Amina Ammar

Scoping reviews are similar to systematic reviews in that they are designed to be transparent and reproducible processes to answer a question while reducing bias. The key difference between scoping reviews and the better‐known systematic review method is the scope of the question being answered. Scoping reviews are best suited to answering broad questions about a topic including mapping the current literature, identifying strengths and gaps in the literature, and tracking the use of terminology or methods used within a field. Scoping reviews can be standalone reviews or used to guide where a systematic review may be needed. Users should understand the purpose of a scoping review and be able to assess the quality of a scoping review before applying it to practice. This article provides an overview of the principles involved in conducting a scoping review, along with a clinical example illustrating each step.

Background: Diabetic ketoacidosis (DKA) is a severe complication of diabetes mellitus requiring insulin. However, there is no consensus on insulin infusion titration strategies, resulting in varied nomograms and potentially suboptimal management. Limited comparative data on insulin nomograms underscore the need for a standardized, evidence-based approach. Objective: The purpose of this study is to evaluate the safety and effectiveness of 3 DKA nomograms. Methods: This multicenter, retrospective observational study included adult patients with confirmed DKA treated with IV insulin for ≥3 hours. Each site used a different variable-rate nomogram: variable rate weight-adjusted IV insulin infusion with no bolus (VR-W-NB), variable-rate IV insulin infusion with bolus (VR-B) or variable-rate IV insulin infusion with no bolus (VR-NB). The primary endpoint was the incidence of hypoglycemia (P < 0.01). After controlling for confounding factors, hypoglycemia remained the highest in the VR-W-NB (odds ratio [OR] = 6.2, 95% confidence interval [CI] = 2.5-15.3, P < 0.01) and VR-B (OR = 5, 95% CI = 2.1-12.1, P < 0.01) cohorts compared with the VR-NB cohort. Diabetic ketoacidosis resolution was significantly shorter in patients receiving VR-W-NB (median of 9.7 hours, interquartile range [IQR] = 5.6-16.9) compared with those receiving VR-B (12.7 hours, IQR = 9.2-25) and VR-NB (16.1 hours, IQR = 10-24.5). DKA recurrence was higher in those treated with VR-B (19.7%) compared with those treated with VR-W-NB (7%) and VR-NB (15.5%) ( P = 0.02). Conclusion and relevance: The VR-W-NB was associated with a higher incidence of hypoglycemia and faster DKA resolution compared with VR-B and VR-NB. These findings support the need for prospective studies to define optimal insulin strategies that improve safety, effectiveness, and resource utilization.

Introduction : Hypoglycemia in critically ill patients increases morbidity and mortality. Subcutaneous long-acting insulin (LAI) in patients without diabetes is associated with hypoglycemia in the SICU. However, limited evidence exists in patients with diabetes. Methods: This was a single-center, retrospective cohort study evaluating patients with T2DM who were admitted to the SICU for 24 h and received LAI in combination with sliding scale insulin (LAI + SSI) or sliding scale insulin (SSI) alone. The primary outcome was the incidence of hypoglycemia (BG < 70 mg/dL) in patients who received LAI + SSI or SSI. Secondary outcomes evaluated the number of glucose values across defined categories: hypoglycemia (54-70 mg/dL), severe hypoglycemia (180 mg/dL) and glycemic variability. Results: A total of 228 patients were included in the final analysis. The incidence of hypoglycemia occurred in 17.5% of patients in the LAI + SSI cohort and 18.4% in the SSI cohort (p = .86). After controlling for confounders, no differences were observed with LAI + SSI versus SSI for hypoglycemia (OR 1.09, 95% CI 0.46-2.6, p = .85). Secondary outcomes demonstrated no difference in total hypoglycemia (37 vs 31, p = .80), severe hypoglycemia (15 vs 34, p = .17) and euglycemia (1622 vs 1780, p = .22) in the LAI + SSI cohort compared to SSI alone. Hyperglycemia occurred more frequently with LAI + SSI. However, after adjusting for confounders there was no difference in hyperglycemia (OR 1.8, 95% CI 0.7-4.6, p = .22). No difference was observed in glycemic variability between LAI + SSI and SSI (26.5 vs 24.5, p = .21). Conclusion and Relevance: The addition of LAI to SSI in SICU patients with T2DM was not associated with an increased risk of hypoglycemia.

Chronic kidney disease (CKD) is a significant global health challenge that impacts both patients and the health care system. This systematic review aims to evaluate the efficacy and safety of emerging therapeutic strategies for CKD management, including sodium‐glucose cotransporter 2 inhibitors (SGLT2i), glucagon‐like peptide‐1 receptor agonists (GLP‐1RA), finerenone, sacubitril/valsartan, and potassium binders. We conducted searches in databases including PubMed, Scopus, CINAHL Complete, and Web of Science Core Collection to identify experimental and observational studies pertaining to each of these agents. Included studies were those that enrolled adult patients with CKD who evaluated SGLT2i, GLP‐1RA, finerenone, sacubitril/valsartan, and potassium binders compared to other medications or placebo and evaluated renal‐related outcomes as a primary or secondary outcome. Methodological quality and risk of bias were assessed using the Cochrane Risk of Bias (version 2) tool for experimental studies and ROBINS‐I for observational studies. After screening 2135 unique studies, 138 studies were eligible for this review. These studies describe a substantial and growing body of evidence focused on improving the management of CKD beyond renin‐angiotensin system inhibitors (RASi), such as angiotensin‐converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs). Currently, SGLT2i have demonstrated consistent benefits with large effect sizes in preventing the progression of CKD, solidifying this class as a first‐line treatment along with RASi. Subsequent consideration for GLP‐1RA, finerenone, and sacubitril/valsartan should be dependent on patient‐specific comorbidities, while potassium binders may allow for longer use of RASi.