1
|
Jones HC, Kiburg KV, Lee MH, O'Neal DN, MacIsaac RJ. Trends in diabetic ketoacidosis in Victoria, Australia 2002-2016. BMC Endocr Disord 2024; 24:128. [PMID: 39075462 PMCID: PMC11285618 DOI: 10.1186/s12902-024-01650-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 07/08/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND International longitudinal studies have indicated an increasing incidence of diabetic ketoacidosis (DKA). We aim to examine the incident trends, demographic differences, length of stay and mortality for DKA in adults with type 1 diabetes (T1D) and type 2 diabetes (T2D) in Victoria, Australia from 2002 to 2016. METHODS Age and sex adjusted incident trends, length of stay and mortality for DKA was retrospectively obtained using the Victorian Admitted Episode Dataset between 2002 and 2016. Data for adults with T1D and T2D was obtained from the National Diabetes Services Scheme (NDSS). Joinpoint regression analysis was used to identify changes in linear trends that were described as average annual percentage change (AAPC). RESULTS There were 23,628 DKA presentations in Victoria between 2002 and 2016. For T1D there was an increase in DKA presentations (AAPC + 6.8%) from 2003 to 2016 and for T2D there was a decline from 2003 to 2011 (APC - 3.5%), increase from 2011 to 2014 (APC + 38.5%), and a decrease from 2014 to 2016 (APC - 20.9%). Length of stay was longer for people with T2D than T1D (P < 0.001) and the mortality rate was 0.51% for the study period. CONCLUSIONS DKA rates increased for T2D from 2011 to 2014 which correlates with the introduction of sodium glucose-linked transport protein 2 inhibitors. However, the aetiology for the observed increase in T1D from 2002 to 2016 remains unknown.
Collapse
Affiliation(s)
- Hanna C Jones
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Katerina V Kiburg
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Medicine, University of Melbourne, Fitzroy, VIC, 3065, Australia
| | - Melissa H Lee
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Medicine, University of Melbourne, Fitzroy, VIC, 3065, Australia
| | - David N O'Neal
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
- Department of Medicine, University of Melbourne, Fitzroy, VIC, 3065, Australia
- Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Parkville, VIC, 3065, Australia
| | - Richard J MacIsaac
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.
- Department of Medicine, University of Melbourne, Fitzroy, VIC, 3065, Australia.
- Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Parkville, VIC, 3065, Australia.
| |
Collapse
|
2
|
Sakane N. Innovations and applications of ketone body monitoring in diabetes care. Diabetol Int 2024; 15:370-378. [PMID: 39101172 PMCID: PMC11291811 DOI: 10.1007/s13340-024-00735-4] [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: 02/19/2024] [Accepted: 05/18/2024] [Indexed: 08/06/2024]
Abstract
Ketone bodies, comprising β-hydroxybutyric acid (BHB), acetoacetate (AcAc), and acetone, play a vital role as essential energy substrates. In individuals with diabetes, ketone bodies can be elevated under various conditions, including diabetic ketoacidosis, use of sodium-glucose transporter type 2 (SGLT2) inhibitors, and extreme carbohydrate restriction. There are three methods for measuring ketone bodies. Urine ketone analysis (AcAc) is a standard clinical test, whereas blood ketone testing (BHB+AcAc) is valuable in identifying or resolving diabetic ketoacidosis. Recently, technology for measuring breath acetone has been introduced, which provides an easy means of monitoring ketogenic diets in obese individuals. The basic breath alcohol detector also reacts with breath acetone. Therefore, it is important for professional drivers taking SGLT2 inhibitors to be cautious as workplace breath alcohol detectors may show false-positive results. Conversely, if a positive result is obtained, a detailed examination of ketosis is necessary. This review provides an overview of ketone body measurements in individuals with diabetes.
Collapse
Affiliation(s)
- Naoki Sakane
- Division of Preventive Medicine, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto, 612-8555 Japan
| |
Collapse
|
3
|
Jaromy M, Miller JD. Potential Clinical Applications for Continuous Ketone Monitoring in the Hospitalized Patient with Diabetes. Curr Diab Rep 2022; 22:501-510. [PMID: 35984565 PMCID: PMC9388986 DOI: 10.1007/s11892-022-01489-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW In this review, the authors discuss potential clinical applications for continuous ketone monitoring (CKM) in a broad continuum of clinical settings from pre-hospital care and the emergency department to acute inpatient management and post-discharge follow-up. RECENT FINDINGS Though in its early stages, the concept of a novel continuous ketone sensing technology exerts great potential for use in the detection and hospital management of DKA, namely to overcome diagnostic barriers associated with ketoacidosis in patients with diabetes and obtain real-time BOHB levels, which may be useful in understanding both patients' response to treatment and DKA trajectory. Peri- and intra-operative use of CKM technology can potentially be applied in a number of urgent and elective surgical procedures frequently underwent by patients with diabetes and in the observation of patients during peri-operative fasting. In transitional care management, CKM technology could potentially facilitate patients' safe transition through levels of care, following hospital discharge from a DKA episode. This evaluation of the literature presents the potential advantages of adopting CKM and integrating this technology into the care algorithm of patients at risk for ketoacidosis.
