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Papadopoulos VP, Koutroulos MV, Zikoudi DG, Bakola SA, Avramidou P, Touzlatzi N, Filippou DK. Diabetes-related acute metabolic emergencies in COVID-19 patients: a systematic review and meta-analysis. Diabetol Int 2021; 12:445-459. [PMID: 33777611 PMCID: PMC7985576 DOI: 10.1007/s13340-021-00502-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/16/2021] [Indexed: 02/07/2023]
Abstract
AIMS COVID-19 is associated with diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar state (HHS) and euglycaemic DKA (EDKA); however, evidence regarding parameters affecting outcome and mortality rates is scarce. METHODS A systematic literature review was conducted using EMBASE, PubMed/Medline, and Google Scholar from January 2020 to 7 January 2021 to identify all studies describing clinical profile, outcome and mortality rates regarding DKA, HHS, DKA/HHS and EDKA cases in COVID-19 patients. The appropriate Joanna Briggs Institute tools were used for quality assessment; quality of evidence was approached using GRADE. Univariate and multivariate analyses were used to assess correlations between clinical characteristics and outcome based on case reports. Combined mortality rates (CMR) were estimated from data reported in case report series, cross-sectional studies, and meta-analyses. The protocol was submitted to PROSPERO (ID: 229356/230737). RESULTS From 312 identified publications, 44 were qualitatively and quantitatively analyzed. Critical COVID-19 necessitating ICU (P = 3 × 10-8), DKA/HHS presence (P = 0.021), and AKI (P = 0.037) were independently correlated with death. Increased COVID-19 severity (P = 0.003), elevated lactates (P < 0.001), augmented anion gap (P < 0.001), and AKI (P = 0.002) were associated with DKA/HHS. SGLT-2i were linked with EDKA (P = 0.004) and negatively associated with AKI (P = 0.023). CMR was 27.1% (95% CI 11.2-46.9%) with considerable heterogeneity (I 2 = 67%). CONCLUSION Acute diabetes-related metabolic emergencies in COVID-19 patients lead to increased mortality; key determinants are critical COVID-19 illness, coexistence of DKA/HHS and AKI. Previous SGLT-2i treatment, though associated with EDKA, might preserve renal function in COVID-19 patients. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s13340-021-00502-9.
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Affiliation(s)
- Vasileios P. Papadopoulos
- Department of Internal Medicine, Xanthi General Hospital, Xanthi, Greece
- First Department of Internal Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- ENARGEIA” Medical Ltd, 6 Elpidos str, Xanthi, Greece
| | | | | | | | - Peny Avramidou
- Department of Internal Medicine, Xanthi General Hospital, Xanthi, Greece
| | - Ntilara Touzlatzi
- Department of Internal Medicine, Xanthi General Hospital, Xanthi, Greece
| | - Dimitrios K. Filippou
- Department of Anatomy and Surgical Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Lee HJ, Sajan A, Tomer Y. Hyperglycemic Emergencies Associated With COVID-19 Vaccination: A Case Series and Discussion. J Endocr Soc 2021; 5:bvab141. [PMID: 34604689 PMCID: PMC8477915 DOI: 10.1210/jendso/bvab141] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Indexed: 01/08/2023] Open
Abstract
CONTEXT Hyperglycemic emergencies such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) and new-onset diabetes mellitus (DM) have been reported in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Hyperglycemia is a predictor of poor prognosis in COVID-19 disease. OBJECTIVES The objective of this work is to describe a case series of HHS and/or DKA likely triggered by the COVID-19 vaccine. The aim is to alert physicians of the potential hyperglycemic complications from the COVID-19 vaccination and to provide further insight into the underlying mechanism of the bidirectional relationship between SARS-CoV-2 and DM. CASE DESCRIPTIONS All 3 patients developed HHS and/or DKA within 2 to 10 days of the COVID-19 vaccination. PCR testing for SARS-CoV-2 was negative and other clinical precipitating factors were excluded. Two patients had a history of type 2 DM (T2DM) with pre-admission HbA1c levels of 7.0% to 7.5% while 1 patient was newly diagnosed with T2DM during the hospitalization. They were each treated with insulin infusion and were discharged on subcutaneous insulin therapy. Due to the rapid resolution of the hyperglycemia, insulin was discontinued in all patients within 8 weeks and they remain well-controlled on oral DM medications. CONCLUSION Severe hyperglycemia including HHS and DKA may be triggered by COVID-19 vaccination. Early evaluation and screening of patients with hyperglycemic symptoms after COVID-19 vaccination is recommended. The vaccine-induced hyperglycemia may provide further insight into the underlying pathogenesis caused by the SARS-CoV-2 infection itself. The underlying robust inflammatory response and "cytokine storm" may be the primary precipitant.
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Affiliation(s)
- Hanna J Lee
- Division of Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA,Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10461, USA,Correspondence: Hanna J. Lee, MD, Division of Endocrinology, Montefiore Medical Center. 3411 Wayne Avenue, Suite 1G. Bx, NY 10461.
| | - Alen Sajan
- Division of Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Yaron Tomer
- Division of Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA,Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10461, USA
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Rupp J, Gillespie A. A Case of Diabetic Hemichorea Hemiballismus Exacerbated by Hypoglycemia. AACE Clin Case Rep 2021; 7:327-329. [PMID: 34522775 PMCID: PMC8426609 DOI: 10.1016/j.aace.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/07/2021] [Accepted: 04/16/2021] [Indexed: 11/20/2022] Open
Abstract
Objective We describe an unusual case of diabetic hemichorea hemiballismus (diabetic HCHB) with symptoms resistant to traditional therapy and exacerbated by hypoglycemia. Case Presentation A 62-year-old woman with a 3-year history of noninsulin dependent type 2 diabetes presented with left-sided, involuntary, “jerking” movements. History included inconsistent metformin use, peripheral vascular disease, hypertension, and hyperlipidemia. Physical exam was documented as chorea of the left upper and lower extremity. Blood glucose was 776 mg/dL (82-115 mg/dL), and head computed tomography scan was read as asymmetric hyperattenuation of the right lentiform nucleus. The chorea dissipated within 48 hours of basal, bolus insulin and maintenance of blood glucose from 140 to 180 mg/dL. Hyperintensities were not documented on magnetic resonance imaging 4 days later. The patient presented twice in the following weeks for increasing frequency of chorea and hypoglycemia of 62 mg/dL and 40 mg/dL. Repeat magnetic resonance imaging was read as right-sided basal ganglia hyperintensities. Short courses of haloperidol, alprazolam, and tizanidine and a 2-week course of olanzapine yielded no improvement in chorea. Two weeks of tetrabenazine did improve the chorea; however, residual weakness and gait dysfunction persisted. Discussion The differential diagnosis for chorea includes hereditary and acquired forms. Diabetic HCHB is a rare, acquired, metabolic form that occurs in older, female, type 2 diabetics with poor glucose control. The patient experienced exacerbations of chorea in the setting of hypoglycemia. Conclusion Glycemic control is important in the long-term management of diabetic HCHB, and this case demonstrates hypoglycemia as a potential cause for resistant cases.
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Affiliation(s)
- Jessica Rupp
- Address correspondence and reprint requests to Ms Jessica Rupp, Lewis Katz School of Medicine at Temple University, 1020 Waverly Street, Unit 1, Philadelphia, PA 19147.
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Dare A, Elrashedy AA, Channa ML, Nadar A. Cardioprotective Effects and In-Silico Antioxidant Mechanism of L-Ergothioneine In Experimental Type-2 Diabetic Rats. Cardiovasc Hematol Agents Med Chem 2021; 20:133-147. [PMID: 34370646 DOI: 10.2174/1871525719666210809122541] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/06/2021] [Accepted: 05/26/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic cardiotoxicity is commonly associated with oxidative injury, inflammation, and endothelial dysfunction. L-ergothioneine (L-egt), a diet-derived amino acid, has been reported to decrease mortality and risk of cardiovascular injury, provides cytoprotection to tissues exposed to oxidative damage, and prevents diabetes-induced perturbation. OBJECTIVE This study investigated the cardioprotective effects of L-egt on diabetes-induced cardiovascular injuries and its probable mechanism of action. METHODS Twenty-four male Sprague-Dawley rats were divided into non-diabetic (n=6) and diabetic groups (n=18). Six weeks after the induction of diabetes, the diabetic rats were divided into three groups (n=6) and administered distilled water, L-egt (35mg/kg), and losartan (20mg/kg) by oral gavage for six weeks. Blood glucose and mean arterial pressure (MAP) were recorded pre-and post-treatment, while biochemical, ELISA, and Rt-PCR analyses were conducted to determine inflammatory, injury-related and antioxidant biomarkers in cardiac tissue after euthanasia. Also, an in-silico study, including docking and molecular dynamic simulations of L-egt toward the Keap1-Nrf2 protein complex, was done to provide a basis for the molecular antioxidant mechanism of L-egt. RESULTS Administration of L-egt to diabetic animals reduced serum triglyceride, water intake, MAP, biomarkers of cardiac injury (CK-MB, LDH), lipid peroxidation, and inflammation. Also, L-egt increased body weight, antioxidant enzymes, upregulated Nrf2, HO-1, NQO1 expression, and decreased Keap1 expression. The in-silico study showed that L-egt inhibits Keap1-Nrf2 complex by binding to the active site of Nrf2 protein, thereby preventing its degradation. CONCLUSION L-egt protects against diabetes-induced cardiovascular injury via the upregulation of Keap1-Nrf2 pathway and its downstream cytoprotective antioxidants.
