51
|
Smuel-Zilberberg K, Shalitin S, Yackobovitch-Gavan M, Phillip M, Nimri R. Diabetes ketoacidosis recovery in youth with newly diagnosed and established type 1 diabetes. Pediatr Res 2022; 91:1272-1277. [PMID: 34148066 DOI: 10.1038/s41390-021-01618-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/06/2021] [Accepted: 05/21/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The objective of this study was to describe the differences in metabolic parameters and in time to recovery from diabetes ketoacidosis (DKA), between children and adolescents with newly diagnosed diabetes compared with established type 1 diabetes (T1DM). METHODS This was a single-center, retrospective study. The cohort consists of 356 children and adolescents with T1DM who had DKA during 2008-2018. Data were obtained from the patients' medical files. Recovery of DKA was defined as the resolution of acidosis (pH >7.3 and bicarbonate >15 meq/L). RESULTS The mean time to recovery from DKA was significantly longer in patients with newly diagnosed diabetes than in those with established diabetes (13± versus 8.5± h) (p < 0.001). This difference was maintained in an analysis according to DKA severity: mild, moderate, and severe. pH at presentation did not differ between the groups, but bicarbonate at presentation was significantly lower in patients with newly diagnosed diabetes than in those with established diabetes, 9.9± versus 12± mmol/L (p < 0.001). Potassium and phosphorus levels were lower, and sodium and chloride levels were higher in patients with newly diagnosed diabetes than in those with established diabetes (p < 0.001). CONCLUSIONS DKA is associated with a shorter recovery time in patients with established diabetes compared to newly diagnosed diabetes. This may have implications on the treatment of people with established diabetes. IMPACT DKA is associated with a shorter recovery time in patients with established diabetes compared with newly diagnosed diabetes. Shorter recovery time in a patient with established diabetes compared with newly diagnosed diabetes was observed in any DKA severity. The time to recovery from DKA did not differ significantly between patients treated with an insulin pump and those treated with multiple daily injections. Triggers for DKA among patients with established diabetes were poor compliance with treatment, infection, pump dysfunction, and dehydration.
Collapse
Affiliation(s)
- Keren Smuel-Zilberberg
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Shlomit Shalitin
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Yackobovitch-Gavan
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
| |
Collapse
|
52
|
Ye X, Xiong L, Fu Q, Wang B, Wang Y, Zhang K, Yang J, Kantawong F, Kumsaiyai W, Zhou J, Lan C, Wu J, Zeng J. Chemical characterization and DPP-IV inhibitory activity evaluation of tripeptides from Gynura divaricata (L.) DC. JOURNAL OF ETHNOPHARMACOLOGY 2022; 292:115203. [PMID: 35304277 DOI: 10.1016/j.jep.2022.115203] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/08/2022] [Accepted: 03/11/2022] [Indexed: 02/05/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Gynura divaricata (L.) DC. (GD), a herbal medicine, has been used for the prevention and treatment of hyperglycemia in China. However, hypoglycemic ingredients within GD have not yet been well studied. AIM OF THE STUDY The aim of this study was to explore undiscovered compounds with dipeptidyl peptidase IV (DPP-IV) inhibitory activity within GD. MATERIALS AND METHODS A four-step strategy was developed to explore undiscovered DPP-IV inhibitors within GD. First, the components were preliminarily characterized using UHPLC-HRMS combined with a library search. Second, preliminarily characterized compounds were searched for potential bioactivity. Third, a mixture of these preliminarily characterized compounds was isolated and thoroughly characterized based on fragmentation patterns associated with molecular networking. Fourth, the activities of these compounds were verified using DPP-IV inhibitory assay and molecular docking. RESULTS Diprotin A, a tripeptide inhibitor against DPP-IV, was identified. Thereafter, a mixture of twenty-five diprotin A analogs was isolated and characterized, which exhibited IC50 of 0.40 mg/mL for DPP-IV. Molecular docking results also confirmed the interactions between the tripeptide analogs and DPP-IV mainly via H-bonds and hydrophobic interactions. CONCLUSIONS This is the first report of DPP-IV inhibitors within GD. These findings demonstrate that the extract of GD might be beneficial for the treatment of type 2 diabetes mellitus, and is expected to promote further development and utilization of GD in herbal medicine.
Collapse
Affiliation(s)
- Xinyuan Ye
- School of Pharmacy, Southwest Medical University, Luzhou, China.
| | - Ling Xiong
- School of Pharmacy, Southwest Medical University, Luzhou, China.
| | - Qifeng Fu
- School of Pharmacy, Southwest Medical University, Luzhou, China.
| | - Binyou Wang
- School of Pharmacy, Southwest Medical University, Luzhou, China.
| | - Yiwei Wang
- School of Pharmacy, Southwest Medical University, Luzhou, China; State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China.
| | - Kailian Zhang
- School of Pharmacy, Southwest Medical University, Luzhou, China.
| | - Jie Yang
- School of Pharmacy, Southwest Medical University, Luzhou, China; Faculty Associated Medical Sciences, Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand.
| | - Fahsai Kantawong
- Faculty Associated Medical Sciences, Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand.
| | - Warunee Kumsaiyai
- Faculty Associated Medical Sciences, Department of Medical Technology, Chiang Mai University, Chiang Mai, Thailand.
| | - Jie Zhou
- School of Pharmacy, Southwest Medical University, Luzhou, China; Education Ministry Key Laboratory of Medical Electrophysiology, Luzhou, China; Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou, China; Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, China.
| | - Cai Lan
- School of Pharmacy, Southwest Medical University, Luzhou, China; Education Ministry Key Laboratory of Medical Electrophysiology, Luzhou, China; Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou, China; Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, China.
| | - Jianming Wu
- School of Pharmacy, Southwest Medical University, Luzhou, China; Education Ministry Key Laboratory of Medical Electrophysiology, Luzhou, China; Key Medical Laboratory of New Drug Discovery and Druggability Evaluation, Luzhou, China; Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Southwest Medical University, Luzhou, China.
| | - Jing Zeng
- School of Pharmacy, Southwest Medical University, Luzhou, China.
| |
Collapse
|
53
|
Glennie JL, Berard L, Levrat-Guillen F. Sensor-Based Technology: Bringing Value to People with Diabetes and the Healthcare System in an Evolving World. Clinicoecon Outcomes Res 2022; 14:75-90. [PMID: 35177913 PMCID: PMC8843785 DOI: 10.2147/ceor.s346736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/15/2022] [Indexed: 02/06/2023]
Affiliation(s)
| | - Lori Berard
- Nurse Consultant, Pink Pearls Inc, Winnipeg, Manitoba, Canada
| | - Fleur Levrat-Guillen
- Abbott Diabetes Care, Maidenhead, UK
- Correspondence: Fleur Levrat-Guillen, Abbott Laboratories Ltd, Abbott House, Vanwall Business Park, Maidenhead, Berkshire, SL6 4XE, UK, Tel +44 7584108032, Email
| |
Collapse
|
54
|
Jahangir A, Jahangir A, Siddiqui FS, Niazi MRK, Yousaf F, Muhammad M, Sahra S, Javed A, Sharif MA, Iqbal QZ, Krzyzak M. Normal Saline Versus Low Chloride Solutions in Treatment of Diabetic Ketoacidosis: A Systematic Review of Clinical Trials. Cureus 2022; 14:e21324. [PMID: 35186583 PMCID: PMC8848863 DOI: 10.7759/cureus.21324] [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] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
Traditionally, normal saline solution (NSS) has been the fluid of choice in diabetic ketoacidosis (DKA) patients, but the NSS is an acidic fluid and may lead to the delayed resolution of DKA. A systemic review search was conducted on PubMed, Embase, and Central Cochrane Registry to compare the efficacy of low chloride solutions with normal saline solution in DKA resolution. Randomized clinical trials with normal saline as a control arm and low chloride solutions as an intervention arm were included. Four studies were included in the analysis. The investigated outcomes, including time to resolution for DKA and duration of insulin infusion, varied depending on the endpoint were reported in the studies. Overall, balanced solutions were generally associated with faster correction of pH. The time to reach overall DKA endpoints was comparable in both groups. We concluded that crystalloid solutions may be used as an initial resuscitation fluid in the DKA population and may lead to earlier resolution of acidosis. More clinical trial data is required to reach statistical significance for the hypothesis.
Collapse
|
55
|
Shiferaw MY, Laeke T/Mariam T, Aklilu AT, Akililu YB, Worku BY. Diabetic ketoacidosis (DKA) induced cerebral edema complicating small chronic subdural hematoma/hygroma/ at Zewuditu memorial hospital: a case report. BMC Endocr Disord 2022; 22:6. [PMID: 35022013 PMCID: PMC8756673 DOI: 10.1186/s12902-021-00916-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While both DKA & CSDH/subdural hygroma/ are known to cause significant morbidity and mortality, there is no a study that shows the role & effect of DKA on CSDH/subdural hygroma/ & vice versa to authors' best knowledge; hence this work will show how important relation does exist between DKA & CSDH/ hygroma. This study highlights the diagnostic & management challenges seen for a case of a 44 years old female black Ethiopian woman admitted with a diagnosis of newly diagnosed type 1 DM with DKA + small CSDH/subdural hygroma/ after she presented with sever global headache and a 3 month history of lost to her work. She needed burrhole & evacuation for complete clinical improvement besides DKA's medical treatment. CONCLUSION DKA induced cerebral edema on the CSDH/subdural hematoma/ can have a role in altering any of the parameters (except the thickness of CSDH) for surgical indication of patients with a diagnosis of both CSDH +DM with DKA. Hence, the treating physicians should be vigilant of different parameters that suggests tight brain &/ cerebral edema (including midline shift, the status of cisterns, fissures & sulci) and should not be deceived of the thickness of the CSDH/subdural hygroma/alone; especially when there is a disproportionately tight brain for the degree of collection. Whether DKA induced cerebral edema causes a subdural hygroma is unknown and needs further study.
Collapse
|
56
|
Carrillo AR, Elwood K, Werth C, Mitchell J, Sarangarm P. Balanced Crystalloid Versus Normal Saline as Resuscitative Fluid in Diabetic Ketoacidosis. Ann Pharmacother 2022; 56:998-1006. [DOI: 10.1177/10600280211063651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Large volume resuscitation with normal saline (NS) may be associated with iatrogenic hyperchloremia and renal injury. Objective: The purpose of this study was to assess clinical outcomes associated with the use of Lactated Ringer’s (LR) compared to NS as resuscitative fluid in diabetic ketoacidosis (DKA). Methods: Single-center, retrospective analysis of patients admitted for DKA. The primary objective of this study was to evaluate the incidence of iatrogenic hyperchloremia associated with fluid resuscitation using balanced crystalloid compared to NS. Results Iatrogenic hyperchloremia occurred more frequently in the NS group compared to the LR group (74.4% vs 64.2%; P = 0.05). Mean maximum serum chloride was higher in the NS group (115.7 mmol/L vs 113.7 mmol/L; P = 0.004). Incidence of hypernatremia was higher in the NS group (18.3% vs 9.3%; P = 0.02). There was no significant difference in the incidence of AKI; however, mean change in serum creatinine at 48 hours showed a significantly greater decrease in the LR group (-0.15 mg/dL vs -0.04 mg/dL; P = 0.002). No significant differences were found in intensive care unit (ICU) length of stay or total hospital length of stay. Conclusion and Relevance This study found a statistically significant reduction in the incidence of iatrogenic hyperchloremia with the use of LR compared to NS as fluid resuscitation in DKA. Serum creatinine was more improved in the LR group versus NS group at 48 hours. Preferential use of balanced crystalloid for fluid resuscitation in DKA may reduce incidence of hyperchloremia and support renal recovery in this population.
Collapse
Affiliation(s)
- Adriana R. Carrillo
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Kirsten Elwood
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Chris Werth
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Jessica Mitchell
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, NM, USA
| | | |
Collapse
|
57
|
Kichloo A, El-Amir Z, Wani F, Shaka H. Hospitalizations for ketoacidosis in type 1 diabetes mellitus, 2008 to 2018. Proc AMIA Symp 2022; 35:1-5. [PMID: 34970023 DOI: 10.1080/08998280.2021.1978741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The objective of this study was to characterize epidemiological trends, outcomes in hospitalized patients, and the disease burden of hospitalizations for diabetic ketoacidosis (DKA) in patients with type 1 diabetes mellitus (T1DM). This was a retrospective interrupted trends study involving hospitalizations for DKA in patients with T1DM in the US from 2008 to 2018 using data from the Nationwide Inpatient Sample. The total number of hospitalizations during each calendar year was obtained, and trends in inpatient mortality rate, mean length of hospital stay (LOS), and mean total hospital cost (THC) were calculated. Between 2008 and 2018, there was a trend toward increasing hospitalizations for T1DM with DKA (P-trend <0.001). Over the decade, there was a steady rise in the proportion of patients with a Charlson comorbidity index >1. There was no statistically significant change in adjusted inpatient mortality in patients with T1DM admitted for DKA over the study period despite an apparent trend of a decreasing crude mortality rate (P-trend = 0.063). There was a statistically significant decrease in both LOS and THC over the study period. In conclusion, there was a significant decrease in both LOS and THC, potentially reflecting improvements in the management of DKA in patients with T1DM.
