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

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Incidence and predictors of hyperglycemic emergencies among adult diabetic patients in Bahir Dar city public hospitals, Northwest Ethiopia, 2021: A multicenter retrospective follow-up study

Background

Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome are the two commonly known life-threatening hyperglycemic emergencies of diabetes mellitus. Despite the growing hyperglycemic emergency impact among adult patients with diabetes, its incidence and predictors have not been well studied in Ethiopia. Thus, this study aimed to assess the incidence and predictors of hyperglycemic emergencies among adult patients with diabetes.

Method

A retrospective follow-up study design was conducted among a randomly selected sample of 453 adult patients with diabetes. Data were entered into EPI data version 4.6 and analyzed using STATA version 14.0. A Cox-proportional hazard regression model was fitted to identify the independent predictors of hyperglycemic emergencies, and variables having a p < 0.05 in the multivariable model were considered statistically significant.

Result

Among the total adult patients with diabetes included in the study, 147 (32.45%) developed hyperglycemic emergencies. Hence, the overall incidence of hyperglycemic emergencies was 14.6 per 100 person-years observation. The incidence of diabetic ketoacidosis was 12.5 per 100 person-years (35.6 and 6.3 among T1DM and T2DM, respectively). The incidence of the hyperglycemic hyperosmolar syndrome was 2.1 per 100 person-years (0.9 and 2.4 among T1DM and T2DM, respectively). The overall median free survival time was 53.85 months. Type 1 diabetes mellitus [AHR = 2.75, 95% CI (1.68, 4.51)], diabetes duration of ≥ 3 years [AHR = 0.33, 95% CI (0.21, 0.50)], recent acute illness [AHR = 2.99, 95% CI (2.03, 4.43)], presence of comorbidity [AHR = 2.36, 95% CI (1.53, 3.63)], poor glycemic control [AHR = 3.47, 95% CI (2.17, 5.56)], history of medication non-compliance [AHR = 1.85,95% CI (1.24, 2.76)], follow-up frequency of 2-3 months [AHR = 1.79,95% CI (1.06, 3.01)], and without community health insurance [AHR = 1.63, 95% CI (1.14, 2.35)] were significant predictors of hyperglycemic emergencies.

Conclusion

The incidence of hyperglycemic emergencies was high. Therefore, giving greater attention to patients with identified predictors could decrease the occurrence of hyperglycemic emergencies and related public health and economic impacts.

Mortality prediction in patients with hyperglycaemic crisis using explainable machine learning: a prospective, multicentre study based on tertiary hospitals

BACKGROUND

Experiencing a hyperglycaemic crisis is associated with a short- and long-term increased risk of mortality. We aimed to develop an explainable machine learning model for predicting 3-year mortality and providing individualized risk factor assessment of patients with hyperglycaemic crisis after admission.

METHODS

Based on five representative machine learning algorithms, we trained prediction models on data from patients with hyperglycaemic crisis admitted to two tertiary hospitals between 2016 and 2020. The models were internally validated by tenfold cross-validation and externally validated using previously unseen data from two other tertiary hospitals. A SHapley Additive exPlanations algorithm was used to interpret the predictions of the best performing model, and the relative importance of the features in the model was compared with the traditional statistical test results.

RESULTS

A total of 337 patients with hyperglycaemic crisis were enrolled in the study, 3-year mortality was 13.6% (46 patients). 257 patients were used to train the models, and 80 patients were used for model validation. The Light Gradient Boosting Machine model performed best across testing cohorts (area under the ROC curve 0.89 [95% CI 0.77-0.97]). Advanced age, higher blood glucose and blood urea nitrogen were the three most important predictors for increased mortality.

CONCLUSION

The developed explainable model can provide estimates of the mortality and visual contribution of the features to the prediction for an individual patient with hyperglycaemic crisis. Advanced age, metabolic disorders, and impaired renal and cardiac function were important factors that predicted non-survival.

TRIAL REGISTRATION NUMBER

ChiCTR1800015981, 2018/05/04.

