1
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Ekberg NR, Hartvig NV, Kaas A, Møller JB, Adolfsson P. Smart Pen Exposes Missed Basal Insulin Injections and Reveals the Impact on Glycemic Control in Adults With Type 1 Diabetes. J Diabetes Sci Technol 2024; 18:66-73. [PMID: 35775735 PMCID: PMC10899845 DOI: 10.1177/19322968221104142] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adherence to basal insulin injections and the effects of missed basal insulin injections in adults with type 1 diabetes (T1D) were investigated using data from continuous glucose monitoring (CGM) and smart insulin pen devices in a real-world study. METHODS This was a post hoc analysis of a prospective, real-world study conducted in Sweden. Adults with T1D who were using CGM received a smart insulin pen device (NovoPen 6) for insulin injections. Missed basal insulin doses (≥40 hours between doses) were evaluated over 14-day periods, and the probability of missing basal insulin doses was estimated. Associations between missed basal insulin doses and glycemic outcomes were also explored. RESULTS Thirty-two patients with 4410 acceptable CGM days (315 14-day periods) were included. The number of missed basal insulin doses ranged from 0 to 4 over 315 14-day periods. The estimated probability of missing at least one basal insulin dose over any given 14-day period was 22% (95% confidence interval: 10%-40%). Missed basal insulin doses were significantly associated with higher mean glycemic levels, higher glucose management indicator, and lower time in range (70-180 mg/dL [3.9-10.0 mmol/L]). Similar results were observed when adjusted for missed bolus insulin doses; age and sex had no statistically significant effect on any glycemic parameter. CONCLUSIONS This is the first study, based on accurate real-world injection data, to demonstrate the challenge of adherence to basal insulin injections in patients with T1D, and document that just one missed basal injection per week can result in clinically significant changes in glycemic control.
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Affiliation(s)
- Neda Rajamand Ekberg
- Center for Diabetes, Academic Specialist Center, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Peter Adolfsson
- Department of Pediatrics, The Hospital of Halland, Kungsbacka, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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2
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Robinson DJ, Hanson K, Jain AB, Kichler JC, Mehta G, Melamed OC, Vallis M, Bajaj HS, Barnes T, Gilbert J, Honshorst K, Houlden R, Kim J, Lewis J, MacDonald B, MacKay D, Mansell K, Rabi D, Sherifali D, Senior P. Diabetes and Mental Health. Can J Diabetes 2023; 47:308-344. [PMID: 37321702 DOI: 10.1016/j.jcjd.2023.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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3
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Santos SS, Ramaldes LAL, Dualib PM, Gabbay MAL, Sá JR, Dib SA. Increased risk of death following recurrent ketoacidosis admissions: a Brazilian cohort study of young adults with type 1 diabetes. Diabetol Metab Syndr 2023; 15:85. [PMID: 37106409 PMCID: PMC10141950 DOI: 10.1186/s13098-023-01054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Recurrent DKA (rDKA) remains an acute type 1 diabetes complication even in post-insulin era. This study aimed to analyze the predictors and effects of rDKA on the mortality of patients with type 1 diabetes. METHODS Patients hospitalized (n = 231) wih diabetic ketoacidosis (between 2007 and 2018) were included. Laboratorial and clinical variables were collected. Mortality curves were compared in four groups: diabetic ketoacidosis as a new-onset type 1 diabetes (group A), single diabetic ketoacidosis episode after diagnosis of type 1 diabetes (group B), 2-5 diabetic ketoacidosis events (group C), and > 5 diabetic ketoacidosis events during follow-up period (group D). RESULTS During the follow-up period (approximately 1823 days), the mortality rate was 16.02% (37/231). The median age at death was 38.7 years. In the survival curve analysis, at 1926 days (5 years), the probabilities of death were indicated by ratios of 7.78%, 4.58%, 24.40%, and 26.63% in groups A, B, C, and D, respectively. One diabetic ketoacidosis episode compared with ≥ 2 events had a relative risk of 4.49 (p = 0.004) of death and > 5 events had 5.81 (p = 0.04). Neuropathy (RR 10.04; p < 0.001), retinopathy (relative risk 7.94; p < 0.01), nephropathy (RR 7.10; p < 0.001), mood disorders (RR 3.57; p = 0.002), antidepressant use (RR 3.09; p = 0.004), and statin use (RR 2.81; p = 0.0024) increased the risk of death. CONCLUSIONS Patients with type 1 diabetes with > 2 diabetic ketoacidosis episodes have four times greater risk of death in 5 years. Microangiopathies, mood disorders, and use of antidepressants and statins were important risk factors for short-term mortality.
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Affiliation(s)
- Sarah S Santos
- Department of Medicine, Endocrinology Division, Diabetes & Endocrinology Center, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Caixa Postal 20266/CEP: 04022-001, Sao Paulo, Brazil.
| | - Luana A L Ramaldes
- Department of Medicine, Endocrinology Division, Diabetes & Endocrinology Center, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Caixa Postal 20266/CEP: 04022-001, Sao Paulo, Brazil
| | - Patricia M Dualib
- Department of Medicine, Endocrinology Division, Diabetes & Endocrinology Center, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Caixa Postal 20266/CEP: 04022-001, Sao Paulo, Brazil
| | - Monica A L Gabbay
- Department of Medicine, Endocrinology Division, Diabetes & Endocrinology Center, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Caixa Postal 20266/CEP: 04022-001, Sao Paulo, Brazil
| | - João R Sá
- Department of Medicine, Endocrinology Division, Diabetes & Endocrinology Center, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Caixa Postal 20266/CEP: 04022-001, Sao Paulo, Brazil
| | - Sergio A Dib
- Department of Medicine, Endocrinology Division, Diabetes & Endocrinology Center, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Caixa Postal 20266/CEP: 04022-001, Sao Paulo, Brazil
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4
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Shand JAD, Morrow P, Braatvedt G. Mortality after discharge from hospital following an episode of diabetic ketoacidosis. Acta Diabetol 2022; 59:1485-1492. [PMID: 35951132 DOI: 10.1007/s00592-022-01953-5] [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: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 11/01/2022]
Abstract
AIMS The rate of inpatient mortality associated with diabetic ketoacidosis (DKA) has steadily decreased in recent decades. However, there remains a significantly increased outpatient death rate following an episode of survived DKA. We undertook this study to investigate the observed increase in mortality following an episode of DKA. METHODS We completed a retrospective cohort study to investigate rates and causes of death in people admitted to our hospital with DKA between 2013 and 2018. DKA was confirmed by pre-defined biochemical parameters and cause of death data was extracted from multiple sources. Follow-up was for two years after discharge for all participants with one-year mortality being the main time point for analysis. RESULTS We identified 818 admissions to hospital with DKA, affecting 284 people. Twenty people died as inpatients and a further 40 people died during the two-year follow-up. Of these 60 participants, cause of death was able to be determined for 41 (68%), with most deaths occurring due to infection or macrovascular disease. Risk factors for death within a year of hospital discharge included older age, vascular complications of diabetes, intellectual impairment and residential care living. Those who survived an episode of DKA had a one-year age-corrected mortality rate 13 times higher than the general population. This was more marked in the younger cohort with those aged 15-39 years being 49 times more likely to die in the year after surviving a DKA admission compared to their general population counterparts. CONCLUSION An episode of diabetic ketoacidosis is associated with a significant outpatient mortality risk with most deaths due to infectious or macrovascular causes. This study should prompt investigation of predictive scoring tools to identify those at increased mortality risk after DKA and encourage the development of targeted interventions to reduce mortality.