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Affiliation(s)
- Ayobami Dare
- Discipline of Physiology, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban X54001, South Africa
| | - Ahmed A Elrashedy
- Department of Natural and Microbial Products, National Research Center, Dokki, Egypt
| | - Mahendra L Channa
- Discipline of Physiology, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban X54001, South Africa
| | - Anand Nadar
- Discipline of Physiology, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Westville Campus, Durban X54001, South Africa
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Adler A, Bennett P, Colagiuri Chair S, Gregg E, Narayan KMV, Inês Schmidt M, Sobngwi E, Tajima N, Tandon N, Unwin N, Wild S, Yudkin J, Levitt N, Mohan V, Montgomery S, Nyirenda MJ, Tuomilehto J, Den Boon S, Hocking S. REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS. Diabetes Res Clin Pract 2021:108972. [PMID: 34343595 DOI: 10.1016/j.diabres.2021.108972] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").
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Affiliation(s)
| | - Peter Bennett
- Phoenix Epidemiology & Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, USA
| | | | - Edward Gregg
- Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Eugene Sobngwi
- Faculté de Medecine et des Sciences Biomedicales et Centre de Biotechnologie, Université de Yaounde 1, Cameroon
| | - Naoko Tajima
- Jikei University School of Medicine, Tokyo, Japan
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Nigel Unwin
- Chronic Disease Research Centre, The University of the West Indies, Bridgetown, Barbados, and MRC Epidemiology Unit, University of Cambridge, UK
| | | | | | - Naomi Levitt
- Diabetic Medicine and Endocrinology, Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa
| | | | | | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute/London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
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Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med 2021; 61:365-375. [PMID: 34256953 DOI: 10.1016/j.jemermed.2021.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations. OBJECTIVE This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state. DISCUSSION Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit. CONCLUSIONS Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - George C Willis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
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The P2X7 Receptor: A Promising Pharmacological Target in Diabetic Retinopathy. Int J Mol Sci 2021; 22:ijms22137110. [PMID: 34281162 PMCID: PMC8268192 DOI: 10.3390/ijms22137110] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022] Open
Abstract
Diabetes is a worldwide emergency. Its chronic complications impose a heavy burden on patients, health systems, and on society as a whole. Diabetic retinopathy is one of the most common and serious complications of diabetes, and an established risk factor for blindness in adults. Over 15 years of investigation led to the identification of vascular endothelial growth factor (VEGF) as a main pathogenic factor in diabetic retinopathy and to the introduction of highly effective anti-VEGF-based therapies, such as the monoclonal antibody bevacizumab or its fragment ranibizumab, which helped to prevent diabetes-related blindness in millions of patients. Recently, a pathogenic role for uncontrolled increases in the extracellular ATP concentration (eATP) and for overactivation of the purinergic receptor P2X7 (P2X7R) has been suggested. The P2X7R is an eATP-gated plasma membrane channel expressed in multiple tissues and organs, with a pleiotropic function in inflammation, immunity, cancer, and hormone and growth factor release. P2X7R stimulation or overexpression positively regulate the secretion and buildup of VEGF, thus promoting neo-angiogenesis in a wide variety of disease processes. In this review, we explore current evidence that supports the role of P2X7R receptor signaling in the pathogenesis of diabetic retinopathy, as well as the most appealing current therapeutical options for P2X7R targeting.
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Guo JY, Chou RH, Kuo CS, Chao TF, Wu CH, Tsai YL, Lu YW, Kuo MR, Huang PH, Lin SJ. The paradox of the glycemic gap: Does relative hypoglycemia exist in critically ill patients? Clin Nutr 2021; 40:4654-4661. [PMID: 34229272 DOI: 10.1016/j.clnu.2021.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Elevated glycemic gap, as the differences between measured glucose and hemoglobin A1c (HbA1c)-derived average glucose (ADAG) levels, is a marker of stress-induced hyperglycemia and is a predictor of mortality in critically ill patients. Whether low glycemic gaps are associated with outcomes in critically ill patients remains unclear. We investigated the association of different glycemic gaps on mortality in critically ill patients. METHODS Totally 935 patients admitted to intensive care units (ICUs) were enrolled retrospectively after the exclusion of patients with absolute hypoglycemia, extreme hyperglycemia, and incomplete glycemic records. Patients were divided into 3 groups according to their glycemic gaps (<-29.7, -29.7-40, ≧40 mg/dL) at the time of ICU admission. The patients were followed for 1 year or until death. RESULTS Patients with low glycemic gap (glycemic gap < -29.7 mg/dL), which implied relative hypoglycemia, had lower serum glucose levels, higher HbA1c levels, and greater disease severity. Compared with medium group (glycemic gap -29.7-40 mg/dL), both the low and the high glycemic gap (glycemic gap ≧40 mg/dL) groups had significantly greater 30-day (log-rank p = 0.0464) and 1-year mortality (log-rank p = 0.0016). However, only the low glycemic gap group was independently associated with greater in-hospital mortality after adjusting for comorbidities (adjusted OR 1.78, 95% CI 1.00-3.16, p = 0.048). CONCLUSION This study revealed the presence of a U-shaped relationship between the glycemic gap and mortality in critically ill patients. Low glycemic gaps suggested relative hypoglycemia at the time of ICU admission, and were associated independently with greater in-hospital mortality.
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Affiliation(s)
- Jiun-Yu Guo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ruey-Hsing Chou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Sung Kuo
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Hsueh Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Lin Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Wen Lu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Ren Kuo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Shing-Jong Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Healthcare and Management Center, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan; Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
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Characteristics of post-mortem beta-hydroxybutyrate-positivet cases - A retrospective study on age, sex and BMI in 1407 forensic autopsies. Forensic Sci Int 2021; 325:110878. [PMID: 34144280 DOI: 10.1016/j.forsciint.2021.110878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Post-mortem biochemistry, including the analysis of beta-hydroxybutyrate (BHB), is increasingly employed in forensic medicine, especially in conditions such as diabetes and chronic alcoholism. However, not much is known about the associations between age, body mass index (BMI), and sex and BHB concentrations in ketoacidotic conditions. AIM To retrospectively study the association between age, BMI and sex in several conditions, such as diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and elevated post-mortem BHB concentrations. METHODS 1407 forensic autopsy cases analysed for BHB were grouped by diagnosis: DKA, AKA, HHS [hyperosmolar hyperglycaemic state], acidosis NOS [not otherwise specified], or hypothermia. Age, sex, BMI and the concentrations of blood alcohol, vitreous glucose and blood BHB were recorded. RESULTS Cases of AKA and DKA were most numerous (184 and 156, respectively). In DKA and in its male subgroup, cases with severe ketosis (BHB>1000 µg/g) were younger and had a lower BMI than those with moderate ketosis (BHB 250-1000 µg/g) and controls (P<0.001). In DKA and in its female subgroup, cases with moderate ketosis cases were older (P = 0.0218 and P = 0.0083) than controls. In AKA and in its male subgroup, cases with severe ketosis had a lower BMI than those with moderate ketosis (P = 0.0391 and P = 0.0469) and controls (P<0.001). Cases with moderate ketosis had a lower BMI than controls (P<0.001). CONCLUSIONS BHB concentration is associated with BMI in DKA and AKA, and with both BMI and age in DKA. Constitutional factors should, therefore, be considered in potential AKA and DKA cases.
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Hospitalization for Short-Term Diabetes-Related Complications: Focus on Patients Aged over 85 Years. Healthcare (Basel) 2021; 9:healthcare9040460. [PMID: 33919723 PMCID: PMC8070693 DOI: 10.3390/healthcare9040460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/10/2021] [Accepted: 04/11/2021] [Indexed: 01/22/2023] Open
Abstract
(1) Background: The prevalence of diabetes in elderly people is frequently high. When occurring in the elderly, diabetes is often accompanied by complications and comorbidities, at least one in 60% and four or more in 40% of older people with diabetes. As far as short-term complications among the elderly are concerned, hypoglycemia and hyperglycemic crises prove to be frequent. The aim of this study was to investigate the difference in hospitalization for short-term diabetes complications in patients below and over 85 years of age. (2) Methods: Data were collected from hospital discharge records (HDRs) of all hospital admissions that occurred in Abruzzo Region, Italy, from 2006 to 2015. Only diabetic patients aged over 65 years were included. Outcomes included were diabetic ketoacidosis, hyperosmolar coma, hypoglycemic shock, iatrogenic hypoglycemic coma, and other diabetic comas. (3) Results: During the study period, 144,376 admissions were collected, 116,305 (80.56%) of which referred to patients below 85 years. Those aged over 85 years were significantly associated to all short-term diabetes-related complications with the exception of ketoacidosis. (4) Conclusions: In older diabetic patients, the avoidance of short-term diabetes complications are a greater concern than in younger patients. Diabetes management among very elderly patients should be tailored accordingly to patient characteristics.
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Abstract
Coronavirus disease 2019 (COVID-19) is a multi-system disease that causes multiple complications. It is linked to the development of new-onset diabetes or unmasking of underlying diabetes. Despite the uncertain exact mechanism, pancreatic angiotensin-converting enzyme 2 (ACE2) receptor, the main enzyme related to COVID-19 pathophysiology has been implied. COVID-19 vaccine was authorized to help control the rapid spread of COVID-19 disease. We report a case of new-onset diabetes type 2 presenting as hyperosmolar hyperglycemic state (HHS) in a patient after receiving COVID-19 vaccine with some literature review of the potential mechanisms by which COVID-19 may cause new-onset diabetes type 2.