Collapse
Affiliation(s)
- Asim Kichloo
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan.,Department of Medicine, Samaritan Medical Center, Watertown, New York
| | - Zain El-Amir
- Department of Internal Medicine, Central Michigan University, Saginaw, Michigan
| | - Farah Wani
- Department of Medicine, Samaritan Medical Center, Watertown, New York
| | - Hafeez Shaka
- Department of Internal Medicine, John H. Stronger Jr. Hospital, Chicago, Illinois
| |
Collapse
|
58
|
Schwartz DD, Banuelos R, Uysal S, Vakharia M, Hendrix KR, Fegan-Bohm K, Lyons SK, Sonabend R, Gunn SK, Dei-Tutu S. An Automated Risk Index for Diabetic Ketoacidosis in Pediatric Patients With Type 1 Diabetes: The RI-DKA. Clin Diabetes 2022; 40:204-210. [PMID: 35669298 PMCID: PMC9160557 DOI: 10.2337/cd21-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Identifying patients at high risk for diabetic ketoacidosis (DKA) is crucial for informing efforts at preventive intervention. This study sought to develop and validate an electronic medical record (EMR)-based tool for predicting DKA risk in pediatric patients with type 1 diabetes. Based on analysis of data from 1,864 patients with type 1 diabetes, three factors emerged as significant predictors of DKA: most recent A1C, type of health insurance (public vs. private), and prior DKA. A prediction model was developed based on these factors and tested to identify and categorize patients at low, moderate, and high risk for experiencing DKA within the next year. This work demonstrates that risk for DKA can be predicted using a simple model that can be automatically derived from variables in the EMR.
Collapse
Affiliation(s)
- David D. Schwartz
- Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Corresponding author: David D. Schwartz,
| | - Rosa Banuelos
- Texas Children’s Hospital Quality Outcomes and Analytics, Houston, TX
| | - Serife Uysal
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Mili Vakharia
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Kristen R. Hendrix
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Piedmont Physicians Endocrinology, Columbus, GA
| | - Kelly Fegan-Bohm
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sarah K. Lyons
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Rona Sonabend
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sheila K. Gunn
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Selorm Dei-Tutu
- Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| |
Collapse
|
59
|
Alsofiani WA, Alessa BH, Alsabaan F, Althemery AU, Ghith AM, Alfaifi AA. Effects of Ultra-Long-Acting Insulin Compared to Long-Acting Insulin on Diabetic Ketoacidosis Incidence in Type 1 Diabetes Mellitus Patients. Diabetes Metab Syndr Obes 2022; 15:733-739. [PMID: 35280501 PMCID: PMC8906698 DOI: 10.2147/dmso.s351155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/16/2022] [Indexed: 12/04/2022] Open
Abstract
PURPOSE This research was intended to explore the effects of new-generation basal insulin (degludec U100 And glargine U300) versus long-acting basal insulin (glargine U100, detemir) on the incidence of diabetic ketoacidosis episodes and diabetes treatment measures. PATIENTS AND METHODS This is a cross-sectional, retrospective medical record analysis. The study population included adults with type 1 diabetes mellitus (DM) who were on the hospital records in 2020. Data were collected from 221 eligible participants through review of electronic medical records. Each record was scanned for basal insulin type, total daily insulin dose, diabetic ketoacidosis (DKA) occurrences, and glycated hemoglobin A1C (HbA1c) levels. Data were collected from 6 months before to 6 months after the initiation of ultra-long-acting insulin. Statistical analysis was conducted using R version 3.5.2. The normality of distribution for each independent variable was verified using Shapiro-Wilk tests. The independent paired t-test was used to compare insulin therapy measures between the two insulin regimens. The main outcome measures were the incidence of DKA episodes and clinical outcomes associated with diabetes. RESULTS The HbA1c did not change significantly before and after ultra-long-acting insulin therapy was initiated (9.9 vs 9.8, respectively; P >0.05). Insulin total daily doses were significantly higher after shifting to ultra-long-acting insulin. Sub-analysis showed higher total daily insulin doses in glargine U300 users compared with degludec U100 users (P =0.0021). However, basal insulin doses did not change after treatment with ultra-long-acting insulin. No statistically significant difference in DKA occurrences was found before and after the start of ultra-long-acting insulin treatment. CONCLUSION The frequency of DKA episodes was not affected by changing the treatment to ultra-long-acting insulin. Moreover, the results suggest that insulin dosage and types are not the only cause of uncontrolled diabetes. Additional efforts should be made to cover all factors affecting diabetes complication control.
Collapse
Affiliation(s)
- Wafa A Alsofiani
- Family Medicine and Diabetes Center, Prince Mansour Hospital, Taif, Saudi Arabia
| | - Bandar H Alessa
- Family Medicine Department, National Guard Hospital, Jeddah, Saudi Arabia
| | - Fahad Alsabaan
- Endocrinology and Diabetes Department, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Abdullah U Althemery
- Department of Clinical Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | - Aliah M Ghith
- Endocrinology and Diabetes Department, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Abdullah A Alfaifi
- Department of Clinical Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia
- Correspondence: Abdullah A Alfaifi, Clinical Pharmacy Department, Prince Sattam Bin Abdulaziz University, P.O. Box 173, Al-Kharj, Riyadh, 11942, Kingdom Of Saudi Arabia, Tel +966 11 588 6058, Fax + 966 11 588 8888, Email
| |
Collapse
|
60
|
Ebrahimi F, Kutz A, Christ ER, Szinnai G. Lifetime risk and health-care burden of diabetic ketoacidosis: A population-based study. Front Endocrinol (Lausanne) 2022; 13:940990. [PMID: 36093075 PMCID: PMC9449722 DOI: 10.3389/fendo.2022.940990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) is a life-threatening complication of both type 1 and type 2 diabetes. We aimed to assess population-based rates, trends and outcomes of patients with DKA. DESIGN AND METHODS This is a nationwide cohort study using hospital discharge claims data from 2010 to 2018 in Switzerland. Incidence rates and in-hospital outcomes of DKA were analyzed throughout lifetime for children (0-9 years), adolescents (10-19 years), and adults (20-29, 30-59, and 60-90 years). Analyses were stratified for type of diabetes mellitus and sex. RESULTS In total, 5,544 hospitalizations with DKA were identified, of whom 3,847 were seen in patients with type 1 diabetes and 1,697 in type 2 diabetes. Incidence rates of DKA among patients with type 1 diabetes were highest during adolescence with 17.67 (girls) and 13.87 (boys) events per 100,000 person-years (incidence rate difference [IRD]: -3.80 [95% CI, -5.59 to -2.02]) and decreased with age in both sexes thereafter. Incidence rates of DKA in patients with type 2 diabetes were low up to an age of 40 years and rose to 5.26 (females) and 6.82 (males) per 100,000 person-years in adults aged 60-90 years. Diabetic ketoacidosis was associated with relevant health-care burden independent of age, sex, or type of diabetes. The population-based incidence rate of DKA increased over time from 7.22 per 100,000 person-years in 2010 to 9.49 per 100,000 person-years in 2018. CONCLUSIONS In type 1 diabetes highest incidence rates of DKA hospitalizations were observed among adolescent females. In comparison, in patients with type 2 diabetes the risk for DKA steadily increased with age with higher rates in adult males. Over the 9 year study period, incidence rates of DKA were increasing irrespective of type of diabetes. DKA was associated with a high burden of disease reflected by high rates of intensive care unit admission, prolonged hospital stay and high mortality rates, especially in elderly.
Collapse
Affiliation(s)
- Fahim Ebrahimi
- University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, Basel, Switzerland
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University Basel, Basel, Switzerland
| | - Alexander Kutz
- Division of Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Emanuel Remigius Christ
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University Hospital Basel, University Basel, Basel, Switzerland
| | - Gabor Szinnai
- Department of Clinical Research, University Hospital Basel, University Basel, Basel, Switzerland
- pt?> Pediatric Endocrinology and Diabetology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| |
Collapse
|
61
|
Duan Z, Song P, Yang C, Deng L, Jiang Y, Deng F, Jiang X, Chen Y, Yang G, Ma Y, Deng W. The impact of hyperglycaemic crisis episodes on long-term outcomes for inpatients presenting with acute organ injury: A prospective, multicentre follow-up study. Front Endocrinol (Lausanne) 2022; 13:1057089. [PMID: 36545333 PMCID: PMC9760800 DOI: 10.3389/fendo.2022.1057089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/16/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND The long-term clinical outcome of poor prognosis in patients with diabetic hyperglycaemic crisis episodes (HCE) remains unknown, which may be related to acute organ injury (AOI) and its continuous damage after hospital discharge. This study aimed to observe the clinical differences and relevant risk factors in HCE with or without AOI. METHODS A total of 339 inpatients were divided into an AOI group (n=69) and a non-AOI group (n=270), and their differences and risk factors were explored. The differences in clinical outcomes and prediction models for evaluating the long-term adverse events after hospital discharge were established. RESULTS The mortality among cases complicated by AOI was significantly higher than that among patients without AOI [8 (11.59%) vs. 11 (4.07%), Q = 0.034] during hospitalization. After a 2-year follow-up, the mortality was also significantly higher in patients with concomitant AOI than in patients without AOI after hospital discharge during follow-up [13 (21.31%) vs. 15 (5.8%), Q < 0.001]. The long-term adverse events in patients with concomitant AOI were significantly higher than those in patients without AOI during follow-up [15 (24.59%) vs. 31 (11.97%), Q = 0.015]. Furthermore, Blood β-hydroxybutyric acid (P = 0.003), Cystatin C (P <0.001), serum potassium levels (P = 0.001) were significantly associated with long-term adverse events after hospital discharge. CONCLUSIONS The long-term prognosis of HCE patients complicated with AOI was significantly worse than that of HCE patients without AOI. The laboratory indicators were closely correlated with AOI, and future studies should explore the improvement of clinical outcome in response to timely interventions.
Collapse
Affiliation(s)
- Zixiao Duan
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Peiyang Song
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Cheng Yang
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Liling Deng
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Youzhao Jiang
- Department of Endocrinology, Banan People’s Hospital of Chongqing, Chongqing, China
| | - Fang Deng
- Department of Endocrinology, Chongqing Southwest Hospital, Chongqing, China
| | - Xiaoyan Jiang
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Yan Chen
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Gangyi Yang
- Department of Endocrinology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Ma
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
| | - Wuquan Deng
- Department of Endocrinology, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
- *Correspondence: Wuquan Deng,
| |
Collapse
|
62
|
Vasireddy D, Sehgal M, Amritphale A. Risk Factors, Trends, and Preventive Measures for 30-Day Unplanned Diabetic Ketoacidosis Readmissions in the Pediatric Population. Cureus 2021; 13:e19205. [PMID: 34873537 PMCID: PMC8638216 DOI: 10.7759/cureus.19205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 11/11/2022] Open
Abstract
Background There has been a steady rise in types 1 and 2 diabetes mellitus among the youth in the USA from 2001 to 2017. Diabetic ketoacidosis (DKA) is a common and preventable presentation of both types of diabetes mellitus. According to the Centers for Disease Control and Prevention's (CDC) United States Diabetes Surveillance System, during 2004-2019 an increase in DKA hospitalization rates by 59.4% was noted, with people aged less than 45 years having the highest rates. Readmissions reflect the quality of disease management, which is integrally tied to care coordination and communication with the patient and their families. This study analyzes the trends and risk factors contributing to 30-day unplanned DKA readmissions in the pediatric age group and looks into possible preventive measures to decrease them. Methods A retrospective study was performed using the National Readmission Database (NRD) from January 1, 2017, to December 1, 2017. Pediatric patients aged 18 years and younger with the primary diagnosis of DKA were included using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code E10.10. All statistical analysis was performed using IBM SPSS Statistics for Windows, version 1.0.0.1327 (IBM Corp., Armonk, NY, USA). Pearson's chi-square test was used for categorical variables and Mann-Whitney U test was used for continuous variables. To independently determine the predictors of readmission within each clinical variable, multiple logistic regressions with values presented as odds ratios (OR) with 95% confidence intervals (CI) were performed. Results A weighted total of 19,519 DKA-related pediatric index admissions were identified from the 2017 NRD. Of these pediatric patients, 831 (4.3%) had 30-day DKA readmission. The median age of a child for readmission was 16 years with an interquartile range of 0 to 18 years. A sharp rise in 30-day DKA readmissions was noted for ages 16 years and over. Females in the 0-25th percentile median household income category, with Medicaid covered, large metropolitan areas with at least 1 million residents, and metropolitan teaching hospitals were found to have a statistically significant higher percentage of readmissions. The mean length of stay for those who had a DKA readmission was 2.06 days, with a standard deviation of 1.84 days. The mean hospital charges for those who had a DKA readmission were $ 20,339.70. The 30-day DKA readmission odds were seen to be increased for female patients, Medicaid-insured patients, admissions at metropolitan non-teaching hospitals, and children from 0-25th percentile median household income category. Conclusion There has not been much of a change in the trend and risk factors contributing to the 30-day unplanned DKA readmissions over the years despite the steady rise in cases of diabetes mellitus. The length of stay for those who did not get readmitted within 30 days was longer than for those who did. This could reflect more comprehensive care and discharge planning that may have prevented them from readmission. Diabetes mellitus is a chronic disease that demands a team effort from the patient, family, healthcare personnel, insurance companies, and lawmakers. There is scope for a lot of improvement with the way our patients are being managed, and a more holistic approach needs to be devised.