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Affiliation(s)
- James A D Shand
- Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand.
| | - Paul Morrow
- Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
| | - Geoff Braatvedt
- Auckland City Hospital, 2 Park Road, Grafton, Auckland, New Zealand
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5
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Allcock B, Stewart R, Jackson M. Psychosocial factors associated with repeat diabetic ketoacidosis in people living with type 1 diabetes: A systematic review. Diabet Med 2022; 39:e14663. [PMID: 34324739 DOI: 10.1111/dme.14663] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/09/2021] [Indexed: 11/26/2022]
Abstract
AIM To systematically review the literature concerning the psychosocial factors associated with repeat diabetic ketoacidosis for people living with type 1 diabetes. METHODS PsycInfo, Web of Science, CINAHL, PubMed and ASSIA were searched according to a registered study protocol (PROSPERO CRD42020167381). Data were extracted into a coding spreadsheet, and findings were synthesised narratively. Included papers were also subject to a quality assessment. RESULTS The search yielded 548 unique articles, of which 22 met inclusion criteria for this review. There was considerable variance across studies with regard to design, quality and outcome measured. Nevertheless, there was relatively consistent evidence to suggest that repeat diabetic ketoacidosis in type 1 diabetes is associated with female gender, adolescent to young adult age range, lower socio-economic status and poor mental health. Some evidence was also observed for the role of ethnicity and, for children and young people at least, family, social and behavioural issues. However, this was limited by issues of methodological rigour and scant investigation. CONCLUSIONS The review identified four psychosocial factors that appear to play a key role in the cycle of repeat diabetic ketoacidosis. Individuals with these factors present may benefit from targeted support and interventions by specialist healthcare professionals. Knowledge and understanding in this area would be considerably enhanced via increased use of prospective study designs and greater consistency in the operationalisation of variables across studies.
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Affiliation(s)
- Bethan Allcock
- North Wales Clinical Psychology Programme, School of Psychology, Bangor University, Bangor, UK
| | - Rose Stewart
- Young Adult Diabetes Service, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Bangor, UK
| | - Mike Jackson
- North Wales Clinical Psychology Programme, School of Psychology, Bangor University, Bangor, UK
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6
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Hare MJL, Deitch JM, Kang MJY, Bach LA. Clinical, psychological and demographic factors in a contemporary adult cohort with diabetic ketoacidosis and type 1 diabetes. Intern Med J 2021; 51:1292-1297. [PMID: 32358796 DOI: 10.1111/imj.14877] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/12/2020] [Accepted: 04/09/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a potentially life-threatening but often preventable acute complication of type 1 diabetes (T1D). Understanding clinical and psychosocial characteristics of people with DKA, particularly those with multiple presentations, may aid the development of prevention strategies. AIMS To describe clinical, psychological and demographic factors in adults with DKA and particularly those factors associated with recurrent admissions. METHODS A retrospective analysis was performed of all admissions with DKA in people with T1D over a 4-year period from 1 November 2013 to 31 October 2017 at a metropolitan tertiary hospital in Australia. Potential cases were identified by International Classification of Diseases-10th Revision coding data. Data were then manually extracted by clinicians from the electronic medical record. RESULTS There were 154 clinician-adjudicated admissions for DKA among 128 people with T1D. Of these, 16 (13%) had multiple DKA admissions. Forty-one (32%) had a history of depression. The most common factors contributing to presentation included insulin omission (54%), infection (31%), alcohol excess (26%) and new diabetes diagnosis (16%). Compared to people with single admissions, those with recurrent DKA were more likely to smoke (69% vs 27%, P = 0.003), be unemployed (31% vs 11%, P = 0.04) and use illicit substances (44% vs 17%, P = 0.02). CONCLUSIONS There is a high prevalence of psychiatric illness, illicit substance use and social disadvantage among people admitted with DKA, particularly those with recurrent presentations. Insulin omission, often due to inappropriate sick day management, was the most common reason for DKA occurrence. Innovative multidisciplinary models of care are required to address these challenges.
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Affiliation(s)
- Matthew J L Hare
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Victoria, Australia.,Wellbeing and Chronic Preventable Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia.,Endocrinology Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Jessica M Deitch
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Victoria, Australia
| | - Matthew J Y Kang
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Victoria, Australia.,Alfred Mental and Addiction Health, Alfred Health, Melbourne, Victoria, Australia
| | - Leon A Bach
- Department of Endocrinology and Diabetes, Alfred Health, Melbourne, Victoria, Australia.,Department of Medicine (Alfred), Monash University, Melbourne, Victoria, Australia
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7
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Golbets E, Brandstaetter E, Sagy I, Zimhony-Nissim N, Lipnitzki I, Musa H, Jotkowitz A, Schwarzfuchs D, Barski L. Predictors and outcomes of recurrent diabetic ketoacidosis in Israeli adults. Diabetes Metab Syndr 2021; 15:102276. [PMID: 34509792 DOI: 10.1016/j.dsx.2021.102276] [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: 03/04/2021] [Revised: 08/01/2021] [Accepted: 09/01/2021] [Indexed: 11/24/2022]
Abstract
AIMS To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies. METHODS Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2). RESULTS 385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112-3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04-0.742; p = 0.018). CONCLUSION High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.
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Affiliation(s)
- Evgeny Golbets
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel.