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Affiliation(s)
| | | | - Naser Eddin Gharaibeh
- Endocrinology, Mercy Hospital Joplin, Joplin, USA.,Endocrinology, Kansas City University, Joplin, USA
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SGLT2 inhibition versus sulfonylurea treatment effects on electrolyte and acid-base balance: secondary analysis of a clinical trial reaching glycemic equipoise: Tubular effects of SGLT2 inhibition in Type 2 diabetes. Clin Sci (Lond) 2021; 134:3107-3118. [PMID: 33205810 DOI: 10.1042/cs20201274] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 12/19/2022]
Abstract
Sodium-glucose transporter (SGLT)2 inhibitors increase plasma magnesium and plasma phosphate and may cause ketoacidosis, but the contribution of improved glycemic control to these observations as well as effects on other electrolytes and acid-base parameters remain unknown. Therefore, our objective was to compare the effects of SGLT2 inhibitors dapagliflozin and sulfonylurea gliclazide on plasma electrolytes, urinary electrolyte excretion, and acid-base balance in people with Type 2 diabetes (T2D). We assessed the effects of dapagliflozin and gliclazide treatment on plasma electrolytes and bicarbonate, 24-hour urinary pH and excretions of electrolytes, ammonium, citrate, and sulfate in 44 metformin-treated people with T2D and preserved kidney function. Compared with gliclazide, dapagliflozin increased plasma chloride by 1.4 mmol/l (95% CI 0.4-2.4), plasma magnesium by 0.03 mmol/l (95% CI 0.01-0.06), and plasma sulfate by 0.02 mmol/l (95% CI 0.01-0.04). Compared with baseline, dapagliflozin also significantly increased plasma phosphate, but the same trend was observed with gliclazide. From baseline to week 12, dapagliflozin increased the urinary excretion of citrate by 0.93 ± 1.72 mmol/day, acetoacetate by 48 μmol/day (IQR 17-138), and β-hydroxybutyrate by 59 μmol/day (IQR 0-336), without disturbing acid-base balance. In conclusion, dapagliflozin increases plasma magnesium, chloride, and sulfate compared with gliclazide, while reaching similar glucose-lowering in people with T2D. Dapagliflozin also increases urinary ketone excretion without changing acid-base balance. Therefore, the increase in urinary citrate excretion by dapagliflozin may reflect an effect on cellular metabolism including the tricarboxylic acid cycle. This potentially contributes to kidney protection.
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Getie A, Wondmieneh A, Bimerew M, Gedefaw G, Demis A. Determinants of diabetes ketoacidosis among diabetes mellitus patients at North Wollo and Waghimra zone public hospitals, Amhara region, Northern Ethiopia. BMC Endocr Disord 2021; 21:26. [PMID: 33602195 PMCID: PMC7890609 DOI: 10.1186/s12902-021-00692-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/08/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetes Mellitus (DM) is a metabolic disorder associated with acute and chronic complications. Diabetic ketoacidosis (DKA) is the most serious diabetic emergency in patients with type one and type two diabetes mellitus. It is the leading cause of mortality in children and young adults. Even though the burden of DKA has increased, no research has been conducted on the determinants of Diabetes ketoacidosis in Ethiopia, particularly in the Amhara region. Thus, this study aimed to identify the determinants of diabetes Ketoacidosis among Diabetes Mellitus patients at North Wollo and Waghimra Zone public Hospitals. METHODS An institution-based unmatched case-control study design was employed among 408 patients at North Wollo and Waghimra Zone Public Hospitals from March 1st to April 30th, 2020. A consecutive sampling method was used to select study participants. The data were collected using structured interviewer-administered questioners and reviewing of patient charts. The analysis was done using a binary logistic regression model. Then, P-value < 0.05 was considered statistically significant. RESULT The mean (±SD) age of the study participants was 46.96 (± 15.175 SD) years. Irregular follow-up in diabetes clinic (AOR:4.19, 95% CI: 2.28-7.71), not received diabetic education (AOR: 2.87, 95% CI:1.44-5.72), alcohol drinking (AOR:2.99, 95% CI: 1.46-6.12), discontinuation of medications (AOR: 4.31, 95% CI:1.92-9.68), presence of comorbidity (AOR:2.57, 95% CI: 1.37-4.84), and being type one of diabetes mellitus (AOR: 2.01, 95% CI:1.11-3.63) were determinant factors of diabetic ketoacidosis . CONCLUSIONS This study showed that the behavioral and clinical characteristics of diabetic patients were determinant factors of DKA. Follow-up in the diabetic clinic, diabetic education, discontinuation of medications, alcohol drinking, presence of comorbidities, and type of diabetes mellitus were independent determinants of diabetic ketoacidosis.
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Affiliation(s)
- Addisu Getie
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Adam Wondmieneh
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Melaku Bimerew
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Getnet Gedefaw
- Department of Midwifery, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
| | - Asmamaw Demis
- Department of Nursing, College of Health Sciences, Woldia University, P.O.Box: 400, Woldia, Ethiopia
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Mohn A, Polidori N, Castorani V, Comegna L, Giannini C, Chiarelli F, Blasetti A. Hyperglycaemic hyperosmolar state in an obese prepubertal girl with type 2 diabetes: case report and critical approach to diagnosis and therapy. Ital J Pediatr 2021; 47:38. [PMID: 33602256 PMCID: PMC7891158 DOI: 10.1186/s13052-021-00983-z] [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: 09/17/2020] [Accepted: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Isolated Hyperosmolar Hyperglycaemic Syndrome (HHS) is a life-threatening condition characterized by elevated serum glucose concentrations and hyperosmolality without significant ketosis. It is often described in obese adults with unknown Type 2 Diabetes (T2D), rarely in youth. In childhood the most common cause of metabolic glucose related derangement is Diabetic Ketoacidosis (DKA) in Type 1 Diabetes (T1D). Interestingly, both components can be combined with each other, thus the prevalent condition needs to be recognised implying a different therapeutic approach. Case presentation In this case, we report a prepubertal Caucasian obese girl admitted for two episodes of combined HHS/DKA in order to elucidate her clinical course taking into account the current pediatric recommendations based on adult guidelines for HHS. Conclusions The treatment of HHS and even more of HHS/DKA in youth is still controversial as no specific guidelines for children are available especially during the prepubertal age. The description of our case might be helpful and offer relevant points for future consensus.
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Affiliation(s)
- Angelika Mohn
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy.
| | - Nella Polidori
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Valeria Castorani
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Laura Comegna
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Cosimo Giannini
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Francesco Chiarelli
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
| | - Annalisa Blasetti
- Department of Paediatrics, University of Chieti, Via dei Vestini, 5, IT-66100, Chieti, Italy
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Muneer M, Akbar I. Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1307:85-114. [PMID: 32488607 DOI: 10.1007/5584_2020_545] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.
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Affiliation(s)
| | - Ijaz Akbar
- Shukat Khanam Cancer Hospital and Research Centre, Lahore, Pakistan
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Delaney SR, Kaleta EJ, Snozek CLH. Extreme Hyperglycemia in an Elderly Patient. Clin Chem 2021; 67:724-728. [PMID: 33462604 DOI: 10.1093/clinchem/hvaa330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/19/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Sarah R Delaney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Erin J Kaleta
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Christine L H Snozek
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Phoenix, AZ, USA
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Farmaki P, Damaskos C, Garmpis N, Garmpi A, Savvanis S, Diamantis E. Complications of the Type 2 Diabetes Mellitus. Curr Cardiol Rev 2021; 16:249-251. [PMID: 33407062 PMCID: PMC7903505 DOI: 10.2174/1573403x1604201229115531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Paraskevi Farmaki
- First Department of Pediatrics, Aghia Sophia Children's Hospital, Athens, Greece
| | - Christos Damaskos
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Garmpis
- Second Department of Propedeutic Surgery, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Garmpi
- Internal Medicine Department, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridon Savvanis
- Department of Internal Medicine, General Hospital of Athens "Elpis", Athens, Greece
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Nishikawa T, Kinoshita H, Ono K, Kodama-Hashimoto S, Kobayashi Y, Nakamura T, Yoshinaga T, Ohkubo Y, Harada M, Toyonaga T, Takahashi T, Araki E. Clinical profiles of hyperglycemic crises: A single-center retrospective study from Japan. J Diabetes Investig 2021; 12:1359-1366. [PMID: 33277786 PMCID: PMC8354495 DOI: 10.1111/jdi.13475] [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: 08/04/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 01/20/2023] Open
Abstract
AIMS/INTRODUCTION The aim of the present study was to clarify the pathophysiologies of hyperglycemic crises in Japanese patients. MATERIALS AND METHODS This was a retrospective study of patients with hyperglycemic crises admitted to Kumamoto Medical Center, Kumamoto, Japan, between 2012 and 2019. Patients were classified as having diabetic ketoacidosis (DKA), hyperglycemic hyperosmotic syndrome (HHS) or a mixed state of the two conditions (MIX), and laboratory data and levels of consciousness at hospital admission, as well as the rates of mortality and coagulation disorders, were compared. RESULTS The diagnostic criteria for hyperglycemic crisis were met in 144 cases, comprising 87 (60.4%), 38 (26.4%) and 19 (13.2%) cases of DKA, HHS and MIX, respectively. Type 1 diabetes was noted in 46.0 and 26.3% of patients in the DKA and MIX groups, respectively. Fibrin degradation product and D-dimer levels were significantly higher in the HHS group than in the DKA group (DKA and HHS groups: fibrin degradation product 7.94 ± 8.43 and 35.54 ± 51.80 μg/mL, respectively, P < 0.01; D-dimer 2.830 ± 2.745 and 14.846 ± 21.430 μg/mL, respectively, P < 0.01). Mortality rates were 5.7, 13.2 and 5.3% in the DKA, HHS and MIX groups, respectively. Seven patients (4.9%), four of whom were in the MIX group, had acute arterial occlusive diseases. CONCLUSIONS The low frequency of type 1 diabetes in DKA and MIX might be responsible for reduced insulin secretion in Japanese populations. Patients with hyperglycemic crises have increased coagulability, and acute arterial occlusion needs to be considered, particularly in MIX.
