Hyperglycaemic crises and lactic acidosis in diabetes mellitus

Diabetic Ketoacidosis Associated With Second Generation Antipsychotics: A Case Study and Review of Literature

OBJECTIVE

Second-generation antipsychotics (SGAs) have revolutionized the treatment of psychiatric disorders, but are associated with significant metabolic risks, including diabetes and hyperglycemic crises. This review explores the complex interplay between antipsychotics, diabetes, and hyperglycemic crises, highlighting the mechanisms underlying SGA-induced diabetes.

METHODS

We present the case of a patient with schizophrenia who was taking antipsychotic medication and was admitted to the emergency room due to the sudden onset of diabetic ketoacidosis (DKA) without any history of diabetes. We extensively searched databases, including Elsevier, PubMed, IEEE, SpringerLink, and Google Scholar, for papers on the effects of antipsychotic drugs on DKA from 2002 to 2021. We focused on DKA, hyperglycemia, and atypical antipsychotics, and retrieved 117 papers. After full-text review, 32 papers were included in this comprehensive review.

RESULTS

DKA was significantly more frequent in patients taking SGAs. Antipsychotics can induce insulin resistance either directly or through the onset of obesity. Antipsychotics can reduce insulin secretion from pancreatic β-cells, which is associated with absolute insulin deficiency.

CONCLUSION

As the use of antipsychotics continues to increase, understanding their risks and mechanisms is crucial for clinicians to enable informed treatment decisions and prevent potentially life-threatening complications.

Pediatric Hyperglycemic Hyperosmolar Syndrome: A Comprehensive Approach to Diagnosis, Management, and Complications Utilizing Novel Summarizing Acronyms

This paper focuses on hyperglycemic hyperosmolar syndrome (HHS), a unique hyperglycemic state requiring divergent diagnosis and treatment approaches from diabetic ketoacidosis (DKA) despite some shared characteristics. We introduce the mnemonic DI-FF-ER-EN-CE-S to encapsulate unique HHS management and complications. 'DI' emphasizes the need to delay and decrease initial insulin therapy until serum glucose decline is managed by fluid resuscitation alone. 'FF' stresses the importance of double fluid replacement compared to DKA due to severe dehydration and 'ER' electrolyte replacement due to profound losses and imbalances. 'EN' denotes the potential for encephalopathy and the requirement for a controlled serum osmolality reduction. 'CE' indicates cerebral edema, a rare complication in HHS. 'S' signifies systemic multiorgan failure. We categorize the associated risks into three mnemonic groups: the 3Rs (renal failure, respiratory distress, rhabdomyolysis), the 3Hs (heart failure, hypercoagulation, hyperthermia), and AP (arrhythmias, pancreatitis) to facilitate awareness and screening of HHS.

Detecting Diabetic Ketoacidosis with Infection: Combating a Life-Threatening Emergency with Practical Diagnostic Tools

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and can lead to patient demise if not immediately treated. From the recent literature, the diabetic ketoacidosis mortality rate, depending on age, is 2-5%. Insulin discontinuation and infection remain the two most common triggers for diabetic ketoacidosis. About 50% of cases of ketoacidosis result from bacterial infections like urinary tract infections and pneumonia. It is also important to diagnose the presence of infection in diabetic ketoacidosis patients to prevent the excessive use of antibiotics, which may lead to antibiotic resistance. Although performing bacterial culture is confirmatory for the presence or absence of bacterial infection, the time required to obtain the result is long. At the same time, emergency treatment needs to be started as early as possible.

METHODS

This narrative review examines various septic markers to identify the appropriate tools for diagnosis and to distinguish between diabetic ketoacidosis with and without infection. Electronic databases were searched using the Google engine with the keywords "Diabetes Mellitus", "Diabetic Ketoacidosis", "Infection with Diabetic Ketoacidosis", "biomarkers for infection in Diabetic Ketoacidosis", "Procalcitonin", "Inflammatory cytokines in DKA", "Lactic acidosis in DKA", and "White blood cell in infection in DKA".

RESULTS

This narrative review article presents the options for diagnosis and also aims to create awareness regarding the gravity of diabetic ketoacidosis with infection and emphasizes the importance of early diagnosis for appropriate management. Diabetes mellitus is a clinical condition that may lead to several acute and chronic complications. Acute diabetic ketoacidosis is a life-threatening condition in which an excess production of ketone bodies results in acidosis and hypovolemia. Infection is one of the most common triggers of diabetic ketoacidosis. When bacterial infection is present along with diabetic ketoacidosis, the mortality rate is even higher than for patients with diabetic ketoacidosis without infection. The symptoms and biomarkers of diabetic ketoacidosis are similar to that of infection, like fever, C reactive protein, and white blood cell count, since both create an environment of systemic inflammation. It is also essential to distinguish between the presence and absence of bacterial infection to ensure the appropriate use of antibiotics and prevent antimicrobial resistance. A bacterial culture report is confirmatory for the existence of bacterial infection, but this may take up to 24 h. Diagnosis needs to be performed approximately in the emergency room upon admission since there is a need for immediate management. Therefore, researching the possible diagnostic tools for the presence of infection in diabetic ketoacidosis patients is of great importance. Several of such biomarkers have been discussed in this research work.

Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group

Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.

The Beneficial Effect of Cinnamon and Red Capsicum Intake on Postprandial Changes in Plasma Metabolites Evoked by a High-Carbohydrate Meal in Men with Overweight/Obesity

The relationship of high-carbohydrate (HC) meal intake to metabolic syndrome is still not fully explained. Metabolomics has the potential to indicate metabolic pathways altered by HC meals, which may improve our knowledge regarding the mechanisms by which HC meals may contribute to metabolic syndrome development. The fasting and postprandial metabolic response to HC or normo-carbohydrate (NC) meals with/without cinnamon + capsicum intake was evaluated using untargeted metabolomics and compared between normal-weight (NW) and overweight/obese (OW/OB) healthy men. Healthy male participants (age-matched) were divided into two groups (12 subjects per group). One was composed of men with normal weight (NW) and the other of men with overweight/obesity (OW/OB). On separate visits (with 2-3 week intervals), the participants received standardized HC or NC meals (89% or 45% carbohydrates, respectively). Fasting (0 min) and postprandial (30, 60, 120, 180 min) blood were collected for untargeted plasma metabolomics. Based on each metabolic feature's intensity change in time, the area under the curve (AUC) was calculated. Obtained AUCs were analyzed using multivariate statistics. Several metabolic pathways were found dysregulated after an HC meal in people from the OW/OB group but not the NW group. The consumption of HC meals by people with overweight/obesity led to a substantial increase in AUC, mainly for metabolites belonging to phospholipids and fatty acid amides. The opposite was observed for selected sphingolipids. The intake of cinnamon and capsicum normalized the concentration of selected altered metabolites induced by the intake of HC meals. A HC meal may induce an unfavourable postprandial metabolic response in individuals with overweight/obesity, and such persons should avoid HC meals.