Collapse
Affiliation(s)
- Michelle Jaromy
- New York Institute of Technology College of Osteopathic Medicine, 101 Northern Blvd, Glen Head, Oyster Bay, NY 11545 USA
| | - Joshua D. Miller
- Division of Endocrinology and Metabolism, Renaissance School of Medicine at Stony Brook University, 100 Nicolls Rd, Stony Brook, Brookhaven, NY 11794 USA
| |
Collapse
|
4
|
Aiello P, Peluso I, Di Giacomo S, Di Sotto A, Villaño Valencia D. Body Composition and Metabolic Status of Italian and Spanish University Students: Relationship with Fruit and Vegetable Consumption. Nutrients 2022; 14:nu14163296. [PMID: 36014802 PMCID: PMC9415832 DOI: 10.3390/nu14163296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
Most university students do not follow recommendations for fruit and vegetable intake, with a consequent increase in the prevalence of cardiovascular disease (CVD) risk factors. The aim of this study was to compare obesity prevalence and biomarkers of metabolic status between Italian and Spanish university students, in relation with the consumption of fruits and vegetables. Food consumption, adherence to a Mediterranean diet (MD), level of physical activity (PA), blood glucose, total cholesterol, triglycerides and ketones, blood pressure, and body composition were evaluated. Among CVD risk factors, only glucose was significantly higher in Spaniards (SP), and only 3.1% of SP presented ketosis. SP had a higher percentage of energy from fat. Although adherence to MD and fruit and vegetable consumption did not differ between Italians and SP, students who consumed at least four servings of fruit and vegetables (FV group) showed better values for pressure and metabolic parameters than the no FV group. We observed an association between consumption of fruit and PA. Students who consumed more vegetables than fruit reported a better body composition profile and lower glucose concentrations. As previously suggested, in addition to PA, two servings of fruit and three servings of vegetables per day should be recommended.
Collapse
Affiliation(s)
- Paola Aiello
- Department of Physiology and Pharmacology “V. Erspamer”, La Sapienza University of Rome, 00185 Rome, Italy
- Health Sciences PhD Program, Universidad Católica de Murcia UCAM, Campus de los Jerónimos n°135, 30107 Guadalupe, Spain
- Correspondence: or (P.A.); (A.D.S.)
| | - Ilaria Peluso
- Council for Agricultural Research and Economics, Research Center for Food and Nutrition, Via Ardeatina 546, 00178 Rome, Italy
| | - Silvia Di Giacomo
- Department of Physiology and Pharmacology “V. Erspamer”, La Sapienza University of Rome, 00185 Rome, Italy
| | - Antonella Di Sotto
- Department of Physiology and Pharmacology “V. Erspamer”, La Sapienza University of Rome, 00185 Rome, Italy
- Correspondence: or (P.A.); (A.D.S.)
| | - Débora Villaño Valencia
- “Nutrición, Estrés Oxidativo y Biodisponibilidad” Research Group, Faculty of Health Sciences, School of Pharmacy, Universidad Católica de Murcia UCAM, Campus de los Jerónimos n°135, 30107 Guadalupe, Spain
- “Producción Animal, Nutrición y Ciencia de los Alimentos” Research Group, Department of Agronomy, Biotechnology and Food Science, Universidad Pública de Navarra (UPNA), Campus de Arrosadía, 31006 Pamplona, Spain
| |
Collapse
|
5
|
Tremblay ES, Millington K, Monuteaux MC, Bachur RG, Wolfsdorf JI. Plasma β-Hydroxybutyrate for the Diagnosis of Diabetic Ketoacidosis in the Emergency Department. Pediatr Emerg Care 2021; 37:e1345-e1350. [PMID: 32011560 PMCID: PMC7394730 DOI: 10.1097/pec.0000000000002035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) is a common emergency department presentation of both new-onset and established diabetes mellitus (DM). β-Hydroxybutyrate (BOHB) provides a direct measure of the pathophysiologic derangement in DKA as compared with the nonspecific measurements of blood pH and bicarbonate. Our objective was to characterize the relationship between BOHB and DKA. METHODS This is a cross-sectional retrospective study of pediatric patients with DM presenting to an urban pediatric emergency department between January 1, 2016, and September 30, 2018. Analyses were performed on each patient's initial, simultaneous BOHB and pH. Diagnostic test characteristics of BOHB were calculated, and logistic regression was performed to investigate the effects of age and other key clinical factors. RESULTS Among 594 patients with DM, with median age of 12.3 years (interquartile range, 8.7-15.9 years), 176 (29.6%) presented with DKA. The inclusion of age, transfer status, and new-onset in the statistical model did not improve the prediction of DKA beyond BOHB alone. β-Hydroxybutyrate demonstrated strong discrimination for DKA, with an area under the curve of 0.95 (95% confidence interval, 0.93-0.97). A BOHB value of 5.3 mmol/L predicted DKA with optimal accuracy (90.6% of patients were correctly classified). The sensitivity, specificity, and positive and negative predictive values of this cut point were 76.7% (95% confidence interval, 69.8%-82.7%), 96.4% (94.2%-98.0%), 90.0% (84.0%-94.3%), and 90.8% (87.7%-93.3%), respectively. CONCLUSIONS β-Hydroxybutyrate accurately predicts DKA in children and adolescents. More importantly, because plasma BOHB is the ideal biochemical marker of DKA, BOHB may provide a more optimal definition of DKA for management decisions and treatment targets.
