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Iradukunda A, Kembabazi S, Ssewante N, Kazibwe A, Kabakambira JD. Diabetic Complications and Associated Factors: A 5-Year Facility-Based Retrospective Study at a Tertiary Hospital in Rwanda. Diabetes Metab Syndr Obes 2021; 14:4801-4810. [PMID: 34984012 PMCID: PMC8703046 DOI: 10.2147/dmso.s343974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/02/2021] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Diabetes mellitus (DM) is a chronic metabolic disorder characterized by hyperglycemia resulting from defects in insulin production, insulin action, or both. Despite advances in DM diagnosis and management, the incidence of DM-related complications remains high. This study aimed to determine patterns of common complications and associated factors among hospitalized patients in Rwanda. METHODS A cross-sectional study, with retrospective chart review, was conducted at CHUK from July to August, 2021. Charts for DM patients admitted from January 2016 to December 2020 were considered while those inaccessible at the time of data collection were excluded. Linear regression model was used to assess the relationship between dependent and independent variables with a p < 0.05 considered statistically significant. RESULTS A total of 246 charts were reviewed. The median age was 56 years (IQR: 14-90). More than half of participants (n = 135; 54.9%) were females; majority from the Central region (n = 138; 56.7%). Recorded DM risk factors included alcohol intake (n = 81; 48.5%); smoking (n = 40; 24.2%), obesity (n = 43; 52.4%), and family history of DM (n = 27; 56.3%). Majority (n = 153; 84.5%) had type 2 DM and (n = 147; 69%) had known their diagnosis for at least 6 years. Hypertension (n = 124, 50.4%), acute hyperglycemic state (n = 59, 24%), nephropathy (n = 58, 23.6%), and stroke (n = 38, 15.4%) were frequently reported complications. Nearly all participants (n = 81, 95.2%) with complications had poor glycemic control. Alcohol intake, age ≥45 years, and T1DM were associated with higher odds of DM complications (aOR = 8, 95% CI = 2-32.6, p = 0.003, aOR = 6.2, 95% CI = 1.4-27.6, p = 0.016 and aOR = 14.1, 95% CI = 1.2-161.5, p = 0.034, respectively). Duration of DM (p = 0.001) was significant at bivariate analysis. CONCLUSION DM complications were prevalent among the studied population with poor glycemic control mainly influenced by alcohol consumption and duration of DM. Expansion of integrated DM and hypertension screening services to lower-level centers is needed to reduce the associated morbidity and mortality.
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Affiliation(s)
- Angelique Iradukunda
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Correspondence: Angelique Iradukunda School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda Email
| | - Shallon Kembabazi
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Nelson Ssewante
- School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Kazibwe
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Wu XY, She DM, Wang F, Guo G, Li R, Fang P, Li L, Zhou Y, Zhang KQ, Xue Y. Clinical profiles, outcomes and risk factors among type 2 diabetic inpatients with diabetic ketoacidosis and hyperglycemic hyperosmolar state: a hospital-based analysis over a 6-year period. BMC Endocr Disord 2020; 20:182. [PMID: 33317485 PMCID: PMC7734851 DOI: 10.1186/s12902-020-00659-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two most common hyperglycemic emergencies (HEs) associated with diabetes mellitus. Individuals with HEs can present with combined features of DKA and HHS. The objective of this study is to assess the clinical characteristics, therapeutic outcomes, and associated predisposing factors of type 2 diabetic patients with isolated or combined HEs in China. METHODS We performed a retrospective analysis of 158 patients with type 2 diabetes (T2DM), complicated with DKA, HHS, or DKA combined with HHS (DKA-HHS) in Shanghai Tongji Hospital, China from 2010 to 2015. Admission clinical features, therapeutic approaches and treatment outcomes of those patients were extracted and analyzed. RESULTS Of the 158 patients with T2DM, 65 (41.1%) patients were DKA, 74 (46.8%) were HHS, and 19 (12.0%) were DKA-HHS. The most common precipitants were infections (111, 70.3%), newly diagnosed diabetes (28,17.7%) and non-compliance to medications (9, 5.7%). DKA patients were divided into mild, moderate and severe group, based on arterial blood gas. Spearman correlation analysis revealed that C-reaction protein (CRP) was positively correlated with severity of DKA, whereas age and fasting C peptide were inversely correlated with severity of DKA (P < 0.05). The mortality was 10.8% (17/158) in total and 21.6% (16/74) in the HHS group, 5.9% (1/17) in DKA-HHS. Spearman correlation analysis indicated that death in patients with HHS was positively correlated to effective plasma osmolality (EPO), renal function indicators and hepatic enzymes, while inversely associated with the continuous subcutaneous insulin infusion (CSII) therapy. Logistic regression analysis suggested that elevated blood urea nitrogen (BUN) on admission was an independent predisposing factor of mortality in HHS, while CSII might be a protective factor for patients with HHS. Furthermore, the receiver-operating characteristic (ROC) curve analysis indicated that BUN had the largest area under the ROC curves for predicting death in patients with HHS. CONCLUSIONS Our findings showed elevated CRP and decreased fasting C-peptide might serve as indicator for severe DKA. Elevated BUN might be an independent predictor of mortality in patients with HHS, whereas CSII might be a protective factor against death in HHS.
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Affiliation(s)
- Xiao-yan Wu
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
- Shanghai Hongkou District Liangcheng New Village Street Community Health Service Center, 200434, Shanghai, China
| | - Dun-min She
- Department of Endocrinology and Metabolism, Northern Jiangsu People’s Hospital, Yangzhou, 225000 China
| | - Fang Wang
- Department of Endocrinology, People’s Hospital of Shanghai Putuo District, Shanghai, 200060 China
| | - Gang Guo
- Department of Emergency, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ran Li
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ping Fang
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ling Li
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Yun Zhou
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ke-qin Zhang
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
| | - Ying Xue
- Department of Endocrinology, Tongji Hospital of Tongji University, Tongji University School of Medicine, Shanghai, 200065 China
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Flores M, Amir M, Ahmed R, Alashi S, Li M, Wang X, Lansang MC, Al-Jaghbeer MJ. Causes of diabetic ketoacidosis among adults with type 1 diabetes mellitus: insulin pump users and non-users. BMJ Open Diabetes Res Care 2020; 8:8/2/e001329. [PMID: 33318067 PMCID: PMC7737023 DOI: 10.1136/bmjdrc-2020-001329] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 09/24/2020] [Accepted: 10/01/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Insulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This study aims to identify the causes of DKA in patients with T1DM on continuous subcutaneous insulin infusion (CSII) and to compare these with patients with T1DM on multiple daily insulin injections (MDIIs). RESEARCH DESIGN AND METHODS This is a prospective observational study between January and June 2019 at the Cleveland Clinic Fairview Hospital. Demographic, clinical, and biochemical data were obtained from chart review. A questionnaire to explore additional clinical data relating to DKA was administered, with additional items for patients on the insulin pump. RESULTS Seventy-four patients were admitted with a diagnosis of DKA between the period of January and June 2019. Of these, 45 met the inclusion criteria and 43 consented. These were divided into two groups: group 1 included patients on MDII and group 2 included CSII. Overall, the most common precipitating factor for developing DKA was insulin non-adherence, seen in 51.2% of the cases. The most common cause of DKA in group 2 was pump/tubing related to 55% of the cases. CONCLUSION Despite non-adherence being common in both CSII and MDII, a combination of social factors, education and insulin pump malfunction, such as pump/tubing problems, might be playing a pivotal role in DKA etiology in young adults with T1DM, especially in CSII users. Continued education on pump use may reduce the rate of DKA in pump users.
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Affiliation(s)
- Monica Flores
- Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maryam Amir
- Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Endocrinology Department, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ramsha Ahmed
- Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Manshi Li
- Department of Medicine, Epidemiology, and Biostatics Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xiaofeng Wang
- Department of Medicine, Epidemiology, and Biostatics Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio, USA
| | - M Cecilia Lansang
- Diabetes and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:165-173. [PMID: 32952507 PMCID: PMC7485658 DOI: 10.4103/sjmms.sjmms_478_19] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/20/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.