Mechanistic Insight into Oxidative Stress-Triggered Signaling Pathways and Type 2 Diabetes

Oxidative stress (OS) is a metabolic dysfunction mediated by the imbalance between the biochemical processes leading to elevated production of reactive oxygen species (ROS) and the antioxidant defense system of the body. It has a ubiquitous role in the development of numerous noncommunicable maladies including cardiovascular diseases, cancers, neurodegenerative diseases, aging and respiratory diseases. Diseases associated with metabolic dysfunction may be influenced by changes in the redox balance. Lately, there has been increasing awareness and evidence that diabetes mellitus (DM), particularly type 2 diabetes, is significantly modulated by oxidative stress. DM is a state of impaired metabolism characterized by hyperglycemia, resulting from defects in insulin secretion or action, or both. ROS such as hydrogen peroxide and the superoxide anion introduce chemical changes virtually in all cellular components, causing deleterious effects on the islets of β-cells, in turn affecting insulin production. Under hyperglycemic conditions, various signaling pathways such as nuclear factor-κβ (NF-κβ) and protein kinase C (PKC) are also activated by ROS. All of these can be linked to a hindrance in insulin signaling pathways, leading to insulin resistance. Hyperglycemia-induced oxidative stress plays a substantial role in complications including diabetic nephropathy. DM patients are more prone to microvascular as well as atherosclerotic macrovascular diseases. This systemic disease affects most countries around the world, owing to population explosion, aging, urbanization, obesity, lifestyle, etc. However, some modulators, with their free radical scavenging properties, can play a prospective role in overcoming the debilitating effects of OS. This review is a modest approach to summarizing the basics and interlinkages of oxidative stress, its modulators and diabetes mellitus. It may add to the understanding of and insight into the pathophysiology of diabetes and the crucial role of antioxidants to weaken the complications and morbidity resulting from this chronic disease.

A movable type bioelectronics printing technology for modular fabrication of biosensors

Biosensors have been widely used in various fields such as food industry, environmental testing and medical testing for their high sensitivity. However, current fabrication methods of biosensors, such as screen printing, micro fabrication and 3D printing suffer from complex procedures, requirement of cleanroom facility and limited fabrication materials, which significantly restrict the development and utilization of biosensors. Here, we propose a movable type bioelectronics printing method for the fabrication of biosensors by directly transferring bioelectronic materials onto various substrates using pre-fabricated molds. This simple, low-cost, yet robust method facilitates on-demand printing of master molds of partial or complete circuits on both rigid or flexible substrates. With this method, bioactive materials such as enzymes can be directly transferred onto substrates together with other electronic components, without complex modification after electrode fabrication using conventional methods. For demonstration, a dual-channel flexible electrochemical biosensor was fabricated by the movable type bioelectronics printing method for continuous monitoring of glucose and lactate. The movable type bioelectronics printing technology holds advantages of repeatability, flexibility and low cost for fabrication of biosensors on rigid and flexible substrates, as well as direct transfer printing of bioactive materials, which greatly promotes small-scale production of biosensors.

One-Year Course of Olanzapine-Induced Diabetic Ketoacidosis: A Case Report

Second-generation antipsychotics, despite being highly effective, are among the drugs known to cause insulin resistance and metabolic syndrome, eventually leading to diabetes mellitus and less commonly diabetic ketoacidosis (DKA). Here, we present the case of a 21-year-old male, who was not previously known to have any comorbid factors but presented with DKA 1 year and 9 months after beginning treatment with olanzapine for an unspecified psychotic disorder requiring hospital admission and the resolution of the same following discontinuation of the drug. Our case report emphasizes the need for regular screening of patients requiring diabetogenic drugs, so that early identification of possible side effects can be noted and averted.

Hyperlactatemia associated with diabetic ketoacidosis in pediatric intensive care unit

BACKGROUND

Children with diabetic ketoacidosis often have elevated lactate. In this study, we investigated the clinical variables associated with hyperlactatemia in children with diabetic ketoacidosis.

METHODS

We designed a single-center retrospective descriptive study of children with diabetic ketoacidosis in a pediatric intensive care unit.

RESULTS

Of the 107 patients with diabetic ketoacidosis included in the analysis, 61 developed hyperlactatemia. Multivariate logistic regression analysis showed that heart rate (p = 0.003),diastolic blood pressure (p = 0.001) and stage of severity (p = 0.042) were independently associated with the development of hyperlactatemia in diabetic ketoacidosis. We found that lactate level was not significantly associated with length of hospital stay (p = 0.115) or the length of time to diabetic ketoacidosis resolution (p = 0.143).

CONCLUSIONS

Children with diabetic ketoacidosis presenting with severer stage, elevated heart rate and higher diastolic blood pressure may be prone to hyperlactatemia. Hyperlactatemia was not associated with length of time to DKA resolution and length of hospital stay.

Bicarbonate enhances the inflammatory response by activating JAK/STAT signalling in LPS + IFN-γ-stimulated macrophages

Macrophages, which develop by changing their functions according to various environmental conditions and stimuli, defend against the pathogens and play roles in homoeostasis and disease states. Bicarbonate (HCO3-) is important in the maintenance of intracellular and extracellular pH in the body. However, the effects of bicarbonate on macrophage function have not been examined. In this study, we investigated the effects of bicarbonate on macrophage activation in lipopolysaccharide (LPS) and interferon (IFN)-γ (LPS + IFN-γ)-stimulated murine macrophage-like RAW264.7 cells. The expression of the interleukin (IL)-6, inducible nitric oxide (NO) synthase and cyclooxygenase-2 genes was enhanced by sodium bicarbonate (NaHCO3) in a concentration-dependent manner in LPS + IFN-γ-stimulated RAW264.7 cells. The production of IL-6, NO2- and prostaglandin E2 was also increased by treatment with NaHCO3 in these cells. Moreover, NaHCO3-mediated elevation of inflammatory gene expression was abrogated by solute carrier (SLC) transporter inhibitors. Furthermore, its NaHCO3-mediated activation was negated by a JAK inhibitor , tofacitinib. NaHCO3-enhanced phosphorylation of STAT1, and its enhancement was abrogated by pre-treating with SLC transporter inhibitors in LPS + IFN-γ-stimulated RAW264.7 cells. In addition, similar results were obtained in murine bone marrow-derived macrophages. These results indicate that bicarbonate enhanced the inflammatory response through the JAK/STAT signalling in LPS + IFN-γ-stimulated macrophages.