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Affiliation(s)
- Takeshi Nishikawa
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Hiroyuki Kinoshita
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Keiko Ono
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Shoko Kodama-Hashimoto
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Yuka Kobayashi
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Tomofumi Nakamura
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Tomoaki Yoshinaga
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Yuma Ohkubo
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Masahiro Harada
- Department of Emergency and Critical Care, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | | | - Takeshi Takahashi
- Department of Diabetes and Endocrinology, National Hospital Organization, Kumamoto Medical Center, Kumamoto, Japan
| | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Alghamdi MA, Alzahrani AM, Alshams HA, Al-Saif MH, Moafa AM, Alenzi MM, Seadawi LE, Ali AKA, Al-Hufayyan NS, Mujallid MF. Hyperosmolar hyperglycemic state management in the emergency department. ARCHIVES OF PHARMACY PRACTICE 2021. [DOI: 10.51847/8gxto9c75t] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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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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Tittel SR, Sondern KM, Weyer M, Poeplau T, Sauer BM, Schebek M, Ludwig KH, Hammer F, Fröhlich-Reiterer E, Holl RW. Multicentre analysis of hyperglycaemic hyperosmolar state and diabetic ketoacidosis in type 1 and type 2 diabetes. Acta Diabetol 2020; 57:1245-1253. [PMID: 32488499 PMCID: PMC7496062 DOI: 10.1007/s00592-020-01538-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 04/18/2020] [Indexed: 02/06/2023]
Abstract
AIMS To compare diabetes patients with hyperglycaemic hyperosmolar state (HHS), diabetic ketoacidosis (DKA), and patients without decompensation (ND). METHODS In total, 500,973 patients with type 1 or type 2 diabetes of all ages registered in the diabetes patient follow-up (DPV) were included. Analysis was stratified by age (≤ / > 20 years) and by manifestation/follow-up. Patients were categorized into three groups: HHS or DKA-during follow-up according to the most recent episode-or ND. RESULTS At onset of diabetes, HHS criteria were met by 345 (68.4% T1D) and DKA by 9824 (97.6% T1D) patients. DKA patients had a lower BMI(-SDS) in both diabetes types compared to ND. HbA1c was higher in HHS/DKA. During follow-up, HHS occurred in 1451 (42.2% T1D) and DKA in 8389 patients (76.7% T1D). In paediatric T1D, HHS/DKA was associated with younger age, depression, and dyslipidemia. Pump usage was less frequent in DKA patients. In adult T1D/T2D subjects, metabolic control was worse in patients with HHS/DKA. HHS and DKA were also associated with excessive alcohol intake, dementia, stroke, chronic kidney disease, and depression. CONCLUSIONS HHS/DKA occurred mostly in T1D and younger patients. However, both also occurred in T2D, which is of great importance in the treatment of diabetes. Better education programmes are necessary to prevent decompensation and comorbidities.
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Affiliation(s)
- S R Tittel
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Technology (ZIBMT), Ulm University, Albert-Einstein-Allee 41, 89081, Ulm, Germany.
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany.
| | | | - M Weyer
- Kamillus-Klinik Internal Medicine, Asbach, Germany
| | - T Poeplau
- Clemenshospital, Ludgerus-Kliniken GmbH, Münster, Germany
| | - B M Sauer
- Medical Clinic Internal Medicine, Spaichingen, Germany
| | | | - K-H Ludwig
- Paediatric Clinic of the Borromeans, Trier, Germany
| | - F Hammer
- Cnopf Children's Clinic, Nuremberg, Germany
| | | | - R W Holl
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Technology (ZIBMT), Ulm University, Albert-Einstein-Allee 41, 89081, Ulm, Germany
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Martucci G, Bonicolini E, Parekh D, Thein OS, Scherkl M, Amrein K. Metabolic and Endocrine Challenges. Semin Respir Crit Care Med 2020; 42:78-97. [PMID: 32882734 DOI: 10.1055/s-0040-1713084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This review aims to provide an overview of metabolic and endocrine challenges in the setting of intensive care medicine. These are a group of heterogeneous clinical conditions with a high degree of overlap, as well as nonspecific signs and symptoms. Several diseases involve multiple organ systems, potentially causing catastrophic dysfunction and death. In the majority of cases, endocrine challenges accompany other organ failures or manifest as a complication of prolonged intensive care unit stay and malnutrition. However, when endocrine disorders present as an isolated syndrome, they are a rare and extreme manifestation. As they are uncommon, these can typically challenge both with diagnosis and management. Acute exacerbations may be elicited by triggers such as infections, trauma, surgery, and hemorrhage. In this complex scenario, early diagnosis and prompt treatment require knowledge of the specific endocrine syndrome. Here, we review diabetic coma, hyponatremia, hypercalcemia, thyroid emergencies, pituitary insufficiency, adrenal crisis, and vitamin D deficiency, highlighting diagnostic tools and tricks, and management pathways through defining common clinical presentations.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Eleonora Bonicolini
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta Specializzazione), Palermo, Italy
| | - Dhruv Parekh
- Critical Care, Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Onn Shaun Thein
- Critical Care, Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Mario Scherkl
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Odak M, Douedi S, Upadhyaya V, Fadhel M, Cosentino J. Focal Neurological Seizure due to Hyperglycemic Hyperosmolar Non-Ketotic Syndrome in Undiagnosed Diabetes Mellitus. Cureus 2020; 12:e9909. [PMID: 32968572 PMCID: PMC7505616 DOI: 10.7759/cureus.9909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) is a life-threatening complication of type 2 diabetes mellitus with a wide range of presenting symptoms. Neurological symptoms, such as coma, can also be part of the manifestation of HHNS; however, focal seizures remain a rare but notable association. A 85-year-old male patient with no history of diabetes presented to our emergency department complaining of a two-day history of twitching movements of his left wrist. Laboratory findings suggested HHNS and his hemoglobin A1c were found to be 10.2%. He was aggressively treated in the intensive care unit with fluids and insulin which also resolved his seizure episodes. He was ultimately discharged in stable condition without any seizure-like activity while having good glycemic control. According to the American Diabetes Association, about 25% of all individuals 65 years and older have diabetes mellitus. With an increasing prevalence, the complications of uncontrolled diabetes are also becoming more notable. While the neurological deficits associated with HHNS are focal, the mechanism by which this occurs is still poorly understood and underreported warranting further studies.
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Affiliation(s)
- Mihir Odak
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Steven Douedi
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Vandan Upadhyaya
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Mustafa Fadhel
- Pulmonary and Critical Care, Jersey Shore University Medical Center, Neptune City, USA
| | - James Cosentino
- Pulmonary and Critical Care, Jersey Shore University Medical Center, Neptune City, USA
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Wang CT, Chang CW, Lu YC, Lam HC, Ku SJ, Tseng KB, Kao YH. An atypical hyperosmolar hyperglycemic state and diabetic ketoacidosis induced by sodium-glucose cotransporter-2 inhibitors: A case report. J Formos Med Assoc 2020; 119:1325-1328. [PMID: 31813656 DOI: 10.1016/j.jfma.2019.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/29/2019] [Accepted: 11/18/2019] [Indexed: 06/10/2023] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have become the best choice of second-line oral antidiabetic drugs for patients with heart or chronic kidney disease. However, it is not clear how safe this treatment is for elderly patients, especially Asians, who are known to be more insulin deficient than Caucasian individuals with a similar insulin resistance. Here, we report a case concerning an elderly patient with type 2 diabetes mellitus without insulin dependence, whose antidiabetic medication had recently been changed to include an SGLT-2 inhibitor. The patient presented with an atypical hyperosmolar hyperglycemic state and diabetic ketoacidosis but recovered after insulin pump treatment and fluid supplementation. The patient was discharged with a prescription of a mixed-type insulin injection instead of oral antidiabetic medications for diabetes control. Our case demonstrates that if SGLT-2 inhibitors are administered to elderly Asian patients, their benefits and adverse effects should be carefully monitored.
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Affiliation(s)
- Chen-Ti Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, No. 1, Yida Road, Kaohsiung City, 824, Taiwan
| | - Che-Wei Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, No. 1, Yida Road, Kaohsiung City, 824, Taiwan
| | - Yung-Chuan Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, No. 1, Yida Road, Kaohsiung City, 824, Taiwan
| | - Hing-Chung Lam
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, No. 1, Yida Road, Kaohsiung City, 824, Taiwan
| | - Shu-Ju Ku
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, No. 1, Yida Road, Kaohsiung City, 824, Taiwan
| | - Kuo-Bin Tseng
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Cancer Hospital/I-Shou University, No. 21, Yida Road, Kaohsiung City, 824, Taiwan
| | - Yu-Hsi Kao
- Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital/I-Shou University, No. 1, Yida Road, Kaohsiung City, 824, Taiwan.
