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Kostopoulou E, Sinopidis X, Fouzas S, Gkentzi D, Dassios T, Roupakias S, Dimitriou G. Diabetic Ketoacidosis in Children and Adolescents; Diagnostic and Therapeutic Pitfalls. Diagnostics (Basel) 2023; 13:2602. [PMID: 37568965 PMCID: PMC10416834 DOI: 10.3390/diagnostics13152602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/21/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023] Open
Abstract
Diabetic ketoacidosis (DKA) represents an acute, severe complication of relative insulin deficiency and a common presentation of Type 1 Diabetes Mellitus (T1DM) primarily and, occasionally, Type 2 Diabetes Mellitus (T2DM) in children and adolescents. It is characterized by the biochemical triad of hyperglycaemia, ketonaemia and/or ketonuria, and acidaemia. Clinical symptoms include dehydration, tachypnoea, gastrointestinal symptoms, and reduced level of consciousness, precipitated by a variably long period of polyuria, polydipsia, and weight loss. The present review aims to summarize potential pitfalls in the diagnosis and management of DKA. A literature review was conducted using the Pubmed/Medline and Scopus databases including articles published from 2000 onwards. Diagnostic challenges include differentiating between T1DM and T2DM, between DKA and hyperosmolar hyperglycaemic state (HHS), and between DKA and alternative diagnoses presenting with overlapping symptoms, such as pneumonia, asthma exacerbation, urinary tract infection, gastroenteritis, acute abdomen, and central nervous system infection. The mainstays of DKA management include careful fluid resuscitation, timely intravenous insulin administration, restoration of shifting electrolyte disorders and addressing underlying precipitating factors. However, evidence suggests that optimal treatment remains a therapeutic challenge. Accurate and rapid diagnosis, prompt intervention, and meticulous monitoring are of major importance to break the vicious cycle of life-threatening events and prevent severe complications during this potentially fatal medical emergency.
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Affiliation(s)
- Eirini Kostopoulou
- Department of Paediatrics, University of Patras, 26504 Patras, Greece; (X.S.); (S.F.); (D.G.); (T.D.); (S.R.); (G.D.)
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Messer LH, Vigers T, Akturk HK, Forlenza GP, Huss KB, Karami AJ, Malecha E, Oser SM, Polsky S, Pyle L, Shah VN, Wadwa RP, Oser TK. Increasing Use of Diabetes Devices: What Do Health Care Professionals Need? Clin Diabetes 2023; 41:386-398. [PMID: 37456091 PMCID: PMC10338282 DOI: 10.2337/cd22-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Despite evidence of improved diabetes outcomes with diabetes technology such as continuous glucose monitoring (CGM) systems, insulin pumps, and hybrid closed-loop (HCL) insulin delivery systems, these devices are underutilized in clinical practice for the management of insulin-requiring diabetes. This low uptake may be the result of health care providers' (HCPs') lack of confidence or time to prescribe and manage devices for people with diabetes. We administered a survey to HCPs in primary care, pediatric endocrinology, and adult endocrinology practices in the United States. Responding HCPs expressed a need for device-related insurance coverage tools and online data platforms with integration to electronic health record systems to improve diabetes technology uptake in these practice settings across the United States.