Increased Incidence of Pediatric Diabetic Ketoacidosis After COVID-19: A Two-Center Retrospective Study in Korea

PURPOSE

We evaluated the clinical characteristics and severity of diabetic ketoacidosis (DKA) in children before and after the coronavirus disease 2019 (COVID-19) outbreak to identify its indirect effects on DKA incidence.

PATIENTS AND METHODS

This retrospective study included 19 children with DKA admitted to the emergency room (ER) in two centers in Jeonbuk province, Korea during the first 6 months of the year from 2017 to 2020. Data were collected on age, height, body weight, clinical symptoms, diabetic mellitus (DM) type, and laboratory findings. DKA severity was based on the presence of acute kidney injury, cerebrovascular accident, and altered mental status. The ratio of patients with DKA in all pediatric patients who visited the study ERs and in the Jeonbuk population was also determined.

RESULTS

There were no differences in anthropometric characteristics and complication rates between the pre-COVID-19 and COVID-19 periods; however, the rate of polydipsia was significantly higher in the COVID-19 period. All seven patients admitted during the COVID-19 pandemic (100%) had polydipsia and polyuria and were newly diagnosed with DM. The rate of pediatric patients with DKA admitted to the ER in 2020 (0.459%) was more than twice the mean rate of 0.206% for the four-year period. The incidence of DKA in the Jeonbuk population (0.00141%) also exceeded the mean rate (0.0009%).

CONCLUSION

The incidence of pediatric DKA might be higher due to the indirect effect of COVID-19 pandemic. Physicians should be aware of nonspecific symptoms related to DKA in children admitted to the ER.

Metformin lactic acidosis: Should we still be afraid?

Metformin, the first choice drug for type 2 diabetes treatment in all stages of therapy, and one of the most widely prescribed anti-hyperglycemic agents worldwide, represents a rare example of an old drug which continues to display new beneficial effects in various fields. However, lactic acidosis (LA) persists as a serious adverse effect. LA incidence is low and is not necessarily determined by the administration of metformin. Unfortunately, the concern for this complication has negatively affected the drug use, particularly in chronic kidney disease, which may impair drug excretion, and in congestive heart failure and chronic liver disease, which may promote lactate accumulation. This review describes how not only these historical contraindications have been considerably scaled back, though rather a recent large body of evidence supports a protective effect of biguanide on kidney, heart and liver and, maybe, against lactic acidosis itself. It is worthy to slow down both contraindications and precautions to metformin use, not to deprive a significant number of diabetic patients, as those with kidney, heart and liver comorbidities, from its potential benefits, and not to hamper in the near future the putative advantages in a wide spectrum of conditions outside of diabetes.

Is lactic acidosis predictive of outcomes in pediatric diabetic ketoacidosis?

OBJECTIVES

The objective of this study was to investigate the significance and prevalence of lactic acidosis in pediatric diabetic ketoacidosis (DKA) presenting to the emergency department.

METHODS

A retrospective cohort study of children (age ≤ 21 years) presenting to a tertiary care emergency department in DKA from December 1, 2015 to December 1, 2018. Patients needed to have DKA requiring admission to the pediatric intensive care unit and have had a lactate level collected while in the emergency department to be included.

RESULTS

92 patients resulting in 113 encounters had DKA and a lactate level collected in the emergency department. The mean lactate level was 3.5 mmol/L (±SD 2.1). 72 (63.7%) encounters had lactic acidosis (p < 0.001). There was no significant association between the presence of lactic acidosis and pediatric intensive care unit length of stay (p = 0.321), hospital length of stay (p = 0.426), morbidity (p = 0.552) and mortality (p = 1.000). Initial glucose levels were significantly higher in the patients presenting with lactic acidosis (p = 0.001).

CONCLUSIONS

Lactic acidosis is a common finding in pediatric DKA patients presenting to the emergency department. Serum lactate alone should not be used as an outcome predictor in pediatric DKA.

Challenges in management of diabetic ketoacidosis in hemodialysis patients, case presentation and review of literature

Chronic kidney disease is associated with accumulation of uremic toxins that increases insulin resistance which will lead to blunted ability to suppress hepatic gluconeogenesis and reduce peripheral utilization of insulin. CKD patients fail to increase insulin secretion in response to insulin resistance because of acidosis, 1,25 vitamin D deficiency, and secondary hyperparathyroidism. Hemodialysis causes further fluctuations in glycemic control due to alterations in insulin secretion, clearance and resistance. DKA is uncommon in hemodialysis patients because of the absence of glycosuria and osmotic diuresis which accounts for most of the fluid and electrolyte losses seen in DKA, anuric patients may be somewhat protected from dehydration and shock, although still subject to hyperkalemia and metabolic acidosis. However, substantial volume loss can still occur due to a prolonged decrease in oral intake or increased insensible water losses related to tachypnoea and fever. There is no current guidelines for the management of diabetic ketoacidosis in anuric hemodialysis patients considering their differences than general population. In this review article we reviewed the literature and came with specific recommendations for management of Ketoacidosis in patients with CKD treated by hemodialysis.

Temporal Trends in the Prevalence of Diabetes Decompensation (Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State) Among Adult Patients Hospitalized with Diabetes Mellitus: A Nationwide Analysis Stratified by Age, Gender, and Race

Background

Disproportionate change in the burden of diabetes mellitus across various subgroups has been reported in the United States. However, changing landscape of the prevalence and mortality of decompensated diabetes (diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)) remains indistinct across various age, gender, and racial groups of hospitalized diabetics.

Methods

The National Inpatient Sample (NIS) datasets (2007-2014) were sought to assess the prevalence and temporal trends in decompensated diabetes stratified by age, gender, and race and related in-hospital outcomes among the adult patients hospitalized with diabetes using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Discharge weights were used to obtain national estimates.