| | - Evgenia Brandstaetter
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Iftach Sagy
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel; Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Noa Zimhony-Nissim
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Inna Lipnitzki
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Hadeel Musa
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Alan Jotkowitz
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Department of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
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8
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Michaelis M, Shochat T, Shimon I, Akirov A. Features and long-term outcomes of patients hospitalized for diabetic ketoacidosis. Diabetes Metab Res Rev 2021; 37:e3408. [PMID: 32942337 DOI: 10.1002/dmrr.3408] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 08/03/2020] [Accepted: 08/31/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute metabolic complication characterized by hyperglycaemia, ketones in blood or urine, and acidosis. OBJECTIVE The aim of this study was to characterize features of patients hospitalized for DKA, to identify triggers for DKA and to evaluate the long-term effects of DKA on glycaemic control, complications of diabetes, re-hospitalizations, and mortality. METHODS Historical prospectively collected data of patients hospitalized to medical wards for DKA between 2011 and 2017. Data regarding comorbidities, mortality, triggers, and re-hospitalizations for DKA were also collected. RESULTS The cohort consisted of 160 patients (mean age 38 ± 18 years, 43% male). One fifth of the patients (34 patients, 21%) were newly diagnosed with diabetes, and DKA was their first presentation of the disease. Among the 126 patients with pre-existing diabetes, the common identified triggers for DKA were poor compliance to treatment (22%) and infectious diseases (18%). During over 7 years of follow-up, mortality rate was 9% (15 patients), and re-hospitalization for DKA rate was 31% (50 patients). Risk factors for re-hospitalization for DKA included young age (OR = 1.02, 95% CI, 1.00-1.04), pre-existing diabetes compared to DKA as the first presentation (OR = 5.4, 95% CI, 1.7-18), and poorer glycaemic control before initial hospitalization (10.5 ± 2.5% vs. 9.4 ± 2.2%; OR = 0.8, 95% CI [0.68-0.96]) and after discharge (10.3 ± 2.4% vs. 9.0 ± 1.9%; OR = 0.73, 95% CI [0.61-0.87]). Laboratory tests during the initial hospitalization, smoking, alcohol, or comorbidities did not increase the risk for re-hospitalization for DKA. CONCLUSIONS The risk for readmission for DKA is higher for young patients with long duration of diabetes, poor compliance of insulin treatment and poorly controlled diabetes.
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Affiliation(s)
- Michal Michaelis
- Department of Internal Medicine E, Rabin Medical Center I Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Ilan Shimon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
| | - Amit Akirov
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Department of Endocrine Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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9
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Lyerla R, Johnson-Rabbett B, Shakally A, Magar R, Alameddine H, Fish L. Recurrent DKA results in high societal costs - a retrospective study identifying social predictors of recurrence for potential future intervention. Clin Diabetes Endocrinol 2021; 7:13. [PMID: 34332631 PMCID: PMC8325863 DOI: 10.1186/s40842-021-00127-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022] Open
Abstract
Aims Diabetic ketoacidosis (DKA) is an emergency with high morbidity and mortality. This study examined patient factors associated with hospitalization for recurrent DKA. Methods Characteristics of 265 subjects admitted for DKA at Hennepin County Medical Center between January 2017 and January 2019 were retrospectively analyzed. Differences between subjects with a single admission versus multiple were reviewed. Results Forty-eight out of 265 patients had recurrent DKA. Risk factors included African American race (adjusted odds ratio (aOR) versus white non-Hispanic = 4.6, 95% CI 1.8–13, p = 0.001) or other race/ethnicity (aOR = 8.6, 2.9–28, p < 0.0001), younger age (aOR 37-52y versus 18-36y = 0.48, 0.19–1.16, p = 0.10; aOR 53-99y versus 18-36y = 0.37, 0.12–0.99, p = 0.05), type 1 diabetes mellitus (aOR = 2.4, 1.1–5.5, p = 0.04), ever homeless (aOR = 2.5, 1.1–5.4, p = 0.03), and drug abuse (aOR = 3.2, 1.3–7.8, p = 0.009). DKA cost a median of $29,981 per admission. Conclusions Recurrent DKA is costly, and social determinants are strong predictors of recurrence. This study highlights the need for targeted preventative care programs.
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Affiliation(s)
| | | | | | | | | | - Lisa Fish
- Hennepin Health, Minneapolis, MN, USA
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10
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Garrett CJ, Moulton CD, Choudhary P, Amiel SA, Fonagy P, Ismail K. The psychopathology of recurrent diabetic ketoacidosis: A case-control study. Diabet Med 2021; 38:e14505. [PMID: 33368581 DOI: 10.1111/dme.14505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite its poor prognosis, the psychological factors associated with recurrent diabetic ketoacidosis are poorly understood. In people with type 1 diabetes, we assessed for psychopathology in those with and without recurrent diabetic ketoacidosis (DKA). METHOD The design was a case-control study. Cases were defined as people with two or more DKA episodes in a 12-month period (recurrent DKA). Cases and controls were matched for gender and age. We compared groups for scores on Beck's Anxiety Inventory (BAI), Beck's Depression Inventory II, Difficulty in Emotion Regulation Scale (DERS), Experiences in Close Relationships-Revised, Standardised Assessment of Personality-Abbreviated Scale (SAPAS), Interpersonal Problem Inventory, Eating Disorder Examination Questionnaire and Problem Areas in Diabetes (PAID) using unpaired t-tests or Mann-Whitney U tests for parametric and non-parametric data, respectively. Correction was made for multiple testing. RESULTS In all, 23 cases and 23 controls were recruited with mean age 31.0 (11.4) years and 65.2% were men. Cases had higher HbA1c levels than controls (101.1 (23.2) vs. 85.7 (21.7) mmol/mol, (p = 0.02)). Compared to controls, people with recurrent DKA had higher scores on the BAI (p = 0.004), PAID (p = 0.004), DERS (p = 0.001) and SAPAS (p < 0.001). Sixteen of 23 (69.6%) cases screened positive for a personality disorder compared to 6 of 23 (26.1%) controls. CONCLUSIONS People with recurrent DKA have elevated levels of anxiety and diabetes distress, greater difficulty with emotion regulation and personality dysfunction compared to matched controls.
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Affiliation(s)
- Christopher J Garrett
- Diabetes and Metabolism Department, Barts Health NHS Trust, London, UK
- Diabetes, Psychiatry and Psychology Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Calum D Moulton
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Pratik Choudhary
- Division of Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Stephanie A Amiel
- Division of Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Peter Fonagy
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Khalida Ismail
- Diabetes, Psychiatry and Psychology Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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11
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Hammersen J, Tittel SR, Warncke K, Fritsch M, Placzek K, Pacaud D, Karges B, Woelfle J, Holl RW. Previous diabetic ketoacidosis as a risk factor for recurrence in a large prospective contemporary pediatric cohort: Results from the DPV initiative. Pediatr Diabetes 2021; 22:455-462. [PMID: 33533571 DOI: 10.1111/pedi.13185] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To assess the role of previous episodes of diabetic ketoacidosis (DKA) and their time-lag as risk factors for recurring DKA in youth with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS In a population-based analysis, data from 29,325 children and adolescents with T1D and at least 5 years of continuous follow-up were retrieved from the "Diabetes Prospective Follow-up" (DPV) multi-center registry in March 2020. Statistical analyses included unadjusted comparisons, logistic and negative binomial regression models. RESULTS Among 29,325 patients with T1D, 86.0% (n = 25,219) reported no DKA, 9.7% (n = 2,833) one, and 4.3% (n = 1,273) more than one episode, corresponding to a DKA rate of 4.4 [95% CI: 4.3-4.6] per 100 patient-years. Female sex, migratory background, higher HbA1c values, higher daily insulin doses, a lower glucose monitoring frequency, and less CGM usage were associated with DKA. In patients with a previous episode, the DKA rate in the most recent year was significantly higher than in patients with no DKA (17.6 [15.9-19.5] vs. 2.8 [2.7-3.1] per 100 patient-years; p < 0.001). Multiple DKAs further increased the recurrence rate. The risk for DKA in the most recent year was higher in patients with an episode in the preceding year than in patients with no previous DKA (OR: 10.0 [95% CI: 8.6-11.8]), and remained significantly elevated 4 years after an episode (OR: 2.3 [1.6-3.1]; p < 0.001). CONCLUSIONS Each episode of DKA is an independent risk factor for recurrence, even 4 years after an event, underlining the importance of a close follow-up after each episode.
