Straub Medical Center

Abstract Disclosure: S.C. Macapagal: None. C.C. Park: None. K. Wirunsawanya: None. We report the first case of a young male with type 2 diabetes mellitus and normal kidney function who presented with combined lactic acidosis and euglycemic diabetic ketoacidosis (euDKA) after the resumption of metformin and empagliflozin. This is a rare presentation, with only a limited number of documented data. According to published case reports, it is typically observed in the setting of acute kidney injury, advanced age, and significant co-morbidities. A 36-year-old diabetic male with non-insulin-dependent diabetes mellitus type 2, dyslipidemia, and prior pancreatitis in 2020 who presented to the emergency department with complaints of nausea, vomiting, and abdominal pain. He had been using empagliflozin and metformin for the past six years, but discontinued both medications two months ago due to financial constraints in transportation that hindered his ability to acquire them. He had poor glycemic control reflected by his HbA1c of 12.4% due to medication non-adherence. When he had the chance to get the medications, he took the metformin 1000 mg followed by another dose in four hours (total: 2,000mg) with a one-time dose of empagliflozin 25 mg. After four hours, he woke up with nausea, vomiting, chills, confusion, and fatigue. Initial investigations showed high anion gap metabolic acidosis (bicarbonate of 10 mEq/L with a gap of 33), ketosis (beta-hydroxybutyrate > 9.00 mmol/L), hyperlactemia (3.2 mEq/L), and hyperkalemia (7.0 mEq/L). He did not have an acute kidney injury. His creatinine and eGFR were 1.0 mg/dL and 100 ml/min/1.73, respectively. He was found to have combined lactic acidosis and euDKA. His home diabetic medications were stopped and he was treated with intravenous fluids and insulin infusion with improvement of symptoms. His blood glucose levels have never exceeded 250 mg/dL throughout the admission. His metabolic derangements and symptoms were resolved following treatment. On discharge, he was started on a short and long-acting insulin regimen. This case emphasized that metformin and empagliflozin resumption can present with an unusual combination of lactic acidosis and euDKA even in a young diabetic male without significant renal impairment and co-morbidities. SGLT2 inhibitors are recognized for causing euDKA, their correlation with lactic acidosis has been rarely documented. Therefore, lactic acidosis and hyperkalemia were probably attributable to metformin use. Clinicians should be aware of this atypical presentation, as early recognition and prompt management are crucial in improving the outcome of such cases. Presentation: Monday, July 14, 2025

To evaluate the relationship between the duration of pre-extracorporeal membrane oxygenation (ECMO) mechanical ventilation and mortality in acute respiratory distress syndrome (ARDS) patients undergoing venovenous ECMO. Retrospective cross-sectional study using the National Inpatient Sample database. National Inpatient Sample database from January 2019 to December 2022. Inclusion criteria were: 1) adults (age ≥ 18 yr old) who received venovenous ECMO and 2) ARDS diagnosis. Exclusion criteria were: 1) receipt of venovenous ECMO before intubation, 2) receipt of lung transplant, and 3) missing data for regression analysis variables. None. Survey-weighted multivariable logistic regression to assess the association between in-hospital mortality and time from mechanical ventilation to venovenous ECMO initiation was performed. A national estimate of 9090 patients were identified. The duration of pre-ECMO mechanical ventilation was not significantly associated with in-hospital mortality (odds ratio [OR], 1.02; 95% CI, 0.98-1.06; p = 0.367). Late initiation of venovenous ECMO (pre-ECMO mechanical ventilation > 7 d) was not associated with an increased risk of in-hospital mortality (OR, 1.18; 95% CI, 0.91-1.54; p = 0.216). Our study suggests that pre-ECMO mechanical ventilation duration does not independently predict mortality in patients with ARDS. This challenges the conventional belief that ECMO must be initiated within 7 days and supports a more individualized approach to ECMO candidacy.