Results

Of 56.7 million hospitalizations with diabetes, 0.5 (0.9%) million patients revealed decompensated diabetes from 2007 to 2014. The decompensated diabetics consisted of younger (~52 vs. 66 yrs), more often black (24.2% vs. 17.3%) and Hispanic (12.9% vs. 10.9%) patients as compared to those without decompensation (p<0.001). Younger diabetes patients demonstrated the highest prevalence of in-hospital decompensation (18-44 yrs; 3.7%) with a relative increase of 32.4% (from 3.4% to 4.5%) from 2007 to 2014 (p_trend<0.001). Older diabetics (≥65 years) with decompensation suffered the highest in-hospital mortality (12.8%). The overall rate of decompensation was similar (0.9%) among male and female diabetes patients. However, over a period of 8 years, the rates of decompensation rose to 1.1% (p_trend<0.001) in males and 1.2% (p_trend<0.001) in females, respectively. All-cause in-hospital mortality among females with decompensated diabetes declined from 6.6% in 2007 to 5.9% in 2014 (p_trend=0.019). However, there was no significant drop in in-hospital mortality among male diabetics with acute decompensation (6.7% in 2007 to 6.8% in 2014, p_trend=0.811). We observed significantly increasing trends in decompensated diabetes among all race groups between 2007 and 2014 (p_trend<0.001). The in-hospital mortality was highest among Asian or Pacific Islander (0.9%) diabetes patients with decompensation from 2007 to 2014. There was a declining trend in the inpatient mortality among Asian or Pacific Islander (p_trend=0.029) and Hispanic (p_trend<0.001) patients with decompensated diabetes, whereas other race groups did not observe any significant decline in mortality over the study period. Diabetes hospitalizations with decompensation demonstrated significantly higher in-hospital mortality (6.3% vs. 2.6%; p<0.001), average length of stay (7.7 vs. 5.4 days; p<0.001), hospital charges ($65,904 vs. $42,889, p<0.001), and more frequent transfers to short-term hospitals (3.9% vs. 2.9%; p<0.001) in comparison to those without decompensation. The rates of acute myocardial infarction (AMI) (10.4% vs. 4.8%; p<0.001), stroke (4.0% vs. 3.3%; p<0.001) and venous thromboembolism (3.5% vs. 2.6%; p<0.001) were substantially higher among diabetics with decompensation compared to those without.

Conclusions

There was an increasing trend in the prevalence of decompensated diabetes from 2007 to 2014, most remarkable among younger black male diabetics. The patients with decompensated diabetes suffered higher in-hospital mortality and rates of AMI, stroke and venous thromboembolism, there was no significant decline in the mortality between 2007 and 2014.

Assessing the incidence of acidosis in patients receiving metformin with and without risk factors for lactic acidosis

BACKGROUND

Despite strong recommendations to use metformin as first-line therapy for type 2 diabetes (T2DM), its use has been suboptimal, likely due to concerns of lactic acidosis. This study compared the association of acidosis in patients with T2DM prescribed metformin with those prescribed other antihyperglycemic medications or no medications.

METHODS

This was a retrospective cohort study of patients with newly diagnosed T2DM utilizing an administrative database, which includes medical and prescription claims. Eligible patients had a diagnosis of T2DM, had continuous health plan enrollment 3 months prior to study enrollment and during the study period, and were at least 18 years of age. Mutually exclusive exposure groups were metformin only, other antihyperglycemic medications, and no medication. Acidosis cases were stratified by exposure group and risk factors for lactic acidosis (chronic obstructive pulmonary disease, hepatic dysfunction, alcohol abuse, heart failure, renal insufficiency, age of 80 years or older, and a history of acidosis). Degree of renal insufficiency was not available. Associations between exposure and acidosis were estimated, and risk factors evaluated.

RESULTS

A total of 132,780 patients met inclusion criteria: 24,936 (20%) metformin only group, 15,059 (11%) other antihyperglycemic medication group, and 92,785 (70%) no medication group. Acidosis was observed in 1.45 per 10,000 patient months (0.78 metformin, 1.59 other antihyperglycemic medication, 1.51 no medication). The unadjusted relative risk of acidosis was 0.5 for patients prescribed metformin only compared with the other exposure groups (95% confidence interval = 0.2-1.2). There was no significant difference in risk of acidosis between exposure groups, irrespective of risk factors for lactic acidosis.

CONCLUSIONS

Risk of acidosis was similar with metformin only compared with those prescribed other antihyperglycemic medications or no medication. These results support expanded use of metformin for T2DM. Additional studies are needed to understand the impact of risk factor severity on risk of lactic acidosis.

Effect of treatment with vitamin D plus calcium on oxidative stress in streptozotocin-induced diabetic rats

Background

In diabetes mellitus, uncontrolled hyperglycemia has been reported to induce oxidative stress, which may lead to health complications. Vitamin D, however, acts as a non-enzymatic antioxidant to protect cells against oxidative stress and damage.

Objective

To investigate the antioxidative effect of vitamin D combined with calcium in streptozotocin (STZ)-induced diabetic rats.

Methods

Rats were divided into four groups (ten rats in each group). The first group (control) received a normal diet and water. The second group, including STZ-induced diabetic rats (diabetic controls), received a normal diet and water. The third group, also including STZ-induced diabetic rats, received vitamin D (2000 IU/day) with calcium (500 mg/kg/day) orally for 28 consecutive days. The fourth group consisted of STZ-induced diabetic rats that received insulin treatment for 28 consecutive days. Activities of superoxide dismutase (SOD), glutathione peroxidase (GPO) and catalase were measured in the liver tissues. The level of malonaldehyde (MDA) was measured in the plasma.

Results

Diabetic rats showed a significant decrease in the activities of SOD, GPO and catalase compared to normal rats. Oral administration of vitamin D with calcium to diabetic rats caused a significant increase in the activities of SOD, GPO and catalase compared with the untreated group. Furthermore, the plasma level of MDA was significantly elevated in diabetic rats compared to normal rats. Diabetic rats treated with vitamin D and calcium had a significantly reduced level of MDA, suggesting that vitamin D with calcium played a vital role in the protection of tissues from damage by free radicals.