Collapse
Affiliation(s)
| | - Mukul Sehgal
- Critical Care Medicine, University of South Alabama, Mobile, USA
| | - Amod Amritphale
- Medicine/Cardiovascular Disease, University of South Alabama College of Medicine, Mobile, USA
| |
Collapse
|
63
|
Akturk HK, Snell-Bergeon J, Pyle L, Fivekiller E, Garg S, Cobry E. Accuracy of a breath ketone analyzer to detect ketosis in adults and children with type 1 diabetes. J Diabetes Complications 2021; 35:108030. [PMID: 34481712 DOI: 10.1016/j.jdiacomp.2021.108030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the accuracy of a breath ketone analyzer to detect ketosis in adults and children with type 1 diabetes. RESEARCH DESIGN AND METHODS This is a proof-of-concept, prospective study comparing breath ketone analyzer and blood ketone meter to detect ketosis. RESULTS A total of 500 measurements from 19 adults and children with type 1 diabetes were analyzed. There was a significant association between the breath ketone analyzer and blood ketone meter results in non-fasting adults (p = 0.0066), but not in children (p = 0.4579). In adults, a cut-off of 3.9 PPM on the breath ketone analyzer maximized the Youden Index with an AUC of 0.73. This cut-off for the breath ketone analyzer had 94.7% sensitivity and 54.2% specificity to detect ketosis (≥0.6 mmol/L in blood ketone meter). CONCLUSIONS The breath ketone analyzer may be considered as a non-invasive screening tool to rule out ketosis in adults with type 1 diabetes.
Collapse
Affiliation(s)
| | | | - Laura Pyle
- Barbara Davis Center, University of Colorado, Aurora, CO,USA
| | | | - Satish Garg
- Barbara Davis Center, University of Colorado, Aurora, CO,USA
| | - Erin Cobry
- Barbara Davis Center, University of Colorado, Aurora, CO,USA
| |
Collapse
|
64
|
Anderson JC, Mattar SG, Greenway FL, Lindquist RJ. Measuring ketone bodies for the monitoring of pathologic and therapeutic ketosis. Obes Sci Pract 2021; 7:646-656. [PMID: 34631141 PMCID: PMC8488448 DOI: 10.1002/osp4.516] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The ketone bodies β-hydroxybutyrate (BOHB) and acetone are generated as a byproduct of the fat metabolism process. In healthy individuals, ketone body levels are ∼0.1 mM for BOHB and ∼1 part per million for breath acetone (BrAce). These levels can increase dramatically as a consequence of a disease process or when used therapeutically for disease treatment. For example, increased ketone body concentration during weight loss is an indication of elevated fat metabolism. Ketone body measurement is relatively inexpensive and can provide metabolic insights to help guide disease management and optimize weight loss. METHODS This review of the literature provides metabolic mechanisms and typical concentration ranges of ketone bodies, which can give new insights into these conditions and rationale for measuring ketone bodies. RESULTS Diseases such as heart failure and ketoacidosis can affect caloric intake and macronutrient management, which can elevate BOHB 30-fold and BrAce 1000-fold. Other diseases associated with obesity, such as brain dysfunction, cancer, and diabetes, may cause dysfunction because of an inability to use glucose, excessive reliance on glucose, or poor insulin signaling. Elevating ketone body concentrations (e.g., nutritional ketosis) may improve these conditions by forcing utilization of ketone bodies, in place of glucose, for fuel. During weight loss, monitoring ketone body concentration can demonstrate program compliance and can be used to optimize the weight-loss plan. CONCLUSIONS The role of ketone bodies in states of pathologic and therapeutic ketosis indicates that accurate measurement and monitoring of BOHB or BrAce will likely improve disease management. Bariatric surgery is examined as a case study for monitoring both types of ketosis.
Collapse
Affiliation(s)
- Joseph C. Anderson
- Department of BioengineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Samer G. Mattar
- Department of SurgeryBaylor College of MedicineHoustonTexasUSA
| | | | | |
Collapse
|
65
|
Kapila V, Topf J. Sodium-Glucose Co-transporter 2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis After Bariatric Surgery: A Case and Literature Review. Cureus 2021; 13:e17093. [PMID: 34527480 PMCID: PMC8432437 DOI: 10.7759/cureus.17093] [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] [Accepted: 08/11/2021] [Indexed: 12/26/2022] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce cardiovascular, kidney, and overall mortality. SGLT2i are also associated with a rare adverse event, euglycemic diabetic ketoacidosis (EDKA). This report describes a case of EDKA one day after bariatric surgery in a 51-year-old female with type 2 diabetes mellitus managed with the SGLT2i, canagliflozin. She was following a ketogenic diet for three weeks prior to surgery. The patient made a steady recovery with rapid anion gap closure followed by prolonged non-anion gap metabolic acidosis. Her medical record was tagged with a life-threatening reaction to SGLT2i. The risk of EDKA from SGLT2i may be increased by a low carbohydrate diet or postoperative status. Our case was complicated by hypokalemia, exemplifying the need for aggressive electrolyte management. Further guidance is needed to manage risk factors provoking EDKA and the use of SGLT2i therapy after an episode of EDKA.
Collapse
Affiliation(s)
- Vaishali Kapila
- Medicine, Central Michigan University College of Medicine, Mt. Pleasant, USA
| | - Joel Topf
- Nephrology, Ascension St. John Hospital, Detroit, USA.,Nephrology, Oakland University William Beaumont School of Medicine, Rochester, USA
| |
Collapse
|
66
|
Vomiting and hyperkalemia are novel clues for emergency room diagnosis of type 1 diabetic ketoacidosis: a retrospective comparison between diabetes types. Diabetol Int 2021; 13:272-279. [DOI: 10.1007/s13340-021-00539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 08/23/2021] [Indexed: 10/20/2022]
|
67
|
McCoy RG, Galindo RJ, Swarna KS, Van Houten HK, O’Connor PJ, Umpierrez GE, Shah ND. Sociodemographic, Clinical, and Treatment-Related Factors Associated With Hyperglycemic Crises Among Adults With Type 1 or Type 2 Diabetes in the US From 2014 to 2020. JAMA Netw Open 2021; 4:e2123471. [PMID: 34468753 PMCID: PMC8411297 DOI: 10.1001/jamanetworkopen.2021.23471] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Hyperglycemic crises (ie, diabetic ketoacidosis [DKA] and hyperglycemic hyperosmolar state [HHS]) are life-threatening acute complications of diabetes. Efforts to prevent these events at the population level have been hindered by scarce granular data and difficulty in identifying individuals at highest risk. OBJECTIVE To assess sociodemographic, clinical, and treatment-related factors associated with hyperglycemic crises in adults with type 1 or type 2 diabetes in the US from 2014 to 2020. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study analyzed administrative claims and laboratory results for adults (aged ≥18 years) with type 1 or type 2 diabetes from the OptumLabs Data Warehouse from January 1, 2014, through December 31, 2020. MAIN OUTCOMES AND MEASURES Rates of emergency department or hospital visits with a primary diagnosis of DKA or HHS (adjusted for age, sex, race/ethnicity, and region, and for year when calculating annualized rates) were calculated separately for patients with type 1 diabetes and type 2 diabetes. The associations of sociodemographic factors (age, sex, race/ethnicity, region, and income), clinical factors (comorbidities), and treatment factors (glucose-lowering medications, hemoglobin A1c) with DKA or HHS in patients with type 1 or type 2 diabetes were assessed using negative binomial regression. RESULTS Among 20 156 adults with type 1 diabetes (mean [SD] age, 46.6 [16.5] years; 51.2% male; 72.6% White race/ethnicity) and 796 382 with type 2 diabetes (mean [SD] age, 65.6 [11.8] years; 50.3% female; 54.4% White race/ethnicity), adjusted rates of hyperglycemic crises were 52.69 per 1000 person-years (95% CI, 48.26-57.12 per 1000 person-years) for type 1 diabetes and 4.04 per 1000 person-years (95% CI, 3.88-4.21 per 1000 person-years) for type 2 diabetes. In both groups, factors associated with the greatest hyperglycemic crisis risk were low income (≥$200 000 vs <$40 000: type 1 diabetes incidence risk ratio [IRR], 0.61 [95% CI, 0.46-0.81]; type 2 diabetes IRR, 0.69 [95% CI, 0.56-0.86]), Black race/ethnicity (vs White race/ethnicity: type 1 diabetes IRR, 1.33 [95% CI, 1.01-1.74]; type 2 diabetes IRR, 1.18 [95% CI, 1.09-1.27]), high hemoglobin A1c level (≥10% vs 6.5%-6.9%: type 1 diabetes IRR, 7.81 [95% CI, 5.78-10.54]; type 2 diabetes IRR, 7.06 [95% CI, 6.26-7.96]), history of hyperglycemic crises (type 1 diabetes IRR, 7.88 [95% CI, 6.06-9.99]; type 2 diabetes IRR, 17.51 [95% CI, 15.07-20.34]), severe hypoglycemia (type 1 diabetes IRR, 2.77 [95% CI, 2.15-3.56]; type 2 diabetes IRR, 4.18 [95% CI, 3.58-4.87]), depression (type 1 diabetes IRR, 1.62 [95% CI, 1.37-1.92]; type 2 diabetes IRR, 1.46 [95% CI, 1.34-1.59]), neuropathy (type 1 diabetes IRR, 1.64 [95% CI, 1.39-1.93]; type 2 diabetes IRR, 1.25 [95% CI, 1.17-1.34]), and nephropathy (type 1 diabetes IRR, 1.22 [95% CI, 1.01-1.48]; type 2 diabetes IRR, 1.23 [95% CI, 1.14-1.33]). Age had a U-shaped association with hyperglycemic crisis risk in patients with type 1 diabetes (compared with patients aged 18-44 years: 45-64 years IRR, 0.72 [95% CI, 0.59-0.87]; 65-74 years IRR, 0.62 [95% CI, 0.47-0.80]; ≥75 years IRR, 0.96 [95% CI, 0.66-1.38]). In type 2 diabetes, risk of hyperglycemic crises decreased progressively with age (45-64 years IRR, 0.57 [95% CI, 0.51-0.63]; 65-74 years IRR, 0.44 [95% CI, .39-0.49]; ≥75 years IRR, 0.41 [95% CI, 0.36-0.47]). In patients with type 2 diabetes, higher risk was associated with sodium-glucose cotransporter 2 inhibitor therapy (IRR, 1.30; 95% CI, 1.14-1.49) and insulin dependency (compared with regimens with bolus insulin: regimens with basal insulin only, IRR, 0.69 [95% CI, 0.63-0.75]; and without any insulin, IRR, 0.36 [95% CI, 0.33-0.40]). CONCLUSIONS AND RELEVANCE In this cohort study, younger age, Black race/ethnicity, low income, and poor glycemic control were associated with an increased risk of hyperglycemic crises. The findings suggest that multidisciplinary interventions focusing on groups at high risk for hyperglycemic crises are needed to prevent these dangerous events.