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Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S. RSSDI-ESI Clinical Practice Recommendations for the Management
of Type 2 Diabetes Mellitus 2020. Int J Diabetes Dev Ctries 2020. [PMCID: PMC7371966 DOI: 10.1007/s13410-020-00819-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rajeev Chawla
- North Delhi Diabetes Centre Rohini, New Delhi, India
| | - S. V. Madhu
- Centre for Diabetes, Endocrinology & Metabolism, UCMS-GTB Hospital, Delhi, India
| | - B. M. Makkar
- Dr Makkar’s Diabetes & Obesity Centre Paschim Vihar, New Delhi, India
| | - Sujoy Ghosh
- Department of Endocrinology & Metabolism, Institute of Post Graduate Medical Education & Research, Kolkata, West Bengal India
| | - Banshi Saboo
- DiaCare - A Complete Diabetes Care Centre, Ahmedabad, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana India
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76
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Khurshid Q, Khalid L, Usman N, Neupane N, Mahmoud A. Rhabdomyolysis Induced Acute Kidney Injury in Hyperglycemic Hyperosmolar State Patient With New-Onset Diabetes: A Case Report. Cureus 2020; 12:e9188. [PMID: 32818120 PMCID: PMC7426665 DOI: 10.7759/cureus.9188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The hyperglycemic hyperosmolar state (HHS) is a serious acute complication of type 2 diabetes mellitus that requires prompt recognition, diagnosis, and treatment. Reversible acute kidney injury is common in hyperglycemic states. However, hyperglycemic emergencies can contribute to the development of rhabdomyolysis, which can further aggravate acute kidney injury and can cause high morbidity and mortality. HHS can be the first clinical presentation of diabetes mellitus in some patients. Here, we present a case of HHS-related rhabdomyolysis and acute kidney injury, which was the first presentation of type 2 diabetes mellitus in this patient. Our case highlights the importance of a rare association between rhabdomyolysis and HHS in diabetic patients.
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77
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Burgos JI, Morell M, Mariángelo JIE, Vila Petroff M. Hyperosmotic stress promotes endoplasmic reticulum stress-dependent apoptosis in adult rat cardiac myocytes. Apoptosis 2020; 24:785-797. [PMID: 31309362 DOI: 10.1007/s10495-019-01558-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In different pathological situations, cardiac cells undergo hyperosmotic stress and cell shrinkage. This change in cellular volume has been associated with contractile dysfunction and cell death. However, the intracellular mechanisms involved in hyperosmotic stress-induced cell death have not been investigated in depth in adult cardiac myocytes. Given that osmotic stress has been shown to promote endoplasmic reticulum stress (ERS), a recognized trigger for apoptosis, we examined whether hyperosmotic stress triggers ERS in adult cardiac myocytes and if so whether this mechanism mediates hyperosmotic stress-induced cell death. Adult rat cardiomyocytes cultured overnight in a hypertonic solution (HS) containing mannitol as the osmolite, showed increased expression of ERS markers, GRP78, CHOP and cleaved-Caspase-12, compared with myocytes in isotonic solution (IS), suggesting that hyperosmotic stress induces ERS. In addition, HS significantly reduced cell viability and increased TUNEL staining and the expression of active Caspase-3, indicative of apoptosis. These effects were prevented with the addition of the ERS inhibitor, 4-PBA, indicating that hyperosmotic stress-induced apoptosis is mediated by ERS. Hyperosmotic stress-induced apoptosis was also prevented when cells were cultured in the presence of a Ca2+-chelating agent (EGTA) or the CaMKII inhibitor (KN93), suggesting that hyperosmotic stress-induced ERS is mediated by a Ca2+ and CaMKII-dependent mechanism. Similar results were observed when hyperosmotic stress was induced using glucose as the osmolite. We conclude that hyperosmotic stress promotes ERS by a CaMKII-dependent mechanism leading to apoptosis of adult cardiomyocytes. More importantly, we demonstrate that hyperosmotic stress-triggered ERS contributes to hyperglycemia-induced cell death.
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Affiliation(s)
- Juan Ignacio Burgos
- Centro de Investigaciones Cardiovasculares, CONICET La Plata, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, 60 y 120, 1900, La Plata, Argentina
| | - Malena Morell
- Centro de Investigaciones Cardiovasculares, CONICET La Plata, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, 60 y 120, 1900, La Plata, Argentina
| | - Juan Ignacio E Mariángelo
- Centro de Investigaciones Cardiovasculares, CONICET La Plata, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, 60 y 120, 1900, La Plata, Argentina
| | - Martin Vila Petroff
- Centro de Investigaciones Cardiovasculares, CONICET La Plata, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, 60 y 120, 1900, La Plata, Argentina.
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Remy KE, Verhoef PA, Malone JR, Ruppe MD, Kaselitz TB, Lodeserto F, Hirshberg EL, Slonim A, Dezfulian C. Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists. Pediatr Crit Care Med 2020; 21:607-619. [PMID: 32420720 PMCID: PMC7331597 DOI: 10.1097/pcc.0000000000002429] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults. DESIGN Narrative review/perspective. SETTING Not applicable. PATIENTS Not applicable. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU. CONCLUSIONS This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise.
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Affiliation(s)
- Kenneth E Remy
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
- Department of Internal Medicine, Washington University in St. Louis, St. Louis, MO
| | - Philip A Verhoef
- Department of Internal Medicine, University of Hawaii-Manoa, Manoa, HI
- Kaiser Permanente Hawaii, Honolulu, HI
| | - Jay R Malone
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Michael D Ruppe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Norton Healthcare, University of Louisville, Louisville, KY
| | - Timothy B Kaselitz
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Frank Lodeserto
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Danville, PA
- Department of Pediatrics, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Eliotte L Hirshberg
- Division of Pulmonary and Critical Care, Department of Internal Medicine and Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Anthony Slonim
- University of Nevada, Reno School of Medicine, Renown Health System, Reno, NV
| | - Cameron Dezfulian
- Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA
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79
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Buscaglia NA, Hanley CS. Hyperglycemic hyperosmolar state in a chimpanzee (Pan troglodytes). J Med Primatol 2020; 49:332-336. [PMID: 32542742 DOI: 10.1111/jmp.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 01/08/2023]
Abstract
A 19-year-old female chimpanzee (Pan troglodytes) presented for cachexia, acute weakness, hyporexia, icterus, and polyuria. The animal was diagnosed with a hyperglycemic hyperosmolar state, which is a well-recognized syndrome in diabetic humans that is rarely diagnosed in animals. This case documents an important and likely under-reported syndrome in non-human primates.
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80
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Alakkas A, Chen P, Chen M, Longardner K, Piccioni DE. Hyperglycaemia-related occipital lobe seizures. JRSM Open 2020; 11:2054270420920999. [PMID: 32595976 PMCID: PMC7297491 DOI: 10.1177/2054270420920999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Recognition of the role of hyperglycaemia in seizures is vital, because they tend to refractory to antiepileptic drugs and respond to insulin therapy and hydration.
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Affiliation(s)
- A Alakkas
- Division of Neurology, Department of Neurosciences, University of California at San Diego, La Jolla, CA 92093-0021, USA
| | - P Chen
- Division of Neurology, Department of Neurosciences, University of California at San Diego, La Jolla, CA 92093-0021, USA
| | - M Chen
- Division of Neurology, Department of Neurosciences, University of California at San Diego, La Jolla, CA 92093-0021, USA
| | - K Longardner
- Division of Neurology, Department of Neurosciences, University of California at San Diego, La Jolla, CA 92093-0021, USA
| | - D E Piccioni
- Division of Neurology, Department of Neurosciences, University of California at San Diego, La Jolla, CA 92093-0021, 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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Benoit SR, Hora I, Pasquel FJ, Gregg EW, Albright AL, Imperatore G. Trends in Emergency Department Visits and Inpatient Admissions for Hyperglycemic Crises in Adults With Diabetes in the U.S., 2006-2015. Diabetes Care 2020; 43:1057-1064. [PMID: 32161050 PMCID: PMC7171947 DOI: 10.2337/dc19-2449] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To report U.S. national population-based rates and trends in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) among adults, in both the emergency department (ED) and inpatient settings. RESEARCH DESIGN AND METHODS We analyzed data from 1 January 2006 through 30 September 2015 from the Nationwide Emergency Department Sample and National Inpatient Sample to characterize ED visits and inpatient admissions with DKA and HHS. We used corresponding year cross-sectional survey data from the National Health Interview Survey to estimate the number of adults ≥18 years with diagnosed diabetes to calculate population-based rates for DKA and HHS in both ED and inpatient settings. Linear trends from 2009 to 2015 were assessed using Joinpoint software. RESULTS In 2014, there were a total of 184,255 and 27,532 events for DKA and HHS, respectively. The majority of DKA events occurred in young adults aged 18-44 years (61.7%) and in adults with type 1 diabetes (70.6%), while HHS events were more prominent in middle-aged adults 45-64 years (47.5%) and in adults with type 2 diabetes (88.1%). Approximately 40% of the hyperglycemic events were in lower-income populations. Overall, event rates for DKA significantly increased from 2009 to 2015 in both ED (annual percentage change [APC] 13.5%) and inpatient settings (APC 8.3%). A similar trend was seen for HHS (APC 16.5% in ED and 6.3% in inpatient). The increase was in all age-groups and in both men and women. CONCLUSIONS Causes of increased rates of hyperglycemic events are unknown. More detailed data are needed to investigate the etiology and determine prevention strategies.