Conclusion

Oral supplementation with vitamin D and calcium may be a useful treatment for diabetic patients to reduce/prevent the pathological complications of diabetes.

Lesson of the month 1: Diabetic ketoacidosis in established renal failure

Diabetic ketoacidosis (DKA) is a common medical emergency. The pathophysiology of DKA in patients with advanced chronic kidney disease differs significantly from patients with preserved renal function. We describe a patient with pre-dialysis renal failure who presented with DKA. This case highlights the importance of tailoring the established management guidelines appropriately.

Extracellular acidification stimulates GPR68 mediated IL-8 production in human pancreatic β cells

Acute or chronic metabolic complications such as diabetic ketoacidosis are often associated with extracellular acidification and pancreatic β-cell dysfunction. However, the mechanisms by which human β-cells sense and respond to acidic pH remain elusive. In this study, using the recently developed human β-cell line EndoC-βH2, we demonstrate that β-cells respond to extracellular acidification through GPR68, which is the predominant proton sensing receptor of human β-cells. Using gain- and loss-of-function studies, we provide evidence that the β-cell enriched transcription factor RFX6 is a major regulator of GPR68. Further, we show that acidic pH stimulates the production and secretion of the chemokine IL-8 by β-cells through NF-кB activation. Blocking of GPR68 or NF-кB activity severely attenuated acidification induced IL-8 production. Thus, we provide mechanistic insights into GPR68 mediated β-cell response to acidic microenvironment, which could be a new target to protect β-cell against acidosis induced inflammation.

Hyperlactatemia and the Outcome of Type 2 Diabetic Patients Suffering Acute Myocardial Infarction

Background. Increased lactate production is frequent in unregulated/complicated diabetes mellitus. Methods. Three groups, each consisting of 40 patients (type 2 diabetics with myocardial infarction, DM+AMI, nondiabetics suffering myocardial infarction, MI, and diabetics with no apparent cardiovascular pathology, DM group), were tested for pH, serum bicarbonate and electrolytes, blood lactate, and CK-MB. Results. Blood lactate levels were markedly higher in AMI+DM compared to MI group (4.54 ± 1.44 versus 3.19 ± 1.005 mmol/L, p < 0.05); they correlated with the incidence of heart failure (ρ = 0.66), cardiac rhythm disorders (ρ = 0.54), oxygen saturation (ρ = 0.72), CK-MB levels (ρ = 0.62), and poor short-term outcome. Lactic acidosis in DM+AMI group was not always related to lethal outcome. Discussion. The lactate cutoff value associated with grave prognosis depends on the specific disease. While some authors proposed cutoff values ranging from 0.76 to 4 mmol/L, others argued that only occurrence of lactic acidosis may be truly predictive of lethal outcome. Conclusion. Both defective glucose metabolism and low tissue oxygenation may contribute to the lactate production in diabetic patients with acute myocardial infarction; high lactate levels indicate increased risk for poor outcome in this population comparing to nondiabetic patients. The rise in blood lactate concentration in diabetics with AMI was associated with increased incidence of heart failure, severe arrhythmias, cardiogenic shock, and high mortality rate.

Management of hyperosmolar hyperglycaemic state in adults with diabetes

Hyperglycaemic hyperosmolar state (HHS) is a medical emergency, which differs from diabetic ketoacidosis (DKA) and requires a different approach. The present article summarizes the recent guidance on HHS that has been produced by the Joint British Diabetes Societies for Inpatient Care, available in full at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_HHS_Adults.pdf. HHS has a higher mortality rate than DKA and may be complicated by myocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis and there is some evidence that rapid changes in osmolality during treatment may be the precipitant of central pontine myelinolysis. Whilst DKA presents within hours of onset, HHS comes on over many days, and the dehydration and metabolic disturbances are more extreme. The key points in these HHS guidelines include: (1) monitoring of the response to treatment: (i) measure or calculate the serum osmolality regularly to monitor the response to treatment and (ii) aim to reduce osmolality by 3-8 mOsm/kg/h; (2) fluid and insulin administration: (i) use i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, (ii) fluid replacement alone will cause a fall in blood glucose (BG) level, (iii) withhold insulin until the BG level is no longer falling with i.v. fluids alone (unless ketonaemic), (iv) an initial rise in sodium level is expected and is not itself an indication for hypotonic fluids and (v) early use of insulin (before fluids) may be detrimental; and (3) delivery of care: (i) The diabetes specialist team should be involved as soon as possible and (ii) patients should be nursed in areas where staff are experienced in the management of HHS.

Upregulation of T-type Ca2+ channels in long-term diabetes determines increased excitability of a specific type of capsaicin-insensitive DRG neurons

Background

Previous studies have shown that increased excitability of capsaicin-sensitive DRG neurons and thermal hyperalgesia in rats with short-term (2–4 weeks) streptozotocin-induced diabetes is mediated by upregulation of T-type Ca²⁺ current. In longer–term diabetes (after the 8th week) thermal hyperalgesia is changed to hypoalgesia that is accompanied by downregulation of T-type current in capsaicin-sensitive small-sized nociceptors. At the same time pain symptoms of diabetic neuropathy other than thermal persist in STZ-diabetic animals and patients during progression of diabetes into later stages suggesting that other types of DRG neurons may be sensitized and contribute to pain. In this study, we examined functional expression of T-type Ca²⁺ channels in capsaicin-insensitive DRG neurons and excitability of these neurons in longer-term diabetic rats and in thermally hypoalgesic diabetic rats.

Results

Here we have demonstrated that in STZ-diabetes T-type current was upregulated in capsaicin-insensitive low-pH-sensitive small-sized nociceptive DRG neurons of longer-term diabetic rats and thermally hypoalgesic diabetic rats. This upregulation was not accompanied by significant changes in biophysical properties of T-type channels suggesting that a density of functionally active channels was increased. Sensitivity of T-type current to amiloride (1 mM) and low concentration of Ni²⁺ (50 μM) implicates prevalence of Ca_v3.2 subtype of T-type channels in the capsaicin-insensitive low-pH-sensitive neurons of both naïve and diabetic rats. The upregulation of T-type channels resulted in the increased neuronal excitability of these nociceptive neurons revealed by a lower threshold for action potential initiation, prominent afterdepolarizing potentials and burst firing. Sodium current was not significantly changed in these neurons during long-term diabetes and could not contribute to the diabetes-induced increase of neuronal excitability.