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Affiliation(s)
- Johanna Hammersen
- Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany
| | - Sascha R Tittel
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Katharina Warncke
- Department of Pediatrics, Kinderklinik München Schwabing, Technical University of Munich School of Medicine, Munich, Germany
| | - Maria Fritsch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Kerstin Placzek
- Pediatric and Adolescent Medicine, University Hospital, Martin-Luther University, Halle, Germany
| | - Danièle Pacaud
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatric Diabetes and Endocrinology, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Beate Karges
- Division of Endocrinology and Diabetology, Medical Faculty, RWTH Aachen University, Aachen, Germany.,Department of Pediatrics, Bethlehem Hospital Stolberg, Stolberg, Germany
| | - Joachim Woelfle
- Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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12
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Hamblin PS, Abdul-Wahab AL, Xu SFB, Steele CE, Vogrin S. Diabetic ketoacidosis: a canary in the mine for mental health disorders? Intern Med J 2021; 52:1002-1008. [PMID: 33462994 DOI: 10.1111/imj.15214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/30/2020] [Accepted: 01/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recurrent diabetic ketoacidosis (DKA) has been linked to mental health disorders, but less is known about single DKA episodes. Most studies are retrospective, lacking control groups. AIMS Prospectively examine psychosocial factors in patients presenting with recurrent or single episode DKA and compare to people who have not had DKA. METHODS Case-controlled study (consecutive adult DKA admissions April 2015 to December 2016) at Western Health, Melbourne. Data were prospectively collected regarding: diagnosed mental health disorders, likely depression (PHQ-9 questionnaire), diabetes distress (PAID questionnaire) and presence of adverse social factors. A control group without a history of DKA was also recruited. RESULTS Of 123 patients admitted with DKA (164 consecutive episodes), 70 consented to participate and 73 age matched type 1 diabetes controls were recruited. Eleven of 18 (61%) with recurrent DKA had a diagnosed mental health disorder, versus 8 of 42 (19%) in the single episode group (p=0.016). The prevalence of likely depression using PHQ-9 was: recurrent 50%, single 40% and controls 22% (recurrent vs controls, p=0.036, single vs controls, p=0.053). Severe diabetes distress (PAID) was present in 47% of recurrent and 34% of single episode DKA (p=0.387). As a group, DKA patients had significantly more unemployment, illicit drug use and tobacco smoking, a lower level of formal education and less regular medical contact compared to controls. CONCLUSIONS Mental health disorders and adverse socio-economic factors appear to be common in patients with DKA. The diagnosis of DKA presents an excellent opportunity to screen for depression and offer appropriate intervention. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peter S Hamblin
- Department of Endocrinology & Diabetes, Western Health, 176 Furlong Road St Albans VIC, 3021, Australia.,Department of Medicine - Western Campus, University of Melbourne, 176 Furlong Road St Albans VIC, 3021, Australia
| | - Azni L Abdul-Wahab
- Department of Endocrinology & Diabetes, Western Health, 176 Furlong Road St Albans VIC, 3021, Australia
| | - Sylvia F B Xu
- Department of Endocrinology & Diabetes, Western Health, 176 Furlong Road St Albans VIC, 3021, Australia
| | - Cheryl E Steele
- Department of Endocrinology & Diabetes, Western Health, 176 Furlong Road St Albans VIC, 3021, Australia
| | - Sara Vogrin
- Department of Medicine - Western Campus, University of Melbourne, 176 Furlong Road St Albans VIC, 3021, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne, 176 Furlong Road, St Albans, 3021, VIC, Australia
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13
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Ahola AJ, Harjutsalo V, Thomas MC, Forsblom C, Groop PH. Dietary intake and hospitalisation due to diabetic ketoacidosis and hypoglycaemia in individuals with type 1 diabetes. Sci Rep 2021; 11:1638. [PMID: 33452386 PMCID: PMC7810746 DOI: 10.1038/s41598-021-81180-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/16/2020] [Indexed: 11/09/2022] Open
Abstract
We investigated the association between diet and risk of hospitalisation for diabetic ketoacidosis (DKA) or hypoglycaemia in type 1 diabetes. Food records were used to assess dietary intake. Data on DKA and hypoglycaemia hospitalisations, within two years of dietary assessments, were obtained from registries. Analyses were conducted with and without macronutrient substitution. Data were available from 1391 participants, 28 (2.0%) and 55 (4.0%) of whom were hospitalised due to DKA or hypoglycaemia, respectively. In the adjusted model, self-reported alcohol intake was associated with increased (per 10 g: B = 1.463, 95% CI = 1.114-1.922, p = 0.006; per E%: B = 1.113, 95% CI = 1.027-1.206, p = 0.009), and fibre intake with reduced (per g/MJ: B = 0.934, 95% CI = 0.878-0.995, p = 0.034) risk of DKA hospitalisation. Substituting carbohydrates for fats was associated with increased risk for hypoglycaemia hospitalisation (B = 1.361, 95% CI = 1.031-1.795, p = 0.029), while substituting alcohol for carbohydrates (B = 1.644, 95% CI = 1.006-2.685, p = 0.047) or proteins (B = 2.278, 95% CI = 1.038-4.999, p = 0.040) increased the risk for DKA hospitalisation. In conclusion, refraining from alcohol intake is a preventable risk factor for DKA, while higher fibre intake seems rather protective. Increasing carbohydrate intake while decreasing that of fats, is associated with higher hypoglycaemia risk. Whether this is a cause or effect of hypoglycaemia remains to be established.
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Affiliation(s)
- Aila J Ahola
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center, Nephrology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Valma Harjutsalo
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center, Nephrology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,National Institute for Health and Welfare, Helsinki, Finland
| | - Merlin C Thomas
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Carol Forsblom
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland.,Abdominal Center, Nephrology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland. .,Abdominal Center, Nephrology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland. .,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland. .,Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia.
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14
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Abstract
Insulin therapy has advanced remarkably over the past few decades. Ultra-rapid-acting and ultra-long-acting insulin analogs are now commercially available. Many additional insulin formulations are in development. This review outlines recent advances in insulin therapy and novel therapies in development.