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Affiliation(s)
- Mohsen S Eledrisi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
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DiSantostefano RL, Sutphin J, Hedrick JA, Klein K, Mansfield C. Parent Preferences for Delaying Insulin Dependence in Children at Risk of Stage III Type 1 Diabetes. Diabetes Technol Ther 2020; 22:584-593. [PMID: 31971833 PMCID: PMC7406995 DOI: 10.1089/dia.2019.0444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Autoantibody screening in type 1 diabetes (T1D) may reduce the chances of potentially life-threatening diabetic ketoacidosis (DKA) at diagnosis by allowing individuals at risk of progression to more actively monitor for and/or manage progression to insulin dependence. We investigated parents' preferences for treatments to delay the onset of insulin dependence in children who are at high risk of developing Stage III T1D. Methods: A web-based survey (n = 1501) was administered to a stratified sample of parents (children <18 years) in the United States from an online panel. Parents were told to hypothetically assume that their youngest child would become insulin dependent within 6 months or 2 years and were offered a series of choices between no treatment and two hypothetical treatments that would delay insulin dependence. Random-parameters logit analysis and maximum acceptable risks were used to evaluate the relative importance of treatment benefits and risks. Results: Most parents chose at least one active treatment (2% always chose monitoring only). For parents of children without T1D (n = 901), delaying insulin dependence and reducing the risk of long-term health complications and serious infection were the most important treatment attributes. In addition, parents of children with T1D (n = 600) also valued reducing the risk of hospitalizations due to DKA. Conclusions: When told to assume their child would develop Stage III T1D, most parents considered active treatments to delay progression. For medicines under development to delay insulin dependence in T1D, the preferences expressed in this survey provide guidance on acceptable benefit-risk trade-offs.
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Affiliation(s)
- Rachael L. DiSantostefano
- Janssen Research & Development, LLC, Titusville, New Jersey
- Address correspondence to: Rachael L. DiSantostefano, PhD, Janssen Research & Development, Titusville, NJ 08560
| | - Jessie Sutphin
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | - Kathleen Klein
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Carol Mansfield
- RTI Health Solutions, Research Triangle Park, North Carolina
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O'Reilly JE, Blackbourn LAK, Caparrotta TM, Jeyam A, Kennon B, Leese GP, Lindsay RS, McCrimmon RJ, McGurnaghan SJ, McKeigue PM, McKnight JA, Petrie JR, Philip S, Sattar N, Wild SH, Colhoun HM. Time trends in deaths before age 50 years in people with type 1 diabetes: a nationwide analysis from Scotland 2004-2017. Diabetologia 2020; 63:1626-1636. [PMID: 32451572 PMCID: PMC7351819 DOI: 10.1007/s00125-020-05173-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/01/2020] [Indexed: 02/04/2023]
Abstract
AIMS/HYPOTHESIS We aimed to examine whether crude mortality and mortality relative to the general population below 50 years of age have improved in recent years in those with type 1 diabetes. METHODS Individuals with type 1 diabetes aged below 50 and at least 1 year old at any time between 2004 and 2017 in Scotland were identified using the national register. Death data were obtained by linkage to Scottish national death registrations. Indirect age standardisation was used to calculate sex-specific standardised mortality ratios (SMRs). Poisson regression was used to test for calendar-time effects as incidence rate ratios (IRRs). RESULTS There were 1138 deaths in 251,143 person-years among 27,935 people with type 1 diabetes. There was a significant decline in mortality rate over time (IRR for calendar year 0.983 [95% CI 0.967, 0.998], p = 0.03), but the SMR remained approximately stable at 3.1 and 3.6 in men and 4.09 and 4.16 in women for 2004 and 2017, respectively. Diabetic ketoacidosis or coma (DKAoC) accounted for 22% of deaths and the rate did not decline significantly (IRR 0.975 [95% CI 0.94, 1.011], p = 0.168); 79.3% of DKAoC deaths occurred out of hospital. Circulatory diseases accounted for 27% of deaths and did decline significantly (IRR 0.946 [95% CI 0.914, 0.979], p = 0.002). CONCLUSIONS/INTERPRETATION Absolute mortality has fallen, but the relative impact of type 1 diabetes on mortality below 50 years has not improved. There is scope to improve prevention of premature circulatory diseases and DKAoC and to develop more effective strategies for enabling people with type 1 diabetes to avoid clinically significant hyper- or hypoglycaemia. Graphical abstract.
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Affiliation(s)
- Joseph E O'Reilly
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XUT, UK
| | - Luke A K Blackbourn
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XUT, UK
| | - Thomas M Caparrotta
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XUT, UK
| | - Anita Jeyam
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XUT, UK
| | - Brian Kennon
- Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Stuart J McGurnaghan
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XUT, UK
| | - Paul M McKeigue
- Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sam Philip
- Grampian Diabetes Research Unit, Diabetes Centre, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sarah H Wild
- Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Helen M Colhoun
- MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, EH4 2XUT, UK.
- Public Health, NHS Fife, Kirkcaldy, UK.
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Lacy ME, Gilsanz P, Eng CW, Beeri MS, Karter AJ, Whitmer RA. Recurrent diabetic ketoacidosis and cognitive function among older adults with type 1 diabetes: findings from the Study of Longevity in Diabetes. BMJ Open Diabetes Res Care 2020; 8:8/1/e001173. [PMID: 32546548 PMCID: PMC7299028 DOI: 10.1136/bmjdrc-2020-001173] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/25/2020] [Accepted: 05/04/2020] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a serious complication of diabetes. DKA is associated with poorer cognition in children with type 1 diabetes (T1D), but whether this is the case in older adults with T1D is unknown. Given the increasing life expectancy in T1D, understanding the role of DKA on brain health in older adults is crucial. RESEARCH DESIGN AND METHODS We examined the association of DKA with cognitive function in 714 older adults with T1D from the Study of Longevity in Diabetes. Participants self-reported lifetime exposure to DKA resulting in hospitalization; DKA was categorized into 0 hospitalization, 1 hospitalization or ≥2 hospitalizations (recurrent DKA). Global and domain-specific cognition (language, executive function/psychomotor speed, episodic memory and simple attention) were assessed. The association of DKA with cognitive function was evaluated via linear and logistic regression models. RESULTS Twenty-eight percent of participants (mean age=67 years; mean age at diagnosis=28 years; average duration of diabetes=39 years) reported a lifetime history of DKA resulting in hospitalization (18.5% single DKA; 9.7% recurrent DKA). In fully adjusted models, those with recurrent DKA had lower global cognitive function (β=-0.13; 95% CI -0.22 to 0.02) and lower scores on the executive function/psychomotor speed domain (β=-0.34; 95% CI -0.51 to 0.17). Individuals with recurrent DKA were also more likely to have the lowest level of cognitive function on the executive function/psychomotor speed domain (defined as 1.5 SD below the population mean; OR=3.26, 95% CI 1.43 to 7.42). CONCLUSIONS Among 714 older adults with T1D, recurrent DKA was associated with lower global cognitive function, lower scores on the executive function/psychomotor speed domain and 3.3 times greater risk of having the lowest level of cognitive function in our sample on the executive function/psychomotor speed domain. These findings suggest that recurrent DKA may negatively impact the brain health of older patients with T1D and highlight the importance of DKA prevention.
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Affiliation(s)
- Mary E Lacy
- Department of Epidemiology, University of Kentucky, Lexington, Kentucky, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Chloe W Eng
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Michal S Beeri
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Joseph Sagol Neuroscience, Sheba Medical Center, Tel HaShomer, Israel
| | - Andrew J Karter
- Division of Research, Kaiser Permanente, Bainbridge Island, Washington, USA
| | - Rachel A Whitmer
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Epidemiology, University of California Davis School of Medicine, Davis, California, USA
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Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Ehrmann D, Kulzer B, Roos T, Haak T, Al-Khatib M, Hermanns N. Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes. Lancet Diabetes Endocrinol 2020; 8:436-446. [PMID: 32333879 DOI: 10.1016/s2213-8587(20)30042-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 01/02/2023]
Abstract
Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.
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Affiliation(s)
- Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; Diabetes Clinic Mergentheim, Bad Mergentheim, Germany
| | - Timm Roos
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany
| | - Thomas Haak
- Diabetes Clinic Mergentheim, Bad Mergentheim, Germany
| | - Mohammed Al-Khatib
- HealthPlus Diabetes & Endocrinology Centre, Abu Dhabi, United Arab Emirates
| | - Norbert Hermanns
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; Diabetes Clinic Mergentheim, Bad Mergentheim, Germany.