Collapse
Affiliation(s)
- Rozalina G. McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Kavya Sindhu Swarna
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
| | - Holly K. Van Houten
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- HealthPartners Institute Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Patrick J. O’Connor
- HealthPartners Institute Center for Chronic Care Innovation, Minneapolis, Minnesota
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Nilay D. Shah
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota
- OptumLabs, Eden Prairie, Minnesota
| |
Collapse
|
68
|
Everett EM, Copeland TP, Moin T, Wisk LE. National Trends in Pediatric Admissions for Diabetic Ketoacidosis, 2006-2016. J Clin Endocrinol Metab 2021; 106:2343-2354. [PMID: 33942077 PMCID: PMC8277205 DOI: 10.1210/clinem/dgab287] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND OBJECTIVES Diabetic ketoacidosis (DKA) rates in the United States are rising. Prior studies suggest higher rates in younger populations, but no studies have evaluated national trends in pediatric populations and differences by subgroups. As such, we sought to examine national trends in pediatric DKA. METHODS We used the 2006, 2009, 2012, and 2016 Kids' Inpatient Database to identify pediatric DKA admissions among a nationally representative sample of admissions of youth ≤20 years old. We estimate DKA admission per 10 000 admissions and per 10 000 population, charges, length of stay (LOS), and trends over time among all hospitalizations and by demographic subgroups. Regression models were used to evaluate differences in DKA rates within subgroups overtime. RESULTS Between 2006 and 2016, there were 149 535 admissions for DKA. Unadjusted DKA rate per admission increased from 120.5 (95% CI, 115.9-125.2) in 2006 to 217.7 (95% CI, 208.3-227.5) in 2016. The mean charge per admission increased from $14 548 (95% CI, $13 971-$15 125) in 2006 to $20 997 (95% CI, $19 973-$22 022) in 2016, whereas mean LOS decreased from 2.51 (95% CI, 2.45-2.57) to 2.28 (95% CI, 2.23-2.33) days. Higher DKA rates occurred among 18- to 20-year-old females, Black youth, without private insurance, with lower incomes, and from nonurban areas. Young adults, men, those without private insurance, and from nonurban areas had greater increases in DKA rates across time. CONCLUSIONS Pediatric DKA admissions have risen by 40% in the United States and vulnerable subgroups remain at highest risk. Further studies should characterize the challenges experienced by these groups to inform interventions to mitigate their DKA risk and to address the rising DKA rates nationally.
Collapse
Affiliation(s)
- Estelle M Everett
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Correspondence: Estelle Everett, MD, MHS, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ste 850, Los Angeles, CA 90024, United States.
| | - Timothy P Copeland
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Tannaz Moin
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Lauren E Wisk
- Division of General Internal Medicine & Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
69
|
James S, Annetts K, Frakking T, Broadbent M, Waugh J, Perry L, Lowe J, Clark S. Diabetic ketoacidosis presentations in a low socio-economic area: are services suitable? BMC Health Serv Res 2021; 21:682. [PMID: 34246266 PMCID: PMC8272902 DOI: 10.1186/s12913-021-06715-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Diabetic ketoacidosis causes a significant number of hospitalisations worldwide, with rates tending to increase with remoteness and socioeconomic disadvantage. Our study aimed to explore healthcare professionals’ perceptions of factors affecting presentation of people with type 1 diabetes in a low socioeconomic area of Queensland, Australia. Methods This was a qualitative study. Individual semi-structured face-to-face or telephone interviews were completed with patients with type 1 diabetes who had presented in diabetic ketoacidosis, and healthcare professionals who have experience in related care. Data were analysed using Gibbs’s framework of thematic analysis. Results Four patients with type 1 diabetes and 18 healthcare professionals were interviewed. Restricted access was identified as a factor contributing to diabetic ketoacidosis and delayed presentation, with ketone testing supplies, continuous glucose monitoring technology and transport considered barriers. Many of these factors were arguably preventable. Opportunities to improve the care available to patients with type 1 diabetes were detailed, with particularly strong support for dedicated out of hours telephone help lines for adults with type 1 diabetes. Conclusions Gaps in support for patient self-care to avoid diabetic ketoacidosis presentations and prevent late presentation of diabetic ketoacidosis revealed by this study require service reconfiguration to support care delivery. Until change is made, people with type 1 diabetes will continue to make both avoidable and delayed, acutely unwell, presentations to Emergency Departments. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06715-7.
Collapse
Affiliation(s)
- Steven James
- University of the Sunshine Coast, Petrie, Queensland, Australia. .,University of Melbourne, Parkville, Victoria, Australia.
| | - Kylie Annetts
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Thuy Frakking
- Caboolture Hospital, Caboolture, Queensland, Australia.,University of Queensland, St. Lucia, Queensland, Australia
| | - Marc Broadbent
- University of the Sunshine Coast, Petrie, Queensland, Australia
| | - John Waugh
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Lin Perry
- University of Technology Sydney, Ultimo, New South Wales, Australia.,South Eastern Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Julia Lowe
- University of Newcastle, Callaghan, New South Wales, Australia
| | - Sean Clark
- University of the Sunshine Coast, Petrie, Queensland, Australia.,Caboolture Hospital, Caboolture, Queensland, Australia
| |
Collapse
|
70
|
Ibrahim A, Bayramoglu B, Hokenek NM, Tekyol D. Lactate clearance during the first 2 hours after hospital admission: A useful biomarker for predicting 30-day mortality in patients with diabetic ketoacidosis. Int J Clin Pract 2021; 75:e14204. [PMID: 33811737 DOI: 10.1111/ijcp.14204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This study assessed whether lactate clearance (LC) during the first 2 hours after admission to the emergency department can be used to predict the 30-day mortality of patients diagnosed with diabetic ketoacidosis (DKA). MATERIAL AND METHODS This was a retrospective observational cohort study of patients admitted to the hospital between January 2014 and January 2019. We identified patients with diabetes who had blood gas test results at the time of admission and 2 hours thereafter. We then calculated the LC in these patients. Patients were divided into groups based on mortality and length of stay (LOS). The groups were compared in terms of age, blood gas pH, osmolarity, glucose level, lactate level on admission and 2 hours thereafter, LC, and bicarbonate (HCO3 - ), blood urea nitrogen, sodium, and potassium levels. RESULTS The overall mortality rate was 7.54% (8/107). Age, pH, osmolarity, the HCO3 - , and sodium levels, the lactate level 2 hours after admission, and LC differed significantly between the groups (Mann-Whitney U test, P < .05). LC cut-off values and areas under the curve were significant (P < .05). Receiver operating characteristic analysis indicated an LC cut-off value of 18.6441; the area under the curve was 0.711 (P < .05). CONCLUSIONS LC during the first 2 hours after admission is useful for predicting 30-day mortality in patients with diabetic ketoacidosis.
Collapse
Affiliation(s)
- Abdullah Ibrahim
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training And Research Hospital, Istanbul, Turkey
| | - Burcu Bayramoglu
- Department of Emergency Medicine, Akcaabat Hackali Baba State Hospital, Trabzon, Turkey
| | - Nihat Mujdat Hokenek
- Department of Emergency Medicine, University of Health Sciences, Kartal Dr. Lütfi Kırdar City Hospital, Istanbul, Turkey
| | - Davut Tekyol
- Department of Emergency Medicine, University of Health Sciences, Haydarpaşa Numune Training And Research Hospital, Istanbul, Turkey
| |
Collapse
|
71
|
Jensen ET, Stafford JM, Saydah S, D'Agostino RB, Dolan LM, Lawrence JM, Marcovina S, Mayer-Davis EJ, Pihoker C, Rewers A, Dabelea D. Increase in Prevalence of Diabetic Ketoacidosis at Diagnosis Among Youth With Type 1 Diabetes: The SEARCH for Diabetes in Youth Study. Diabetes Care 2021; 44:1573-1578. [PMID: 34099516 PMCID: PMC8323183 DOI: 10.2337/dc20-0389] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We previously reported a high (˜30%) but stable prevalence of diabetic ketoacidosis (DKA) at youth-onset diagnosis of type 1 diabetes (2002 and 2010). Given the changing demographics of youth-onset type 1 diabetes, we sought to evaluate temporal trends in the prevalence of DKA at diagnosis of type 1 diabetes from 2010 to 2016 among youth <20 years of age and evaluate whether any change observed was associated with changes in sociodemographic distribution of those recently diagnosed. RESEARCH DESIGN AND METHODS We calculated prevalence of DKA within 1 month of type 1 diabetes diagnosis by year and evaluated trends over time (2010-2016) (n = 7,612 incident diabetes cases; mean [SD] age 10.1 [4.5] at diagnosis). To assess whether trends observed were attributable to the changing distribution of sociodemographic factors among youth with incident type 1 diabetes, we estimated an adjusted relative risk (RR) of DKA in relation to calendar year, adjusting for age, sex, race/ethnicity, income, education, health insurance status, language, season of diagnosis, and SEARCH for Diabetes in Youth Study site. RESULTS DKA prevalence increased from 35.3% (95% CI 32.2, 38.4) in 2010 to 40.6% (95% CI 37.8, 43.4) in 2016 (P trend = 0.01). Adjustment for sociodemographic factors did not substantively change the observed trends. We observed a 2% annual increase in prevalence of DKA at or near diagnosis of type 1 diabetes (crude RR 1.02 [95% CI 1.01, 1.04] and adjusted RR 1.02 [95% CI 1.01, 1.04]; P = 0.01 for both). CONCLUSIONS Prevalence of DKA at or near type 1 diabetes diagnosis has increased from 2010 to 2016, following the high but stable prevalence observed from 2002 to 2010. This increase does not seem to be attributable to the changes in distribution of sociodemographic factors over time.
Collapse
Affiliation(s)
- Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeanette M Stafford
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sharon Saydah
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Lawrence M Dolan
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Jean M Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Santica Marcovina
- Northwest Lipid Research Laboratories, University of Washington, Seattle, WA
| | | | | | - Arleta Rewers
- Department of Pediatrics, University of Colorado Denver, Aurora, CO
| | - Dana Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| |
Collapse
|
72
|
Li L, Andrews EB, Li X, Doder Z, Zalmover E, Sharma K, Oliveira JH, Juhaeri J, Wu C. Incidence of diabetic ketoacidosis and its trends in patients with type 1 diabetes mellitus identified using a U.S. claims database, 2007-2019. J Diabetes Complications 2021; 35:107932. [PMID: 33902995 DOI: 10.1016/j.jdiacomp.2021.107932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/05/2021] [Accepted: 04/08/2021] [Indexed: 11/21/2022]
Abstract
Diabetic ketoacidosis (DKA) is a common complication of type 1 diabetes mellitus (T1DM). We found that the incidence of DKA was 55.5 per 1000 person-years in US commercially insured patients with T1DM; age-sex-standardized incidence decreased at an average annual rate of 6.1% in 2018-2019 after a steady increase since 2011.
Collapse
Affiliation(s)
- Lin Li
- Epidemiology & Benefit-Risk Evaluation, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA.
| | | | - Xinyu Li
- Epidemiology & Benefit-Risk Evaluation, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Zoran Doder
- Global Pharmacovigilance, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Evgeny Zalmover
- Global Pharmacovigilance, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Kristen Sharma
- Global Pharmacovigilance, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Juliana H Oliveira
- Development Diabetes CV and Metabolism, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Juhaeri Juhaeri
- Epidemiology & Benefit-Risk Evaluation, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Chuntao Wu
- Epidemiology & Benefit-Risk Evaluation, Sanofi, 55 Corporate Drive, Bridgewater, NJ 08807, USA
| |
Collapse
|
73
|
Galindo RJ, Pasquel FJ, Vellanki P, Zambrano C, Albury B, Perez-Guzman C, Ziduo Z, Umpierrez GE. Biochemical Parameters of Diabetes Ketoacidosis in Patients with End-stage Kidney Disease and Preserved Renal Function. J Clin Endocrinol Metab 2021; 106:e2673-e2679. [PMID: 33659978 PMCID: PMC8502445 DOI: 10.1210/clinem/dgab126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/02/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Differences in biochemical parameters of diabetic ketoacidosis in patients with end-stage kidney disease (ESKD) has not been established. Accordingly, we assessed the relationship between degree of metabolic acidosis and ß-hydroxybutyrate in patients with ESKD (eGFR < 15 mL/min/1.73 m2), moderate renal failure (eGFR 15-60), or preserved renal function (eGFR > 60). METHODS This observational study included adults (18-80 years) with diabetes ketoacidosis (DKA), admitted to Emory University Hospitals between January 1, 2006 to December 31, 2016. DKA and renal stages were confirmed on admission laboratory values. RESULTS Admission bicarbonate levels (13.9 ± 5 vs 13.4 ± 5.3 vs 13.8 ± 4.2 mmol/L, P = 0.7), and pH levels (7.2 ± 0.3 vs 7.2 ± 0.2 vs 7.2 ± 0.2, P = 0.8) were similar among groups. Patients with ESKD had lower mean ß-hydroxybutyrate level (4.3 ± 3.3 vs 5.6 ± 2.9 vs 5.9 ± 2.5 mmol/L, P = 0.01), but higher admission glucose (852 ± 340.4 vs 714.6 ± 253.3 mg/dL vs 518 ± 185.7 mg/dL, P < 0.01), anion gap (23.4 ± 7.6 vs 23 ± 6.9 vs 19.5 ± 4.7 mmol/L, P < 0.01), and osmolality (306 ± 20.6 vs 303.5 ± vs 293.1 ± 3.1mOsm/kg, P < 0.01) compared with patients with moderate renal failure and preserved renal function, respectively. The sensitivity of ß-hydroxybutyrate > 3 mmol/L for diagnosing DKA by bicarbonate level < 15 and <18 mmol/L was 86.9% and 72% in ESKD, 89.3% and 83.7% in moderate renal failure, and 96.2% and 88.3% in preserved renal function. In patients with ESKD, the corresponding ß-hydroxybutyrate with bicarbonate levels < 10, 10-15, <18 mmol/L were 5.5, 3.9, 3.0 mmol/L, respectively. CONCLUSIONS Significant metabolic differences were found among DKA patients with different levels of renal function. In patients with ESKD, a ß-hydroxybutyrate level > 3 mmol/L may assist with confirmation of DKA diagnosis.