Conclusions

Capsaicin-insensitive low-pH-sensitive type of DRG neurons shows diabetes-induced upregulation of Ca_v3.2 subtype of T-type channels. This upregulation results in the increased excitability of these neurons and may contribute to nonthermal nociception at a later-stage diabetes.

Antipsychotics-induced metabolic alterations: focus on adipose tissue and molecular mechanisms

The use of antipsychotic drugs for the treatment of mood disorders and psychosis has increased dramatically over the last decade. Despite its consumption being associated with beneficial neuropsychiatric effects in patients, atypical antipsychotics (which are the most frequently prescribed antipsychotics) use is accompanied by some secondary adverse metabolic effects such as weight gain, dyslipidemia and glucose intolerance. The molecular mechanisms underlying these adverse effects are not fully understood but have been suggested to involve a dysregulation of adipose tissue homeostasis. As such, the aim of this paper is to review and discuss the role of adipose tissue in the development of secondary adverse metabolic effects induced by atypical antipsychotics. Data analyzed in this article suggest that atypical antipsychotics may increase adipose tissue (particularly visceral adipose tissue) lipogenesis, differentiation/hyperplasia, pro-inflammatory mediator secretion and insulin resistance and decrease adipose tissue lipolysis. Consequently, patients receiving antipsychotic medication could be at risk of developing obesity, type 2 diabetes and cardiovascular disease. A better knowledge of the impact of these drugs on adipose tissue homeostasis may unveil strategies to develop novel antipsychotic drugs with less adverse metabolic effects and to develop adjuvant therapies (e.g. behavioral and nutritional therapies) to neuropsychiatric patients receiving antipsychotic medication.

Utility of ketone measurement in the prevention, diagnosis and management of diabetic ketoacidosis

Ketone measurement is advocated for the diagnosis of diabetic ketoacidosis and assessment of its severity. Assessing the evidence base for ketone measurement in clinical practice is challenging because multiple methods are available but there is a lack of consensus about which is preferable. Evaluating the utility of ketone measurement is additionally problematic because of variability in the biochemical definition of ketoacidosis internationally and in the proposed thresholds for ketone measures. This has led to conflicting guidance from expert bodies on how ketone measurement should be used in the management of ketoacidosis. The development of point-of-care devices that can reliably measure the capillary blood ketone β-hydroxybutyrate (BOHB) has widened the spectrum of applications of ketone measurement, but whether the evidence base supporting these applications is robust enough to warrant their incorporation into routine clinical practice remains unclear. The imprecision of capillary blood ketone measures at higher values, the lack of availability of routine laboratory-based assays for BOHB and the continued cost-effectiveness of urine ketone assessment prompt further discussion on the role of capillary blood ketone assessment in ketoacidosis. In the present article, we review the various existing methods of ketone measurement, the precision of capillary blood ketone as compared with other measures, its diagnostic accuracy in predicting ketoacidosis and other clinical applications including prevention, assessment of severity and resolution of ketoacidosis.

Serum C-peptide assay of patients with hyperglycemic emergencies at the Lagos State University Teaching Hospital (LASUTH), Ikeja

INTRODUCTION

HE are common acute complications of diabetes mellitus (DM) and include diabetic ketoacidosis (DKA), normo-osmolar hyperglycemic state (NHS) and hyperosmolar hyperglycemic state (HHS). They contribute a lot to the mortality and morbidity of DM. The clinical features include dehydration, hyperglycemia, altered mental status and ketosis. The basic mechanism of HE is a reduction in the net effective action of circulating insulin, resulting in hyperglycemia and ketonemia (in DKA) causing osmotic diuresis and electrolytes loss. Infection is a common precipitating factor. Measurement of serum C-peptide provides an accurate assessment of residual β-cell function and is a marker of insulin secretion in DM patients.

AIM AND OBJECTIVES

To assess the level of pancreatic beta cell function in HE patients, using the serum C-peptide.

METHODOLOGY

The biodata and clinical characteristics of the 99 subjects were collated using a questionnaire. All subjects had their serum C-peptide, glucose, electrolytes, urea, creatinine levels, urine ketones determined at admission. Results of statistical analysis were expressed as mean ± standard deviation (SD). A p value <0.05 was regarded statistically significant. Correlation between levels of serum C-peptide and admission blood glucose levels and the duration of DM respectively was done.

RESULTS

The mean age of the subjects was 51 (SD ± 16) years and comparable in both sexes. Mean duration of DM was 6.3 (SD ± 7.1) years, with 35% newly diagnosed at admission. The types of HE in this study are: DKA (24.7%), NHS (36.1%), and HHS (39.2%). Mean blood glucose in this study was 685 mg/dL, significantly highest in HHS and lowest in NHS. Mean serum C-peptide level was 1.6 ng/dL. It was 0.9 ng/dL in subjects with DKA and NHS while 2.7 ng/dL in HHS (p>0.05). Main precipitating factors were poor drug compliance, new-onset of DM and infection.

CONCLUSION

Most (70%) of subjects had poor pancreatic beta cell function, this may be a contributory factor to developing HE. Most subjects with high C-peptide levels had HHS.

Effects of sodium-glucose cotransporter 2 selective inhibitor ipragliflozin on hyperglycaemia, oxidative stress, inflammation and liver injury in streptozotocin-induced type 1 diabetic rats

OBJECTIVE

Sodium-glucose cotransporter (SGLT) 2 plays an important role in renal glucose reabsorption and has been highlighted as a therapeutic target for the treatment of diabetes. Here, we investigated the therapeutic effects of SGLT2 selective inhibitor ipragliflozin in type 1 diabetic rats.

METHODS

Type 1 diabetic rats were prepared by intravenous administration of streptozotocin (STZ). Ipragliflozin was acutely or chronically administered, and therapeutic effects were investigated.

KEY FINDINGS

Single administration of ipragliflozin significantly increased urinary glucose excretion, and its effect lasted over 12 h. In addition, ipragliflozin improved glucose tolerance and sustainably reduced hyperglycaemia. Repeated administration of ipragliflozin to diabetic rats for 4 weeks significantly improved not only hyperglycaemia, but also hyperlipidaemia and hepatic steatosis with concomitant increases in urinary glucose excretion. In addition, ipragliflozin ameliorates renal glomerular hyperfiltration and albuminuria. Further, ipragliflozin reduced liver levels of oxidative stress biomarkers and plasma levels of inflammatory markers, and improved liver injury as assessed by plasma levels of aminotransferases.