Clinical and biochemical characteristics of diabetic ketoacidosis in adults with type 1 or type 2 diabetes at a tertiary hospital in the United Arab Emirates

Background

Diabetes ketoacidosis (DKA) is a well-known acute complication of diabetes. This study aims to describe the sociodemographic, clinical, and biochemical characteristics of adult patients with different diabetes types and DKA severities attending a tertiary hospital in the UAE.

Methods

We retrospectively extracted sociodemographic, clinical, and laboratory data from the electronic medical records of 220 adult patients with DKA admitted to Tawam Hospital between January 2017 and October 2020.Results: The average age was 30.6 ± 16.6 years of whom 54.5% were women, 77.7% were UAE nationals and 77.9% were Type 1 diabetes (T1DM). 12.7% were newly diagnosed with diabetes. Treatment noncompliance (31.4%), and infection (26.4%) were the main precipitating factors. Most patients presented with moderate DKA (50.9%). Compared to T1DM, patients with Type 2 diabetes (T2DM) were older (53.6 vs 23.9 years, p < 0.001), had longer hospital stay (12.1 days vs 4.1 days, p < 0.001), had more complications (52.1%, vs 18.9% p <0.001), and a higher mortality rate (6.3% vs 0.6%, p = 0.035). Patients with severe DKA had a shorter diabetes duration compared to mild and moderate DKA (5.7 vs 11.0 vs 11.7 years, respectively, p = 0.007), while complications were significantly lower in the mild group compared to both the moderate and severe groups (11.6% vs 32.1% vs 33.3%, respectively).

Conclusion

The risk of DKA is higher for patients with T1DM than for those with T2DM. The clinical characteristics and outcomes of patients with T2DM differ from those with T1DM highlighting the importance of educating all patients about DKA.

Characteristics of patients with emergency attendance for severe hypoglycemia and hyperglycemia in a general hospital in Japan

Despite advances in treatments for diabetes mellitus (DM), severe acute glycemic crises still occur. In this study, the characteristics of patients who were transported to an emergency department due to acute glycemic crises were investigated.We enrolled patients who were transported to our hospital by ambulance due to hypoglycemia or hyperglycemia during the period from January 2015 to December 2019. Initial glucose levels below 70 mg/dL and above 250 mg/dL were defined as hypoglycemia and hyperglycemia, respectively.In the 5-year period, 16,910 patients were transported to our hospital by ambulance. Of those patients, 87 patients (0.51%) were diagnosed with hypoglycemia, 26 patients (0.15%) were diagnosed with hyperglycemia and 1 patient was diagnosed with lactic acidosis. Compared to patients with hypoglycemia, blood urea nitrogen, serum potassium and hemoglobin levels were higher in patients with hyperglycemia. Systolic blood pressure was lower and pulse rate was higher in patients with hyperglycemia, possibly reflecting dehydration in hyperglycemia. Patients with hyperglycemia were younger (63 vs 70 years old, median), more likely to be hospitalized (92.3% vs 23.0%) with poorer prognosis (23.1% vs 4.6%) than those with hypoglycemia. In 64 DM patients with hypoglycemia, 34 patients were treated with insulin and 24 patients were treated with sulfonylurea or glinide, and their medication was often inappropriate. Excessive alcohol intake and malnutrition were the main causes of hypoglycemia in 23 non-DM patients. The main reasons for hyperglycemia were interrupted treatment, forgetting insulin injection and infection.To avoid acute glycemic crises, optimization of anti-DM therapy and education of patients are needed.

Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA

Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.

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)

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.

Trends in Emergency Department Visits and Inpatient Admissions for Hyperglycemic Crises in Adults With Diabetes in the U.S., 2006-2015

OBJECTIVE

To report U.S. national population-based rates and trends in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) among adults, in both the emergency department (ED) and inpatient settings.

RESEARCH DESIGN AND METHODS

We analyzed data from 1 January 2006 through 30 September 2015 from the Nationwide Emergency Department Sample and National Inpatient Sample to characterize ED visits and inpatient admissions with DKA and HHS. We used corresponding year cross-sectional survey data from the National Health Interview Survey to estimate the number of adults ≥18 years with diagnosed diabetes to calculate population-based rates for DKA and HHS in both ED and inpatient settings. Linear trends from 2009 to 2015 were assessed using Joinpoint software.