Collapse
Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
- Correspondence: Rodolfo J. Galindo, MD, FACE, Assistant Professor of Medicine, Emory University School of Medicine, Address: 69 Jesse Hill Jr. Dr., Glenn Building, Suite 202, Atlanta, GA 30303, USA.
| | - Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
| | - Cesar Zambrano
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
| | - Bonnie Albury
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
| | - Citlalli Perez-Guzman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
| | - Zheng Ziduo
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30303, USA
| |
Collapse
|
74
|
Roussel R, Riveline JP, Vicaut E, de Pouvourville G, Detournay B, Emery C, Levrat-Guillen F, Guerci B. Important Drop in Rate of Acute Diabetes Complications in People With Type 1 or Type 2 Diabetes After Initiation of Flash Glucose Monitoring in France: The RELIEF Study. Diabetes Care 2021; 44:1368-1376. [PMID: 33879536 PMCID: PMC8247513 DOI: 10.2337/dc20-1690] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 03/02/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The RELIEF study assessed rates of hospitalization for acute diabetes complications in France before and after initiation of the FreeStyle Libre system. RESEARCH DESIGN AND METHODS A total of 74,011 patients with type 1 diabetes or type 2 diabetes who initiated the FreeStyle Libre system were identified from the French national claims database with use of ICD-10 codes, from hospitalizations with diabetes as a contributing diagnosis, or the prescription of insulin. Patients were subclassified based on self-monitoring of blood glucose (SMBG) strip acquisition prior to starting FreeStyle Libre. Hospitalizations for diabetic ketoacidosis (DKA), severe hypoglycemia, diabetes-related coma, and hyperglycemia were recorded for the 12 months before and after initiation. RESULTS Hospitalizations for acute diabetes complications fell in type 1 diabetes (-49.0%) and in type 2 diabetes (-39.4%) following FreeStyle Libre initiation. DKA fell in type 1 diabetes (-56.2%) and in type 2 diabetes (-52.1%), as did diabetes-related comas in type 1 diabetes (-39.6%) and in type 2 diabetes (-31.9%). Hospitalizations for hypoglycemia and hyperglycemia decreased in type 2 diabetes (-10.8% and -26.5%, respectively). Before initiation, hospitalizations were most marked for people noncompliant with SMBG and for those with highest acquisition of SMBG, which fell by 54.0% and 51.2%, respectively, following FreeStyle Libre initiation. Persistence with FreeStyle Libre at 12 months was at 98.1%. CONCLUSIONS This large retrospective study on hospitalizations for acute diabetes complications shows that a significantly lower incidence of admissions for DKA and for diabetes-related coma is associated with use of flash glucose monitoring. This study has significant implications for patient-centered diabetes care and potentially for long-term health economic outcomes.
Collapse
Affiliation(s)
- Ronan Roussel
- Department of Diabetology, Endocrinology, and Nutrition, Bichat-Claude Bernard Hospital, Paris, France .,Unité INSERM U1138 Immunity and Metabolism in Diabetes, ImMeDiab Team, Centre de Recherches des Cordeliers, Paris, France.,Université de Paris, Paris, France
| | - Jean-Pierre Riveline
- Unité INSERM U1138 Immunity and Metabolism in Diabetes, ImMeDiab Team, Centre de Recherches des Cordeliers, Paris, France.,Université de Paris, Paris, France.,Department of Diabetology and Endocrinology, Lariboisière Hospital, Paris, France
| | - Eric Vicaut
- Clinical Research Unit, Fernand Vidal Hospital, Paris, France
| | | | | | | | | | - Bruno Guerci
- Department of Endocrinology, Diabetology, and Nutrition, Brabois Adult Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| |
Collapse
|
75
|
Greenbaum CJ. A Key to T1D Prevention: Screening and Monitoring Relatives as Part of Clinical Care. Diabetes 2021; 70:1029-1037. [PMID: 33931405 PMCID: PMC8173797 DOI: 10.2337/db20-1112] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
The 2019 report of a randomized, placebo-controlled clinical trial demonstrating that immune therapy can delay the onset of clinical type 1 diabetes (T1D) in antibody-positive relatives by a median of 2 years stands out as a landmark in the decades-long effort to prevent T1D. With this important step achieved, it is now time to consider what is needed to bring disease-modifying therapy for prevention or delay of T1D to clinical use from this point. Long considered a chicken and egg problem (why screen for T1D risk when we have no therapy, and how can we develop therapies without more screening), we now have the opportunity to break this impasse. The purpose of this article is to place this clinical trial result in context, highlighting key foundational studies leading to this accomplishment, addressing the current gaps, and suggesting that a key next step for prevention of T1D is to screen and monitor relatives for T1D risk in the context of clinical care.
Collapse
|
76
|
Donda K, Agyemang CO, Adjetey NA, Agyekum A, Princewill N, Ayensu M, Bray L, Yagnik PJ, Bhatt P, Dapaah-Siakwan F. Tracheostomy trends in preterm infants with bronchopulmonary dysplasia in the United States: 2008-2017. Pediatr Pulmonol 2021; 56:1008-1017. [PMID: 33524218 DOI: 10.1002/ppul.25273] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/03/2021] [Accepted: 01/11/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the trends in tracheostomy placement and resource use in preterm infants less than or equal to 30 weeks gestational age (GA) with bronchopulmonary dysplasia (BPD) in the United States from 2008 to 2017. STUDY DESIGN This was a retrospective, serial cross-sectional study using data from the NIS. Inclusion criteria were: GA less than or equal to 30 weeks, hospitalization at less than or equal to 28 days of age, assignment of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9-CM) or ICD10-CM codes for BPD and tracheostomy. Trends in tracheostomy and resource utilization were assessed using Jonckheere-Terpstra test. p-value < .05 was considered significant. RESULTS Overall, 987 out of 68,953 (1.4%) hospitalizations with BPD had tracheostomy. Characteristics of the study population: 60.8% were male, 68.4% less than or equal to 26 weeks GA, 43.8% White, 60.5% with Medicaid or self-pay, 65.2% in the Midwest and South census regions of the United States, and 45.7% had gastrostomy tube placement. Tracheostomy placement (expressed as per 100,000 live births) decreased from 2.7 in 2008 to 1.9 in 2011. Thereafter, it increased from 1.9 in 2011 to 3.5 in 2017 (p < .001). GA less than or equal to 24 weeks was significantly associated with increased odds of tracheostomy placement. Median length of stay increased significantly from 170 to 231 days while median inflation adjusted hospital cost increased significantly from $323,091 in 2008-2009 to $687,141 between 2008-2009 and 2016-2017. CONCLUSION Although tracheostomy placement among preterm hospitalizations with BPD was rare, the frequency of its placement and its associated resource utilization significantly increased during the study period. Future studies should probe the reasons and factors behind these trends.
Collapse
Affiliation(s)
- Keyur Donda
- Department of Pediatrics, University of South Florida, Tampa, Florida, USA
| | | | - Naa A Adjetey
- Department of Pediatrics and Child Health, Upper West Regional Hospital, Wa, Ghana
| | - Afua Agyekum
- Department of Anesthesia, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Marian Ayensu
- The Trust Hospital, Accra, Greater Accra Region, Ghana
| | - Leonita Bray
- Department of Pediatrics, Woodhull Medical and Mental Health Center, Brooklyn, New York, USA
| | - Priyank J Yagnik
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Parth Bhatt
- Department of Pediatrics, United Hospital Center, Bridgeport, West Virginia, USA
| | | |
Collapse
|
77
|
Okada A, Yamana H, Morita K, Sato Y, Yamaguchi S, Kurakawa KI, Michihata N, Matsui H, Fushimi K, Nangaku M, Yamauchi T, Yasunaga H, Kadowaki T. Potassium Concentration in Initial Fluid Therapy and In-Hospital Mortality of Patients with Diabetic Ketoacidosis. J Clin Endocrinol Metab 2021; 106:e2162-e2175. [PMID: 33493293 DOI: 10.1210/clinem/dgab029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Guidelines worldwide recommend potassium replacement of 10 to 40 mmol/L in the initial fluid therapy for patients with diabetic ketoacidosis. However, evidence is lacking as to the association between infused potassium concentration and mortality. OBJECTIVE We aimed to determine the association between infused potassium concentration and in-hospital mortality. METHODS Using the Japanese Diagnosis Procedure Combination database, we retrospectively identified inpatients admitted for treatment of diabetic ketoacidosis from July 2010 to March 2018. Patients with kidney dysfunction or serum potassium abnormalities were excluded. We evaluated the association of the potassium concentration in the total infused solutions in the first 2 days of hospitalization with 28-day in-hospital mortality using multivariable regression analysis with a cubic spline model. We also assessed the association between potassium concentration and occurrence of hyperkalemia. RESULTS We identified 14 216 patients with diabetic ketoacidosis and observed 261 deaths. The quartile cut-points for potassium concentration were 7.7, 11.4, and 16.1 mmol/L. Within the range of approximately 10 to 40 mmol/L, potassium concentration was not associated with occurrence of hyperkalemia or death. Lower potassium concentrations were associated with higher 28-day in-hospital mortality; the odds ratio for patients receiving 8 mmol/L was 1.69 (95% CI, 1.03 to 2.78; reference: 20 mmol/L), and the odds ratio increased monotonically as potassium concentration decreased further. CONCLUSION Patients receiving potassium replacement at concentrations of 10 to 40 mmol/L had similar in-hospital mortality rates, whereas lower concentrations were associated with higher mortality.
Collapse
Affiliation(s)
- Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hayato Yamana
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Yukihito Sato
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, Tokyo, Japan
| | - Satoko Yamaguchi
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kayo Ikeda Kurakawa
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, The University of Tokyo, Tokyo, Japan
| | - Takashi Kadowaki
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Toranomon Hospital, Tokyo, Japan
| |
Collapse
|
78
|
Klostermann S, Iskander J, Enlow P, Delamater AM, Dolan L, Pendley JS. Predicting healthcare utilization in youth with type 1 diabetes: The importance of family level variables. Pediatr Diabetes 2021; 22:294-302. [PMID: 33169899 DOI: 10.1111/pedi.13146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/29/2020] [Accepted: 11/06/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Little is known about how family factors impacting treatment adherence in type 1 diabetes are directly associated with unplanned healthcare utilization (e.g., emergency room visits and hospital admissions). Given the substantial financial burden of diabetes, understanding predictors of healthcare utilization in particular is important to inform behavioral interventions aimed toward improving adherence. RESEARCH DESIGN AND METHODS The current study examined the relationship between family-level variables and healthcare utilization in a sample of 239 youth with type 1 diabetes and their parents. Healthcare utilization was determined via parent report and chart review. Parent- and youth-reports regarding levels of family conflict, youth autonomy, and parent support related to diabetes management were obtained via questionnaire, and negative reciprocity was obtained by coding observations of parent and youth interactions. Generalized Estimating Equations were used to examine the longitudinal association between healthcare utilization and family-level factors. RESULTS Higher levels of observed negative reciprocity were associated with more frequent hospital admissions, while higher levels of youth-reported parent involvement in diabetes management were associated with fewer hospital admissions and ED visits. CONCLUSIONS These findings highlight how family-level factors are directly related to healthcare utilization and point to the continued importance of integrating family-focused behavioral interventions in routine medical care for improving type 1 diabetes outcomes and reducing healthcare costs.