CONCLUSION

These results suggest that SGLT2 selective inhibitor ipragliflozin exerts a beneficial effect on glycaemic control and ameliorates diabetes-associated metabolic abnormalities and complications in STZ-induced diabetic rats, and would be a potential agent for the treatment of type 1 diabetes.

Markers of Oxidative Stress during Diabetes Mellitus

The prevalence of diabetes mellitus is rising all over the world. Uncontrolled state of hyperglycemia due to defects in insulin secretion/action leads to a variety of complications including peripheral vascular diseases, nephropathy, neuropathy, retinopathy, morbidity, and/or mortality. Large body of evidence suggests major role of reactive oxygen species/oxidative stress in development and progression of diabetic complications. In the present paper, we have discussed the recent researches on the biomarkers of oxidative stress during type 2 diabetes mellitus.

Microdialysis monitoring of glucose, lactate, glycerol, and pyruvate in patients with diabetic ketoacidosis

PURPOSE

The objective was to assess glucose, lactate, glycerol, and pyruvate concentrations in the interstitial fluid of the adipose tissue as well as the glucose relative recovery coefficient in reference to capillary blood (RC) during the first two days of the standard treatment of diabetic ketoacidosis (DKA) in patients with type 1 and type 2 diabetes.

MATERIALS AND METHODS

The study group consisted of 19 patients (12 with type 1 diabetes and 7 with type 2 diabetes). The metabolic state of the patients was monitored using the microdialysis technique. The analysis of variance was used to investigate whether the type of diabetes and the duration of treatment influenced the assessed parameters.

RESULTS

Concentrations of all the monitored components were stable after the initial 12 h of treatment. Glucose concentration was higher and concentrations of all the other components were lower (p<0.0001) in patients with type 1 diabetes than in patients with type 2 diabetes. Significantly higher RC was observed in patients with type 1 diabetes during the initial 12 h.

CONCLUSIONS

The results suggest that the standard treatment of DKA is effective in stabilizing a concentration of the studied metabolic components in the interstitial fluid in patients with type 1 and type 2 diabetes despite differences in the glucose concentration at the beginning of the treatment.

Managing hyperglycaemic emergencies: an illustrative case and review of recent British guidelines

Diabetic ketoacidosis and hyperosmolar hyperglycaemic syndrome are important hyperglycaemic emergencies seen in patients with diabetes. Occasionally, differentiation between the two conditions can be difficult. We present the case of a patient whose hyperglycaemic emergency was managed in a way that could have adversely influenced the outcome. We also discuss important aspects of the new Joint British Diabetes Societies Guidelines on the management of hyperglycaemic emergencies.

Atypical antipsychotics and diabetic ketoacidosis: a review

RATIONALE

Atypical antipsychotics have been linked to weight gain and type 2 diabetes, but are also associated with diabetic ketoacidosis (DKA), which can occur more acutely and in the absence of weight gain.

OBJECTIVES

Our aim was to review current case reports of DKA in the context of atypical antipsychotic treatment to better understand (a) the scope of the problem, (b) its relationship to different atypical agents, (c) risk factors, (d) long-term outcome, and (e) putative mechanisms of action.

METHOD

Searches in PubMed/Medline, as well as the University of Toronto's Scholar Portal, were performed for all relevant articles/abstracts in English.

RESULTS

Sixty reports, yielding 69 cases, affirm that DKA is a rare but serious risk with almost all atypical antipsychotics; however, liability seems to vary between agents, at least partially mirroring risk of weight gain. Mean age of onset was 36.9 years (range 12-80), with 68 % of cases occurring in males, and 41 % in individuals of African American or African Caribbean descent. Over one third of cases present with either no weight gain or weight loss, and 61 % of these require ongoing treatment for glycemic control. Death occurred in 7.25 % of cases.

CONCLUSION

While the underlying mechanisms are not well understood, antipsychotic-related DKA can occur soon after treatment onset and in the absence of weight gain. Although rare, clinicians must remain vigilant given its acute onset and potential lethality.

Hyperglycemia increases susceptibility to ischemic necrosis

Diabetic patients are at risk for spontaneous foot ulcers, chronic wounds, infections, and tissue necrosis. Current theories suggest that the development and progression of diabetic foot ulcers are mainly caused by arteriosclerosis and peripheral neuropathy. Tissue necrosis plays a primordial role in the progression of diabetic foot ulcers but the underlying mechanisms are poorly understood. The aim of the present study was to investigate the effects of hyperglycemia per se on the susceptibility of ischemic tissue to necrosis, using a critical ischemic hind limb animal model. We inflicted the same degree of ischemia in both euglycemic and streptozotocin-induced hyperglycemic rats by resecting the external iliac, the femoral, and the saphenous arteries. Postoperative laser Doppler flowmetry of the ischemic feet showed the same degree of reduction in skin perfusion in both hyperglycemic and euglycemic animals. Nevertheless, we found a significantly higher rate of limb necrosis in hyperglycemic rats compared to euglycemic rats (71% versus 29%, resp.). In this study, we revealed that hyperglycemia per se increases the susceptibility to limb necrosis in ischemic conditions. Our results may help to better understand the physiopathology of progressive diabetic wounds and underline the importance of strict glycemic control in patients with critical limb ischemia.

Diabetes, hyperglycaemia, and acute ischaemic stroke

Diabetes and ischaemic stroke often arise together. People with diabetes have more than double the risk of ischaemic stroke after correction for other risk factors, relative to individuals without diabetes. Multifactorial treatment of risk factors for stroke-in particular, lifestyle factors, hypertension, and dyslipidaemia-will prevent a substantial number of these disabling strokes. Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Admission hyperglycaemia is associated with poor functional outcome, possibly through aggravation of ischaemic damage by disturbing recanalisation and increasing reperfusion injury. Uncertainty surrounds the question of whether glucose-lowering treatment for early stroke can improve clinical outcome. Achievement of normoglycaemia in the early stage of stroke can be difficult, and the possibility of hypoglycaemia remains a concern. Phase 3 studies of glucose-lowering therapy in acute ischaemic stroke are underway.