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Affiliation(s)
- Leah M. Wilson
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Jessica R. Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon, USA
- Address correspondence to: Jessica R. Castle, MD, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, L607, Portland, OR 97239-3098, USA
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15
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Mejia-Otero JD, Adhikari S, White PC. Risk factors for hospitalization in youth with type 1 diabetes: Development and validation of a multivariable prediction model. Pediatr Diabetes 2020; 21:1268-1276. [PMID: 32737942 DOI: 10.1111/pedi.13090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/18/2020] [Accepted: 07/28/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To develop a multivariable prediction model to identify patients with type 1 diabetes at increased risk of hospitalization for diabetic ketoacidosis or hyperglycemia with ketosis in the 12 months following assessment. METHODS Retrospective review of clinical data from patients with type 1 diabetes less than 17 years old at a large academic children's hospital (5732 patient years, 652 admissions). Data from the previous 12 months were assessed on October 15, 2015, 2016, 2017, and 2018, and used to predict hospitalization in the following 12 months using generalized estimating equations. Variables that were significant predictors of hospitalization in univariate analyses were entered into a multivariable model. 2014 to 2016 data were used as a training dataset, and 2017 to 2019 data for validation. Discrimination of the model was assessed with receiver operator characteristic curves. RESULTS Admission in the preceding year, hemoglobin (Hb)A1c, non-commercial insurance, female sex, and non-White race were all individual predictors of hospitalization, but age, duration of diabetes and number of office visits in the preceding year were not. In multivariable analysis with threshold P < .0033, admissions in the previous 12 months, HbA1c, and non-commercial insurance remained as significant predictors. The model identified a subset of ~8% of the patients with a collective 42% risk of hospitalization, thus increased 5-fold compared with the 8% risk of hospitalization in the remaining 93% of patients. Similar results were obtained with the validation dataset. CONCLUSION Our multivariable prediction model identified patients at increased risk of admission in the 12 months following assessment.
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Affiliation(s)
- Juan D Mejia-Otero
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA.,Division of Pediatric Endocrinology, University of Arkansas Medical School, Little Rock, Arkansas, USA
| | - Soumya Adhikari
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Perrin C White
- Division of Pediatric Endocrinology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
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16
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Gartner A, Daniel R, Farewell D, Paranjothy S, Townson J, Gregory JW. Demographic and socioeconomic patterns in the risk of alcohol-related hospital admission in children and young adults with childhood onset type-1 diabetes from a record-linked longitudinal population cohort study in Wales. Pediatr Diabetes 2020; 21:1333-1342. [PMID: 32737911 DOI: 10.1111/pedi.13089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/18/2020] [Accepted: 07/28/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Little is known about alcohol-related harm in children and young adults with type 1 diabetes (T1D). Education on managing alcohol intake is provided to teenagers with T1D in paediatric clinics in Wales, but its effectiveness is unknown. We compared the patterns in risk of alcohol-related hospital admissions (ARHA) between individuals with and without childhood-onset T1D. METHODS We extracted data for 1 791 577 individuals born during 1979 to 2014 with a general practitioner registration in Wales, and record-linked the demographic data to ARHA between 1998 and June 2016 within the Secure Anonymised Information Linkage Databank (SAIL). Linkage to a national T1D register (Brecon Cohort) identified 3575 children diagnosed aged <15 years since 1995. We estimated hazard ratios (HRs) with 95% confidence intervals (95% CIs) for the risk of ARHA using recurrent-event models, including interaction terms. RESULTS Individuals with T1D had a higher riskof ARHA (HR: 1.78; 95% CI: 1.60-1.98), adjusted for age group, sex, and deprivation. The risk in people with diabetes was highest aged 14 to 17 years, around three times higher than the peak in non-T1D aged 18 to 22. Females with diabetes had a lower risk generally. The association between deprivation and ARHA was weaker in the T1D group. CONCLUSION Young people with T1D had increased risks of ARHA, particularly at school age, and smaller socioeconomic inequalities in ARHA. A review of interventions to reduce alcohol-related harm in T1D is needed, perhaps including modification of current education and guidance for teenagers on managing alcohol consumption and reviewing criteria for hospital admission.
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Affiliation(s)
- Andrea Gartner
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Rhian Daniel
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Shantini Paranjothy
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Julia Townson
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - John W Gregory
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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17
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Lapolla A, Amaro F, Bruttomesso D, Di Bartolo P, Grassi G, Maffeis C, Purrello F, Tumini S. Diabetic ketoacidosis: A consensus statement of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Italian Society of Endocrinology and Pediatric Diabetoloy (SIEDP). Nutr Metab Cardiovasc Dis 2020; 30:1633-1644. [PMID: 32771260 DOI: 10.1016/j.numecd.2020.06.006] [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] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Diabetic ketoacidosis (DKA) is a serious medical emergency once considered typical of type 1 diabetes (T1DM), but now reported to occur in type 2 and GDM patients as well. DKA can cause severe complications and even prove fatal. The aim of our study was to review recent international and national guidelines on diagnosis, clinical presentation and treatment of diabetic ketoacidosis, to provide practical clinical recommendations. METHODS AND RESULTS Electronic databases (MEDLINE (via PUB Med), Scopus, Cochrane library were searched for relevant literature. Most international and national guidelines indicate the same accurate flow chart to diagnose, to evaluate from clinical and laboratory point of view, and treat diabetic ketoacidosis. CONCLUSION Prompt diagnosis, rapid execution of laboratory analysis and correct treatment are imperative to reduce the mortality related to diabetic ketoacidosis. These recommendations are designed to help healthcare professionals reduce the frequency and burden of DKA.
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Affiliation(s)
| | - Flavia Amaro
- Department of Pediatrics University of Chieti, Chieti, Italy
| | | | - Paolo Di Bartolo
- Ravenna Diabetes Clinic, Romagna Diabetes Network, Internal DPT of Romagna Local Health Autorithy, Italy; Chief Italian Association of Diabetologists (AMD), Rome, Italy
| | - Giorgio Grassi
- Endocrinology, Diabetology and Metabolic Unit, City of Health and Science Torino, Italy
| | - Claudio Maffeis
- Chief Italian Society of Pediatric Endocrinology and Diabetology (SIEDP), Torino, Italy; Chief Pediatric Diabetes and Metabolic Disorder Unit, University Hospital, Verona, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania Catania, Italy; Chief Italian Diabetes Society (SID), Rome, Italy
| | - Stefano Tumini
- Department of Maternal and Child Health, UOSD Regional Center of Pediatric Diabetology, Chieti Hospital, Chieti, Italy
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18
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Turan C, Yurtseven A, Basa EG, Gökşen D, Ulaş Saz E. The Effects of Prehospital Care on Outcome in Pediatric Diabetic Ketoacidosis. J Clin Res Pediatr Endocrinol 2020; 12:189-196. [PMID: 31722517 PMCID: PMC7291399 DOI: 10.4274/jcrpe.galenos.2019.2019.0121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Despite the guidelines, significant variations can be encountered in initial therapy for pediatric diabetic ketoacidosis (DKA) in the prehospital setting. These variations occur mostly in fluid administration, insulin dosing, route of administration, and other aspects of the initial resuscitation and stabilization. The aim was to identify the effect of transport care on outcomes in children with DKA admitted to the emergency department (ED). METHODS Patients admitted to a tertiary-care pediatric ED between 2015-2019 with a diagnosis of DKA were retrospectively identified. Details of pre-pediatric ED care, including transport modality, patient demographics, clinical features, laboratory evaluation, fluid therapy, insulin dosing, and short-term outcome were recorded. RESULTS The study cohort included 147 episodes of DKA in 136 patients aged 9 months-21 years. Emergency Medical Service (EMS) transported only 37.4% of cases. EMS utilization rate was significantly higher (p=0.003) in severe cases, most of whom were >10 years (p=0.04). During transport 85% received intravenous fluid bolus. Use of fluids other than normal saline was significantly higher when transport time was >30 minutes (p=0.001). Acute kidney injury and cerebral edema developed in 21.7% and 7.4% of episodes, respectively. These complications were more common in the EMS transport group. Pediatric intensive care admission rate was also higher in the EMS compared to the non-EMS group (p=0.01). CONCLUSION Parents did not call the ambulance for most cases although a higher complication rate occurred in EMS patients. EMS providers and referral facilities should improve their knowledge of pediatric DKA.