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Pasquel FJ, Tsegka K, Wang H, Cardona S, Galindo RJ, Fayfman M, Davis G, Vellanki P, Migdal A, Gujral U, Narayan KMV, Umpierrez GE. Clinical Outcomes in Patients With Isolated or Combined Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State: A Retrospective, Hospital-Based Cohort Study. Diabetes Care 2020; 43:349-357. [PMID: 31704689 PMCID: PMC6971788 DOI: 10.2337/dc19-1168] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Many patients with hyperglycemic crises present with combined features of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). The implications of concomitant acidosis and hyperosmolality are not well known. We investigated hospital outcomes in patients with isolated or combined hyperglycemic crises. RESEARCH DESIGN AND METHODS We analyzed admissions data listing DKA or HHS at two academic hospitals. We determined 1) the frequency distributions of HHS, DKA, and combined DKA-HHS (DKA criteria plus elevated effective osmolality); 2) the relationship of markers of severity of illness and clinical comorbidities with 30-day all-cause mortality; and 3) the relationship of hospital complications associated with insulin therapy (hypoglycemia and hypokalemia) with mortality. RESULTS There were 1,211 patients who had a first admission with confirmed hyperglycemic crises criteria, 465 (38%) who had isolated DKA, 421 (35%) who had isolated HHS, and 325 (27%) who had combined features of DKA-HHS. After adjustment for age, sex, BMI, race, and Charlson Comorbidity Index score, subjects with combined DKA-HHS had higher in-hospital mortality compared with subjects with isolated hyperglycemic crises (adjusted odds ratio [aOR] 2.7; 95% CI 1.4, 4.9; P = 0.0019). In all groups, hypoglycemia (<40 mg/dL) during treatment was associated with a 4.8-fold increase in mortality (aOR 4.8; 95% CI 1.4, 16.8). Hypokalemia ≤3.5 mEq/L was frequent (55%). Severe hypokalemia (≤2.5 mEq/L) was associated with increased inpatient mortality (aOR 4.9; 95% CI 1.3, 18.8; P = 0.02). CONCLUSIONS Combined DKA-HHS is associated with higher mortality compared with isolated DKA or HHS. Severe hypokalemia and severe hypoglycemia are associated with higher hospital mortality in patients with hyperglycemic crises.
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Affiliation(s)
| | - Katerina Tsegka
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | - Saumeth Cardona
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | | | - Maya Fayfman
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Georgia Davis
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | | | - Alexandra Migdal
- Department of Medicine/Endocrinology, Emory University, Atlanta, GA
| | - Unjali Gujral
- Rollins School of Public Health, Emory University, Atlanta, GA
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Bennie M, Malcolm W, McTaggart S, Mueller T. Improving prescribing through big data approaches-Ten years of the Scottish Prescribing Information System. Br J Clin Pharmacol 2020; 86:250-257. [PMID: 31758595 PMCID: PMC7015743 DOI: 10.1111/bcp.14184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 12/16/2022] Open
Abstract
Medicines are a major component of modern healthcare delivery, both in resource consumption and as drivers of innovation. The ever-increasing application of digitalisation within day-to-day living and as part of our healthcare systems-with the resultant data generation-presents the opportunity to better define the populations exposed to medicines, and their benefits and harm in real world settings. This article outlines the development of the Scottish National Prescribing Information System (PIS) and describes how this capability is being used to support the safe and effective use of medicines, both nationally and internationally. Since 2009, PIS has included e-prescribed/e-dispensed and reimbursed medicines data, now totalling 976 million prescriptions, with codified structured data on dose instructions. A literature review, covering the period from January 2009 to March 2019, identified 40 full publications using PIS, the first occurring in 2014. The majority involved pharmacoepidemiology/drug-use studies (50%) in cancer and cardiovascular disease. Measuring the value and impact of PIS was extended beyond publication quantification by illustrating the translation of PIS outputs into the learning health system at scale. The developing Scottish capabilities add breadth and depth to the wider evolving international environment, and offer the potential to contribute collegiately to the global effort on medicine safety and effectiveness, including support for the World Health Organisation Global Patient Safety Challenge: Medication Without Harm.
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Affiliation(s)
- Marion Bennie
- Strathclyde Institute of Pharmacy and Biomedical SciencesUniversity of StrathclydeGlasgowUK
- Public Health and Intelligence Strategic Business UnitNHS National Services ScotlandEdinburghUK
| | - William Malcolm
- Public Health and Intelligence Strategic Business UnitNHS National Services ScotlandEdinburghUK
| | - Stuart McTaggart
- Public Health and Intelligence Strategic Business UnitNHS National Services ScotlandEdinburghUK
| | - Tanja Mueller
- Strathclyde Institute of Pharmacy and Biomedical SciencesUniversity of StrathclydeGlasgowUK
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Larroumet A, Camoin M, Foussard N, Alexandre L, Mesli S, Redonnet I, Baillet-Blanco L, Rigalleau V, Mohammedi K. Euglycemic ketoacidosis induced by therapeutic fasting in a non-diabetic patient. Nutrition 2019; 72:110668. [PMID: 31982728 DOI: 10.1016/j.nut.2019.110668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 11/08/2019] [Accepted: 11/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ketoacidosis is a severe metabolic complication mainly reported in diabetic patients. Therapeutic fasting is a millennial worldwide practice, believed to improve a large panel of health conditions, but its efficiency and safety profile have not yet been established. We report here a case of euglycemic ketoacidosis in a non-diabetic woman. CASE DESCRIPTION A 51-year-old woman without a history of excessive alcohol use or medical history, except for a depressive disorder, was admitted in the emergency room for altered general status, deep asthenia, muscular weakness, articular pain, nausea, vomiting, and consciousness disorders. She was practicing during the previous 48 h a therapeutic fasting following a progressive restrictive diet for 4 d. She was diagnosed with ketoacidosis and hospitalized in the intensive care unit. Her laboratory test results indicated pH 7.28, bicarbonate 7 mmol/L, significant ketone bodies, glycemia 8.9 mmol/L without glycosuria, and negative blood alcohol assessment. Glycated hemoglobin was 5.5%, and blood glucose never went above 9 mmol/L. Serum concentrations of free fatty acids were high at 1.13 mmol/L (normal range: 0.13-0.45). Plasma insulin and peptide C were in the normal ranges. Comprehensive plasma and urinary biochemistry panels, including energetic substrates, and chromatography of amino acids and organic acids did not indicate any energetic or metabolic deficiency. The ketoacidosis regressed, and the overall outcome was favorable after intravenous glucose infusion for 48 h, without insulin requirement. CONCLUSIONS This report is the first case, to our knowledge, of euglycemic ketoacidosis thought to be induced by therapeutic fasting in a non-diabetic patient. Practitioners should be aware of this complication of fasting.
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Affiliation(s)
- Alice Larroumet
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France
| | - Marion Camoin
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France
| | - Ninon Foussard
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France
| | - Laure Alexandre
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France
| | - Samir Mesli
- Hôpital Pellegrin, Département de Biochimie, Bordeaux, France
| | | | - Laurence Baillet-Blanco
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France
| | - Vincent Rigalleau
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France
| | - Kamel Mohammedi
- Hôpital Haut-Lévêque, Département d'Endocrinologie, Diabétologie, Nutrition, Pessac, Bordeaux, France.
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Nguyen AD, Luong CQ, Chu HC, Nguyen VKD, Nguyen CV, Nguyen TA, Nguyen QH, Mai TD, Nguyen DV, Nguyen BQ, Tran TH, Dao PV, Nguyen DT, Nguyen NN, Do SN. Successful management of severe diabetic ketoacidosis in a patient with type 2 diabetes with insulin allergy: a case report. BMC Endocr Disord 2019; 19:121. [PMID: 31711488 PMCID: PMC6849168 DOI: 10.1186/s12902-019-0451-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion. CASE PRESENTATION A 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 min of injection and lasting over 24 h. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 μmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 h, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites. CONCLUSIONS In this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.
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Affiliation(s)
- Anh Dat Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Chinh Quoc Luong
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Hieu Chi Chu
- Allerology and Clinical Immunology Center, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Van Khoa Dieu Nguyen
- Emergency Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Allergy and Clinical Immunology, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Chi Van Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Quan Huu Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Ton Duy Mai
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Dinh Van Nguyen
- Allerology and Clinical Immunology Center, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Bay Quang Nguyen
- Emergency Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Allergy and Clinical Immunology, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Thong Huu Tran
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Phuong Viet Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Dat Tuan Nguyen
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
| | - Nguyet Nhu Nguyen
- Allerology and Clinical Immunology Center, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
| | - Son Ngoc Do
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, 01 Ton That Tung street, Kim Lien ward, Dong Da district, Hanoi, Vietnam
- Endocrinology and Diabetes Department, Bach Mai Hospital, 78 Giai Phong road, Phuong Mai ward, Dong Da district, Hanoi, Vietnam
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Garrett CJ, Choudhary P, Amiel SA, Fonagy P, Ismail K. Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention. Diabet Med 2019; 36:1329-1335. [PMID: 31418474 DOI: 10.1111/dme.14109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 12/11/2022]
Abstract
Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.