A case of hyperosmolar hyperglycaemic state with involuntary movements - diagnostic dilemma and clinical considerations

Hyperosmolar hyperglycaemic state (HHS) is a medical emergency which needs immediate medical intervention. A 37-year-old Chinese woman with a history of hypertension attended the Emergency Department. She had a two-day history of involuntary movement, i.e. chorea of the upper limbs, preceded by a one-week history of upper respiratory tract infection. She also had polyuria and polydipsia, although she was never diagnosed as diabetic. The main aim of reporting the present case was to highlight the importance of biochemical investigations involved in the diagnosis of involuntary movements.

Treatment of hypophosphatemia in the intensive care unit: a review

Introduction

Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients.

Methods

We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior.

Results

Incidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies, hypophosphatemia was associated with higher mortality; a paucity of randomized controlled evidence exists for whether correction of hypophosphatemia improves the outcome in critically ill patients.

Conclusions

Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder.

Diabetic emergencies in small animals

Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome are two serious and potentially life-threatening complications of diabetes mellitus. Understanding pathophysiology is crucial to the proper management of veterinary patients with these disorders. This article reviews the biochemical alterations contributing to these conditions, and discusses traditional and controversial management strategies.

[Severe hypertriglyceridemia in diabetic ketoacidosis: case report]

OBJECTIVES

Diabetic ketoacidosis is a recurrent problem in the emergency room that requires prompt and effective treatment. Usually, it may be associated with an increase in triglyceride levels, exposing the patient to the risk of pancreatitis.

METHODS

We report the case of a 38-year-old female patient with diabetic ketoacidosis and severe hypertriglyceridemia (triglycerides: 11.758 mg/dL).

RESULTS

The patient was admitted to the Intensive Care Unit. Hydration and intravenous insulin were performed with success. During hospitalization, the levels of triglycerides decreased significantly and the levels of amylase and lipase remained at normal ranges, not suggesting pancreatitis. No other Brazilian cases with these levels of triglycerides were found.

CONCLUSION

We conclude that, in diabetic ketoacidosis, lipid profile, including triglycerides, should be requested, due to a not negligible prevalence of complications such as hypertriglycerides and pancreatitis.

[Diabetic ketoacidosis in adults--update of an old complication]

Diabetic ketoacidosis is an acute complication of Diabetes Mellitus characterized by hyperglycemia, metabolic acidosis, dehydration, and ketosis, in patients with profound insulin deficiency. It occurs predominantly in patients with type 1 diabetes and is frequently precipitated by infections, insulin withdrawal or undiagnosed type 1 diabetes. The authors review its pathophysiology, diagnostic criteria and treatment options in adults, as well as its complications.

Diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome - clinical guidelines

BACKGROUND

The aim of this study was to establish a standardized approach to the initial care of patients with diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar syndrome (HHS). DKA and HHS are metabolic emergencies. Effective and efficient management is the responsibility of the multidisciplinary team. The admission of patients to the intensive care unit (ICU) with DKA and HHS is rare, and management of patients' diverse problems is prone to error because of a lack of familiarity.

AIM

The paper's aim is to set the developmental process of a clinical guideline following a review of the literature.

DISCUSSION

This clinical guideline is based on a review of the evidence available within the literature in the early phase of resuscitation. Collaborative working among the multidisciplinary team through clinical practice group was the method adopted. Management of DKA and HHS is divided into three main areas: intravenous fluid replacement, insulin therapy and electrolyte management. The controversy associated with the administration of sodium bicarbonate is discussed.

CONCLUSION

Effective treatment requires a rapid initial assessment of the patient based on current medical history and clinical presentation. To this end, a quick reference algorithm and guide to management were also developed. Key criteria for evaluating the effectiveness of treatment are provided and complications of treatment are addressed. The formation of the practice development group that led to this innovation is outlined, and in conclusion, the success of the group is reflected upon.

Microdialysis technique as a monitoring system for acute complications of diabetes

The objective of the study was to establish the quasi-continuous courses, using microdialysis technique, of glucose, lactate, and glycerol concentrations in interstitial fluid of abdominal adipose tissue during the standard treatment of acute diabetes complications. Clinical studies were carried out on 31 diabetic patients during the initial 48 h of the treatment. In all but two obese female patients with hyperglycemic hyperosmolar state (HHS) did glucose concentration in perfusion fluid (PF) reflect concentration in capillary blood. The recovery of glucose correlated with patients' body mass index (r = 0.55). It was significantly higher in lean and overweight patients (91 +/- 15%) than in obese patients (55 +/- 31%). The course of lactate concentration in PF coincided with the course in venous blood (2.1 +/- 0.3 mmol/L vs. 2.0 +/- 0.5 mmol/L, P = 0.35). Glycerol concentration was 267 +/- 41 micromol/L and 133 +/- 40 micromol/L in PF and venous blood, respectively (P = 0.004). The study indicated that microdialysis may be an effective tool to monitor concentration of different metabolites in interstitial fluid of the adipose tissue during treatment of the acute complications of diabetes. Applicability of the technique in the monitoring of HHS, especially in obese female patients, needs further investigation.

Diabetes and hyperglycemia: strict glycemic control

OBJECTIVE

To critically review recent evidence on pathophysiology, diagnosis, and control of acute and chronic hyperglycemia in medical and surgical intensive care unit (ICU) patients.

DATA SOURCE AND STUDY SELECTION

A MEDLINE/PubMed search (1966 through February 2006) with manual cross-referencing was conducted, including all relevant articles published on blood glucose control in intensive care patients. An emphasis was placed on more recent clinical trials investigating the effects of tight glycemic control in ICU patients and on basic science studies investigating the pathophysiology and systemic effects of transient hyperglycemia in nondiabetic patients.

DATA EXTRACTION AND SYNTHESIS

Original articles, selected reviews, letters to the editor, and chapters of selected textbooks were extracted. The reviewed information was then analyzed with respect to the prevalence of hyperglycemia in ICU patients, the pathophysiology of hyperglycemia in nondiabetics, and evidence on glycemic control in various subgroups of ICU patients. The risk of iatrogenic hypoglycemia in the ICU and potential future research directions are discussed at the end of the review.

CONCLUSIONS

Recent evidence shows direct improvements in patient mortality and in-hospital morbidity with strict control of even short-term elevations of glucose levels in certain subgroups of ICU patients. However, precisely defined target glucose levels, subgroup analyses of different patient populations and treatment interventions, and the avoidance of hypoglycemic episodes during insulin therapy remain incompletely resolved and warrant future investigation.