Collapse
Affiliation(s)
- Susan Klostermann
- Department of Pediatrics, Nemours Children's Health System, Wilmington, Delaware, USA.,Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Paul Enlow
- Department of Pediatrics, Nemours Children's Health System, Wilmington, Delaware, USA.,Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alan M Delamater
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Lawrence Dolan
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Shroff Pendley
- Department of Pediatrics, Nemours Children's Health System, Wilmington, Delaware, USA.,Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
79
|
Zeller WP, DeGraff R, Zeller W. A novel telemedicine protocol improved outcomes for high-risk patients with type 1 diabetes: A 3-month quality improvement project during the COVID-19 pandemic. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2021; 19:100078. [PMID: 33527071 PMCID: PMC7839402 DOI: 10.1016/j.jecr.2021.100078] [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: 10/16/2020] [Revised: 12/21/2020] [Accepted: 01/15/2021] [Indexed: 11/05/2022] Open
Abstract
Our endocrinology practice needed to protect its highest-risk patients with type 1 diabetes (T1D) during the COVID-19 pandemic. To do so, we needed to identify these patients and develop a protocol to keep them out of the hospital (to limit risk of infection and conserve medical resources), and do so without in-person visits. So we used our peer-reviewed software, Diabetes Reporting, to identify 87 patients whose glucose management indicator (GMI) scores were over 9%. The GMI is a method for estimating the laboratory A1C using the patient's actual blood glucose measurements over the past 90 days. A GMI (or A1C) over 9% indicates a heightened risk of diabetic ketoacidosis (DKA) and, possibly, a slightly higher risk of severe hypoglycemia (SH), the two most common acute complications leading patients with T1D to be hospitalized. We contacted these 87 at-risk patients and enrolled them in a quality improvement project. This project consisted of additional online meetings with their doctors as well as weekly reports generated by Diabetes Reporting for three months, between March 28, 2020 and June 28, 2020. We hypothesized that this heightened communication would reduce the incidence of DKA and SH among the participants by reducing their GMI. As a comparison group, we used data from the T1D Exchange, which showed that, among patients with an A1C over 9%, 6.7% were hospitalized for DKA and 7% experienced SH leading to loss of consciousness in a three-month period. This led us to predict 6 incidences of DKA and 6 incidences of SH among our 87 participants during the three-month period. Instead, we saw 2 incidences of DKA and 1 incidence of SH. Moreover, the mean GMI of our participants dropped from 9.91% to 9.25%, a clinically-significant 0.66% improvement, which supports the conclusion that our protocol helped avoid acute complications among a cohort of at-risk patients with T1D by improving glycemic control during a time when we were limited to largely online care. This telemedicine protocol merits further research for its potential to improve and lower costs of care for patients with T1D, particularly for those at higher risk for acute complications.
Collapse
|
80
|
Singh B, Kaur P, Patel P, Reid RJ, Kumar A, Kaur S, Guragai N, Rushdy A, Bikkina M, Shamoon F. COVID-19 and Diabetic Ketoacidosis: A Single Center Experience. Cureus 2021; 13:e13000. [PMID: 33542884 PMCID: PMC7847783 DOI: 10.7759/cureus.13000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background and objectives: To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients with diabetic ketoacidosis (DKA) -- a single center tertiary hospital experience. Materials and Methods: A retrospective study was conducted among patients admitted to our hospital in the United States between March 1st and June 15th, 2020 with DKA and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection known as COVID-19. We compared the baseline characteristics, laboratory data, and clinical course between survivors and nonsurvivors to identify the risk factors associated with mortality in the patients with DKA. Results: A total number of 43 patients were included in this study. The median age was 52 years. Thirty-three (76.7%) patients were male. Median value of initial glucose on presentation was 553 mg/dL (300.0-1927.0 mg/dL). On admission, 33 (76.7%) patients had glycated hemoglobin (HbA1c) ≥ 8% (64 mmol/mol) and HbA1c was not obtained in 10 (23.3%) patients. Acute kidney injury (AKI) was seen in 37 (86.0%) patients, 6 (14%) patients required renal replacement therapy and 22 (51.2%) required mechanical ventilation. Among the 43 patients, 25 (58.1%) died. Out of 25 patients who died 15 (60.0%) were Hispanics, 6 (24.0%) were White, 3 (12.0%) were African American, 1 (4%) was Arabic, and 1 (4%) was Asian. The patients who died were older in age than who survived (mean age 58 ± 6.13 vs 46 ± 9.39; p = 0.023). Some 95% of the patients requiring mechanical ventilation died (odds ratio [OR]: 89.25; 95% confidence interval [CI]: 9.10-874.96); p = 0.001). Compared to survivors, nonsurvivors had significantly higher d-dimer (13.00 ± 3.20 mcg/mL vs 6.15 ± 3.66 mcg/mL; p< 0.006) and peak ferritin values (2763.66 ± 1105.32 ng/mL vs 835.16 ± 257.07 ng/mL; p= 0.016). Conclusion: Our retrospective study shows COVID-19 infection may present as DKA in patients with diabetes mellitus (DM). Older age, mechanical ventilation, elevated d-dimer, and ferritin are associated with poor prognosis in these patients. Our study shows that COVID-19 is associated with substantial mortality in DKA patients and adds to the limited literature available regarding poor risk factors associated with mortality in these patients.
Collapse
Affiliation(s)
- Balraj Singh
- Hematology/Oncology, Saint Joseph's University Medical Center, Paterson, USA
| | - Parminder Kaur
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Prem Patel
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Ro-Jay Reid
- Internal Medicine, Saint Joseph's University Medical Center, Paterson, USA
| | - Abhishek Kumar
- Hematology/Oncology, Jacobi Medical Center, New York, USA
| | - Supreet Kaur
- Hematology/Oncology, Saint Joseph's University Medical Center, Paterson, USA
| | - Nirmal Guragai
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Abanoub Rushdy
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Mahesh Bikkina
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Fayez Shamoon
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| |
Collapse
|
81
|
Temporal patterns of hospitalizations for diabetic ketoacidosis in children and adolescents. PLoS One 2021; 16:e0245012. [PMID: 33411822 PMCID: PMC7790255 DOI: 10.1371/journal.pone.0245012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/19/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives To examine the temporal patterns of hospitalizations with diabetic ketoacidosis (DKA) in the pediatric population and their associated fiscal impact. Methods The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1month-19 years with a primary diagnosis of DKA during 2005–2014. Temporal changes of population-adjusted hospitalization rates and hospitalization volumes were examined for the whole cohort and on stratified analyses of sociodemographic attributes. Changes in the aggregate and per-hospitalization charges were assessed overall and on stratified analyses. Results There were 24,072 DKA hospitalizations during the study period. The population-adjusted hospitalization rate for the whole cohort increased from 31.3 to 35.9 per 100,000 between 2005–2006 and 2013–2014. Hospitalization volume increased by 30.2% over the same period, driven mainly by males, ethnic minorities, those with Medicaid insurance and uninsured patients. The aggregate hospital charges increased from approximately $69 million to $130 million between 2005–2006 and 2013–2014, with 66% of the rise being due to increased per-hospitalization charges. Conclusions There was progressive rise in pediatric DKA hospitalizations over the last decade, with concurrent near-doubling of the associated fiscal footprint. Marked disparities were noted in the increasing hospitalization burden of DKA, born predominantly by racial and ethnic minorities, as well as by the underinsured and the uninsured. Further studies are needed to identify scalable preventive measures to achieve an equitable reduction of pediatric DKA events.
Collapse
|
82
|
Perez MM, Medar S, Quigley L, Clark BC. QTc Prolongation in Pediatric Patients with Diabetic Ketoacidosis. J Pediatr 2021; 228:235-239.e2. [PMID: 32890580 DOI: 10.1016/j.jpeds.2020.08.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To investigate the association between diabetic ketoacidosis (DKA) and prolonged QTc interval and to assess for correlation between DKA severity and QTc prolongation. STUDY DESIGN Retrospective observational study in a pediatric hospital. Patients admitted with DKA diagnosed by laboratory criteria and an electrocardiogram (ECG) performed during a period of acidosis were identified using Looking Glass Clinical Analytics. Data including age, sex, pH, electrolytes, anion gap, and ECG variables were collected. Patients were excluded if they had a prior diagnosis of prolonged QTc or were taking QTc prolonging medications. Severity of DKA was classified as mild (pH 7.24-7.3), moderate (pH 7-7.24), or severe (pH <7). ECGs were read by a pediatric electrophysiologist and QTc interval was manually calculated utilizing the Bazett formula. RESULTS Ninety-six patients were included (mean age 15.2 ± 4.2 years, pH 7.12 ± 0.12, bicarbonate 8.6 ± 3.7 mmol/L, potassium 5.3 ± 1.1 mEq/L). Mean QTc interval for all patients in DKA was 454 ± 32 msec. Mean QTc in the mild group was 441 ± 22 msec, moderate group 460 ± 36 msec, and severe group 461 ± 34 msec. There was a significant difference in QTc interval across DKA severity groups (P = .05). There was a significant association between higher anion gaps and greater QTc intervals (r = 0.21, P = .04). CONCLUSIONS Thirty-one percent of pediatric patients with DKA demonstrated QTc prolongation on ECG. Severity of DKA and worsening acidosis were associated with increased prolongation of the QTc. Further study is required to evaluate the clinical impact of these findings.
Collapse
Affiliation(s)
- Michelle M Perez
- Division of Pediatric Critical Care, Children's Hospital at Montefiore, Bronx, NY.
| | - Shivanand Medar
- Division of Pediatric Critical Care, Children's Hospital at Montefiore, Bronx, NY; Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Leanne Quigley
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
| | - Bradley C Clark
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Division of Cardiology, Children's Hospital at Montefiore, Bronx, NY
| |
Collapse
|
83
|
Mohamed A, Ploetz J, Hamarshi MS. Evaluation of Early Administration of Insulin Glargine in the Acute Management of Diabetic Ketoacidosis. Curr Diabetes Rev 2021; 17:e030221191986. [PMID: 33655870 DOI: 10.2174/1573399817666210303095633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution. OBJECTIVES To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients. METHODS This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed. RESULTS Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76-37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8-36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04-7.92; p<0.0001). CONCLUSION Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion.
Collapse
Affiliation(s)
- Adham Mohamed
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| | - Jeannette Ploetz
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| | - Majdi S Hamarshi
- Saint Luke's Hospital of Kansas City, 4401 Wornall Rd., Kansas City, MO 64111, United States
| |
Collapse
|
84
|
Kwa T, Zhang G, Shepard K, Wherry K, Chattaraj S. The improved survival rate and cost-effectiveness of a 7-day continuous subcutaneous insulin infusion set. J Med Econ 2021; 24:837-845. [PMID: 34154504 DOI: 10.1080/13696998.2021.1945784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS The purpose of this article is to compare the insulin cost-savings of the Medtronic Extended Infusion Set (or EIS, a.k.a. Extended Wear Infusion Set) designed and labeled for up to 7-day use with rapid-acting insulins to the current standard of care, 2- to 3-day infusion sets. METHODS There are three major improvements (reducing insulin waste, plastic waste, and adverse events) with the extended duration of infusion set wear. This analysis focuses on cost savings from reduced insulin wastage during set changes. Studies published on insulin infusion set survival and EIS clinical trial data (NCT04113694) were used to estimate device lifetime performance using a Markov chain Monte Carlo model, including the assessment of adverse effects and device failure. Total costs associated with infusion set change or failure were systematically found in published literature or estimated based on physical usage, and the direct impact on insulin costs was calculated. RESULTS Based on the model and clinical data, EIS users can expect to change their infusion sets about 75 fewer times than standard set users each year. The costs related to unrecoverable insulin during an infusion set and reservoir change in the US were estimated to range from $19.79 to $22.48, resulting in approximately $1324 to $1677 in annual cost-savings for the typical user from minimizing insulin wastage. LIMITATIONS The study only assessed devices used within a monitored setting, that is, clinical trials. In addition, the variability associated with healthcare standards and costs and individual treatment variability including insulin dosages, contribute to the uncertainties with the calculations. CONCLUSIONS Our analysis demonstrates that by extending the duration of infusion set wear, there may be substantial cost savings by reducing insulin wastage.