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Affiliation(s)
- Laurel H. Messer
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Tim Vigers
- University of Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO
| | - Halis K. Akturk
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Gregory P. Forlenza
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Kelsey B. Huss
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
| | - Angela J. Karami
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Emily Malecha
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Sean M. Oser
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
| | - Sarit Polsky
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Laura Pyle
- University of Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO
| | - Viral N. Shah
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - R. Paul Wadwa
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Tamara K. Oser
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
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Moreno-Fernandez J, Chico A, Martínez-Brocca MA, Beato-Víbora PI, Vidal M, Piedra M, Quirós C, Muñoz-Rodríguez JR. Continuous Subcutaneous Insulin Infusion in Type 1 Diabetes Mellitus Patients: Results from the Spanish National Registry. Diabetes Technol Ther 2022; 24:898-906. [PMID: 35947087 DOI: 10.1089/dia.2022.0207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aim: To analyze the clinical effect of continuous subcutaneous insulin infusion (CSII) in type 1 diabetes mellitus (T1D) patients in the Spanish real-world scenario. Methods: All T1D patients on CSII registered in the SPAnish Insulin Pump (SPAIP) registry were included. The primary efficacy outcome was change in HbA1c during follow-up. Secondary efficacy outcomes included: insulin pump indications, diabetes complication rates, insulin and pump use, and continuous glucose monitoring (CGM) glycometrics. Patient data were typed through the web-based SPAIP registry. Results: Data from 2979 T1D patients treated with CSII were analyzed. The median age was 44 years (interquartile range [IQR] 34-52 years), and T1D duration was 27 years (IQR 18-35 years). The median duration of CSII therapy was 6 years (IQR 3-10 years). The main indications for treatment were suboptimal glycemic control (33.8%), hypoglycemia (22.1%), and increased glycemic variability (18.8%). Glycated hemoglobin decreased by 6 mmol/mol (95% CI, -5 to -6 mmol/mol, P < 0.001) [-0.5%, 95% CI, -0.4 to -0.5, P < 0.001] during the follow-up. The percentage of patients with severe hypoglycemia decreased from 14.9% to 0.9% (P < 0.001). We observed an inverse correlation between final HbA1c levels and CGM adherence (R = -0.24, P < 0.001) or percentage of time with active hybrid closed-loop functions (R = -0.25, P < 0.001). Conclusions: CSII treatment was associated with a sustained improvement in glycemic control in the Spanish population. This benefit was greater among patients with higher CGM or active hybrid closed-loop functions adherence. The protocol was publicly registered at ClinicalTrials.gov (NCT04761094).
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Affiliation(s)
- Jesus Moreno-Fernandez
- Department of Endocrinology and Nutrition, Ciudad Real General University Hospital, Ciudad Real, Spain
| | - Ana Chico
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Mercé Vidal
- Department of Endocrinology and Nutrition, Barcelona Clinic Hospital, Barcelona, Spain
| | - María Piedra
- Department of Endocrinology and Nutrition, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Carmen Quirós
- Department of Endocrinology and Nutrition, Terrassa Hospital, Terrassa, Barcelona, Spain
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Sastre J, Pinés PJ, del Val F, Moreno-Fernandez J, Gonzalez López J, Quiroga I, Herranz S, López Gallardo G, Calderón D, López López J. Control metabólico y pautas de tratamiento en pacientes con diabetes tipo 1 en Castilla-La Mancha, 10 años después. Estudio DIACAM1 2020. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sastre J, Pinés PJ, Del Val F, Moreno-Fernandez J, Gonzalez López J, Quiroga I, Herranz S, López Gallardo G, Calderón D, López López J. Metabolic control and treatment regimens in patients with type 1 diabetes in Castilla-La Mancha, 10 years later: The 2020 DIACAM1 study. ENDOCRINOL DIAB NUTR 2022; 69:483-492. [PMID: 36008243 DOI: 10.1016/j.endien.2022.07.006] [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: 05/03/2021] [Accepted: 10/05/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate degree of metabolic control and treatment regimens in patients with type 1 diabetes mellitus (T1DM) enrolled in the DIACAM1 study, after 10 years of follow-up under routine clinical practice conditions. PATIENTS AND METHODS A total of 1,465 patients enrolled in the DIACAM1 study, a multicentre, cross-sectional study conducted in Castilla-La Mancha in 2010, were analysed. Of these patients, 58 (4%) died during the 10-year follow-up period. Anthropometric, clinical, laboratory and treatment data were reviewed for 1,121 (76.5%) patients in active follow-up. RESULTS Mean glycosylated haemoglobin (HbA1c) levels were 7.66% lower than in 2010 (p<0.001), 26% of patients achieved HbA1c levels <7%, 24.4% were obese, 51.7% had dyslipidaemia and 33.6% had hypertension. The following were found to be predictive factors for good glycaemic control (HbA1c<7%): good glycaemic control in 2010 (odds ratio [OR] 4.8); the use of intensified insulin regimens, including the Institute for Clinical Systems Improvement (ICSI) guideline and glucose monitoring (OR 2.8); no hyperlipidaemia (OR 1.97); and higher levels of education (OR 1.4). The recommended targets for lipid and blood pressure control were met by 76% of patients; 40% of the patients enrolled required drug treatment. CONCLUSIONS Glycaemic control in patients with T1DM in Castilla-La Mancha improved after 10 years of follow-up. The use of intensified insulin regimens and technology applied to diabetes care appear to be determining factors in achieving this improvement. Despite the increase in the prevalence of cardiovascular risk factors, the majority of the patients achieved good lipid and blood pressure control.