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Affiliation(s)
- C J Garrett
- Diabetes and Metabolism Department, Bart's Health NHS Trust, London, UK
- Diabetes and Mental Health Research Group, King's College London, London, UK
| | - P Choudhary
- Diabetes Research Group, King's College London, London, UK
| | - S A Amiel
- Diabetes Research Group, King's College London, London, UK
| | - P Fonagy
- Division of Psychology and Language Sciences at University College London, London, UK
| | - K Ismail
- Diabetes and Mental Health Research Group, King's College London, London, UK
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Yang Y, Liu B, He J, Gupta S, Thumma S, Luo Y, Everett G, Mattana J. Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Diabetic Ketoacidosis. Am J Med Sci 2019; 358:350-356. [PMID: 31514963 DOI: 10.1016/j.amjms.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/27/2019] [Accepted: 07/24/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Diabetic ketoacidosis entails a huge health burden among patients with diabetes. Atrial fibrillation (AF) is the most common type of heart arrhythmia. This study aimed to evaluate the impact of AF on clinical outcomes in patients with diabetic ketoacidosis. METHODS Using the 2012-2014 National Inpatient Sample database, we identified adult patients hospitalized with diabetic ketoacidosis as the principal discharge diagnosis. The identified admissions were stratified into 2 cohorts based on the AF presence. We used multivariable regression models and propensity score matching models to evaluate in-hospital mortality, length of stay, comorbidities, and in-hospital complications. RESULTS The study included 478,890 adult patients who were admitted for diabetic ketoacidosis in the year 2012-2014. A total of 467,780 (97.68%) had no AF and 11,125 (2.32%) had AF. In both multivariable regression models and propensity score matching models, compared with nonatrial fibrillation group, the AF group had higher in-hospital mortality rates (2.36 [1.69-3.32], P < 0.001) and longer length of stay (5.5 versus 3.3 days, P < 0.001). AF was also associated with a significantly higher incidence of complications including septic shock, pulmonary failure, mechanical ventilation, neurological failure, cerebral edema, acute kidney injury, acute hematologic failure, and cardiac arrest. CONCLUSIONS Among patients who were hospitalized for diabetic ketoacidosis, comorbid AF led to increasing in-hospital mortality rates and longer length of stay. A potential explanation was that AF increased the risk of in-hospital complications including respiratory failure with a more frequent requirement for mechanical ventilation, cardiac arrest, and metabolic encephalopathy.
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Affiliation(s)
- Yifeng Yang
- Department of Medicine, St. Vincent's Medical Center, Bridgeport, Connecticut; The Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut.
| | - Baoqiong Liu
- Department of Medicine, AdventHealth, Orlando, Florida.
| | - Jiabei He
- Department of Oncology, Emory University, Atlanta, Georgia
| | - Sonali Gupta
- Department of Medicine, St. Vincent's Medical Center, Bridgeport, Connecticut; The Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Soumya Thumma
- Department of Medicine, St. Vincent's Medical Center, Bridgeport, Connecticut; The Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
| | - Yiming Luo
- Department of Medicine, Icahn School of Medicine at Mount Sinai/St. Luke's-Roosevelt Hospital Center, New York, New York
| | | | - Joseph Mattana
- Department of Medicine, St. Vincent's Medical Center, Bridgeport, Connecticut; The Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, Connecticut
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66
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Weissenbacher S, Yang CY, Kuan TC, Demircik F, Hanna M, Pfützner A. System accuracy assessments with a blood glucose meter with combined glucose and ß-hydroxybutyrate measurement capabilities. Expert Rev Mol Diagn 2019; 19:1043-1048. [PMID: 31482753 DOI: 10.1080/14737159.2019.1662300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: We evaluated the Wellion Galileo GLU/KET blood and ketone (ß-Hydroxybutyrate, ß-OHB) meter to demonstrate that it meets ISO15107:2015 regulatory approval criteria. Research Design and Methods: A total of 100 subjects (52 female, age: 30 to 84 years, diabetes: 10 type 1/90 type 2) with blood glucose levels distributed over the entire measurement range as required by the ISO15197 protocol were tested (double determinations with 3 strip lots and two devices). A similar test protocol was followed to test ß-OHB strip performance (reference devices: YSI 2300plus for glucose and STANBIO ß-HOB LiquiColor TestKit for ß-OHB). Precision was tested for glucose with 3 blood glucose concentrations (ß-OHB: 2 control solutions). Results: All glucose test-strip lots met the strict ISO acceptance criteria. Mean absolute relative difference (MARD) was 4.9% and all data pairs were in zone A of the consensus error grid. The ß-OHB test-strips also met the pre-defined acceptance criteria. Within-run and between-run precision was calculated to be 2.3% and 0.7% for the glucose strips (3.7%/0.8% for the ketone strips). Conclusions: When tested according to the ISO15197:2015 guideline, the device showed very accurate measurement performance for glucose and ß-OHB testing and fully met regulatory accuracy approval criteria.
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Affiliation(s)
| | | | | | | | - Mina Hanna
- Pfützner Science & Health Institute , Mainz , Germany
| | - Andreas Pfützner
- Pfützner Science & Health Institute , Mainz , Germany.,Department of Biotechnology, Technical University Bonn-Rhein-Sieg , Rheinbach , Germany.,Department of Internal Medicine and Laboratory Medicine, University for Digitalized Technologies in Medicine & Dentistry , Luxembourg
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Dhatariya KK. Defining and characterising diabetic ketoacidosis in adults. Diabetes Res Clin Pract 2019; 155:107797. [PMID: 31344382 DOI: 10.1016/j.diabres.2019.107797] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/21/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
AIMS Diabetic ketoacidosis (DKA) remains one of the most frequently encountered diabetes related emergencies, and despite updates in management and increasing standardisation of care, still has an appreciable morbidity and mortality. This review focusses on the pathophysiology and epidemiology of DKA, but also on the importance of having a standardised definition. METHODS Relevant data were reviewed where there was available basic science or clinical papers published in peer-reviewed international journals on DKA. These included consensus documents and national or international guidelines. RESULTS The prevalence of DKA varies around the world, but part of this could be down to the way the condition is defined. Examples of this difference include the recent studies on sodium glucose co-transporter inhibitors in people with type 1 and type 2 diabetes which have all been associated with increased rates of DKA, but have highlighted how differences in definitions can make comparisons between agents very difficult. CONCLUSIONS DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK; Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK.
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Everett E, Mathioudakis N. Association of Area Deprivation and Diabetic Ketoacidosis Readmissions: Comparative Risk Analysis of Adults vs Children With Type 1 Diabetes. J Clin Endocrinol Metab 2019; 104:3473-3480. [PMID: 31220288 PMCID: PMC6599429 DOI: 10.1210/jc.2018-02232] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 04/05/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Recurrent diabetic ketoacidosis (DKA) is associated with mortality in adults and children with type 1 diabetes (T1D). We aimed to evaluate the association of area deprivation and other patient factors with recurrent DKA in pediatric patients compared with adults. RESEARCH DESIGN AND METHODS This cross-sectional study used the Maryland Health Services Cost Review Commission's database to identify patients with T1D admitted for DKA between 2012 and 2017. Area deprivation and other variables were obtained from the first DKA admission of the study period. Multivariable logistic regression analysis was performed to determine predictors of DKA readmissions. Interactions (Ints) evaluated differences among the groups. RESULTS There were 732 pediatric and 3305 adult patients admitted with DKA. Area deprivation was associated with higher odds of readmission in pediatric patients than in adults. Compared with the least deprived, moderately deprived pediatric patients had an OR of 7.87-(95% CI, 1.02 to 60.80) compared with no change in odds in adults for four or more readmissions (Pint < 0.01). Similar odds were observed in the most deprived pediatric patients, which differed significantly from the OR of 2.23 (95% CI, 1.16 to 4.25) in adults (Pint of 0.2). Moreover, increasing age, female sex, Hispanic ethnicity, and discharge against medical advice conferred a high odds for four or more readmissions in pediatric patients compared with adults. CONCLUSION Area deprivation was predictive of recurrent DKA admissions, with a more pronounced influence in pediatric than adult patients with T1D. Further studies are needed to understand the mechanisms behind these associations and address disparities specific to each population.