Collapse
|
85
|
Sato Y, Morita K, Okada A, Matsui H, Fushimi K, Yasunaga H. Factors affecting in-hospital mortality of diabetic ketoacidosis patients: A retrospective cohort study. Diabetes Res Clin Pract 2021; 171:108588. [PMID: 33310121 DOI: 10.1016/j.diabres.2020.108588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/23/2020] [Accepted: 11/30/2020] [Indexed: 02/08/2023]
Abstract
AIMS With advances in the diagnosis and treatment of diabetic ketoacidosis (DKA), its rate of in-hospital mortality has declined. However, the risk factors for in-hospital mortality in patients with DKA remain to be elucidated. METHODS Using a Japanese national inpatient database from 01 July 2010 to 31 March 2018, we performed multivariable logistic regression analyses to identify factors associated with in-hospital mortality of DKA patients. RESULTS We identified 25,627 DKA patients and 839 (3.3%) in-hospital deaths. Factors associated with increased in-hospital mortality included higher Charlson comorbidity index (≥4) (odds ratio, 3.38; 95% confidence interval, 2.30-4.96; p < 0.001), sepsis (odds ratio, 3.09; 95% confidence interval, 2.38-4.00; p < 0.001), type 2 diabetes mellitus (odds ratio, 2.67; 95% confidence interval, 2.09-3.41; p < 0.001), and obesity (odds ratio, 2.51; 95% confidence interval, 2.05-3.07; p < 0.001). Other factors positively associated with in-hospital mortality included male sex, age ≥ 60 years, consciousness disturbance, lower activities of daily living score at admission, admission requiring ambulance, and admission at non-academic hospital. CONCLUSIONS The present findings may help clinicians to identify DKA patients at higher risk of in-hospital mortality.
Collapse
Affiliation(s)
- Yukihito Sato
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan; Astellas Pharma Inc., 2-5-1 Nihonbashi Honcho, Chuo-ku, Tokyo 1030023, Japan.
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138519, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| |
Collapse
|
86
|
Ramphul K, Joynauth J. An Update on the Incidence and Burden of Diabetic Ketoacidosis in the U.S. Diabetes Care 2020; 43:e196-e197. [PMID: 33051332 DOI: 10.2337/dc20-1258] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/04/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Kamleshun Ramphul
- Shanghai Xin Hua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | |
Collapse
|
87
|
Nonsevere Diabetic Ketoacidosis and Adrenal Insufficiency: Exploring the Impact of Glucocorticoid Replacement on Metabolic Outcomes and ICU Length of Stay. Crit Care Explor 2020; 2:e0260. [PMID: 33196048 PMCID: PMC7655087 DOI: 10.1097/cce.0000000000000260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: There is a paucity of clinical data on corticosteroid replacement in patients with adrenal insufficiency who present with nonsevere noncomplicated diabetic ketoacidosis. Case Summary: We analyzed five consecutive admissions for diabetic ketoacidosis of mild/moderate severity due to insulin omission in a 21-year-old man with type 1 diabetes and stable Addison disease. Despite similar presentations, the approach to steroid replacement differed: maintenance/moderate doses of hydrocortisone (< 60 mg/d) or high stress-doses (≥ 120 mg/d). Resolution of diabetic ketoacidosis and ICU and hospital length of stay were prolonged when high-dose versus maintenance/moderate glucocorticoids were provided: 45.5, 47.0, and 63.0 versus 12.0, 24.5, and 31 hours, respectively. Conclusions: Although our findings remain hypothesis-generating, our case study raises awareness on the importance of categorizing diabetic ketoacidosis by severity and complication status when deciding on the intensity of steroid replacement in patients with stable Addison disease. Excessive glucocorticoid administration may delay the resolution of nonsevere and otherwise noncomplicated diabetic ketoacidosis and prolong ICU and hospital stays.
Collapse
|
88
|
Ekanayake PS, Juang PS, Kulasa K. Review of Intravenous and Subcutaneous Electronic Glucose Management Systems for Inpatient Glycemic Control. Curr Diab Rep 2020; 20:68. [PMID: 33165676 DOI: 10.1007/s11892-020-01364-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize current literature on electronic glucose management systems (eGMS) and discuss their benefits and disadvantages in the inpatient setting. RECENT FINDINGS We review different versions of commercially available eGMS: Glucommander™ (Glytec, Greenville, SC), EndoToolR (MD Scientific LLC, Charlotte, NC), GlucoStabilizer™ (Medical Decision Network, Charlottesville, VA), GlucoCare™ (Pronia Medical Systems, KY), and discuss advantages such as reducing rates of hypoglycemia, hyperglycemia, and glycemic variability. In addition, eCGMs offer a uniform standard of care and may improve workflows across institutions as well reduce barriers. Despite ample literature on intravenous (IV) versions of eGMS, there is little published research on subcutaneous (SQ) insulin guidance. Although use of eGMS requires extensive training and institution-wide adoption, time spent on diabetes management is better facilitated by their use.
Collapse
Affiliation(s)
- Preethika S Ekanayake
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA.
| | - Patricia S Juang
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
| | - Kristen Kulasa
- Department of Internal Medicine, Division of Endocrinology and Metabolism, University of California, San Diego, San Diego, CA, USA
| |
Collapse
|
89
|
Peters AL, McGuire DK, Danne T, Kushner JA, Rodbard HW, Dhatariya K, Sawhney S, Banks P, Jiang W, Davies MJ, Lapuerta P. Diabetic Ketoacidosis and Related Events With Sotagliflozin Added to Insulin in Adults With Type 1 Diabetes: A Pooled Analysis of the inTandem 1 and 2 Studies. Diabetes Care 2020; 43:2713-2720. [PMID: 32928957 PMCID: PMC7576419 DOI: 10.2337/dc20-0924] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/09/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the incidence and risk factors for diabetic ketoacidosis (DKA) and related adverse events (AEs) in adults with type 1 diabetes treated with sotagliflozin adjunctive to insulin. RESEARCH DESIGN AND METHODS Data from two identically designed, 52-week, randomized studies were pooled and analyzed for DKA, changes in β-hydroxybutyrate (BHB), and percentage of patients with BHB >0.6 and >1.5 mmol/L. The patients were administered placebo, sotagliflozin 200 mg, or sotagliflozin 400 mg once daily. RESULTS A total of 191 ketosis-related AEs were reported, and 98 underwent adjudication. Of these, 37 events (36 patients) were adjudicated as DKA, with an exposure-adjusted incidence rate of 0.2, 3.1, and 4.2 events per 100 patient-years for placebo, sotagliflozin 200 mg, and sotagliflozin 400 mg, respectively. No patient died of a DKA event. From a baseline BHB of ∼0.13 mmol/L, sotagliflozin treatment led to a small median increase over 52 weeks (≤0.05 mmol/L at all time points). Of sotagliflozin-treated patients, approximately 47% and 7% had ≥1 BHB measurement >0.6 mmol/L and >1.5 mmol/L, respectively (vs. 20% and 2%, respectively, of placebo-treated patients). Subsequent to the implementation of a risk mitigation plan, annualized DKA incidence was lower versus preimplementation in both the sotagliflozin 200 and 400 mg groups. CONCLUSIONS In patients with type 1 diabetes, confirmed DKA incidence increased when sotagliflozin was added to insulin compared with insulin alone. A lower incidence of DKA was observed following the implementation of an enhanced risk mitigation plan, suggesting that this risk can be managed with patient education.
Collapse
Affiliation(s)
- Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Thomas Danne
- Kinder Krakenhaus auf der Bult, Diabetes Zentrum für Kinder and Jugendliche, Hannover, Germany
| | | | - Helena W Rodbard
- Endocrine and Metabolic Consultants Research Center, Rockville, MD
| | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norwich, U.K
| | | | | | - Wenjun Jiang
- Lexicon Pharmaceuticals, Inc., The Woodlands, TX
| | | | | |
Collapse
|
90
|
Forbes TH, Hodgson J, Crespo J, Jones E, Hardee S. Putting the Pieces Together: An Exploration of Diabetes Ketoacidosis Readmissions. CONTEMPORARY FAMILY THERAPY 2020. [DOI: 10.1007/s10591-020-09551-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
91
|
Ferdinand AO, Akinlotan MA, Callaghan T, Towne SD, Bolin JN. Factors affecting the likelihood of a hospitalization following a diabetes-related emergency department visit: A regional and urban-rural analysis. J Diabetes 2020; 12:686-696. [PMID: 32436371 DOI: 10.1111/1753-0407.13066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The objective of this study is to examine place-based and individual-level predictors of diabetes-related hospitalizations that stem from emergency department (ED) visits. METHODS We conducted a pooled cross-sectional analysis of the National Inpatient Sample (NIS) for 2009 to 2014 to identify ED-initiated hospitalizations that were driven by the need for diabetes care. The odds of an ED-initiated diabetes-related hospitalization were assessed for the United States as a whole and separately for each census region. RESULTS Nationally, residents of noncore areas (odds ratio [OR] 1.10; CI 1.08, 1.12), the South (OR 8.03; CI 6.84, 9.42), Blacks (OR 2.49; CI 2.47, 2.52), Hispanics (OR 2.32; CI 2.29, 2.35), Asians or Pacific Islanders (OR 1.20; CI 1.16, 1.23), Native Americans (OR 2.18; CI 2.10, 2.27), and the uninsured (OR 2.14; CI 2.11, 2.27) were significantly more likely to experience an ED-initiated hospitalization for diabetes care. Census region-stratified models showed that noncore residents of the South (OR 1.17; CI 1.14, 1.20) and Midwest (OR 1.06; CI 1.02, 1.11) had higher odds of a diabetes-related ED-initiated hospitalization. CONCLUSIONS As continued efforts are made to reduce place-based disparities in diabetes care and management, targeted focus should be placed on residents of noncore areas in the South and Midwest, racial and ethnic minorities, as well as the uninsured population.
Collapse
Affiliation(s)
- Alva O Ferdinand
- Department of Health Policy & Management, Texas A&M University, School of Public Health, College Station, Texas, USA
- Southwest Rural Health Research Center, Texas A&M University, School of Public Health, College Station, Texas, USA
| | - Marvellous A Akinlotan
- Department of Health Policy & Management, Texas A&M University, School of Public Health, College Station, Texas, USA
- Southwest Rural Health Research Center, Texas A&M University, School of Public Health, College Station, Texas, USA
- College of Nursing, Texas A&M University, Bryan, Texas, USA
| | - Timothy Callaghan
- Department of Health Policy & Management, Texas A&M University, School of Public Health, College Station, Texas, USA
- Southwest Rural Health Research Center, Texas A&M University, School of Public Health, College Station, Texas, USA
| | - Samuel D Towne
- Southwest Rural Health Research Center, Texas A&M University, School of Public Health, College Station, Texas, USA
- Department of Health Management & Informatics, University of Central Florida, Orlando, Florida, USA
- Disability, Aging, & Technology Faculty Cluster Initiative, University of Central Florida, Orlando, Florida, USA
| | - Jane N Bolin
- Department of Health Policy & Management, Texas A&M University, School of Public Health, College Station, Texas, USA
- Southwest Rural Health Research Center, Texas A&M University, School of Public Health, College Station, Texas, USA
- College of Nursing, Texas A&M University, Bryan, Texas, USA
| |
Collapse
|
92
|
Ferrat LA, Vehik K, Sharp SA, Lernmark Å, Rewers MJ, She JX, Ziegler AG, Toppari J, Akolkar B, Krischer JP, Weedon MN, Oram RA, Hagopian WA. A combined risk score enhances prediction of type 1 diabetes among susceptible children. Nat Med 2020; 26:1247-1255. [PMID: 32770166 PMCID: PMC7556983 DOI: 10.1038/s41591-020-0930-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/08/2020] [Indexed: 11/08/2022]
Abstract
Type 1 diabetes (T1D)-an autoimmune disease that destroys the pancreatic islets, resulting in insulin deficiency-often begins early in life when islet autoantibody appearance signals high risk1. However, clinical diabetes can follow in weeks or only after decades, and is very difficult to predict. Ketoacidosis at onset remains common2,3 and is most severe in the very young4,5, in whom it can be life threatening and difficult to treat6-9. Autoantibody surveillance programs effectively prevent most ketoacidosis10-12 but require frequent evaluations whose expense limits public health adoption13. Prevention therapies applied before onset, when greater islet mass remains, have rarely been feasible14 because individuals at greatest risk of impending T1D are difficult to identify. To remedy this, we sought accurate, cost-effective estimation of future T1D risk by developing a combined risk score incorporating both fixed and variable factors (genetic, clinical and immunological) in 7,798 high-risk children followed closely from birth for 9.3 years. Compared with autoantibodies alone, the combined model dramatically improves T1D prediction at ≥2 years of age over horizons up to 8 years of age (area under the receiver operating characteristic curve ≥ 0.9), doubles the estimated efficiency of population-based newborn screening to prevent ketoacidosis, and enables individualized risk estimates for better prevention trial selection.
