Loneliness is a little discussed concept in today's self-obsessed climate, where it is seen as a negative embarrassing condition. It is unique for every individual, and as such, it is difficult to define. There are other closely related concepts, for example, aloneness and solitude, that further complicate an already complex issue. Loneliness also has various causes and effects that can be one and the same, and so it can be confused with similar but different conditions, for example, depression and self-esteem. But, at the end of the day, if the word loneliness is mentioned in conversation, everybody will understand what it means to them, and how distressing an ordeal it can be. Everyone is lonely to some degree, no matter how much they pretend they are not: it is part of being human. Nursing literature looks at loneliness from a rather basic, superficial perspective, when discussing whether such a traumatic state of being can be solved, but this is not a solution as such. It is such an innate part of the human psyche, that it cannot be solved like a puzzle; it can only be alleviated and made less painful. This can only be achieved by increasing humankind's awareness of this distressing condition that everyone has to endure in some way, shape or form, some time during their lives, about which there is nothing to be embarrassed. If non-lonely individuals could spare a smile or a word for people who might be perceived as being lonely, even if in doing so they selfishly think 'there but for the grace of God go I', such a small gesture might just make their day a little less of an ordeal.

We present a case of a significant insulin overdose that was managed by monitoring daily plasma insulin levels. A 39-year-old male with poorly controlled diabetes mellitus presented to the Emergency Department via emergency medical services after an attempted suicide by insulin overdose. In the attempted suicide, he injected 800 U of insulin lispro and 3800 U of insulin glargine subcutaneously over several parts of his abdomen. The patient was conscious upon arrival to the emergency department. His vital parameters were within normal range. The abdominal examination, in particular, was nonfocal and showed no evidence of hematomas. He was awake, alert, conversant, tearful, and without any focal deficits. An infusion of 10% dextrose was begun at 100 mL/h with hourly blood glucose (BG) checks. The patient was transferred to the intensive care unit where his BG began to decrease and fluctuate between 50 and 80 mg/dL, and the rate of 10% dextrose was increased to 200 mL/h where it was maintained for the next 48 hours. The initial plasma insulin level was found to be 3712.6 uU/mL (reference range 2.6-31.1 uU/mL). At 10 hours, this had decreased to 1582.1 uU/ml. On five occasions, supplemental dextrose was needed when the BG was <70 mg/dL. Thirty-four hours after admission, the plasma insulin level was 724.8 uU/mL. Fifty-eight hours after admission, the plasma insulin level was 321.2 uU/mL, and the 10% dextrose infusion was changed to 5% dextrose solution at 200 mL/h. The plasma insulin levels continued to fall daily to 112.7 uU/mL at 80 hours and to 30.4 uU/mL at 108 hours. He was transferred to an inpatient psychiatric facility 109 hours after initial presentation. Monitoring daily plasma insulin levels and adjusting treatment on a day-to-day basis in terms of basal glucose infusions provides fewer opportunities for episodic hypoglycemia. Furthermore, it was easier to predict daily glucose requirements and eventual medical clearance based on the plasma levels.

Background In contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity. Methods and results CLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis &gt;50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure. Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest. Conclusion In patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes. ClinicalTrials identifier ISRCTN43070564

Isopropyl ingestion is usually a benign occurrence with little metabolic or renal abnormalities. We describe a case of a false elevation of serum creatinine due to laboratory interference in the setting of a toxic alcohol exposure that could have led to a misdiagnosis of ethylene glycol intoxication and a different treatment plan. Clinicians should be aware of this laboratory anomaly when treating suspected toxic alcohol ingestions.