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Affiliation(s)
- Estelle Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Tyndall V, Stimson RH, Zammitt NN, Ritchie SA, McKnight JA, Dover AR, Gibb FW. Marked improvement in HbA 1c following commencement of flash glucose monitoring in people with type 1 diabetes. Diabetologia 2019; 62:1349-1356. [PMID: 31177314 PMCID: PMC6647076 DOI: 10.1007/s00125-019-4894-1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/15/2019] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS Minimal evidence supports the efficacy of flash monitoring in lowering HbA1c. We sought to assess the impact of introducing flash monitoring in our centre. METHODS We undertook a prospective observational study to assess change in HbA1c in 900 individuals with type 1 diabetes following flash monitoring (comparator group of 518 with no flash monitoring). Secondary outcomes included changes in hypoglycaemia, quality of life, flash monitoring data and hospital admissions. RESULTS Those with baseline HbA1c ≥58 mmol/mol (7.5%) achieved a median -7 mmol/mol (interquartile range [IQR] -13 to -1) (0.6% [-1.2 to -0.1]%) change in HbA1c (p < 0.001). The percentage achieving HbA1c <58 mmol/mol rose from 34.2% to 50.9% (p < 0.001). Median follow-up was 245 days (IQR 182 to 330). Individuals not using flash monitoring experienced no change in HbA1c across a similar timescale (p = 0.508). Higher HbA1c (p < 0.001), younger age at diagnosis (p = 0.003) and lower social deprivation (p = 0.024) were independently associated with an HbA1c fall of ≥5 mmol/mol (0.5%). More symptomatic (OR 1.9, p < 0.001) and asymptomatic (OR 1.4, p < 0.001) hypoglycaemia was reported after flash monitoring. Following flash monitoring, regimen-related and emotional components of the diabetes distress scale improved although the proportion with elevated anxiety (OR 1.2, p = 0.028) and depression (OR 2.0, p < 0.001) scores increased. Blood glucose test strip use fell from 3.8 to 0.6 per day (p < 0.001). Diabetic ketoacidosis admissions fell significantly following flash monitoring (p = 0.043). CONCLUSIONS/INTERPRETATION Flash monitoring is associated with significant improvements in HbA1c and fewer diabetic ketoacidosis admissions. Higher rates of hypoglycaemia may relate to greater recognition of hitherto unrecognised events. Impact upon quality of life parameters was mixed but overall treatment satisfaction was overwhelmingly positive.
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Affiliation(s)
- Victoria Tyndall
- Edinburgh Centre for Endocrinology and Diabetes, Western General Hospital, Edinburgh, UK
| | - Roland H Stimson
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH14 4TJ, UK
| | - Nicola N Zammitt
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Stuart A Ritchie
- Edinburgh Centre for Endocrinology and Diabetes, Western General Hospital, Edinburgh, UK
| | - John A McKnight
- Edinburgh Centre for Endocrinology and Diabetes, Western General Hospital, Edinburgh, UK
| | - Anna R Dover
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Fraser W Gibb
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK.
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH14 4TJ, UK.
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Singh H, Saroch A, Pannu AK, Sachin HJ, Sharma N, Dutta P. Clinical and biochemical profile, precipitants and prognostic factors of diabetic ketoacidosis: A retrospective study from a tertiary care center of north India. Diabetes Metab Syndr 2019; 13:2357-2360. [PMID: 31405643 DOI: 10.1016/j.dsx.2019.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/07/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND We aimed to retrospectively investigate the clinical and biochemical profile of Diabetic ketoacidosis (DKA) patients and various precipitating and prognostic factors. METHODS This was a hospital-based retrospective observational study, conducted in a tertiary care hospital in north India, from March 2014 to March 2017. RESULTS Among 50 patients who satisfied the study criteria, 10 (20%) had DKA as their first presentation. Most common symptoms were nausea and vomiting (74%). Noncompliance was the major precipitating cause in 26 cases (52%) followed by infections in 18 cases (36%). The mean value of blood sugar at presentation was 406.8 ± 130.4 mg/dl with serum ketone 5.38 ± 1.56 mmol/l and mean pH 7.128 ± 0.157 with severe DKA in 14 (28%) patients. Mean duration of hospital stay was 8.2.±5.0 days, and low hemoglobin (p = 0.019) and high pulse rate (p = 0.025) were independent predictors of a longer stay. CONCLUSION With intensive care, mortality did not occur; however, non-compliance remained the most common precipitating cause of DKA followed by infections.
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Affiliation(s)
- Harpreet Singh
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Saroch
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - H J Sachin
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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71
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Karslioglu French E, Donihi AC, Korytkowski MT. Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients. BMJ 2019; 365:l1114. [PMID: 31142480 DOI: 10.1136/bmj.l1114] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.
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Affiliation(s)
- Esra Karslioglu French
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amy C Donihi
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Higuchi R, Iwane T, Suwa K, Nakajima K. Adjustment for Waist Circumference Reveals a U-Shaped Association Between Glycated Hemoglobin Levels and Body Mass Index in Young Adults. Can J Diabetes 2019; 43:201-206. [PMID: 30503869 DOI: 10.1016/j.jcjd.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 08/14/2018] [Accepted: 09/14/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Body mass index (BMI) is used to assess adiposity worldwide. However, additional adjustment for waist circumference (WC), a surrogate marker of abdominal fat, may be capable of revealing a latent relationship between low body weight and glycated hemoglobin (A1C) concentration. Here, we investigated the relationship between A1C and BMI in young adults, adjusting for WC. METHODS We reviewed A1C, BMI, WC and other clinical data in a cross-sectional study of 26,475 apparently healthy Japanese people 20 to 39 years of age who were undergoing health check-ups. RESULTS Although the values of most serum parameters were high in subjects with a high BMI in both younger (20 to 29 years of age, n=10,810) and older subjects (30 to 39 years of age, n=15,665), A1C had a J-shaped relationship with BMI category in younger subjects, regardless of sex. A traditional linear model via a generalized linear model showed that in younger subjects, an inverse association of A1C level with BMI category (19 to 26.9 kg/m2 vs. ≤18.9 kg/m2) was identified after adjustment for WC. This indicates positive associations between A1C and BMI categories of ≤18.9 (beta=0.06; p<0.0001), 19.0 to 20.9 (beta=0.03; p<0.01) and ≥27.0 kg/m2 (beta=0.08; p<0.0001), in contrast to individuals with BMIs of 23.0 to 24.9 kg/m2. Similarly, in older subjects, BMIs ≤18.9 kg/m2 were associated with A1C levels but to a lesser extent (beta=0.04; p<0.05) than in younger subjects. CONCLUSIONS Additional adjustment of BMI for WC revealed a latent U-shaped association between A1C concentration and BMI, particularly in young adults; this deserves further investigation.
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Affiliation(s)
- Ryoko Higuchi
- School of Nutrition and Dietetics, Faculty of Health and Social Services, Kanagawa University of Human Services, Yokosuka, Kanagawa, Japan
| | - Taizo Iwane
- School of Nutrition and Dietetics, Faculty of Health and Social Services, Kanagawa University of Human Services, Yokosuka, Kanagawa, Japan
| | - Kaname Suwa
- Saitama Health Promotion Corporation, Yoshimimachi, Hikigun, Saitama, Japan
| | - Kei Nakajima
- School of Nutrition and Dietetics, Faculty of Health and Social Services, Kanagawa University of Human Services, Yokosuka, Kanagawa, Japan; Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
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73
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Everett E, Mathioudakis NN. Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database. BMJ Open Diabetes Res Care 2019; 7:e000621. [PMID: 31114699 PMCID: PMC6501850 DOI: 10.1136/bmjdrc-2018-000621] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify patient and hospital predictors of recurrent diabetic ketoacidosis (DKA) admissions in adults in the USA with type 1 diabetes, focusing on socioeconomic indicators. RESEARCH DESIGN AND METHODS This cross-sectional study used the National Readmission Database to identify adult patients with type 1 diabetes admitted for DKA between 2010 and 2015. The index DKA admission was defined as the first admission within the calendar year and the primary outcome was recurrent DKA admission(s) within the same calendar year. Multivariable logistic regression analysis was performed using covariates of patient and hospital factors at the index admission to determine the odds of DKA readmission(s). RESULTS Among 181 284 index DKA admissions, 39 693 (22%) had at least one readmission within the calendar year, of which 33 931 (86%) and 5762 (14%) had 1-3 and ≥4 DKA readmissions, respectively. When compared with the highest income quartile, patients in the first and second income quartiles had 46% (95% CI 30% to 64%) and 34% (95% CI 19% to 51%) higher odds of four or more DKA readmissions, respectively. Medicaid and Medicare insurance were both associated with a 3.3-fold adjusted risk (95% CI 3.0 to 3.7) for ≥4 readmissions compared with private insurance, respectively. Younger age, female sex, and discharge against medical advice were also predictive. CONCLUSIONS Lower socioeconomic status and Medicaid insurance are strong predictors of DKA readmissions in adults with type 1 diabetes in the USA. Further studies are needed to understand the mediators of this association to inform multilevel interventions for this high-risk population. SIGNIFICANCE OF THE STUDY The association of socioeconomic status (SES) and hospital admission for DKA has been studied in pediatrics with type 1 diabetes, but the data in adults are limited, and studies evaluating recurrent DKA admissions are scarcer. To our knowledge, this is the first study to describe predictors of recurrent DKA admissions in adults with type 1 diabetes on a national level in the USA. We found that those at highest risk of recurrent DKA are young women with low SES who had Medicaid or Medicare insurance. These findings should prompt further studies to explore the mediators of these disparities in patients with type 1 diabetes, as recurrent DKA results in high healthcare utilization and increased risk of long-term complications.