Collapse
Affiliation(s)
- Elise Schlissel Tremblay
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Kate Millington
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Richard G. Bachur
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Joseph I. Wolfsdorf
- Division of Endocrinology, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| |
Collapse
|
6
|
Dye AM, Alemzadeh R, Wang J, Tolley EA, Lahoti A. Intensive sick day rules to prevent recurrent diabetic ketoacidosis- An intervention that exemplifies health disparities. J Natl Med Assoc 2021; 114:30-37. [PMID: 34838266 DOI: 10.1016/j.jnma.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 08/28/2021] [Accepted: 10/12/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes (T1D). In established T1D patients, DKA is frequently a result of insulin omission or inadequate insulin administration during illness or stress. Ethnic minorities and patients with lower socioeconomic status are affected disproportionately. We hypothesized that implementation of intensive sick day rules with frequent reinforcement would reduce hospitalizations secondary to DKA in T1D youth irrespective of their demographics. METHODS Intensive sick day rules were implemented beginning January 2016. All T1D patients seen in the pediatric endocrinology clinic or hospital between January 1st 2015 through December 31st 2017 were included for chart review. Categorical variables were analyzed with Chi-square test. For the continuous variables, t test was used. Episodes of DKA per 100 patients were compared using the trends test over the three-year period. Patients who had DKA in 2015 were analyzed as a subgroup. RESULTS The frequency of DKA episodes per 100 patient years for 2015 was 19.1, for 2016 was 15.2 and was 12.4 for 2017. This decrease was statistically significant (p=0.006). The decline was also statistically significant for the subgroup of patients who developed DKA in 2015 and followed longitudinally. The decline was not uniform across all patient groups and DKA episodes remained associated with African- American race, Medicaid insurance status and higher HbA1c throughout the years. CONCLUSION Implementation of intensive sick day rules led to a decrease in total number of DKA admissions in our population with T1D youth. However, this intervention did not reduce the health disparity in this population and African-Americans on Medicaid insurance continued to form the disproportionate majority of admissions with DKA. This study highlights the need for further research into interventions that can improve outcomes across racial and socio-economic barriers.
Collapse
Affiliation(s)
- Alyssa M Dye
- Department of Pediatric Endocrinology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN, 38103, USA.
| | - Ramin Alemzadeh
- Department of Pediatric Endocrinology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN, 38103, USA.
| | - Jiajing Wang
- Department of Biostatistics and Epidemiology, University of Tennessee Health Science Center, 66 N Pauline, Memphis, TN, 38105, USA.
| | - Elizabeth A Tolley
- Department of Biostatistics and Epidemiology, University of Tennessee Health Science Center, 66 N Pauline, Memphis, TN, 38105, USA.
| | - Amit Lahoti
- Department of Pediatric Endocrinology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 848 Adams Avenue, Memphis, TN, 38103, USA.
| |
Collapse
|
7
|
Anderson JC, Mattar SG, Greenway FL, Lindquist RJ. Measuring ketone bodies for the monitoring of pathologic and therapeutic ketosis. Obes Sci Pract 2021; 7:646-656. [PMID: 34631141 PMCID: PMC8488448 DOI: 10.1002/osp4.516] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The ketone bodies β-hydroxybutyrate (BOHB) and acetone are generated as a byproduct of the fat metabolism process. In healthy individuals, ketone body levels are ∼0.1 mM for BOHB and ∼1 part per million for breath acetone (BrAce). These levels can increase dramatically as a consequence of a disease process or when used therapeutically for disease treatment. For example, increased ketone body concentration during weight loss is an indication of elevated fat metabolism. Ketone body measurement is relatively inexpensive and can provide metabolic insights to help guide disease management and optimize weight loss. METHODS This review of the literature provides metabolic mechanisms and typical concentration ranges of ketone bodies, which can give new insights into these conditions and rationale for measuring ketone bodies. RESULTS Diseases such as heart failure and ketoacidosis can affect caloric intake and macronutrient management, which can elevate BOHB 30-fold and BrAce 1000-fold. Other diseases associated with obesity, such as brain dysfunction, cancer, and diabetes, may cause dysfunction because of an inability to use glucose, excessive reliance on glucose, or poor insulin signaling. Elevating ketone body concentrations (e.g., nutritional ketosis) may improve these conditions by forcing utilization of ketone bodies, in place of glucose, for fuel. During weight loss, monitoring ketone body concentration can demonstrate program compliance and can be used to optimize the weight-loss plan. CONCLUSIONS The role of ketone bodies in states of pathologic and therapeutic ketosis indicates that accurate measurement and monitoring of BOHB or BrAce will likely improve disease management. Bariatric surgery is examined as a case study for monitoring both types of ketosis.