Most studies investigating the influence of race on patient reported outcomes (PROs) compare Black and/or Hispanic patients to White patients. Few have examined differences in PROs between Native Hawaiian/Pacific Islander (NHPI), Asian, and White patients, which comprise most of the population of Hawai'i. The purpose of this study was to examine differences in perioperative PROs between NHPI, Asian, and White patients and discuss observed outcome disparities if present. A retrospective evaluation of Asian, White and NHPI patients undergoing elective, unilateral total hip (THA) or total knee arthroplasty (TKA) between April 2019 and April 2023 was performed. Patient demographics, Charlson Comorbidity Index (CCI), Patient-Reported Outcomes Measurement Information System (PROMIS) global physical health (GPH) and global mental health (GMH), patient satisfaction, and Hip/Knee Disability and Osteoarthritis Outcome Score for Joint replacement (H/KOOS JR) were collected. Analysis of variance and chi-square tests were performed to detect differences between racial groups. NHPI patients had the highest average body mass index (BMI, kg/m2) and the largest proportion of patients classified as obese for both surgical groups. NHPI patients also reported the lowest preoperative H/KOOS JR, PROMIS GPH, and PROMIS GMH scores compared to Asian and White patients. However, by 1 year post surgery, there were no significant differences in H/KOOS JR and PROMIS GPH amongst NHPI, Asian and White patients. PROMIS GMH was not significantly different for TKA patients at 1 year post surgery, but was significantly different for THA patients, with NHPIs reporting the lowest scores. NHPI patients undergoing TKA and THA reported poorer preoperative scores but achieved similar outcomes as Asian and White patients following surgery. Lower preoperative scores may be due to higher levels of obesity in NHPI patients, but these factors do not seem to be predictive of poorer outcomes.

We present a case of successfully treating an adult woman with a lethal bupropion overdose with VA-ECMO. The patient presented to the hospital with severe encephalopathy, which progressed to seizures and cardiac arrest shortly after arrival. This was preceded by ingesting numerous tablets of 300 mg extended-release bupropion. Her bupropion level was 946 ng/dL (therapeutic level 10–100 ng/dL). The patient’s clinical presentation was compounded by severe neurological failure that met the clinical brain death criterion. Despite high-dose catecholamines, the patient remained in refractory shock. An echocardiogram demonstrated severe biventricular failure with a left ventricular ejection fraction (LVEF) of under 10%. VA-ECMO support was initiated, and the patient was retrieved to our ECMO center, where a percutaneous left-ventricular assist device (LVAD) was further placed. Her cardiovascular status slowly improved, with catecholamine support significantly weaned down by hospital day (HOD) 6. The patient was removed from VA-ECMO and LVAD on HOD 8 and 10, respectively. A subsequent echocardiogram showed an LVEF of 45%. The patient’s neurological recovery lagged, with only a weak gag reflex on HOD 8; however, by HOD 10, she intermittently regained consciousness. By HOD 13, although weak and requiring mechanical ventilation, the patient could stay awake and express her needs effectively. On HOD 34, the patient was discharged with intact neurological and cardiopulmonary function. Severe bupropion overdose can cause refractory shock and apparent brain death, as seen in the patient. In this case, extracorporeal life support was vital in bridging detoxification and recovery.

Understanding the average time from surgery to discharge is important to successfully and strategically schedule cases planned for same day discharge (SDD) for total knee arthroplasty (TKA). The purpose of this study was to (1) evaluate the average time to discharge following unilateral TKA performed in a community hospital and (2) describe patient characteristics and peri-operative factors that may impact SDD. This retrospective review included 75 patients having achieved SDD following unilateral TKA between March 2017 and September 2021 at a high-volume multi-specialty community hospital. Time to discharge was calculated from end of surgery, defined as completion of dressing application, to physical discharge from the hospital. Time surgery completed and association with time of discharge was also examined. Pearson's correlations were performed to evaluate the relationship between total time to discharge and patient demographics. The average age for all patients was 66.6 ± 10.9 years (Range: 38 to 86) and average BMI of 29.9 ± 5.6kg/m2 (Range: 20.4 to 46.3). The average time to discharge was 5.8 ± 1.8h (range: 2.2 to 10.5h). Time to discharge was significantly longer for patients finishing surgery prior to noon (6.0 ± 1.8h), than after noon (4.8 ± 1.4h, p = 0.046). Total time to discharge was not correlated with age (r = 0.018, p = 0.881) or BMI (r=-0.158, p = 0.178), but was negatively correlated with surgical start time (r=-0.196, p = 0.094). An average of six hours was required to achieve SDD following unilateral TKA performed in a community hospital. The time required for SDD was not found to be related to intrinsic patient factors but more likely due to extrinsic factors associated with time of scheduled surgery. To improve success of SDD, focus should be placed on the development of efficient discharge pathways rather than unchangeable intrinsic patient characteristics.