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Affiliation(s)
- Julia Sastre
- Servicio de Endocrinología, Hospital Universitario de Toledo, Toledo, Spain.
| | - Pedro José Pinés
- Servicio de Endocrinología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Florentino Del Val
- Sección de Endocrinología, Complejo Hospitalario La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | | | | | - Iván Quiroga
- Sección de Endocrinología, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Sandra Herranz
- Sección de Endocrinología, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Gema López Gallardo
- Unidad de Endocrinología, Hospital Santa Bárbara, Puertollano, Ciudad Real, Spain
| | - Dulce Calderón
- Sección de Endocrinología, Hospital Virgen de la Luz, Cuenca, Spain
| | - José López López
- Servicio de Endocrinología, Hospital Universitario de Toledo, Toledo, Spain
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Gargallo Fernández M, Artola Menéndez S, Picón César MJ, Reyes García R. Application of the changes in the Standards of Medical Care in Diabetes ADA 2021 to clinical practice in our country. SED-SEEN document. ENDOCRINOL DIAB NUTR 2021; 68:664-667. [PMID: 34906347 DOI: 10.1016/j.endien.2021.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Manuel Gargallo Fernández
- Endocrinología y Nutrición, Hospital Universitario Infanta Leonor, Fundación Jiménez Díaz, Madrid, Spain.
| | | | | | - Rebeca Reyes García
- Unidad de Endocrinología y Nutrición, Hospital Universitario Torrecárdenas, Almería, Spain
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Gargallo Fernández M, Artola Menéndez S, Picón César MJ, Reyes García R. Application of the changes in the Standards of Medical Care in Diabetes ADA 2021 to clinical practice in our country. SED-SEEN document. ENDOCRINOL DIAB NUTR 2021; 68:S2530-0164(21)00179-8. [PMID: 34364840 DOI: 10.1016/j.endinu.2021.04.006] [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: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Manuel Gargallo Fernández
- Endocrinología y Nutrición, Hospital Universitario Infanta Leonor. Fundación Jiménez Díaz, Madrid, España.
| | | | | | - Rebeca Reyes García
- Unidad de Endocrinología y Nutrición, Hospital Universitario Torrecárdenas, Almería, España
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Effect of Insulin Pump Use on Diabetic Ketoacidosis in Type 1 Diabetes Mellitus: A Matched Cohort Study. J Clin Med 2021; 10:jcm10050898. [PMID: 33668749 PMCID: PMC7956187 DOI: 10.3390/jcm10050898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 01/25/2023] Open
Abstract
Background: Diabetic ketoacidosis (DKA) is a well-known complication of diabetes mellitus with a significantly high mortality if not immediately and properly treated. Therefore, strategies for prevention of DKA are ever so important when managing diabetes mellitus, especially in the non-compliant patient population. Previously studies have suggested insulin pump use to carry an increased risk of DKA compared to insulin injections, while European studies suggest the opposite. We aimed to perform a retrospective cohort study to determine the risk of DKA in insulin pump versus injection in the United States. Methods: We utilized the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2017 database, which represents a 20% sample of all payer hospitalizations in the United States. These hospitalizations were systematically selected by the Agency for Healthcare Resources and Quality (AHRQ) and we included all type 1 diabetes mellitus patients over the age of 18 who were on insulin, either pump or injections, in our study. Results: We found a total of 58,260 admissions for patients with type 1 DM. Of these, 7850 had insulin pump, 30,672 used insulin injection, and 19,738 had no prior insulin use. We found that insulin pump use, compared to injections, failed to predict a lower incidence of DKA in hospitalized patients. Conclusion: Although several studies from European countries have found a reduction of DKA risk with insulin pump use, in this study we found no clear significant difference in a United States-based study. While this may be possible due to different legislating and regulation organizations, further studies are warranted to further evaluate the benefit of either insulin dispensing modality.