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Affiliation(s)
- Estelle Everett
- Endocrinology, Johns Hopkins University, Baltimore, Maryland, USA
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Landau Z, Kowen-Sandbank G, Jakubowicz D, Raziel A, Sakran N, Zaslavsky-Paltiel I, Lerner-Geva L, Pinhas-Hamiel O. Bariatric surgery in patients with type 1 diabetes: special considerations are warranted. Ther Adv Endocrinol Metab 2019; 10:2042018818822207. [PMID: 30728940 PMCID: PMC6354304 DOI: 10.1177/2042018818822207] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/06/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE We examined short and long-term outcomes of bariatric surgery in patients with obesity and type 1 diabetes mellitus (T1DM). METHODS We reviewed the records of all adults insured by Maccabi Healthcare Services during 2010 -2015, with body mass index (BMI) ⩾30 kg/m2 and T1DM; and compared weight reduction and glucose control according to the performance of bariatric surgery. BMI and glycated hemoglobin (HbA1c) levels were extracted for baseline and every 6 months, for a mean 3.5 years. RESULTS Of 52 patients, 26(50%) underwent bariatric surgery. Those who underwent surgery were more often female and with a longer duration of diabetes. Immediately postoperative, 4(15%) developed diabetic ketoacidosis, while 6(23%) experienced severe hypoglycemic episodes. The mean BMI decreased among surgery patients: from 39.5±4.4 to 30.1±5.0 kg/m2 (p < 0.0001); and increased among those who did not undergo surgery: from 33.6±3.9 to 35.1±4.4 kg/m2 (p = 0.49). The mean HbA1c level decreased during the first 6 months postoperative: from 8.5±0.9% to 7.9±0.9%; however, at the end of follow-up, was similar to baseline, 8.6±2.0% (p = 0.87). For patients who did not undergo surgery, the mean HbA1c increased from 7.9±1.9% to 8.6±1.5% (p = 0.09). CONCLUSIONS Among individuals with obesity and T1DM, weight loss was successful after bariatric surgery, but glucose control did not improve. The postoperative risks of diabetic ketoacidosis and severe hypoglycemic episodes should be considering when performing bariatric surgery in this population.
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Affiliation(s)
| | | | - Daniela Jakubowicz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Diabetes Unit, Wolfson Medical Center, Holon, Israel
| | - Asnat Raziel
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
| | - Nasser Sakran
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel; Department of Surgery A, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Inna Zaslavsky-Paltiel
- Gertner Institute for Epidemiology and Health Policy Research, Women and Children’s Health Research, Tel Hashomer, Israel
| | - Liat Lerner-Geva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Gertner Institute for Epidemiology and Health Policy Research, Women and Children’s Health Research, Tel Hashomer, Israel
| | - Orit Pinhas-Hamiel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Maccabi Juvenile Diabetes Center, Raanana, Israel; Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan, Israel
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75
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Robbins T, Lim Choi Keung SN, Sankar S, Randeva H, Arvanitis TN. Diabetes and the direct secondary use of electronic health records: Using routinely collected and stored data to drive research and understanding. Digit Health 2018; 4:2055207618804650. [PMID: 30305917 PMCID: PMC6176528 DOI: 10.1177/2055207618804650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 09/05/2018] [Indexed: 12/19/2022] Open
Abstract
Introduction Electronic health records provide an unparalleled opportunity for the use of
patient data that is routinely collected and stored, in order to drive
research and develop an epidemiological understanding of disease. Diabetes,
in particular, stands to benefit, being a data-rich, chronic-disease state.
This article aims to provide an understanding of the extent to which the
healthcare sector is using routinely collected and stored data to inform
research and epidemiological understanding of diabetes mellitus. Methods Narrative literature review of articles, published in both the medical- and
engineering-based informatics literature. Results There has been a significant increase in the number of papers published,
which utilise electronic health records as a direct data source for diabetes
research. These articles consider a diverse range of research questions.
Internationally, the secondary use of electronic health records, as a
research tool, is most prominent in the USA. The barriers most commonly
described in research studies include missing values and misclassification,
alongside challenges of establishing the generalisability of results. Discussion Electronic health record research is an important and expanding area of
healthcare research. Much of the research output remains in the form of
conference abstracts and proceedings, rather than journal articles. There is
enormous opportunity within the United Kingdom to develop these research
methodologies, due to national patient identifiers. Such a healthcare
context may enable UK researchers to overcome many of the barriers
encountered elsewhere and thus to truly unlock the potential of electronic
health records.
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Affiliation(s)
- Tim Robbins
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Sailesh Sankar
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Harpal Randeva
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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77
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Lin YH, Chen KJ, Peng YS, Chen PC, Yang YH. Type 1 diabetes impairs female fertility even before it is diagnosed. Diabetes Res Clin Pract 2018; 143:151-158. [PMID: 30003941 DOI: 10.1016/j.diabres.2018.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/21/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
Abstract
AIMS The aim of this study was to assess the fertility rate in Taiwanese women before and after a diagnosis of type 1 diabetes. The potential risk factors which may have influenced fertility were also investigated. METHODS We conducted this retrospective, nationwide, population-based, matched cohort study using data from the Taiwan National Health Insurance Research Database. The diabetic group (n = 1191) included women with type 1 diabetes aged between 16 and 30 years in 2000. The non-diabetic group (n = 4764) was matched by sex, gender, income, and urbanization. The endpoints, including live births, abortions, and fertility, were tracked until the end of 2013. Poisson regression was used to assess incidence rate ratios (IRRs). We also analyzed the influence of autoimmune thyroid disease, diabetic ketoacidosis, diabetic complications, and daily insulin dose on the endpoints. RESULTS The diabetic group had a lower rate of live births (IRR 0.67 [95% CI 0.62-0.73]) than the non-diabetic group, and it was even lower when combined with hyperthyroidism (IRR 0.54 [0.39-0.74]). There were also fewer live births before a diagnosis of diabetes than after a diagnosis of diabetes (IRR 0.58 [0.52-0.65] vs. 0.80 [0.71-0.90]). Diabetic ketoacidosis and a higher daily insulin dose were strongly associated with abortion. Diabetic complications significantly reduced the number of live births. CONCLUSIONS Type 1 diabetes compromises female fertility, even before it is diagnosed. Associated hyperthyroidism further reduces fertility. Blood glucose and thyroid function surveillance in infertile females may allow for an early diagnosis of type 1 diabetes and associated thyroid disease.
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Affiliation(s)
- Yung-Hsiang Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Chiayi Branch, Chiayi County, Taiwan
| | - Ko-Jung Chen
- Health Information and Epidemiology Laboratory of Chang Gung, Memorial Hospital Chiayi Branch, Chiayi County, Taiwan
| | - Yun-Shing Peng
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Chiayi Branch, Chiayi County, Taiwan
| | - Pau-Chung Chen
- Department of Environmental and Occupational Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory of Chang Gung, Memorial Hospital Chiayi Branch, Chiayi County, Taiwan; Department of Traditional Chinese Medicine, Chang Gung Memorial, Hospital Chiayi Branch, Chiayi County, Taiwan and School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Affiliation(s)
- Priyathama Vellanki
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
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Abstract
PURPOSE OF REVIEW This review summarizes the literature on care and outcome disparities in young adults (YA) with type 1 and type 2 diabetes, and outlines remaining needs and suggestions to reduce disparities and improve care. RECENT FINDINGS Despite well-documented disparities and data from large national and international diabetes populations, the role that social determinants of health play in disease management is largely unstudied. Further, mechanisms of how these risk factors interact with the unique developmental needs of racial-ethnic minority and economically vulnerable young adults with diabetes remain unknown. Little intervention research has focused on improving outcomes in this vulnerable population. More research needs to focus on identifying and addressing risk factors in racial-ethnic minority and economically vulnerable young adults with diabetes. Interventions need to be adapted and developed to meet the unique needs of this high-risk population. Clinicians and healthcare systems must recognize the inequity in care and outcomes for this group and structure clinical programs and policies to promote their optimal care.