Collapse
Affiliation(s)
- Joseph C. Anderson
- Department of BioengineeringUniversity of WashingtonSeattleWashingtonUSA
| | - Samer G. Mattar
- Department of SurgeryBaylor College of MedicineHoustonTexasUSA
| | | | | |
Collapse
|
8
|
Hwang SI, Chen HY, Fenk C, Rothfuss MA, Bocan KN, Franconi NG, Morgan GJ, White DL, Burkert SC, Ellis JE, Vinay ML, Rometo DA, Finegold DN, Sejdic E, Cho SK, Star A. Breath Acetone Sensing Based on Single-Walled Carbon Nanotube-Titanium Dioxide Hybrids Enabled by a Custom-Built Dehumidifier. ACS Sens 2021; 6:871-880. [PMID: 33720705 DOI: 10.1021/acssensors.0c01973] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Acetone is a metabolic byproduct found in the exhaled breath and can be measured to monitor the metabolic degree of ketosis. In this state, the body uses free fatty acids as its main source of fuel because there is limited access to glucose. Monitoring ketosis is important for type I diabetes patients to prevent ketoacidosis, a potentially fatal condition, and individuals adjusting to a low-carbohydrate diet. Here, we demonstrate that a chemiresistor fabricated from oxidized single-walled carbon nanotubes functionalized with titanium dioxide (SWCNT@TiO2) can be used to detect acetone in dried breath samples. Initially, due to the high cross sensitivity of the acetone sensor to water vapor, the acetone sensor was unable to detect acetone in humid gas samples. To resolve this cross-sensitivity issue, a dehumidifier was designed and fabricated to dehydrate the breath samples. Sensor response to the acetone in dried breath samples from three volunteers was shown to be linearly correlated with the two other ketone bodies, acetoacetic acid in urine and β-hydroxybutyric acid in the blood. The breath sampling and analysis methodology had a calculated acetone detection limit of 1.6 ppm and capable of detecting up to at least 100 ppm of acetone, which is the dynamic range of breath acetone for someone with ketosis. Finally, the application of the sensor as a breath acetone detector was studied by incorporating the sensor into a handheld prototype breathalyzer.
Collapse
Affiliation(s)
- Sean I. Hwang
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Hou-Yu Chen
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Courtney Fenk
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Michael A. Rothfuss
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Kara N. Bocan
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Nicholas G. Franconi
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Gregory J. Morgan
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - David L. White
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Seth C. Burkert
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - James E. Ellis
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - Miranda L. Vinay
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
| | - David A. Rometo
- Department of Endocrinology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, United States
| | - David N. Finegold
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Ervin Sejdic
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Sung Kwon Cho
- Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Alexander Star
- Department of Chemistry, University of Pittsburgh, Pittsburgh, Pennsylvania 15260, United States
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| |
Collapse
|
9
|
Yan JW, Azzam D, Columbus MP, Van Aarsen K, Liu SL, Spaic T, Shepherd LG. Seeking Care for Hyperglycemia in the Emergency Department: Through the Eyes of the Patient. Diabetes Spectr 2021; 34:60-66. [PMID: 33627995 PMCID: PMC7887526 DOI: 10.2337/ds20-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Health care systems often provide a range of options of care for patients with illnesses who do not require hospital admission. For individuals with diabetes, these options may include primary care providers, specialized diabetes clinics, and urgent care and walk-in clinics. We explored the reasons why patients choose the Emergency Department over other health care settings when seeking care for hyperglycemia.
Collapse
Affiliation(s)
- Justin W. Yan
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Dimah Azzam
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Melanie P. Columbus
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Kristine Van Aarsen
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Selina L. Liu
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, St. Joseph’s Healthcare, London, Ontario, Canada
| | - Tamara Spaic
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Division of Endocrinology and Metabolism, Department of Medicine, St. Joseph’s Healthcare, London, Ontario, Canada
| | - Lisa G. Shepherd
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Eledrisi MS, Elzouki AN. Management of Diabetic Ketoacidosis in Adults: A Narrative Review. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:165-173. [PMID: 32952507 PMCID: PMC7485658 DOI: 10.4103/sjmms.sjmms_478_19] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/20/2020] [Accepted: 06/02/2020] [Indexed: 12/20/2022]
Abstract
Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency and causes the greatest risk for death in patients with diabetes mellitus. DKA more commonly occurs among those with type 1 diabetes, yet almost a third of the cases occur among those with type 2 diabetes. Although mortality rates from DKA have declined to low levels in general, it continues to be high in many developing countries. DKA is characterized by hyperglycemia, metabolic acidosis and ketosis. Proper management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement as well as identification and treatment of the underlying precipitating event along with frequent monitoring of patient's clinical and laboratory states. The most common precipitating causes for DKA include infections, new diagnosis of diabetes and nonadherence to insulin therapy. Clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors. Discharge plans should include appropriate choice and dosing of insulin regimens and interventions to prevent recurrence of DKA. Future episodes of DKA can be reduced through patient education programs focusing on adherence to insulin and self-care guidelines during illness and improved access to medical providers. New approaches such as extended availability of phone services, use of telemedicine and utilization of public campaigns can provide further support for the prevention of DKA.
Collapse
Affiliation(s)
- Mohsen S Eledrisi
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Abdel-Naser Elzouki
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| |
Collapse
|
12
|
Teymourian H, Moonla C, Tehrani F, Vargas E, Aghavali R, Barfidokht A, Tangkuaram T, Mercier PP, Dassau E, Wang J. Microneedle-Based Detection of Ketone Bodies along with Glucose and Lactate: Toward Real-Time Continuous Interstitial Fluid Monitoring of Diabetic Ketosis and Ketoacidosis. Anal Chem 2019; 92:2291-2300. [DOI: 10.1021/acs.analchem.9b05109] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | - Chochanon Moonla
- Applied Chemistry Program, Faculty of Science, Maejo University, Chiang Mai 50290, Thailand
| | | | | | | | | | - Tanin Tangkuaram
- Applied Chemistry Program, Faculty of Science, Maejo University, Chiang Mai 50290, Thailand
| | | | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts 02138, United States
| | | |
Collapse
|
13
|
Gonzalez-Solino C, Lorenzo MD. Enzymatic Fuel Cells: Towards Self-Powered Implantable and Wearable Diagnostics. BIOSENSORS 2018; 8:E11. [PMID: 29382147 PMCID: PMC5872059 DOI: 10.3390/bios8010011] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 01/17/2018] [Accepted: 01/22/2018] [Indexed: 12/18/2022]
Abstract
With the rapid progress in nanotechnology and microengineering, point-of-care and personalised healthcare, based on wearable and implantable diagnostics, is becoming a reality. Enzymatic fuel cells (EFCs) hold great potential as a sustainable means to power such devices by using physiological fluids as the fuel. This review summarises the fundamental operation of EFCs and discusses the most recent advances for their use as implantable and wearable self-powered sensors.