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Affiliation(s)
- Caner Turan
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency, İzmir, Turkey
| | - Ali Yurtseven
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency, İzmir, Turkey,* Address for Correspondence: Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency, İzmir, Turkey Phone: +90 505 205 21 44 E-mail:
| | - Elif Gökçe Basa
- Ege University Faculty of Medicine, Department of Pediatrics, İzmir, Turkey
| | - Damla Gökşen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Eylem Ulaş Saz
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Emergency, İzmir, Turkey
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19
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Ehrmann D, Kulzer B, Roos T, Haak T, Al-Khatib M, Hermanns N. Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes. Lancet Diabetes Endocrinol 2020; 8:436-446. [PMID: 32333879 DOI: 10.1016/s2213-8587(20)30042-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 01/02/2023]
Abstract
Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.
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Affiliation(s)
- Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
| | - Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; Diabetes Clinic Mergentheim, Bad Mergentheim, Germany
| | - Timm Roos
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany
| | - Thomas Haak
- Diabetes Clinic Mergentheim, Bad Mergentheim, Germany
| | - Mohammed Al-Khatib
- HealthPlus Diabetes & Endocrinology Centre, Abu Dhabi, United Arab Emirates
| | - Norbert Hermanns
- Research Institute Diabetes Academy Mergentheim, Bad Mergentheim, Germany; Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany; Diabetes Clinic Mergentheim, Bad Mergentheim, Germany.
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20
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Garrett CJ, Choudhary P, Amiel SA, Fonagy P, Ismail K. Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention. Diabet Med 2019; 36:1329-1335. [PMID: 31418474 DOI: 10.1111/dme.14109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 12/11/2022]
Abstract
Pharmacological, technological and educational approaches have advanced the treatment of Type 1 diabetes in the last four decades and yet diabetic ketoacidosis (DKA) continues to be a leading cause of admission in Type 1 diabetes. This article begins by reviewing the contemporary epidemiological evidence in DKA. It highlights a rise in DKA episodes in the last two decades, with DKA continuing to be the leading cause of death in young people with Type 1 diabetes, and that DKA episodes are a marker for subsequent all-cause mortality. It also summarizes the limited evidence base for DKA prevention and associations with psychopathology. To emphasize the importance of this group with high-risk Type 1 diabetes and the degree to which they have been overlooked in the past two decades, the article summarizes the research literature of recurrent DKA during 1976-1991 when it was extensively investigated as part of the phenomenon of 'brittle diabetes'. This period saw numerous basic science studies investigating the pathophysiology of recurrent DKA. Subsequently, research centres published their experiences of brittle diabetes research participants manipulating their treatment under research conditions. Unfortunately, the driver for this behaviour and whether it was indicative of other people with ketoacidosis was not pursued. In summary, we suggest there has been a stasis in the approach to recurrent DKA prevention, which is likely linked to historical cases of mass sabotage of brittle diabetes research. Further investigation is required to clarify possible psychological characteristics that increase the risk of DKA and thereby targets for DKA prevention.
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Affiliation(s)
- C J Garrett
- Diabetes and Metabolism Department, Bart's Health NHS Trust, London, UK
- Diabetes and Mental Health Research Group, King's College London, London, UK
| | - P Choudhary
- Diabetes Research Group, King's College London, London, UK
| | - S A Amiel
- Diabetes Research Group, King's College London, London, UK
| | - P Fonagy
- Division of Psychology and Language Sciences at University College London, London, UK
| | - K Ismail
- Diabetes and Mental Health Research Group, King's College London, London, UK
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21
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Wolf RA, Haw JS, Paul S, Spezia Faulkner M, Cha E, Findley MK, Khan F, Markley Webster S, Alexopoulos AS, Mehta K, Alfa DA, Ali MK. Hospital admissions for hyperglycemic emergencies in young adults at an inner-city hospital. Diabetes Res Clin Pract 2019; 157:107869. [PMID: 31560962 PMCID: PMC6914263 DOI: 10.1016/j.diabres.2019.107869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/18/2019] [Accepted: 09/23/2019] [Indexed: 12/16/2022]
Abstract
AIMS There is limited information characterizing young adults (18-35 years) (YA) with diabetes, especially those admitted for hyperglycemic emergencies. The study aims were to examine associations of patient-level characteristics with hyperglycemic emergency hospitalization and to identify variations based on diabetes type and glycemic control. METHODS We conducted retrospective analysis of 273 YA admitted to an inner-city hospital with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHS). T-tests, Chi-Square tests, and ANOVA identified differences in demographics, diabetes history, clinical indicators, complications/comorbidities, and hospital admission stratified separately by diabetes type (1 vs 2) and admission HbA1c < 9% (75 mmol/mol), ≥9% to 12% (108 mmol/mol), ≥12%). RESULTS Mean admission HbA1c was 12.4% (112 mmol/ml). HbA1c was ≥9.0% for 90.5%. The main DKA/HHS trigger was medication nonadherence (57.9%), with 35.6% presenting with new-onset type 2 diabetes. Only 3.7% utilized outpatient diabetes clinics, 38.8% were re-hospitalized within the year, and 69% lacked insurance. Diabetes complications (44.7%) and psychiatric co-morbidities (35.5%) were common. Significantly more YA with type 1 diabetes had insurance, whereas YA with type 2 diabetes had higher admission HbA1c. YA with HbA1c ≥12% were more likely to be Black and lack insurance. CONCLUSIONS YA hospitalized for DKA/HHS in an inner-city hospital tended to have severely uncontrolled diabetes. Many already had comorbidities and diabetes complications, high use of acute care services and low use of diabetes specialty services. YA characteristics varied by diabetes type and HbA1c. Overall, a substantial percentage lacked insurance, potentially impacting healthcare utilization patterns and medication adherence, and leading to DKA/HHS admissions.