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Real-world outcomes of insulin pump compared to multiple daily injection therapy in adult type 1 diabetes mellitus patients in a Mediterranean scenario. Int J Diabetes Dev Ctries 2020. [DOI: 10.1007/s13410-020-00887-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Moreno-Fernandez J, López LM, Gomez FJ, Pinés P, Blanco B, González J, López J, Herranz S, Roa C, Gómez-Romero FJ. Long-term effects of continuous subcutaneous insulin infusion in adults with type 1 diabetes mellitus patients: Results of a public healthcare system. ACTA ACUST UNITED AC 2020; 68:116-122. [PMID: 32007441 DOI: 10.1016/j.endinu.2019.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/11/2019] [Accepted: 10/30/2019] [Indexed: 12/27/2022]
Abstract
AIM To evaluate the long-term clinical effect of continuous subcutaneous insulin infusion (CSII) in adult type 1 diabetes mellitus (T1DM) patients in a regional public healthcare system real-world scenario. METHODS All adult T1DM patients on CSII for ≥10 years subjected to follow-up in the regional Castilla-La Mancha Public Health Service were included. The primary efficacy outcome was the variation in HbA1c during follow-up. Direct patient data were compiled through the web-based Spanish national registry on CSII therapy. RESULTS A total of 69 T1DM adult patients were treated with insulin pumps for ≥10 years in our region. The mean age was 45.0±10.5 years, with a T1DM duration of 13.9±8.5 years. The mean duration of CSII therapy was 11.4±2.1 years. The main indications for treatment were high glucose variability (39%), problematic hypoglycemia (26%), and HbA1c >53mmol/mol (7%) on multiple daily injections (20%). Sensor-augmented pump therapy was used by 31% of the patients. Glycosylated hemoglobin did not change during follow-up (58±11mmol/mol vs. 58±11mmol/mol; 7.5±1.0 vs. 7.5±1.0; p=0.66). However, the percentage of patients with at least one episode of severe hypoglycemia during the last year and unnoticed hypoglycemia decreased from 36% to 7% (p=0.006) and from 38% to 32% (p<0.001), respectively. The proportion of subjects with ≥1 episode of diabetic ketoacidosis in the last year decreased from 30% to 6% (p=0.045). CONCLUSIONS The reduction of severe hypoglycemia without deterioration of glycemic control can be sustained over long-term CSII therapy.
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Affiliation(s)
- Jesus Moreno-Fernandez
- Service of Endocrinology and Nutrition, Ciudad Real University Hospital, Ciudad Real, Spain.
| | - Luz María López
- Service of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Francisco Javier Gomez
- Service of Endocrinology and Nutrition, La Mancha-Centro General Hospital, Alcázar de San Juan, Ciudad Real, Spain
| | - Pedro Pinés
- Service of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Benito Blanco
- Service of Endocrinology and Nutrition, Nuestra Señora del Prado Hospital, Talavera de la Reina, Toledo, Spain
| | - Javier González
- Service of Endocrinology and Nutrition, Virgen de la Luz Hospital, Cuenca, Spain
| | - José López
- Service of Endocrinology and Nutrition, Virgen de la Salud Hospital, Toledo, Spain
| | - Sandra Herranz
- Service of Endocrinology and Nutrition, Guadalajara University Hospital, Guadalajara, Spain
| | - Carlos Roa
- Service of Endocrinology and Nutrition, Santa Barbara Hospital, Puertollano, Ciudad Real, Spain
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