this was not significant (p = 0.24) with an effect size of 0.34 (Cohen's d). Conclusions: Teaching optimism to residents with the objective of decreasing the risk of burnout is feasible and easily integrated into residency education sessions. The encouraging results of this pilot study lay the foundation for additional studies and suggest a practical role for implementing optimism curricula in residency training programs.

Background Patients with end‐stage renal disease (ESRD) have a cardiovascular mortality about 15–30 times the general population and this is reduced by about 70% with renal transplant. Dobutamine stress echocardiography (DSE) is commonly performed for preoperative cardiac evaluation before renal transplantation. Hypertensive response during DSE occurs in about 1%–5% of DSE studies. However, it seems to be more frequent in patients with ESRD. But its frequency and clinical implications are not known. Methods and Results Of the 249‐consecutive adult ESRD patients undergoing DSE for pre‐kidney transplant cardiac risk assessment at our dedicated clinic, 53 (21%) had a hypertensive response. Half of the patients with a hypertensive response had stress‐induced segmental wall motion abnormalities, of whom only half had angiographically significant coronary artery disease by quantitative coronary angiography. The hypertensive response was not a predictor of survival. Stress‐induced segmental wall motion abnormalities predicted poor survival in those with a normotensive response, but not in those with a hypertensive response. The main and independent predictor of a hypertensive response was higher baseline systolic blood pressure (P < .0001). Conclusions Hypertensive response to dobutamine stress is common in ESRD patients and is not a predictor of survival. Stress‐induced segmental wall motion abnormalities occur nearly thrice as frequently with a hypertensive response, but this is a poor predictor of angiographically significant coronary artery disease and does not predict survival.