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Metformin-associated lactic acidosis (MALA) and euglycaemic diabetic ketoacidosis (EKA) are both life-threatening endocrine emergencies. MALA is a well-documented complication of anti-glycaemic therapy in diabetics while EKA is an increasingly recognized disease entity with the advent of use of sodium-glucose co-transporter-2 (SGLT-2) inhibitors. However, the occurrence of concurrent metformin-associated lactic acidosis and euglycaemic ketoacidosis (MALKA) is uncommon and rarely reported in the literature. We report an unusual case of MALKA, in a 74-year-old gentleman with no previous history of chronic kidney disease and SGLT-2 inhibitor use, who presented with altered mental status, acute renal failure and profound high anion-gap metabolic acidosis (HAGMA) with lactaemia, ketonaemia and normoglycaemia (pH 6.965, bicarbonate 3.1, creatinine 522, glucose 6.6, lactate 17.5, ketones >8). The patient was initiated on intravenous insulin infusion with dextrose-containing drip and continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The patient had a prolonged hospital stay but was eventually discharged with a normalised renal function without need for long-term dialysis. The parallel occurrence of MALA and EKA suggest a metformin-associated inhibition of gluconeogenesis. This case highlights the importance of early recognition and investigation of concurrent diabetic ketoacidosis in the presence of MALA and vice versa as MALKA benefits from both prompt institution of parenteral glucose therapy and insulin infusion and consideration of initiation of haemodialysis.

Introduction: End-of-life (EOL) conditions are commonly encountered by emergency physicians (EP). We aim to explore EPs' experience and perspectives toward EOL discussions in acute settings. Methods: A qualitative survey was conducted among EPs in three tertiary institutions. Data on demographics, EOL knowledge, conflict management strategies, comfort level, and perceived barriers to EOL discussions were collected. Data analysis was performed using SPSS and SAS. Results: Of 63 respondents, 40 (63.5%) were male. Respondents comprised 22 senior residents/registrars, 9 associate consultants, 22 consultants, and 10 senior consultants. The median duration of emergency department practice was 8 (interquartile range: 6–10) years. A majority (79.3%) reported conducting EOL discussions daily to weekly, with most (90.5%) able to obtain general agreement with families and patients regarding goals of care. Top barriers were communications with family/clinicians, lack of understanding of palliative care, and lack of rapport with patients. 38 (60.3%) deferred discussions to other colleagues (e.g., intensivists), 10 (15.9%) involved more family members, and 13 (20.6%) employed a combination of approaches. Physician's comfort level in discussing EOL issues also differed with physician seniority and patient type. There was a positive correlation between the mean general comfort level when discussing EOL and the seniority of the EPs up till consultancy. However, the comfort level dropped among senior consultants as compared to consultants. EPs were most comfortable discussing EOL of patients with a known terminal illness and least comfortable in cases of sudden death. Conclusions: Formal training and standardized framework would be useful to enhance the competency of EPs in conducting EOL discussions.

BACKGROUND: This study aimed to review bicycle-related injuries during the COVID-19 pandemic to assist with reinforcement or implementation of new policies for injury prevention. METHODS: This is a retrospective descriptive analysis of injuries sustained during cycling for patients 18 years old and above who presented to Singapore General Hospital from January to June 2021. Medical records were reviewed and consolidated. Descriptive analyses were used to summarize patient characteristics, and differences in characteristics sub grouped by triage acuity and discharge status were analyzed. RESULTS: The study included 272 patients with a mean age of 43 years and a male predominance (71.7%). Most presented without referrals (88.2%) and were not conveyed by ambulances (70.6%). Based on acuity category, there were 24 (8.8%) Priority 1 (P1) patients with 7 trauma activations, 174 (64.0%) and 74 (27.2%) P2 and P3 patients respectively. The most common injuries were fractures (34.2%), followed by superficial abrasion/contusion (29.4%) and laceration/wound (19.1%). Thirteen (4.8%) patients experienced head injury and 85 patients (31.3%) were documented to be wearing a helmet. The majority occurred on the roads as traffic accidents (32.7%). Forty-two patients (15.4%) were admitted with a mean length of stay of 4.1 d and 17 (6.3%) undergone surgical procedures. Out of 214 (78.7%) discharged patients, no re-attendances or mortality were observed. In the subgroup analysis, higher acuity patients were generally older, with higher proportions of head injuries leading to admission. CONCLUSION: Our study highlights significant morbidities in bicycle-related injuries. There is also a high proportion of fractures in the young healthy male population. Injury prevention is paramount and we propose emphasizing helmet use and road user safety. [ABSTRACT FROM AUTHOR]