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Affiliation(s)
- Stephen R Benoit
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Israel Hora
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann L Albright
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Giuseppina Imperatore
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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83
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Microbiota and Malodor-Etiology and Management. Int J Mol Sci 2020; 21:ijms21082886. [PMID: 32326126 PMCID: PMC7215946 DOI: 10.3390/ijms21082886] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023] Open
Abstract
Accumulating evidence indicates that microbiota plays a critical role in physiological processes in humans. However, it might also contribute to body malodor by producing numerous odorous molecules such as ammonia, volatile sulfur compounds or trimethylamine. Although malodor is commonly overlooked by physicians, it constitutes a major problem for many otherwise healthy people. Thus, this review aims to investigate most common causes of malodor and describe potential therapeutic options. We searched PUBMED and Google Scholar databases to identify the clinical and pre-clinical studies on bad body smell, malodor, halitosis and microbiota. Unpleasant smell might originate from the mouth, skin, urine or reproductive fluids and is usually caused by odorants that are produced by resident bacterial flora. The accumulation of odorous compounds might result from diet, specific composition of microbiota, as well as compromised function of the liver, intestines and kidneys. Evidence-based guidelines for management of body malodor are lacking and no universal treatment exists. However, the alleviation of the symptoms may be achieved by controlling the diet and physical elimination of bacteria and/or accumulated odorants.
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84
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Sebaiy MM, El-Adl SM, Baraka MM, Hassan AA. Rapid RP-HPLC method for simultaneous estimation of metformin, pioglitazone, and glimepiride in human plasma. ACTA CHROMATOGR 2020. [DOI: 10.1556/1326.2018.00515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
An isocratic reversed-phase high-performance liquid chromatography (RP-HPLC) method has been developed for rapid and simultaneous separation and estimation of 3 antidiabetic drugs, namely, metformin, pioglitazone, and glimepiride, in human plasma within 3 min. Separation was carried out on a MAGELLEN 5U C18 (5 μm, 150 mm × 4.60 mm) using a mobile phase of MeOH–0.025 M KH2PO4 adjusted to pH 3.20 using ortho-phosphoric acid (85:15, v/v) at ambient temperature. The flow rate was 1 mL/min, and the maximum absorption was measured at 235 nm. The retention time of metformin, pioglitazone, and glimepiride was noted to be 1.24, 2.32, and 2.77 min, respectively, indicating a very short analysis time compared to that of other reported methods. Also, limits of detection were reported to be 0.05, 0.26, and 0.10 μg/mL for metformin, pioglitazone, and glimepiride, respectively, showing a high degree of method sensitivity. The method was then validated according to the FDA guidelines for the determination of the three drugs clinically in human plasma, in particular, regarding pharmacokinetic and bioequivalence simulation studies.
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Affiliation(s)
- Mahmoud M. Sebaiy
- Medicinal Chemistry Department, Faculty of Pharmacy, Zagazig University, Egypt
| | - Sobhy M. El-Adl
- Medicinal Chemistry Department, Faculty of Pharmacy, Zagazig University, Egypt
| | - Mohamed M. Baraka
- Medicinal Chemistry Department, Faculty of Pharmacy, Zagazig University, Egypt
| | - Amira A. Hassan
- Medicinal Chemistry Department, Faculty of Pharmacy, Zagazig University, Egypt
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85
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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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Sato Y, Kakizawa M, Aso SI, Takayama M, Yamashita K, Miyamoto T, Aizawa T. Startling hyperglycaemia with transient beta cell stunning in a patient with type 2 diabetes. Endocr J 2020; 67:95-98. [PMID: 31597815 DOI: 10.1507/endocrj.ej19-0305] [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] [Indexed: 11/23/2022] Open
Abstract
A 59-year-old woman unaware of having diabetes was transferred due to coma. Upon discovery at home, her consciousness on the Glasgow Coma Scale was E1V2M4, BP 95/84 mmHg, body temperature 34.7°C. On arrival at ER, height was 1.63 m, weight 97 kg, plasma glucose (PG) 1,897 mg/dL, HbA1c 13.6%, osmolality 421 mosm/kg, arterial pH 7.185, lactate 6.34 mmol/L, β-hydroxybutyrate 7.93 mmol/L. With saline and regular insulin infusion, PG was lowered to 1,440 mg/dL at 2 hours and then to 250 mg/dL by Day 3, and consciousness normalized by Day 5. On admission, serum immunoreactive insulin (IRI) was undetectable (<0.03 U/mL), C-peptide immunoreactivity (CPR) undetectable (<0.003 ng/mL), and anti-glutamic acid decarboxylase antibody negative. Following the above-described treatment, fasting PG was 186 mg/dL and CPR 1.94 ng/mL, respectively, on Day 14; 2-h post-breakfast PG 239 mg/dL and CPR 6.28 ng/mL, respectively, on Day 18. The patient discharged on Day 18 with 1,800 kcal diet, 32 U insulin glargine and 40 mg gliclazide. Fifteen months later at outpatient clinic, her HbA1c was 6.9% and 2-h post-breakfast PG 123 mg/dL and CPR 5.30 ng/dL with 750 mg metformin, 10 mg gliclazide and 18 U insulin glargine. Transient, but total cessation of insulin secretion was documented in a patient with type 2 diabetes under severe metabolic decompensation. Swift, sustained recovery of insulin release indicated that lack of insulin at the time of emergency was due to secretory failure, i.e., unresponsive exocytotic machinery or depletion of releasable insulin, rather than loss of beta cells.
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Affiliation(s)
- Yuka Sato
- Diabetes Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Masaki Kakizawa
- Department of Neurology, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Shin-Ichi Aso
- Department of Cardiovascular Medicine, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Masayuki Takayama
- Clinical Laboratory Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Koh Yamashita
- Diabetes Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | | | - Toru Aizawa
- Diabetes Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
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Cen L, Xing F, Xu L, Cao Y. Potential Role of Gene Regulator NFAT5 in the Pathogenesis of Diabetes Mellitus. J Diabetes Res 2020; 2020:6927429. [PMID: 33015193 PMCID: PMC7512074 DOI: 10.1155/2020/6927429] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/15/2020] [Accepted: 08/31/2020] [Indexed: 02/05/2023] Open
Abstract
Nuclear factor of activated T cells 5 (NFAT5), a Rel/nuclear factor- (NF-) κB family member, is the only known gene regulator of the mammalian adaptive response to osmotic stress. Exposure to elevated glucose increases the expression and nuclear translocation of NFAT5, as well as NFAT5-driven transcriptional activity in vivo and in vitro. Increased expression of NFAT5 is closely correlated with the progression of diabetes in patients. The distinct structure of NFAT5 governs its physiological and pathogenic roles, indicating its opposing functions. The ability of NFAT5 to maintain cell homeostasis and proliferation is impaired in patients with diabetes. NFAT5 promotes the formation of aldose reductase, pathogenesis of diabetic vascular complications, and insulin resistance. Additionally, NFAT5 activates inflammation at a very early stage of diabetes and induces persistent inflammation. Recent studies revealed that NFAT5 is an effective therapeutic target for diabetes. Here, we describe the current knowledge about NFAT5 and its relationship with diabetes, focusing on its diverse regulatory functions, and highlight the importance of this protein as a potential therapeutic target in patients with diabetes.
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Affiliation(s)
- Lusha Cen
- Department of Ophthalmology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Fengling Xing
- Department of Dermatology, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Liying Xu
- Department of Emergency, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Yi Cao
- Department of Dermatology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Youdian Rd. 54th, Hangzhou 310006, China
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88
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Chawla R, Madhu SV, Makkar BM, Ghosh S, Saboo B, Kalra S. RSSDI-ESI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2020. Indian J Endocrinol Metab 2020; 24:1-122. [PMID: 32699774 PMCID: PMC7328526 DOI: 10.4103/ijem.ijem_225_20] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Rajeev Chawla
- North Delhi Diabetes Centre, Rohini, New Delhi, India
| | - S. V. Madhu
- Centre for Diabetes, Endocrinology and Metabolism, UCMS-GTB Hospital, New Delhi, India
| | - B. M. Makkar
- Dr. Makkar's Diabetes and Obesity Centre, Paschim Vihar, New Delhi, India
| | - Sujoy Ghosh
- Department of Endocrinology and Metabolism, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Banshi Saboo
- DiaCare - A Complete Diabetes Care Centre, Ahmedabad, Gujarat, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
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Ticona J, Zaccone V, Zaman U, Kashani D, Chung Z, McFarlane IM. Hemichorea-Hemiballismus as an Unusual Presentation of Hyperosmolar Hyperglycemic Syndrome. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2020; 8:159-161. [PMID: 32432159 PMCID: PMC7236990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetes mellitus can lead to a diverse array of systemic complications. Poorly managed hyperglycemia can result in serious neurological consequences ranging from peripheral neuropathy to seizures and coma. A rare neurologic disorder seen in acute decompensated type 2 diabetes mellitus (T2DM) is hemichorea-hemiballismus (HCHB). HCHB is a movement disorder primarily associated with cerebrovascular accidents of infarct or hemorrhagic origin. It is a condition that can occur in a diabetic patient, especially when no other signs or symptoms of hyperglycemia are present. It is urgent to recognize HCHB movement disorder quickly as it may be the only presenting sign of hyperglycemia and can alert medical personnel to a possible hyperosmolar hyperglycemic state (HHS). We report an unusual case of HCHB in a patient with HHS, whose only presenting sign was unilateral hyperkinesis, which completely resolved after adequate blood glucose control. Prompt treatment and management of hyperglycemia yields an excellent prognosis in HCHB.