Collapse
Affiliation(s)
| | - Mirella Di Lorenzo
- Department of Chemical Engineering, University of Bath, Bath BA2 7AY, UK.
| |
Collapse
|
14
|
Dhatariya K. Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis. Rev Diabet Stud 2017; 13:217-225. [PMID: 28278308 DOI: 10.1900/rds.2016.13.217] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Diabetic ketoacidosis (DKA) remains a common medical emergency. Over the last few years, new national guidelines have changed the focus in managing the condition from being glucose-centered to ketone-centered. With the advent of advancing technology and the increasing use of hand-held, point-of-care ketone meters, greater emphasis is placed on making treatment decisions based on these readings. Furthermore, recent warnings about euglycemic DKA occurring in people with diabetes using sodium-glucose co-transporter 2 (SGLT-2) inhibitors urge clinicians to inform their patients of this condition and possible testing options. This review describes the reasons for a change in treating DKA, and outlines the benefits and limitations of using ketone readings, in particular highlighting the difference between urine and capillary readings.
Collapse
Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK
| |
Collapse
|
15
|
Al Nemri A, Amer YS, Gasim H, Osman ME, Aleyadhy A, Al Otaibi H, Iqbal SM, Aljurayyan NA, Assiri AM, Babiker A, Mohamed S. Substantial reduction in hospital stay of children and adolescents with diabetic ketoacidosis after implementation of Clinical Practice Guidelines in a university hospital in Saudi Arabia. J Eval Clin Pract 2017; 23:173-177. [PMID: 27896902 DOI: 10.1111/jep.12661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 10/05/2016] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES We aimed to determine the effect of Clinical Practice Guideline (CPG) implementation on length of hospital stay of children and adolescents with diabetic ketoacidosis (DKA). METHODS This was a 6-year (2008-2014) case-control retrospective study conducted at King Khalid University Hospital, Riyadh, that compared patients with DKA managed using CPG with those treated before CPG implementation. RESULTS There were 63 episodes of DKA in 41 patients managed using CPG compared with 40 episodes in 33 patients treated before implementation of CPG. Baseline characteristics of the 2 groups were similar (age, sex, newly diagnosed patients, recurrent DKA, DKA severity, and mean glycosylated hemoglobin). The mean length of hospital stay (±SD) was 68.6 ± 53.1 hours after implementation of CPG compared with 107.4 ± 65.6 hours before implementation (P < .001). The reduction in length of hospital stay equals to 1700 bed days saved per year per 1000 patients. CONCLUSIONS Implementation of CPG for DKA decreased the length of hospital stay.
Collapse
Affiliation(s)
- Abdulrahman Al Nemri
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Yasser Sami Amer
- Quality Management, King Khalid University Hospital, Riyadh, Saudi Arabia.,CPGs Steering Committee, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hala Gasim
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Elfaki Osman
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Aleyadhy
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hessah Al Otaibi
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Shaikh Mohammed Iqbal
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Asaad M Assiri
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah bin Khalid Coeliac Disease Research Chair, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Amir Babiker
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatrics, National Guard Hospital, Riyadh, Saudi Arabia
| | - Sarar Mohamed
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
16
|
Goffinet L, Barrea T, Beauloye V, Lysy PA. Blood versus urine ketone monitoring in a pediatric cohort of patients with type 1 diabetes: a crossover study. Ther Adv Endocrinol Metab 2017; 8:3-13. [PMID: 28203360 PMCID: PMC5298446 DOI: 10.1177/2042018816681706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of our study was to determine the influence of routine ketone monitoring on hyperglycemic events (HE) and ketosis in youngsters with type 1 diabetes (T1D). METHODS Our single-site, controlled and randomized study was conducted on children and adolescents with T1D outside of remission phase. During two crossover periods of 6 months, patients (n = 22) experiencing HE tested ketones alternatively with a blood ketone meter or urine ketone test strips and gave their opinion on screening methods after completion of clinical trial. Moreover, we evaluated levels of awareness of ketone production in a series of 58 patients and sometimes parents via a multiple-choice questionnaire. RESULTS Based on self-monitoring data, patients experienced a mean of 4.8 HE/month (range 0-9.3). Patients performed accurate ketone tests more frequently during urine (46%) than during blood-testing (29%) periods (p < 0.05); while globally, 50% of ketone tests were inaccurate (i.e. without HE). Ketosis occurred significantly more often during urine (46.4%) than during blood (14.8%) monitoring (p = 0.01), although no episodes of diabetic ketoacidosis (DKA) were noticed. Duration of hyperglycemia was not different whether patients measured ketones or not, suggesting that ketone monitoring did not affect correction of glycemia. Patients evaluated blood monitoring more frequently as being practical, reliable, and useful compared with urine testing. Scores in the awareness questionnaire were globally low (36.8%) without difference between patients and their parents. CONCLUSIONS Although our study shows differences in outcomes (e.g. accurate use, detection of ketosis) of urine versus blood ketone monitoring, these did not affect the occurrence of HE. Whereas ketone monitoring is part of standardized diabetes education, its implementation in daily routine remains difficult, partly because patient awareness about mechanisms of ketosis is lacking.