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Affiliation(s)
- Shivani Agarwal
- Endocrinology, Diabetes, and Metabolism, University of Pennsylvania, Smilow Translational Research Center Room 12-142 3400 Civic Center Blvd., Philadelphia, PA, USA.
| | - Marisa Hilliard
- Baylor College of Medicine and Texas Children's Hospital, Feigin Tower 1102 Bates Ave., Suite 940, Houston, TX, 77030, USA
| | - Ashley Butler
- Baylor College of Medicine and Texas Children's Hospital, Feigin Tower 1102 Bates Ave., Suite 940, Houston, TX, 77030, USA
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McCoy RG, Herrin J, Lipska KJ, Shah ND. Recurrent hospitalizations for severe hypoglycemia and hyperglycemia among U.S. adults with diabetes. J Diabetes Complications 2018; 32:693-701. [PMID: 29751961 PMCID: PMC6015781 DOI: 10.1016/j.jdiacomp.2018.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/17/2022]
Abstract
AIMS Examine 30-day readmissions for recurrent hypoglycemia and hyperglycemia in a national cohort of adults with diabetes. METHODS Retrospective analysis of data from OptumLabs Data Warehouse for all adults with diabetes hospitalized January 1, 2009 to December 31, 2014 with a principal diagnosis of hypoglycemia or hyperglycemia. We examined the rates and risk factors of 30-day readmissions for hypoglycemia and hyperglycemia. RESULTS After 6419 index hypoglycemia hospitalizations, 1.2% were readmitted for recurrent hypoglycemia, 0.2% for hyperglycemia, and 8.6% for other causes. Multimorbidity was the strongest predictor of recurrent hypoglycemia. After 6872 index hyperglycemia hospitalizations, 4.0% were readmitted for recurrent hyperglycemia, 0.4% for hypoglycemia, and 5.4% for other causes. Recurrent hyperglycemia was less likely in older patients (OR 0.6, 95% CI 0.5-0.9 for 45-64 vs. <45 years) and with the addition of a new glucose-lowering medication at index discharge (OR 0.40; 95% CI 0.2-0.7). New hypoglycemia readmissions were most likely among patients ≥75 years (OR 13.3, 95% CI 2.4-73.4, vs. <45 years). CONCLUSIONS Patients hospitalized for hyperglycemia are often readmitted for recurrent hyperglycemia, while patients hospitalized for hypoglycemia are generally readmitted for unrelated causes. Early recognition of high risk patients may identify opportunities to improve post-discharge management and reduce these events.
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Affiliation(s)
- Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN 55905, United States.
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, PO Box 208056, New Haven, CT 06520, United States
| | - Kasia J Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, PO Box 208020, New Haven, CT 06520, United States
| | - Nilay D Shah
- Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN 55905, United States; OptumLabs, 1 Main Street, 10th Floor, Cambridge, MA 02142, United States
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81
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Affiliation(s)
- Mark A Sperling
- From the Department of Pediatrics, Division of Endocrinology and Diabetes, Icahn School of Medicine at Mt. Sinai, New York
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82
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van Megen KM, van ’t Wout EJT, Forman SJ, Roep BO. A Future for Autologous Hematopoietic Stem Cell Transplantation in Type 1 Diabetes. Front Immunol 2018; 9:690. [PMID: 29696017 PMCID: PMC5904498 DOI: 10.3389/fimmu.2018.00690] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/20/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Kayleigh M. van Megen
- Department of Diabetes Immunology, Diabetes & Metabolism Research Institute, Beckman Research Institute at the City of Hope, Duarte, CA, United States
| | - Ernst-Jan T. van ’t Wout
- Department of Diabetes Immunology, Diabetes & Metabolism Research Institute, Beckman Research Institute at the City of Hope, Duarte, CA, United States
| | - Stephen J. Forman
- Department of Hematology & Hematopoietic Cell Transplantation, T Cell Therapeutics Research Laboratory, City of Hope Beckman Research Institute and Medical Center, Duarte, CA, United States
| | - Bart O. Roep
- Department of Diabetes Immunology, Diabetes & Metabolism Research Institute, Beckman Research Institute at the City of Hope, Duarte, CA, United States
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
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83
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Phillips C, Sinha A. Successful management of diabetic ketoacidosis: an innovative protocol. PRACTICAL DIABETES 2018. [DOI: 10.1002/pdi.2161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Caroline Phillips
- Department of Anaesthesia and Critical Care; West Suffolk NHS Foundation Trust; Bury St Edmunds UK
| | - Ayush Sinha
- Department of Anaesthesia and Critical Care; West Suffolk NHS Foundation Trust; Bury St Edmunds UK
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Seventy-Two Hour Mortality Prediction Model in Patients with Diabetic Ketoacidosis: A Retrospective Cohort Study. J ASEAN Fed Endocr Soc 2018; 33:124-129. [PMID: 33442117 PMCID: PMC7784165 DOI: 10.15605/jafes.033.02.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 05/31/2018] [Indexed: 12/26/2022] Open
Abstract
Objective This study aims to identify predictors of 72-hour mortality in patients with diabetic ketoacidosis (DKA). Methodology In this retrospective cohort study, data were obtained from medical records of adult patients with DKA in Cipto Mangunkusumo General Hospital from January 2011 to June 2017. Associations of predictors (age, type of diabetes, history of DKA, comorbidities, level of consciousness, renal function, bicarbonate, potassium, lactate, betahydroxybutyrate levels, and anion gap status) and 72-hour mortality were analyzed. The mortality prediction model was formulated by dividing the coefficient B by the standard error for all variables with p<0.05 in the multivariate analysis. Results Eighty-six of 301 patients did not survive 72 hours after hospital admission. Comorbidities (HR 2.407; 95% CI 1.181–4.907), level of consciousness (HR 10.345; 95% CI 4.860–22.019), history of DKA (HR 2.126; 95% CI 1.308–3.457), and lactate level (HR 5.585; 95% CI 2.966–10.519) were significant predictors from multivariate analysis and were submitted to the prediction model. The prediction model had good performance. Patients with total score less than 3 points were at 15.41 % risk of mortality, 3 – 4 points were 78.01% and 5 – 6 points were 98.22% risk of mortality. Conclusion The 72-hour mortality rate in Cipto Mangunkusumo General Hospital was 28.57%. The mortality prediction model had a good performance and consisted of comorbidities, history of DKA, level of consciousness and lactate level.
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85
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Gomes MB, Rodacki M, Pavin EJ, Cobas RA, Felicio JS, Zajdenverg L, Negrato CA. The impact of ethnicity, educational and economic status on the prescription of insulin therapeutic regimens and on glycemic control in patients with type 1 diabetes. A nationwide study in Brazil. Diabetes Res Clin Pract 2017; 134:44-52. [PMID: 28951342 DOI: 10.1016/j.diabres.2017.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 09/01/2017] [Accepted: 09/19/2017] [Indexed: 02/06/2023]
Abstract
AIMS Establish the relationship between demographic, educational and economic status on insulin therapeutic regimens (ITRs) and on glycemic control in patients with type 1 diabetes. METHODS This was a cross-sectional, multicenter study with 1760 patients conducted between August 2011 and August 2014 in 10 Brazilian cities. RESULTS Patients were stratified according to ITRs as follows: only NPH insulin (group 1, n=80(4.5%)); only long-acting insulin analogs (group 2, n=6(0.3%)); continuous subcutaneous insulin infusion (CSII) (group 3, n=62(3.5%)); NPH plus regular insulin (group 4, n=710(40.3%)); NPH plus ultra-rapid insulin analogs (group 5, n=259(14.8%)); long-acting insulin analogs plus regular insulin (group 6, n=25(4.4%)) and long-acting plus ultra-rapid insulin analogs (group 7, n=618 (35.1%)). As group A (provided free of charge by the government) we considered groups 1 and 4, and as group B (obtained through lawsuit or out-of-pocket) groups 2, 3 and 7. Multivariate logistic analysis showed that independent variables related to group B were older age, more years of school attendance, higher economic status and ethnicity (Caucasians). The independent variables related to better glycemic control were older age, higher adherence to diet, higher frequency of self-monitoring of blood glucose, more years of school attendance and belonging to group B. CONCLUSIONS In Brazilian National Health Care System, prescriptions of insulin analogs or CSII are more frequent in Caucasian patients with type 1 diabetes, with higher economic status and more years ofschool attendance. Among these variables years of school attendance was the only one associated with better glycemic control.
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Affiliation(s)
- Marilia Brito Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Brazil
| | - Melanie Rodacki
- Diabetes and Nutrition Section, Department of Internal Medicine, Federal University of Rio de Janeiro, Brazil
| | - Elizabeth João Pavin
- Endocrinology Division, Department of Internal Medicine, Faculty of Medical Sciences, University of Campinas, São Paulo, Brazil
| | - Roberta Arnoldi Cobas
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Brazil
| | - João S Felicio
- University Hospital João de Barros Barreto, Federal University of Pará, Endocrinology Division, Belém, Pará, Brazil
| | - Lenita Zajdenverg
- Diabetes and Nutrition Section, Department of Internal Medicine, Federal University of Rio de Janeiro, Brazil
| | - Carlos Antonio Negrato
- Bauru's Diabetics Association, Department of Internal Medicine, Bauru, São Paulo, Brazil.