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90
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Sarikaya M, Yazihan N, Daş Evcimen N. Relationship between aldose reductase enzyme and the signaling pathway of protein kinase C in an in vitro diabetic retinopathy model. Can J Physiol Pharmacol 2019; 98:243-251. [PMID: 31743046 DOI: 10.1139/cjpp-2019-0211] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Protein kinase C (PKC) and aldose reductase (AR) enzyme activities are increased in diabetes and complications are include retinopathy, nephropathy, and neuropathy. However, the relationship between PKC and AR and the underlying molecular mechanisms is still unclear. We aimed to evaluate the relationship between these two enzymes and clarify the underlying molecular mechanisms by the related signaling molecules. The effects of hyperglycemia and oxidative stress on AR and PKC enzymes and the signaling molecules such as nuclear factor-kappa B (NF-κB), inhibitor kappa B-alpha (IkB-α), total c-Jun, phospho c-Jun, and stress-activated protein kinases (SAPK)/Jun amino-terminal kinases (JNK) were evaluated in human retinal pigment epithelial cells (ARPE-19). AR, PKC protein levels, and related signaling molecules increased with hyperglycemia and oxidative stress. The AR inhibitor sorbinil decreased PKC expression and activity and all signaling molecule protein levels. Increased AR expression during hyperglycemia and oxidative stress was found to be correlated with the increase in PKC expression and activity in both conditions. Decreased expression and activity of PKC and the protein levels of related signaling molecules with the AR inhibitor sorbinil showed that AR enzyme may play a key role in the expression of PKC enzyme and oxidative stress during diabetes.
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Affiliation(s)
- Mutlu Sarikaya
- Department of Biochemistry, Faculty of Pharmacy, Ankara University, Ankara, Turkey
| | - Nuray Yazihan
- Department of Pathophysiology, Faculty of Medicine, Internal Medicine, Ankara University, Ankara, Turkey
| | - Net Daş Evcimen
- Department of Biochemistry, Faculty of Pharmacy, Ankara University, Ankara, Turkey
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91
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Blackstock S, Witham MD, Wade AN, Crampin A, Beran D, Ogle GD, Davies JI. Ability of verbal autopsy data to detect deaths due to uncontrolled hyperglycaemia: testing existing methods and development and validation of a novel weighted score. BMJ Open 2019; 9:e026331. [PMID: 31630097 PMCID: PMC6803086 DOI: 10.1136/bmjopen-2018-026331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Verbal autopsy (VA) is a useful tool to ascertain cause of death where no other mechanisms exist. We aimed to assess the utility of VA data to ascertain deaths due to uncontrolled hyperglycaemia and to develop a weighted score (WS) to specifically identify cases. Cases were identified by a study or site physician with training in diabetes. These diagnoses were also compared with diagnoses produced by a standard computer algorithm (InterVA-4). SETTING This study was done using VA data from the Health and Demographic Survey sites in Agincourt in rural South Africa. Validation of the WS was done using VA data from Karonga in Malawi. PARTICIPANTS All deaths from ages 1 to 49 years between 1992 and 2015 and between 2002 and 2016 from Agincourt and Karonga, respectively. There were 8699 relevant deaths in Agincourt and 1663 in Karonga. RESULTS Of the Agincourt deaths, there were 77 study physician classified cases and 58 computer algorithm classified cases. Agreement between study physician classified cases and computer algorithm classified cases was poor (Cohen's kappa 0.14). Our WS produced a receiver operator curve with area under the curve of 0.952 (95% CI 0.920 to 0.985). However, positive predictive value (PPV) was below 50% when the WS was applied to the development set and the score was dominated by the necessity for a premortem diagnosis of diabetes. Independent validation showed the WS performed reasonably against site physician classified cases with sensitivity of 86%, specificity of 99%, PPV of 60% and negative predictive value of 99%. CONCLUSION Our results suggest that widely used VA methodologies may be missing deaths due to uncontrolled hyperglycaemia. Our WS may offer improved ability to detect deaths due to uncontrolled hyperglycaemia in large populations studies where no other means exist.
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Affiliation(s)
- Sarah Blackstock
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, London, UK
| | - Miles D Witham
- Department of Aging and Health, School of Medicine, University of Dundee, Dundee, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals Trust, Newcastle, UK
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Amelia Crampin
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiology and Intervention Research Unit, Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - David Beran
- Division of Tropical and Humanitarian Medicine, University of Geneva and Geneva University Hospitals, Geneva, Switzerland
| | - Graham D Ogle
- Life for a Child Program, Diabetes NSW, Glebe, New South Wales, Australia
| | - Justine I Davies
- MRC/Wits Rural Public Health and Health Transitions Research Unit, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Centre for Global Health, King's College London, London, UK
- Institute for Applied Health Research, Birmingham University, Birmingham, UK
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92
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Al Hassani N, Kaplan W. Hyperglycaemic hyperosmolar syndrome in a 5-year-old girl with newly diagnosed type 2 diabetes mellitus. DIABETES & METABOLISM 2019; 45:488-489. [PMID: 29233451 DOI: 10.1016/j.diabet.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/06/2017] [Accepted: 11/12/2017] [Indexed: 06/07/2023]
Affiliation(s)
- N Al Hassani
- Division of Diabetes and Endocrinology, Department of Pediatrics, Tawam Hospital, P O Box 15258, Khalifa-Ibn-Zayed street, Al Ain, United Arab Emirates.
| | - W Kaplan
- Division of Diabetes and Endocrinology, Department of Pediatrics, Tawam Hospital, P O Box 15258, Khalifa-Ibn-Zayed street, Al Ain, United Arab Emirates
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93
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Gershkovich B, English SW, Doyle MA, Menon K, McIntyre L. Choice of crystalloid fluid in the treatment of hyperglycemic emergencies: a systematic review protocol. Syst Rev 2019; 8:228. [PMID: 31481108 PMCID: PMC6720374 DOI: 10.1186/s13643-019-1130-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening complications of diabetes mellitus which require prompt treatment with large volume crystalloid fluid administration. A variety of crystalloid fluids is currently available for use and differs in their composition and ion concentrations. While there are potential pros and cons for different crystalloid fluids, it remains unknown if any particular fluid confers a clinical outcome benefit over others in the treatment of hyperglycemic emergencies. METHODS A systematic search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews will be conducted to identify eligible studies, which will include observational and interventional studies involving adult and pediatric patients admitted to the hospital with either DKA or HHS. The interventions will include intravenous treatment with 0.9% saline versus other buffered (Ringer's lactate, Hartmann's, etc.), and non-buffered (0.45% saline) crystalloid fluids. The primary outcome is mortality at the latest follow-up time point. Secondary outcomes will include mortality at specific time points, length of hospital stay, development of acute kidney injury, requirement for renal replacement therapy, altered level of consciousness, and the time to normalization of several serum biochemical parameters. Where appropriate, meta-analyses will be performed for the outcomes and conducted separately for adult and pediatric patient populations. DISCUSSION DKA and HHS are dangerous complications of diabetes mellitus and account for significant morbidity and mortality. Given the importance of crystalloid fluid administration in the management of these conditions, a systematic synthesis of the existing evidence base will identify potential evidence gaps and may help guide future clinical practice.
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Affiliation(s)
- Benjamin Gershkovich
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
| | - Shane W. English
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| | - Mary-Anne Doyle
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Kusum Menon
- CHEO Research Institute, Ottawa, Ontario Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
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94
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You JH, Song SO, Park SH, Park KH, Nam JY, Kim DW, Kim HM, Kim DJ, Lee YH, Lee BW. Trends in Hyperglycemic Crisis Hospitalizations and in- and out-of-Hospital Mortality in the Last Decade Based on Korean National Health Insurance Claims Data. Endocrinol Metab (Seoul) 2019; 34:275-281. [PMID: 31565880 PMCID: PMC6769342 DOI: 10.3803/enm.2019.34.3.275] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hyperglycemic crisis is a metabolic emergency associated with diabetes mellitus. However, accurate epidemiologic information on cases of hyperglycemic crisis in Korea remains scarce. We evaluated trends in hyperglycemic crisis hospitalizations and in- and out-of-hospital mortality in Korea. We also predicted future trends. METHODS We extracted claims data with hyperglycemic crisis as the principal diagnosis from the National Health Insurance Service database in Korea from January 2004 to December 2013. We investigated the numbers of claims with hyperglycemic crisis and identified trends in hyperglycemic crisis based on those claims data. We predicted future trends by statistical estimation. RESULTS The total annual number of claims of hyperglycemic crisis increased from 2,674 in 2004 to 5,540 in 2013. Statistical analysis revealed an increasing trend in hyperglycemic crisis hospitalizations (P for trend <0.01). In contrast, the hospitalization rate per 1,000 diabetes cases showed a decreasing trend (P for trend <0.01) during this period. The mortality rate per 1,000 diabetes cases also showed a decreasing trend (P for trend <0.0001). However, no distinct linear trend in the case-related fatality rate at <60 days over the last decade was observed. The predicted number of annual claims of hyperglycemic crisis will increase by 2030. CONCLUSION The number of hyperglycemic crisis hospitalizations in Korea increased in the last decade, although the hospitalization rate per 1,000 diabetes cases and mortality rate decreased. Also, the predicted number of annual claims will increase in the future. Thus, it is necessary to establish long-term healthcare policies to prevent hyperglycemic crisis.