Collapse
Affiliation(s)
- Lauric A Ferrat
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Kendra Vehik
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Seth A Sharp
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University and Skåne University Hospital, Malmö, Sweden
| | - Marian J Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jin-Xiong She
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Anette-G Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, Munich, Germany
- Forschergruppe Diabetes, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
- Forschergruppe Diabetes e.V., Munich, Germany
| | - Jorma Toppari
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Beena Akolkar
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey P Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Academic Renal Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | |
Collapse
|
93
|
Kao KT, Islam N, Fox DA, Amed S. Incidence Trends of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes in British Columbia, Canada. J Pediatr 2020; 221:165-173.e2. [PMID: 32446476 DOI: 10.1016/j.jpeds.2020.02.069] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To estimate the 11-year incidence trend of diabetic ketoacidosis (DKA) at and after the diagnosis of type 1 diabetes. STUDY DESIGN A retrospective cohort study using a population-based administrative cohort diagnosed with type 1 diabetes at <20 years of age from 2002 to 2012 in British Columbia, Canada. DKA at (1 episode per individual) and DKA after (multiple episodes per individual) the diagnosis of diabetes were defined as DKA occurring ≤14 days or >14 days, respectively, from diagnosis, identified using International Classification of Diseases,9th and 10theditions codes. Incidence rate ratios were estimated using Poisson regression and DKA trends using Joinpoint regression analyses. RESULTS There were 1519 individuals (mean age at first-DKA, 12.6 ± 5.9 years; 50% male) with ≥1 DKA episode identified. Of 2615 incident cases of type 1 diabetes, there were 847 (32.4%; mean age, 9.9 ± 4.8 years; 52% male) episodes of DKA at the diagnosis of diabetes. Among prevalent cases of type 1 diabetes (1790 cases in 2002 increasing to 2264 in 2012), there were 1886 episodes of DKA after the diagnosis of diabetes (mean age at first DKA, 15.7 ± 5.2 years). The rates per 100 person-years of DKA at diabetes diagnosis (ranging from 24.1 in 2008 to 37.3 in 2006) and DKA after diabetes diagnosis (ranging from 4.9 in 2002 to 7.7 in 2008) remained stable. Females showed a 67% higher rate of incidence of DKA after the diagnosis of diabetes compared with their male counterparts (incidence rate ratio, 1.67; 95% CI, 1.50-1.86; P < .001), adjusted for the temporal trend by fiscal year. Younger age at diagnosis (<5 years) was associated with a greater risk of DKA at the time of diabetes diagnosis and older children (≥10 years) had a greater risk of DKA after the diagnosis of diabetes. CONCLUSIONS The risk of DKA at the time of diagnosis of diabetes was greater with younger age and the risk of DKA after the diagnosis of diabetes was higher in females and older children and youth.
Collapse
Affiliation(s)
- Kung-Ting Kao
- Divisions of Diabetes and Endocrinology, British Columbia Children's Hospital and Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Nazrul Islam
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Danya A Fox
- Divisions of Diabetes and Endocrinology, British Columbia Children's Hospital and Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Shazhan Amed
- Divisions of Diabetes and Endocrinology, British Columbia Children's Hospital and Department of Pediatrics, University of British Columbia, Vancouver, Canada.
| |
Collapse
|
94
|
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.
Collapse
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
| | | |
Collapse
|
95
|
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.
Collapse
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
| |
Collapse
|
96
|
Ehrmann D, Kulzer B, Roos T, Haak T, Al-Khatib M, Hermanns N. Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes. Lancet Diabetes Endocrinol 2020; 8:436-446. [PMID: 32333879 DOI: 10.1016/s2213-8587(20)30042-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 01/02/2023]
Abstract
Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.
Collapse
Affiliation(s)
- Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; Diabetes Clinic Mergentheim, Bad Mergentheim, Germany
| | - Timm Roos
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany
| | - Thomas Haak
- Diabetes Clinic Mergentheim, Bad Mergentheim, Germany
| | - Mohammed Al-Khatib
- HealthPlus Diabetes & Endocrinology Centre, Abu Dhabi, United Arab Emirates
| | - Norbert Hermanns
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; Diabetes Clinic Mergentheim, Bad Mergentheim, Germany.
| |
Collapse
|
97
|
Rabbone I, Maltoni G, Tinti D, Zucchini S, Cherubini V, Bonfanti R, Scaramuzza A. Diabetic ketoacidosis at the onset of disease during a national awareness campaign: a 2-year observational study in children aged 0-18 years. Arch Dis Child 2020; 105:363-366. [PMID: 31597646 DOI: 10.1136/archdischild-2019-316903] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 09/11/2019] [Accepted: 09/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE After a previous survey on the incidence of diabetic ketoacidosis (DKA) at onset of type 1 diabetes in children in 2013-2014 in Italy, we aimed to verify a possible decline in the incidence of DKA at onset during a national prevention campaign. DESIGN Prospective observational study. SETTING Multicentre study throughout Italy. INTERVENTION National awareness campaign started in November 2015 and held until December 2017. PATIENTS During 2016 and 2017 we collected data on all patients aged 0-18 years with new-onset diabetes. MAIN OUTCOME MEASURES DKA (pH <7.30), severe DKA (pH <7.1), DKA in children below 6 years and DKA treatment according to the Italian Society for Pediatric Endocrinology and Diabetology (ISPED) protocol were evaluated. RESULTS Records (n=2361) of children with newly diagnosed type 1 diabetes were collected from 58 out of 68 (85.3%) centres of the original survey participants and 100% of the previously surveyed tertiary centres. Overall, DKA was observed in 1124 patients, with an increased rate when compared with the previous survey (47.6% vs 38.5%, p=0.002), and severe DKA in 15.3%. In children below 6 years, DKA was observed in 323 out of 617 (52.5%) and severe DKA in 16.7%; in this age group, occurrence of DKA reduced by 21.3% (p=0.009). DKA treatment according to the ISPED guidelines was adopted in 95% of the centres, with a 27% improvement (p=0.025). CONCLUSIONS During a 2-year awareness campaign, DKA at onset of diabetes in children and adolescents 0-18 years is still common and increased when compared with the 2013-2014 survey.
Collapse
Affiliation(s)
- Ivana Rabbone
- Pediatric, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giulio Maltoni
- Pediatric Department, S Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Davide Tinti
- Pediatric, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Stefano Zucchini
- Pediatric Department, S Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Valentino Cherubini
- Regional Center for Diabetes in Children and Adolescents, Department of Woman and Child Health, AOU Salesi Hospital, Ancona, Italy
| | | | - Andrea Scaramuzza
- Pediatrics, Azienda Socio Sanitaria Territoriale di Cremona, Cremona, Italy
| | | |
Collapse
|
98
|
Dai H, Su X, Li H, Zhu L. Association between red blood cell distribution width and mortality in diabetic ketoacidosis. J Int Med Res 2020; 48:300060520911494. [PMID: 32228354 PMCID: PMC7132821 DOI: 10.1177/0300060520911494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 02/14/2020] [Indexed: 01/15/2023] Open
Abstract
Background No epidemiological studies have assessed the impact of red blood cell distribution width (RDW) on the prognosis of diabetic ketoacidosis (DKA) patients in the intensive care unit (ICU). Thus, we investigated whether RDW was associated with mortality in DKA patients. Material and method We analyzed data from MIMIC-III. RDW was measured at ICU admission. The relationship between RDW and mortality of DKA was determined using a multivariate Cox regression analysis. The primary outcome of the study was 365-day mortality from the date of ICU admission. We also conducted a subgroup analysis to further confirm the consistency of associations. Results In total, 495 critically ill DKA patients were eligible for analysis. In the univariable Cox regression model for 365-day all-cause mortality, RDW was a predictor of all-cause mortality in DKA patients (hazard ratio [HR]: 1.30, 95% confidence interval [CI]: 1.19–1.43). After adjusting for confounders, RDW was still a particularly strong predictor (HR: 1.23, 95% CI: 1.05–1.45). The same relationship was also observed for 90-day all-cause mortality (HR: 1.29, 95% CI: 1.02–1.65). Conclusions High RDW was associated with risk of all-cause mortality in DKA patients in the ICU. RDW was an independent prognostic factor for these patients.
Collapse
Affiliation(s)
- Huifang Dai
- Department of Endocrinology and Vascular Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Xiaoyou Su
- Department of Endocrinology and Vascular Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Hai Li
- Department of Endocrinology and Vascular Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| | - Lielie Zhu
- Department of Emergency, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, P.R. China
| |
Collapse
|
99
|
Moderate-Intensity Insulin Therapy Is Associated With Reduced Length of Stay in Critically Ill Patients With Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State. Crit Care Med 2020; 47:700-705. [PMID: 30855284 DOI: 10.1097/ccm.0000000000003709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Insulin infusion therapy is commonly used in the hospital setting to manage diabetic ketoacidosis and hyperosmolar hyperglycemic state. Clinical evidence suggests both hypoglycemia and glycemic variability negatively impact patient outcomes. The hypothesis of this study was that moderate-intensity insulin therapy decreases hospital length of stay and prevalence of hypoglycemia in patients with diabetic ketoacidosis and hyperosmolar hyperglycemic state. DESIGN Pre-post study. SETTING Large academic medical center in the United States. PATIENTS Two-hundred one consecutive, nonpregnant, adult patients admitted for diabetic ketoacidosis and hyperosmolar hyperglycemic state between October 2010 and December 2014. INTERVENTIONS High-intensity insulin therapy versus moderate-intensity insulin therapy. High-intensity insulin therapy was designed to rapidly normalize blood glucose levels with bolus doses of insulin and rapid insulin titration. Moderate-intensity insulin therapy was designed to mitigate glycemic variability and hypoglycemia through avoidance of bolus dosing, a liberalized blood glucose target, and gradual insulin titration. MEASUREMENTS AND MAIN RESULTS Hospital and ICU length of stay were reduced by 23.6% and 38%, respectively. The relative risk of remaining in the hospital at day 7 (0.51; p = 0.022) and day 14 (0.28; p = 0.044) were significantly reduced by the moderate-intensity insulin therapy strategy. The relative risk of remaining in the ICU at 48 hours was significantly lower in the moderate-intensity insulin therapy cohort (0.34; p = 0.0048). The prevalence (35% vs 1%; p = 0.0003) and relative risk (0.028; p = 0.0004) of hypoglycemia were significantly lower in the moderate-intensity insulin therapy cohort. Glycemic variability decreased by 28.6% (p < 0.0001). There was no difference in the time to anion gap closure (p = 0.123). CONCLUSIONS Moderate-intensity insulin therapy for diabetic ketoacidosis and hyperosmolar hyperglycemic state resulted in improvements in hospital and ICU length of stay, which appeared to be associated with decreased glycemic variability.
Collapse
|
100
|
Sussman M, Benner J, Haller MJ, Rewers M, Griffiths R. Estimated Lifetime Economic Burden of Type 1 Diabetes. Diabetes Technol Ther 2020; 22:121-130. [PMID: 31886730 DOI: 10.1089/dia.2019.0398] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The financial strain of type 1 diabetes on the United States health care system, patients, and employers underscores the importance of developing novel treatments for the disease. This study estimated the lifetime economic burden attributable to type 1 diabetes in the United States. Methods: A patient-level, Markov state/transition simulation model was developed to compare cumulative societal costs among patients with and without type 1 diabetes. For each patient type, 1 prevalent and 10 incident cohorts were constructed and followed annually over a lifetime horizon. The 1 prevalent cohort with type 1 diabetes entered in the first year of the model and at the current age of each patient, whereas the 10 incident cohorts entered in each of 10 subsequent years and at the age of diagnosis of each patient. Patients were assigned age-specific annual medical expenditures and lost wages. Model outputs included the total cumulative medical and lost productivity costs attributable to type 1 diabetes, defined as the difference in costs between patients with and without type 1 diabetes. Results: The model consisted of 1,630,317 patients with type 1 diabetes and an equal number of patients without type 1 diabetes. The difference in lifetime costs was $813 billion (95% confidence interval: $682-$1037 billion), representing a high burden of illness compared with patients without type 1 diabetes. Sensitivity analyses demonstrated robustness in model results. Conclusions: Our findings suggest significant investment in research and development of novel treatments for type 1 diabetes is justified, given the high burden of illness associated with the disease.
Collapse
Affiliation(s)
| | | | - Michael J Haller
- Department of Pediatric Endocrinology, University of Florida, Gainesville, Florida
| | - Marian Rewers
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, Colorado
| | - Robert Griffiths
- Boston Health Economics, LLC, Boston, Massachusetts
- Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|