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86
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Polcwiartek C, Kragholm K, Rohde C, Hashemi N, Vang T, Nielsen J. Diabetic ketoacidosis and diabetes associated with antipsychotic exposure among a previously diabetes-naive population with schizophrenia: a nationwide nested case-control study. Diabetologia 2017; 60:1678-1690. [PMID: 28593353 DOI: 10.1007/s00125-017-4320-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
AIMS/HYPOTHESIS Diabetic ketoacidosis (DKA) is a potentially fatal metabolic emergency of both type 1 and type 2 diabetes. Although there is a reduced risk of type 1 diabetes in schizophrenia, the incidence of DKA is tenfold higher than that of the general population. Thus, we aimed to investigate associations between exposure to antipsychotic medication (within 3 months prior to event) and DKA, type 1 diabetes and type 2 diabetes. We also reported related, clinically relevant outcomes. METHODS Using a nested case-control study design, we identified cases of DKA, type 1 diabetes and type 2 diabetes in a previously diabetes-naive population with schizophrenia in Denmark from 1995 to 2014. Cases were matched (by age, sex and year of schizophrenia onset) 1:5 to schizophrenic control individuals who were alive and had not emigrated prior to event. Conditional logistic regression was used to compute ORs with 95% CIs. Other outcomes included diabetes aetiology of DKA, in-hospital mortality, DKA readmissions and temporal trends of use of insulin and oral glucose-lowering agents. RESULTS Of 29,955 individuals with schizophrenia, we identified 28 individuals with DKA, 90 with type 1 diabetes and 2140 with type 2 diabetes. These were matched to 137, 410 and 9861 individuals in the control group, respectively. Antipsychotic exposure was associated with DKA (OR 2.60; 95% CI 1.06, 6.38) and type 2 diabetes (OR 1.64; 95% CI 1.48, 1.83). A trend towards increased risk of type 1 diabetes was found but remained insignificant (OR 1.38; 95% CI 0.84, 2.29). Diabetes aetiology of DKA was type 1 in eight cases and type 2 in 14 cases. Of the remaining six cases of DKA, aetiology could not be determined, as four were fatal within 8 days and for two, no prescriptions for insulin and oral glucose-lowering agents were redeemed. Of all DKA cases, six had more than one episode of DKA, and of all type 1 diabetes and type 2 diabetes cases, four and 11, respectively, had at least one episode. Use of insulin and oral glucose-lowering agents was higher among individuals with DKA relative to those with type 1 diabetes and type 2 diabetes. CONCLUSIONS/INTERPRETATION Antipsychotic exposure was associated with DKA and type 2 diabetes in a previously diabetes-naive schizophrenia population. Antipsychotic-associated DKA is relevant not only for psychiatrists but also for other physicians who may manage and admit such patients.
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Affiliation(s)
- Christoffer Polcwiartek
- Department of Psychiatry, Aalborg University Hospital, Brandevej 5, 9220, Aalborg, Denmark.
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Kristian Kragholm
- Department of Psychiatry, Aalborg University Hospital, Brandevej 5, 9220, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Christopher Rohde
- Department of Psychiatry, Aalborg University Hospital, Brandevej 5, 9220, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nasseh Hashemi
- Department of Psychiatry, Aalborg University Hospital, Brandevej 5, 9220, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Torkel Vang
- Department of Psychiatry, Aalborg University Hospital, Brandevej 5, 9220, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jimmi Nielsen
- Department of Psychiatry, Aalborg University Hospital, Brandevej 5, 9220, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Mental Health Centre Glostrup, Copenhagen University Hospital, Copenhagen, Denmark
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Farsani SF, Brodovicz K, Soleymanlou N, Marquard J, Wissinger E, Maiese BA. Incidence and prevalence of diabetic ketoacidosis (DKA) among adults with type 1 diabetes mellitus (T1D): a systematic literature review. BMJ Open 2017; 7:e016587. [PMID: 28765134 PMCID: PMC5642652 DOI: 10.1136/bmjopen-2017-016587] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To summarise incidence and prevalence of diabetic ketoacidosis (DKA) in adults with type 1 diabetes (T1D) for the overall patient population and different subgroups (age, sex, geographical region, ethnicity and type of insulin administration). DESIGN Systematic literature review (SLR). DATA SOURCES Medline (via PubMed) and Embase (1 January 2000 to 23 June 2016). STUDY SELECTION Peer-reviewed observational studies with reported data on the incidence or prevalence of DKA in T1D adults were included. A single reviewer completed the study screening and selection process and a second reviewer performed an additional screening of approximately 20% of the publications; two reviewers independently conducted the quality assessment; the results were narratively synthesised. RESULTS Out of 1082 articles, 19 met the inclusion and exclusion criteria, with two additional studies identified that did not specify the patient age range and are therefore not included in the SLR. Overall, eight studies reported incidence with a range of 0-56 per 1000 person-years (PYs), with one outlying study reporting an incidence of 263 per 1000 PYs. Eleven studies reported prevalence with a range of 0-128 per 1000 people. Prevalence of DKA decreased with increasing age. Subgroup analyses were performed using data from no more than two studies per subgroup. There was a higher prevalence of DKA reported in women, non-whites and patients treated with insulin injections compared with men, whites and patients using continuous subcutaneous insulin infusion pumps, respectively. CONCLUSIONS To our knowledge, this is the first SLR on the epidemiology of DKA in T1D adults. Despite an increasing prevalence of T1D in recent years, DKA in adults has been poorly characterised. In an era when the benefit-risk profiles of new antidiabetic therapies are being evaluated, including the potential risk of DKA, there is a clear need to better elucidate the expected rate of DKA among T1D adults.
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Affiliation(s)
- Soulmaz Fazeli Farsani
- Corporate Department GlobalEpidemiology, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Kimberly Brodovicz
- Global Epidemiology, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, USA
| | | | - Jan Marquard
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany
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Dhatariya KK, Vellanki P. Treatment of Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS): Novel Advances in the Management of Hyperglycemic Crises (UK Versus USA). Curr Diab Rep 2017; 17:33. [PMID: 28364357 PMCID: PMC5375966 DOI: 10.1007/s11892-017-0857-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are diabetic emergencies that cause high morbidity and mortality. Their treatment differs in the UK and USA. This review delineates the differences in diagnosis and treatment between the two countries. RECENT FINDINGS Large-scale studies to determine optimal management of DKA and HHS are lacking. The diagnosis of DKA is based on disease severity in the USA, which differs from the UK. The diagnosis of HHS in the USA is based on total rather than effective osmolality. Unlike the USA, the UK has separate guidelines for DKA and HHS. Treatment of DKA and HHS also differs with respect to timing of fluid and insulin initiation. There is considerable overlap but important differences between the UK and USA guidelines for the management of DKA and HHS. Further research needs to be done to delineate a unifying diagnostic and treatment protocol.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
- University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Priyathama Vellanki
- Division of Endo, Metabolism & Lipids, Emory University School of Medicine, Atlanta, GA, USA
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Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am 2017; 101:587-606. [PMID: 28372715 PMCID: PMC6535398 DOI: 10.1016/j.mcna.2016.12.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.
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Affiliation(s)
- Maya Fayfman
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Francisco J Pasquel
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, 69 Jesse Hill Jr. Drive Southeast, 2nd Floor, Atlanta, GA 30303, USA.
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Cardoso L, Vicente N, Rodrigues D, Gomes L, Carrilho F. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism 2017; 68:43-54. [PMID: 28183452 DOI: 10.1016/j.metabol.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/15/2016] [Accepted: 11/22/2016] [Indexed: 01/22/2023]
Abstract
Hyperglycaemic emergencies are associated with significant morbi-mortality and healthcare costs. Management consists on fluid replacement, insulin therapy, and electrolyte correction. However, some areas of patient management remain debatable. In patients without respiratory failure or haemodynamic instability, arterial and venous pH and bicarbonate measurements are comparable. Fluid choice varies upon replenishment phase and patient's condition. If patient is severely hypovolaemic, normal saline solution should be the first option. However, if patient has mild/moderate dehydration, fluid choice must take in consideration sodium concentration. Insulin therapy should be guided by β-hydroxybutyrate normalization and not by blood glucose. Variations of conventional insulin infusion protocols emerged recently. Priming dose of insulin may not be required, and fixed rate insulin infusion represents the best option to suppress hepatic glucose production, ketogenesis, and lipolysis. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycaemia. Simpler protocols using subcutaneous rapid-acting insulin analogues for mild/moderate diabetic ketoacidosis treatment have proven to be safe and effective, but further studies are required to confirm these results. Treatment with bicarbonate, phosphate, and low-molecular-weight heparin is still disputable, and randomized controlled trials are urgently needed to optimize patient management and decrease the morbi-mortality of hyperglycaemic emergencies.
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Affiliation(s)
- Luís Cardoso
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Nuno Vicente
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Dírcea Rodrigues
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Leonor Gomes
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Francisco Carrilho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Affiliation(s)
- Mark A Sperling
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, Box 1616, New York, New York 10029-6574, USA
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