Collapse
Affiliation(s)
- Line Goffinet
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Thierry Barrea
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Véronique Beauloye
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | | |
Collapse
|
17
|
Soni A, Agwu JC, Wright NP, Moudiotis C, Kershaw M, Edge J, Drew JH, Ng SM. Management of children with type 1 diabetes during illness: a national survey: Table 1. Postgrad Med J 2016; 92:447-9. [DOI: 10.1136/postgradmedj-2015-133786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 01/28/2016] [Indexed: 11/03/2022]
|
18
|
Nwose EU, Bwititi PT. Misleading Presentation of Euglycemic Diabetic Ketoacidosis: Implication for Low-Mid-Income Communities. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:537-9. [PMID: 26713304 PMCID: PMC4683811 DOI: 10.4103/1947-2714.170629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ezekiel Uba Nwose
- School of Community Health, Charles Sturt University, New South Wales, Australia
| | | |
Collapse
|
19
|
Chafe R, Albrechtsons D, Hagerty D, Newhook LA. Reducing episodes of diabetic ketoacidosis within a youth population: a focus group study with patients and families. BMC Res Notes 2015; 8:395. [PMID: 26323283 PMCID: PMC4553941 DOI: 10.1186/s13104-015-1358-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 08/17/2015] [Indexed: 01/03/2023] Open
Abstract
Background Diabetic ketoacidosis (DKA) is the most common cause of morbidity and mortality for youth with type 1 diabetes mellitus (T1DM). This article reports qualitative data from focus groups with youth and parents of youth with T1DM on the barriers that they identify to DKA prevention and resources that may aid youth better manage their diabetes. Methods Four focus groups were held in three communities, two rural and one urban, in the Canadian province of Newfoundland and Labrador (NL) with adolescents and parents of youth with diabetes. Open-ended questions focused on knowledge of DKA, diabetes education, personal experiences with DKA, barriers to diabetes self-management, situations which put them at risk for DKA and resources that could be developed to aid youth in preventing DKA. Results There were 19 participants (14 parents and 5 youth). Participants identified factors which increased their risk of DKA as difficulty in distinguishing cases of DKA from other illnesses; variations in diabetes education received; information overload about their condition; the long period from initial diagnosis, when most education about the condition was received; and stress regarding situations where youth are not in the direct care of their parents. Participants from rural areas reported geographical isolation and lack of regular access to specialist health care personnel as additional barriers to better diabetes management. Conclusions The project identified barriers to DKA prevention for youth which were not previously identified in the medical literature, e.g., the stress associated with temporary guardians, risk of information overload at initial diagnosis and the long period from initial diagnosis when most diabetes education is received. Families from rural areas do report additional burdens, but in some cases these families have developed community supports to help offset some of these problems. Mobile and online resources, educational refreshers about DKA, concise resources for teachers and other temporary guardians, and DKA treatment kits for parents may help improve diabetes management and prevent future episodes of DKA. Electronic supplementary material The online version of this article (doi:10.1186/s13104-015-1358-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Roger Chafe
- Janeway Pediatric Research Unit, Division of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, Room 409, Janeway Hostel, 300 Prince Phillip Drive, St. John's, NL, A1B 3V6, Canada.
| | | | - Donna Hagerty
- Eastern Health, Outreach Department, St. John's, NL, Canada.
| | - Leigh Anne Newhook
- Division of Pediatrics, Faculty of Medicine, Janeway Child Health Care Centre, Memorial University of Newfoundland, St. John's, NL, Canada.
| |
Collapse
|
20
|
Ziegler R, Eichholz R, Schulz B. Use of a Combined Blood-Glucose- and ß-Ketone-Measuring Device Improves Glycemic Control in Insulin-Treated Patients With Diabetes: The Gold Plus Study. J Diabetes Sci Technol 2015; 9:1270-4. [PMID: 25986628 PMCID: PMC4667309 DOI: 10.1177/1932296815587936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Using self-measurements of blood glucose (SMBG) is daily routine for patients with insulin-treated diabetes, however measuring ß-ketones in blood is not widespread. How the use of a combined device, which can measure both, is accepted in daily routine by patients and will lead to better glycemic control is not well studied. METHODS This multicenter, prospective, noninterventional study assessed the impact of routine use of the GlucoMen® LX Plus on patient acceptance, usage and glycemic control among insulin-treated patients with diabetes mellitus type 1 and type 2. A1c and self-reported frequency of SMBG were evaluated at baseline and also postprandial SMBG, ß-ketone measurements, and use of reminders after 3 and 6 months of use. A total of 631 patients, 254 type 1/350 type 2 (27 no type specified), with mean (SD) baseline A1c 8.5% (1.5), age 54.6 (15.6) years, and 47.3% female were studied. RESULTS Frequent use of SMBG at baseline led to a higher decrease in A1c at 6 month (V3): -0.3% if SMBG measured up to 1/day versus -0.9% in 4-6/day. Increase of SMBG frequency during the study showed also a negative correlation to A1c, 9.2% at V1 versus 7.6% at V3. Postprandial SMBG was done by 77.7% and ß-ketone measurements by 45.5% of all patients; the reminders were used by 33.4% and led to an increased frequency of SMBG at 6 months. CONCLUSIONS A combined device for SMBG and ß-ketone measurements is well accepted by patients with insulin-treated diabetes and can lead through the avoidance or detection of ketoacidosis/increased frequency of SMBG and increased awareness of the patients to an improved glycemic outcome.