Previous arthroplasty utilization research predominantly examined Black and White populations within the US. This is the first known study to examine utilization and complications in poorly studied minority racial groups such as Asians and Native Hawaiian/Pacific-Islanders (NHPI) as compared to Whites. Data from 3304 primary total hip and knee arthroplasty patients (2011 to 2019) were retrospectively collected, involving 1789 Asians (52.2%), 1164 Whites (34%) and 320 Native Hawaiians/Pacific Islanders (NHPI) (9.3%). The 2012 arthroplasty utilization rates for Asian, White, and NHPI increased by 32.5%, 11.2%, and 86.5%, respectively, by 2019. Compared to Asians, Whites more often underwent hip arthroplasty compared to knee arthroplasty (odds ratio (OR) 1.755; p < 0.001). Compared to Asians, Whites and NHPI more often received total knee compared to unicompartmental knee arthroplasty (White: OR 1.499; NHPI: OR 2.013; p < 0.001). White patients had longer hospitalizations (2.66days) compared to Asians (2.19days) (p = 0.005) following bilateral procedures. Medicare was the most common insurance for Asians (66.2%) and Whites (54.2%) while private insurance was most common for NHPI (49.4%). Compared to Asians, economic status was higher for Whites (White OR 0.695; p < 0.001) but lower for NHPI (OR 1.456; p < 0.001). After controlling for bilateral procedures, NHPI had a lower risk of transfusion compared to Asians (OR 0.478; p < 0.001) and Whites had increased risk of wound or systemic complications compared to Asians (OR 2.086; p = 0.045). Despite NHPI demonstrating a significantly poorer health profile and lower socioeconomic status, contrary to previous literature involving minority racial groups, no significant overall differences in arthroplasty utilization rates or perioperative complications could be demonstrated amongst the racial groups examined.

survival rate

Long-term outcomes of vein morphologies in the endoscopic vein harvesting setting are lacking. We analyzed 15-year follow-up for endoscopic versus open vein harvesting and associated vein morphology outcomes in coronary artery bypass grafting at a single center. This single-center, prospectively collected, retrospective, observational study evaluated 15-year major adverse cardiovascular events (MACE) of endoscopic versus open vein harvesting and associated vein morphologies. Among 729 patients, no differences were found between endoscopic and open vein harvesting in MACE hazard ratios despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Asian and Filipino patients had more thin-walled veins and Asian and multirace patients had more vasovasoral branches than White patients. Bifid veins were associated with increased risk of cardiac catheterization. Varicose veins were associated with myocardial infarction, congestive heart failure, and death. Thick-walled veins were associated with revascularization and dense adhesions with cardiac catheterization and revascularization. Fifteen-year adjusted MACE was similar between endoscopic and open vein harvesting in small coronary targets despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Bifid, varicose, thick-walled veins, and dense adhesions had worse MACE.

Preoperative arthroplasty classes decrease complications and readmissions, however, in-person classes are inconvenient for elderly patients with mobility limitations. This retrospective review included 232 patients (305 joints) with in-person preoperative educational classes (IPC) and 155 patients (192 joints) with telephone preoperative educational classes (TC). Compared to IPC, TC patients had a shorter length of stay (P<.009), but a greater percentage made at least one postoperative clinic call (22.8% vs 40%; P<.001). No differences were noted in complications, but emergency room visits significantly decreased for total knee TC patients (P=.039). The increase in clinic calls may be addressed through focused changes to the preoperative telephone dialogue, providing a safe and efficient alternative to IPCs.