RESULTS

In 2014, there were a total of 184,255 and 27,532 events for DKA and HHS, respectively. The majority of DKA events occurred in young adults aged 18-44 years (61.7%) and in adults with type 1 diabetes (70.6%), while HHS events were more prominent in middle-aged adults 45-64 years (47.5%) and in adults with type 2 diabetes (88.1%). Approximately 40% of the hyperglycemic events were in lower-income populations. Overall, event rates for DKA significantly increased from 2009 to 2015 in both ED (annual percentage change [APC] 13.5%) and inpatient settings (APC 8.3%). A similar trend was seen for HHS (APC 16.5% in ED and 6.3% in inpatient). The increase was in all age-groups and in both men and women.

CONCLUSIONS

Causes of increased rates of hyperglycemic events are unknown. More detailed data are needed to investigate the etiology and determine prevention strategies.

Outcomes and Predictors of Mortality in Hospitalized Frail Patients Undergoing Percutaneous Coronary Intervention

Objective To study the impact of frailty on inpatient outcomes among patients undergoing percutaneous coronary intervention (PCI). Methods The National Inpatient Sample data of all PCI-related hospitalizations throughout the United States (US) from 2010 through 2014 was utilized. Patients were divided into two groups: frailty and no-frailty. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to stratify groups and outcomes. In order to address the substantial difference in the total number of valid observations between the two groups, a propensity-matched analysis was performed at a 1:1 ratio and caliper width of 0.01. Results A total of 2,612,661 PCI-related hospitalizations throughout the US from 2010 through 2014 were identified, out of which 16,517 admissions (0.6%) had coexisting frailty. Only 1:1 propensity-matched data was utilized for the study. Propensity-matched frailty group (n=14,717) as compared to no-frailty (n=14,755) was frequently older, white, and Medicare enrollee (p<0.05). The frailty group had significantly higher rates of comorbidities and complications (p<0.05). All-cause in-hospital mortality was higher in the no-frailty group (p<0.05). Age, white race, non-elective admission, urban hospitals, and comorbidities predicted in-hospital mortality in frailty group (p<0.05). Rheumatoid arthritis, depression, hypertension, obesity, dyslipidemia, and history of previous PCI decreased odds of in-hospital mortality in frailty group (p<0.05). Frailty group had prolonged hospital stay and higher hospital charges (p<0.05). Conclusions Frailty has a significant effect on PCI-related outcomes. We present a previously unknown protective effect of cardiovascular disease risk factors and other health risk factors on frail patients undergoing PCI. Frailty's inclusion in risk stratification will help in predicting the post-procedure complications and improve resource utilization.

Triad of Diabetic Ketoacidosis, Hypertriglyceridemia, and Acute Pancreatitis: Severity of Acute Pancreatitis May Correlate with the Level of Hypertriglyceridemia

A 50-year-old African-American male with no known previous medical comorbidities presented to the emergency room with complaints of three days of worsening epigastric pain associated with nausea and vomiting. Laboratory parameters on admission revealed high lipase: 1796 U/L (normal range 0-160 U/L), high blood glucose level: 300 mg/dl, anion gap metabolic acidosis, ketonuria, significant hyperlipidemia (triglyceride: 1226 mg/dl (normal range <150 mg/dl), and LDL cholesterol: 307 mg/dl (normal range <100 mg/dl)). Treatment with intravascular volume and electrolytes replacement as well as administration of intravenous insulin successfully resolved diabetic ketoacidosis (DKA) and hypertriglyceridemia (HTG) with a drop in triglyceride (TG) level from 1226 mg/dl to 193 mg/dl. Radiologic imaging studies by ultrasonography (USG) and CT of the abdomen showed features suggestive of interstitial pancreatitis. Glycated hemoglobin (HbA1) was 10.7% suggesting uncontrolled diabetes mellitus. Here, we explain the possible pathophysiology and management of this uncommon triad-DKA, hypertriglyceridemia, and acute pancreatitis-followed by discussion and literature review, which highlight the diagnostic challenge and possible relation of the severity of pancreatitis with the degree of hypertriglyceridemia.