Collapse
Affiliation(s)
- Ralph Ziegler
- Diabetes Clinic for Children and Adolescents, Muenster, Germany
| | | | - Birgit Schulz
- A. Menarini Diagnostics, Division of Berlin-Chemie AG, Berlin, Germany
| |
Collapse
|
21
|
Guisado-Vasco P, Cano-Megías M, Carrasco-de la Fuente M, Corres-González J, Matei AM, González-Albarrán O. Clinical features, mortality, hospital admission, and length of stay of a cohort of adult patients with diabetic ketoacidosis attending the emergency room of a tertiary hospital in Spain. ACTA ACUST UNITED AC 2015; 62:277-84. [PMID: 25888157 DOI: 10.1016/j.endonu.2015.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 02/08/2015] [Accepted: 02/09/2015] [Indexed: 01/11/2023]
Abstract
AIM To assess the clinical features, length of stay, incidence rate, mortality, and hospital admissions of patients with episodes of diabetic ketoacidosis (DKA). PATIENTS It was conducted retrospective, cross-sectional study of 164 consecutive admissions of adult patients (2008-August 2012), with type 1 or type 2 diabetes already known or new onset. RESULTS Mortality rate was 1.2%. The DKA episodes were mild (18.9%), moderate (31.7%), or severe (49.4%). The cumulative incidence was 2.66 cases/1000 patients with diabetes (DM) in 4.5 years. The most common causes triggering DKA were infection (33.2%) and dietary transgression and/or insulin dose omission (30.7%). A total of 12.8% of patients had new onset DM, 56.7% type 1, and 26.8% type 2 DM. Patients with type 2 DM were older and had at admission higher creatinine, BUN, osmolality, sodium, and anion gap levels. Patients with new-onset of DM had higher levels of glucose and sodium, but lower potassium levels. No differences were found in pH or bicarbonate. Admission to the intensive care unit (ICU) was required in >50% of cases (p<0.001), and 86.6% of patients were finally admitted to a medical ward (p=0.005). The length of stay at the ICU (p<0.001) and hospital (p=0.013) was significantly different depending on DKA severity. CONCLUSIONS Most DKA episodes require hospital admission, but mortality is <2%, and length of stay at the ER and medical ward depends on type of DM and initial severity of the episode.
Collapse
Affiliation(s)
- Pablo Guisado-Vasco
- Emergency and Internal Medicine Department, University Hospital Ramón y Cajal, Colmenar Viejo Road km 9.1, Z.P. 28034 Madrid, Spain.
| | - Marta Cano-Megías
- Endocrinology and Nutrition Department, University Hospital Ramón y Cajal, Colmenar Viejo Road km 9.1, Z.P. 28034 Madrid, Spain
| | - Marta Carrasco-de la Fuente
- Endocrinology and Nutrition Department, University Hospital Ramón y Cajal, Colmenar Viejo Road km 9.1, Z.P. 28034 Madrid, Spain
| | - Jesús Corres-González
- Emergency Department, University Hospital Ramón y Cajal, Colmenar Viejo Road km 9.1, Z.P. 28034 Madrid, Spain
| | - Ana Maria Matei
- Endocrinology and Nutrition Department, University Hospital Ramón y Cajal, Colmenar Viejo Road km 9.1, Z.P. 28034 Madrid, Spain
| | - Olga González-Albarrán
- Endocrinology and Nutrition Department, University Hospital Ramón y Cajal, Colmenar Viejo Road km 9.1, Z.P. 28034 Madrid, Spain
| |
Collapse
|
22
|
Klocker AA, Phelan H, Twigg SM, Craig ME. Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review. Diabet Med 2013; 30:818-24. [PMID: 23330615 DOI: 10.1111/dme.12136] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 11/02/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
Abstract
AIM Diabetic ketoacidosis is a life-threatening complication of Type 1 diabetes. Blood β-hydroxybutyrate testing is now widely available as an alternative to urine acetoacetate testing for detecting ketosis. The aim of this study was to review the effectiveness of capillary or serum β-hydroxybutyrate compared with urine acetoacetate testing in prevention and management of diabetic ketoacidosis. METHODS MEDLINE, EMBASE, EBM Reviews, The Cochrane Library and CINAHL (until April 2012, no language restrictions, studies in humans) were searched for experimental and observational studies comparing the effectiveness of blood β-hydroxybutyrate and urine acetoacetate testing. Outcomes examined were prevention of diabetic ketoacidosis, time to recovery from diabetic ketoacidosis, healthcare costs and patient or caregiver satisfaction. Additional sources included reference lists, conference proceedings and contact with experts in the field. RESULTS Four studies (two randomized controlled trials and two cohort studies) met eligibility criteria, including 299 participants across 11 centres. Risk of bias was low to moderate. Blood ketone testing compared with urine testing was associated with reduced frequency of hospitalization (one study), reduced time to recovery from diabetic ketoacidosis (three studies), cost benefits (one study) and greater satisfaction (one study, intervention group only). No study assessed prevention of diabetic ketoacidosis. Meta-analysis could not be performed because of heterogeneity in study design and published data. CONCLUSIONS There is evidence suggesting that blood β-hydroxybutyrate testing is more effective than urine acetoacetate testing in reducing emergency department assessment, hospitalization and time to recovery from diabetic ketoacidosis, as well as potentially lowering healthcare expenditure. Further research in both young people and adults is needed.