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Affiliation(s)
- Rachel A Wolf
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States.
| | - J Sonya Haw
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Melissa Spezia Faulkner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; School of Nursing, Georgia State University, Atlanta, GA, United States
| | - EunSeok Cha
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Chungnam National University, College of Nursing, Daejeon, South Korea
| | - M K Findley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Farah Khan
- School of Medicine, Emory University, Atlanta, GA, United States; Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, United States
| | | | | | - Komal Mehta
- School of Medicine, Emory University, Atlanta, GA, United States
| | - David A Alfa
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Mohammed K Ali
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Rollins School of Public Health, Emory University, Atlanta, GA, United States
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22
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Risk Factors for Recurrent Diabetic Ketoacidosis in Adults With Type 1 Diabetes. Can J Diabetes 2019; 43:472-476.e1. [DOI: 10.1016/j.jcjd.2019.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/23/2018] [Accepted: 01/17/2019] [Indexed: 11/22/2022]
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23
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Brandstaetter E, Bartal C, Sagy I, Jotkowitz A, Barski L. Recurrent diabetic ketoacidosis. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:531-535. [PMID: 31365631 PMCID: PMC10522260 DOI: 10.20945/2359-3997000000158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 03/17/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. MATERIALS AND METHODS Review article. RESULTS Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. CONCLUSIONS Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.
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Affiliation(s)
- Evgenia Brandstaetter
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Carmi Bartal
- Department of Internal Medicine ESoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine E, Soroka University Medical Center, Beer-Sheva, Israel
| | - Iftach Sagy
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
- Clinical Research CenterSoroka University Medical CenterBeer ShevaIsraelClinical Research Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Alan Jotkowitz
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
| | - Leonid Barski
- Department of Internal Medicine FSoroka University Medical CenterBeer-ShevaIsraelDepartment of Internal Medicine F, Soroka University Medical Center, Beer-Sheva, Israel
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Robbins TD, Lim Choi Keung SN, Sankar S, Randeva H, Arvanitis TN. Risk factors for readmission of inpatients with diabetes: A systematic review. J Diabetes Complications 2019; 33:398-405. [PMID: 30878296 DOI: 10.1016/j.jdiacomp.2019.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/04/2019] [Accepted: 01/22/2019] [Indexed: 12/16/2022]
Abstract
AIM We have limited understanding of which risk factors contribute to increased readmission rates amongst people discharged from hospital with diabetes. We aim to complete the first review of its kind, to identify, in a systematic way, known risk factors for hospital readmission amongst people with diabetes, in order to better understand this costly complication. METHOD The review was prospectively registered in the PROSPERO database. Risk factors were identified through systematic review of literature in PubMed, EMBASE & SCOPUS databases, performed independently by two authors prior to data extraction, with quality assessment and semi-quantitative synthesis according to PRISMA guidelines. RESULTS Eighty-three studies were selected for inclusion, predominantly from the United States, and utilising retrospective analysis of local or regional data sets. 76 distinct statistically significant risk factors were identified across 48 studies. The most commonly identified risk factors were; co-morbidity burden, age, race and insurance type. Few studies conducted power calculations; unstandardized effect sizes were calculated for the majority of statistically significant risk factors. CONCLUSION This review is important in assessing the current state of the literature and in supporting development of interventions to reduce readmission risk. Furthermore, it provides an important foundation for development of rigorous, pre-specified risk prediction models.
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Affiliation(s)
- Tim D Robbins
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom; Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
| | - S N Lim Choi Keung
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - S Sankar
- Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - H Randeva
- Warwickshire Institute for the Study of Diabetes, Endocrinology & Metabolism, University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - T N Arvanitis
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
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Carlsund Å, Söderberg S. Living with type 1 diabetes as experienced by young adults. Nurs Open 2019; 6:418-425. [PMID: 30918692 PMCID: PMC6419143 DOI: 10.1002/nop2.222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 10/21/2018] [Accepted: 11/01/2018] [Indexed: 12/16/2022] Open
Abstract
AIM Describe young adults` (19-30 years) experiences of living with Type 1 Diabetes (T1D). BACKGROUND Young adulthood is characterized by adaption to adult roles, gradual separation from parental support and leaving the parental home. Living with T1D in young adulthood raises challenges and concerns. DESIGN This study has a qualitative design. METHODS Semistructured interviews with 12 young adults living with T1D for 3-14 years, analysed with qualitative content analysis. RESULTS The analysis revealed contradictory ways of handling the illness, as is illuminated in two main categories (a) and five subcategories (b). Handling the situation and dealing with different opinions (a), (b) managing daily life, emotional roller coaster and general attitudes, own views and apprehensions, ignorance and lack of motivation. Most participants were motivated, had knowledge and were in control of their long-term illness. Planning and structure were an essential part of their daily life. The participants were anxious about losing control of their bodies, the situation, die or be a burden to other people.
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Affiliation(s)
- Åsa Carlsund
- Department of Nursing SciencesMid‐Sweden UniversityÖstersundSweden
| | - Siv Söderberg
- Department of Nursing SciencesMid‐Sweden UniversityÖstersundSweden
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Potter K, Virtanen H, Luca P, Pacaud D, Nettel-Aguirre A, Kaminsky L, Ho J. Knowledge and practice of harm-reduction behaviours for alcohol and other illicit substance use in adolescents with type 1 diabetes. Paediatr Child Health 2018; 24:e51-e56. [PMID: 30833824 DOI: 10.1093/pch/pxy075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective To survey adolescents with type 1 diabetes mellitus (T1DM) about their knowledge and application of harm-reduction recommendations when they engage in alcohol and other illicit substance use. Methods Cross-sectional survey and chart review of adolescents with T1DM aged 13 to 18 years. Results One hundred and ninety patients were approached and 164 were included in the analysis. Mean age was 15.6 years (standard deviation [SD]=1.5). Fifty-one per cent were male. Of those who reported consuming alcohol, 95% knew that they should have a friend or parent check their blood glucose in the middle of the night after drinking but only 62% reported actually doing this in practice. Similarly, 98% reported knowing that they should wear a medic alert identification but only 79% reported actually doing this. Of those who reported consuming cannabis, 14% reported forgetting to check blood glucose and 14% reported forgetting insulin when using cannabis. From the chart review, a significantly lower proportion of adolescents reported substance use during their clinic visits (alcohol 26%, tobacco 19%, illicit substance 25%) compared to the self report in the survey (alcohol 55%, tobacco 30%, illicit substance 32%). Conclusions Adolescents' knowledge of harm-reduction practices for the use of alcohol and other illicit substances is not always put to practice. Motivating adolescents to use their knowledge in practice is an important area to improve in diabetes self-management. Those who reported engaging in substance use in the survey had not always reported use during interactions with health care providers. This emphasizes the need for unbiased, universal education of all adolescents in the clinic.