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Affiliation(s)
- Ji Hong You
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sun Ok Song
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Se Hee Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Kyoung Hye Park
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Joo Young Nam
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Dong Wook Kim
- Department of Policy Research Affairs, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hyun Min Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dong Jun Kim
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yong Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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95
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Kharode I, Coppedge E, Antal Z. Care of Children and Adolescents with Diabetes Mellitus and Hyperglycemia in the Inpatient Setting. Curr Diab Rep 2019; 19:85. [PMID: 31440933 DOI: 10.1007/s11892-019-1205-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Children and adolescents with acute hyperglycemia and diabetes mellitus frequently have acute, potentially life-threatening presentations which require high-acuity care in an inpatient and often intensive care setting. This review discusses the evaluation and care of hyperglycemia and diabetes mellitus in hospitalized children in both critical and non-critical care settings, highlighting important differences in their care relative to adults. RECENT FINDINGS Diabetic ketoacidosis remains highly prevalent at diagnosis among children with type 1 diabetes, and hyperglycemic hyperosmolar state is increasingly prevalent among children with type 2 diabetes. Recent clinical trials have investigated the potential benefits of various types of intravenous fluids and their rates of administration as well as the risks and benefits of intensive glucose control in critically ill children. The Endocrine Society has developed guidelines focused on managing hyperglycemic hyperosmolar state, outlining important aspects of care shown to decrease morbidity and mortality. In the non-critical illness setting, intensive therapy on newly diagnosed diabetes is increasingly recommended at the outset. With the increasing incidence of diabetes mellitus in children and adolescents, recent studies addressing acute diabetes emergencies help inform best practices for care of hospitalized children with hyperglycemia and diabetes.
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Affiliation(s)
- Ishita Kharode
- Division of Pediatric Endocrinology, Richmond University Medical Center, 355 Bard Avenue, Staten Island, NY, 10310, USA
| | - Emily Coppedge
- Weill Cornell Medicine, Division of Pediatric Endocrinology, NY Presbyterian Hospital, 505 East 70 Street, New York, NY, 10021, USA
| | - Zoltan Antal
- Weill Cornell Medicine, Division of Pediatric Endocrinology, NY Presbyterian Hospital, 505 East 70 Street, New York, NY, 10021, USA.
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96
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Papadopoulou A, Todaro A, Eliades T, Kletsas D. Effect of hyperglycaemic conditions on the response of human periodontal ligament fibroblasts to mechanical stretching. Eur J Orthod 2019; 41:583-590. [DOI: 10.1093/ejo/cjz051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Summary
Objectives
The aim of the present study was to investigate the impact of high glucose concentration on the response of human periodontal ligament fibroblasts (PDLFs) to cyclic tensile strain.
Materials and Methods
Human PDLFs were incubated under normal or high glucose conditions, and then were subjected to cyclic tensile stretching (8 per cent extension, 1 Hz). Gene expression was determined by quantitative real-time polymerase chain reaction. Intracellular reactive oxygen species (ROS) were determined by the 2’,7’-dichlorofluorescein-diacetate assay, activation of mitogen-activated protein kinase (MAPK) was monitored by western analysis and osteoblastic differentiation was estimated with Alizarin Red-S staining.
Results
Cyclic tensile stretching of PDLF leads to an immediate activation of extracellular signal-regulated kinase (ERK) and c-Jun N-terminal kinase (JNK), as well as to the increased expression of the transcription factor c-fos, known to regulate many osteogenesis-related genes. At later time points, the alkaline phosphatase and osteopontin genes were also upregulated. Hyperglycaemic conditions inhibited these effects. High glucose conditions were unable to increase ROS levels, but they increased the medium’s osmolality. Finally, increase of osmolality mimics the inhibitory effect of hyperglycaemia on MAPK activation, c-fos and osteoblast-specific gene markers’ upregulation, as well as osteogenic differentiation capacity.
Conclusion
Our findings indicate that under high glucose conditions, human PDLFs fail to adequately respond to mechanical deformation, while their strain-elicited osteoblast differentiation ability is deteriorated. The aforementioned effects are most probably mediated by the increased osmolality under hyperglycaemic conditions.
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Affiliation(s)
- Adamantia Papadopoulou
- Laboratory of Cell Proliferation & Ageing, Institute of Biosciences & Applications, National Centre for Scientific Research ‘Demokritos’, Athens, Greece
| | - Alexia Todaro
- Clinic of Orthodontics and Paediatric Dentistry, University of Zurich, Zurich, Switzerland
| | - Theodore Eliades
- Clinic of Orthodontics and Paediatric Dentistry, University of Zurich, Zurich, Switzerland
| | - Dimitris Kletsas
- Laboratory of Cell Proliferation & Ageing, Institute of Biosciences & Applications, National Centre for Scientific Research ‘Demokritos’, Athens, Greece
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97
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Broadley L, Clark K, Ritchie G. Prevention and management of hyperglycaemic crisis. Nurs Stand 2019; 34:75-82. [PMID: 31468825 DOI: 10.7748/ns.2019.e11387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2019] [Indexed: 06/10/2023]
Abstract
Hyperglycaemia is a defining feature of diabetes mellitus. It involves an elevated level of glucose in the blood, which develops as a result of the body's inability to produce insulin or process insulin effectively. If left unchecked and untreated, patients with diabetes are at risk of short-term, potentially life-threatening hyperglycaemic crises such as diabetic ketoacidosis or hyperosmolar hyperglycaemic state. Nurses frequently care for patients diagnosed with diabetes in various clinical settings; therefore, it is essential that they have an awareness of the prevention and management of hyperglycaemia and hyperglycaemic crises. This article explains the causes and clinical manifestations of hyperglycaemic crises, and details the management of patients with these conditions, in accordance with national guidelines.
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Affiliation(s)
- Lisa Broadley
- School of Health Sciences, University of Central Lancashire, Preston, England
| | - Kerry Clark
- School of Nursing, University of Central Lancashire, Preston, England
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98
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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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99
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Flaherty K, Godfrey A. The Gland Plan. PHYSICIAN ASSISTANT CLINICS 2019. [DOI: 10.1016/j.cpha.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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100
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Desai R, Singh S, Syed MH, Dave H, Hasnain M, Zahid D, Haider M, Jilani SMA, Mirza MA, Kiran N, Aziz A. Temporal Trends in the Prevalence of Diabetes Decompensation (Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State) Among Adult Patients Hospitalized with Diabetes Mellitus: A Nationwide Analysis Stratified by Age, Gender, and Race. Cureus 2019; 11:e4353. [PMID: 31192058 PMCID: PMC6550510 DOI: 10.7759/cureus.4353] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Disproportionate change in the burden of diabetes mellitus across various subgroups has been reported in the United States. However, changing landscape of the prevalence and mortality of decompensated diabetes (diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)) remains indistinct across various age, gender, and racial groups of hospitalized diabetics. Methods The National Inpatient Sample (NIS) datasets (2007-2014) were sought to assess the prevalence and temporal trends in decompensated diabetes stratified by age, gender, and race and related in-hospital outcomes among the adult patients hospitalized with diabetes using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Discharge weights were used to obtain national estimates. Results Of 56.7 million hospitalizations with diabetes, 0.5 (0.9%) million patients revealed decompensated diabetes from 2007 to 2014. The decompensated diabetics consisted of younger (~52 vs. 66 yrs), more often black (24.2% vs. 17.3%) and Hispanic (12.9% vs. 10.9%) patients as compared to those without decompensation (p<0.001). Younger diabetes patients demonstrated the highest prevalence of in-hospital decompensation (18-44 yrs; 3.7%) with a relative increase of 32.4% (from 3.4% to 4.5%) from 2007 to 2014 (ptrend<0.001). Older diabetics (≥65 years) with decompensation suffered the highest in-hospital mortality (12.8%). The overall rate of decompensation was similar (0.9%) among male and female diabetes patients. However, over a period of 8 years, the rates of decompensation rose to 1.1% (ptrend<0.001) in males and 1.2% (ptrend<0.001) in females, respectively. All-cause in-hospital mortality among females with decompensated diabetes declined from 6.6% in 2007 to 5.9% in 2014 (ptrend=0.019). However, there was no significant drop in in-hospital mortality among male diabetics with acute decompensation (6.7% in 2007 to 6.8% in 2014, ptrend=0.811). We observed significantly increasing trends in decompensated diabetes among all race groups between 2007 and 2014 (ptrend<0.001). The in-hospital mortality was highest among Asian or Pacific Islander (0.9%) diabetes patients with decompensation from 2007 to 2014. There was a declining trend in the inpatient mortality among Asian or Pacific Islander (ptrend=0.029) and Hispanic (ptrend<0.001) patients with decompensated diabetes, whereas other race groups did not observe any significant decline in mortality over the study period. Diabetes hospitalizations with decompensation demonstrated significantly higher in-hospital mortality (6.3% vs. 2.6%; p<0.001), average length of stay (7.7 vs. 5.4 days; p<0.001), hospital charges ($65,904 vs. $42,889, p<0.001), and more frequent transfers to short-term hospitals (3.9% vs. 2.9%; p<0.001) in comparison to those without decompensation. The rates of acute myocardial infarction (AMI) (10.4% vs. 4.8%; p<0.001), stroke (4.0% vs. 3.3%; p<0.001) and venous thromboembolism (3.5% vs. 2.6%; p<0.001) were substantially higher among diabetics with decompensation compared to those without. Conclusions There was an increasing trend in the prevalence of decompensated diabetes from 2007 to 2014, most remarkable among younger black male diabetics. The patients with decompensated diabetes suffered higher in-hospital mortality and rates of AMI, stroke and venous thromboembolism, there was no significant decline in the mortality between 2007 and 2014.
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Affiliation(s)
- Rupak Desai
- Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, USA
| | - Sandeep Singh
- Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center University of Amsterdam, Amsterdam, NLD
| | | | - Hitanshu Dave
- Internal Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune City, USA
| | | | - Daniyal Zahid
- Internal Medicine, Robert Wood Johnson University Hospital, New Brunswick, USA
| | - Mohammad Haider
- Internal Medicine, Newyork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | | | | | - Nfn Kiran
- Public Health, Emory Rollins School of Public Health, Decatur, USA
| | - Ali Aziz
- Hospitalist, Covenant Medical Center, Waterloo, USA
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