Collapse
Affiliation(s)
- A A Klocker
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | | | | | | |
Collapse
|
23
|
Weingart C, Lotz F, Kohn B. Measurement of β-hydroxybutyrate in cats with nonketotic diabetes mellitus, diabetic ketosis, and diabetic ketoacidosis. J Vet Diagn Invest 2011; 24:295-300. [DOI: 10.1177/1040638711428332] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). The standard method of detection of ketone bodies is the dipstick method, which detects semiquantitatively acetoacetate, but not β-hydroxybutyrate (β-HB). The objectives of the current study were to assess the diagnostic utility of β-HB to diagnose diabetic ketosis (DK) and DKA in cats and to establish a cut-off value for the diagnosis of DKA. Sixty-two cats were included in the study. Eleven cats were healthy (group 1); in the remainder of cats (51), a diagnosis of DM was based on hyperglycemia, glucosuria, and increased fructosamine concentrations. Nineteen of 51 cats suffered from nonketotic diabetes mellitus (group 2). In 11 cats, plasma ketone bodies were detected with the dipstick method (diabetic ketosis, group 3). In 21 cats, plasma ketone bodies and metabolic acidosis were present (DKA, group 4). Plasma β-HB was measured in all cats by an enzymatic method (spectrophotometry). A cut-off value for the diagnosis of DKA was calculated based on the receiver operating characteristic curve. In healthy cats, the β-HB concentration ranged from 0 to 0.1 mmol/l; in cats of group 2, from 0 to 0.9 mmol/l (median: 0.1 mmol/l); in cats of group 3, from 0.6 to 6.8 mmol/l (median: 1.7 mmol/l); and in cats of group 4, from 3.8 to 12.2 mmol/l (median: 7.9 mmol/l). A cut-off value of 2.4 mmol/l revealed 100% sensitivity and 87% specificity to diagnose DKA. Beta-hydroxybutyrate is a useful parameter for the diagnosis of diabetic ketosis and DKA in cats.
Collapse
Affiliation(s)
- Christiane Weingart
- Clinic of Small Animals (Weingart, Kohn), Faculty of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
- Institute for Biometrics and Data Processing (Lotz), Faculty of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Fabian Lotz
- Clinic of Small Animals (Weingart, Kohn), Faculty of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
- Institute for Biometrics and Data Processing (Lotz), Faculty of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| | - Barbara Kohn
- Clinic of Small Animals (Weingart, Kohn), Faculty of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
- Institute for Biometrics and Data Processing (Lotz), Faculty of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany
| |
Collapse
|
24
|
Macular Diseases: Moving the Battlefield to the Patient's Home. Retina 2011; 31:1445-8. [DOI: 10.1097/iae.0b013e31822528ea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
25
|
|
26
|
Voulgari C, Tentolouris N. The performance of a glucose-ketone meter in the diagnosis of diabetic ketoacidosis in patients with type 2 diabetes in the emergency room. Diabetes Technol Ther 2010; 12:529-35. [PMID: 20597827 DOI: 10.1089/dia.2010.0011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a serious metabolic complication. One of its precipitating causes is insulin omission. DKA requires early diagnosis and strict glucose control, which increases the use of glucose meters in the Emergency Room (ER). We aimed to determine the performance of a glucose-ketone meter in the diagnosis of DKA. METHODS From 450 type 2 diabetes mellitus insulin-treated patients attending the ER with a capillary glucose level >13.9 mmol/L, 50 patients (26 men and 24 women, mean age 60.2 +/- 8.2 years) had DKA. Capillary glucose and beta-hydroxybutyrate (beta-OHB) were measured with the Precision-Xtra device (Abbott Laboratories, Abingdon, UK). Serum glucose and biochemical parameters were measured on an automatic analyzer; serum beta-OHB was determined using an enzymatic end-point spectrophotometric method. Urine ketones were determined using a semiquantitative assay (Ketodiastix, Bayer Diagnostics, Stoke Poges, Slough, UK). RESULTS Serum and capillary beta-OHB values were highly correlated (r = 0.99, P < 0.001), and the mean difference between them was 0.49 mmol/L (95% confidence interval [CI], 0.35-0.95 mmol/L; P = 0.81). Similarly, serum and capillary glucose values were significantly correlated (r = 0.86, P < 0.001), and the mean difference between them was 0.43 mmol/L (95% CI, 0.82-0.93 mmol/L; P = 0.71). Patients with DKA were inadequately treated with insulin and missed clinic appointments: 80% of patients with DKA compared to 20% of patients without DKA. In all cases, DKA was attributed to insulin omission. Capillary ketonemia (beta-OHB >3.0 mmol/L) had the highest performance (sensitivity 99.87%, specificity 92.89%, positive predictive value 92.89%) for the diagnosis of DKA compared with serum ketonemia (sensitivity 90.45%, specificity 88.65%, positive predictive value 87.76%) or ketonuria (sensitivity 89.89%, specificity 52.73%, positive predictive value 41.87%). CONCLUSIONS Implementation of measures such as home glucose and ketone monitoring can possibly decrease the number of hospital admissions due to DKA.
Collapse
Affiliation(s)
- Christina Voulgari
- 1st Department of Propaedeutic and Internal Medicine, Laiko General Hospital, Athens University Medical School, Athens, Greece.
| | | |
Collapse
|