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Affiliation(s)
- Kathryn Potter
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta
| | - Heidi Virtanen
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta
| | - Paola Luca
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta
| | - Danièle Pacaud
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta
| | | | - Laura Kaminsky
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta
| | - Josephine Ho
- Department of Pediatrics, Alberta Children's Hospital, Calgary, Alberta
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Seventy-Two Hour Mortality Prediction Model in Patients with Diabetic Ketoacidosis: A Retrospective Cohort Study. J ASEAN Fed Endocr Soc 2018; 33:124-129. [PMID: 33442117 PMCID: PMC7784165 DOI: 10.15605/jafes.033.02.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 05/31/2018] [Indexed: 12/26/2022] Open
Abstract
Objective This study aims to identify predictors of 72-hour mortality in patients with diabetic ketoacidosis (DKA). Methodology In this retrospective cohort study, data were obtained from medical records of adult patients with DKA in Cipto Mangunkusumo General Hospital from January 2011 to June 2017. Associations of predictors (age, type of diabetes, history of DKA, comorbidities, level of consciousness, renal function, bicarbonate, potassium, lactate, betahydroxybutyrate levels, and anion gap status) and 72-hour mortality were analyzed. The mortality prediction model was formulated by dividing the coefficient B by the standard error for all variables with p<0.05 in the multivariate analysis. Results Eighty-six of 301 patients did not survive 72 hours after hospital admission. Comorbidities (HR 2.407; 95% CI 1.181–4.907), level of consciousness (HR 10.345; 95% CI 4.860–22.019), history of DKA (HR 2.126; 95% CI 1.308–3.457), and lactate level (HR 5.585; 95% CI 2.966–10.519) were significant predictors from multivariate analysis and were submitted to the prediction model. The prediction model had good performance. Patients with total score less than 3 points were at 15.41 % risk of mortality, 3 – 4 points were 78.01% and 5 – 6 points were 98.22% risk of mortality. Conclusion The 72-hour mortality rate in Cipto Mangunkusumo General Hospital was 28.57%. The mortality prediction model had a good performance and consisted of comorbidities, history of DKA, level of consciousness and lactate level.
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Pastor A, Conn J, Teng J, O'Brien CL, Loh M, Collins L, MacIsaac R, Bonomo Y. Alcohol and recreational drug use in young adults with type 1 diabetes. Diabetes Res Clin Pract 2017. [PMID: 28646702 DOI: 10.1016/j.diabres.2017.05.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Alcohol and other recreational drug use reaches peak prevalence in young adulthood, including for those with chronic medical conditions such as type 1 diabetes. This review summarises the current literature on the patterns of substance use amongst young adults with type 1 diabetes and the mechanisms through which alcohol and recreational drugs may affect diabetes related health outcomes. These include the direct physical effect of intoxication, as well as the effects of alcohol and drugs on mental health and glucose metabolism. Evidence for increased associated mortality and morbidity is also presented, and current guidelines, management strategies and directions for further research are discussed.
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Affiliation(s)
- Adam Pastor
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Australia; Department of Medicine, University of Melbourne, Australia.
| | - Jennifer Conn
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Australia
| | - Jessie Teng
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Australia
| | - Casey L O'Brien
- Mental Health Services, St Vincent's Hospital Melbourne, Australia; Department of Psychiatry, University of Melbourne, Australia
| | - Margaret Loh
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Australia
| | - Lisa Collins
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Australia
| | - Richard MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Australia; Department of Medicine, University of Melbourne, Australia
| | - Yvonne Bonomo
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, Australia; Department of Medicine, University of Melbourne, Australia
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Simmons D, Hartnell S, Davenport K, Jenaway A. Risk factors for recurrent admissions with diabetic ketoacidosis: importance of mental health. Diabet Med 2017; 34:451. [PMID: 27504864 DOI: 10.1111/dme.13202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D Simmons
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - S Hartnell
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Davenport
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Jenaway
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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30
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Braatvedt G, Cooper H, Tekiteki A, Khanolkar M. Risk factors for recurrent DKA: reply to Simmons et al. Diabet Med 2017; 34:451-452. [PMID: 27627875 DOI: 10.1111/dme.13261] [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: 07/12/2016] [Accepted: 09/09/2016] [Indexed: 11/30/2022]
Affiliation(s)
- G Braatvedt
- Department of Medicine, Auckland Hospital, Auckland, New Zealand
| | - H Cooper
- Department of Medicine, Auckland Hospital, Auckland, New Zealand
| | - A Tekiteki
- Department of Medicine, Auckland Hospital, Auckland, New Zealand
| | - M Khanolkar
- Department of Diabetes, Green Lane Hospital, Auckland, New Zealand
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Gibb FW, Teoh WL, Graham J, Lockman KA. Risk of death following admission to a UK hospital with diabetic ketoacidosis. Diabetologia 2016; 59:2082-7. [PMID: 27397023 PMCID: PMC5016550 DOI: 10.1007/s00125-016-4034-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/09/2016] [Indexed: 01/17/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to assess the risk of death during hospital admission for diabetic ketoacidosis (DKA) and, subsequently, following discharge. In addition, we aimed to characterise the risk factors for multiple presentations with DKA. METHODS We conducted a retrospective cohort study of all DKA admissions between 2007 and 2012 at a university teaching hospital. All patients with type 1 diabetes who were admitted with DKA (628 admissions of 298 individuals) were identified by discharge coding. Clinical, biochemical and mortality data were obtained from electronic patient records and national databases. Follow-up continued until the end of 2014. RESULTS Compared with patients with a single DKA admission, those with recurrent DKA (more than five episodes) were diagnosed with diabetes at an earlier age (median 14 [interquartile range 9-23] vs 24 [16-34] years, p < 0.001), had higher levels of social deprivation (p = 0.005) and higher HbA1c values (103 [89-108] vs 79 [66-96] mmol/mol; 11.6% [10.3-12.0%] vs 9.4% [8.2-10.9%], p < 0.001), and tended to be younger (25 [22-36] vs 31 [23-42] years, p = 0.079). Antidepressant use was greater in those with recurrent DKA compared with those with a single episode (47.5% vs 12.6%, p = 0.001). The inpatient DKA mortality rate was no greater than 0.16%. A single episode of DKA was associated with a 5.2% risk of death (4.1 [2.8-6.0] years of follow-up) compared with 23.4% in those with recurrent DKA admissions (2.4 [2.0-3.8] years of follow-up) (HR 6.18, p = 0.001). CONCLUSIONS/INTERPRETATION Recurrent DKA is associated with substantial mortality, particularly among young, socially disadvantaged adults with very high HbA1c levels.
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Affiliation(s)
- Fraser W Gibb
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Wei Leng Teoh
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Joanne Graham
- Acute Medical Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K Ann Lockman
- Acute Medical Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
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