Inflammatory biomarkers predict higher risk of hyperglycemic crises but not outcomes in diabetic patients with COVID-19

Background

Inflammation is a predictor of severe complications in patients with COVID-19 infection under a variety of clinical settings. A few studies suggested that COVID-19 infection was a trigger of hyperglycemic crises including diabetic ketoacidosis (DKA) and/or hyperglycemic hyperosmolar state (HHS). However, the association between inflammation and hyperglycemic crises in diabetic patients with COVID-19 infection is unclear.

Methods

One hundred and twenty-four patients with type 2 diabetes mellitus (T2DM) and COVID-19 infection from January 2023 to March 2023 were retrospectively analyzed. Demographic, clinical, and laboratory data, especially inflammatory markers including white blood cell (WBC), neutrophils, neutrophil-to-lymphocyte ratio (NLR), c-reactive protein (CRP) and procalcitonin (PCT) were collected and compared between patients with or without DKA and/or HHS. Multivariable logistic regression analysis was conducted to explore the association between inflammatory biomarkers and the prevalence of hyperglycemic crises. Patients were followed up 6 months for outcomes.

Results

Among 124 diabetic patients with COVID-19, 9 were diagnosed with DKA or HHS. Comparing COVID-19 without acute diabetic complications (ADC), patients with DKA or HHS showed elevated levels of c-reactive protein (CRP, P=0.0312) and procalcitonin (PCT, P=0.0270). The power of CRP and PCT to discriminate DKA or HHS with the area under the receiver operating characteristics curve (AUROC) were 0.723 and 0.794, respectively. Multivariate logistic regression indicated 1.95-fold and 1.97-fold increased risk of DKA or HHS with 1-unit increment of CRP and PCT, respectively. However, neither CRP nor PCT could predict poor outcomes in diabetic patients with COVID-19.

Conclusion

In this small sample size study, we firstly found that elevated serum CRP and PCT levels increased the risk of hyperglycemic crises in T2DM patients with COVID-19 infection. More study is needed to confirm our findings.

Mortality Due to Hyperglycemic Crises in the US, 1999-2022

This study analyzes trends in US mortality attributed to both diabetic ketoacidosis and hyperosmolar hyperglycemic state from 1999-2022.

Clinical profile of patients with diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome in Japan: a multicenter retrospective cohort study

INTRODUCTION

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. Their clinical profiles have not been fully investigated.

METHODS

A multicenter retrospective cohort study was conducted in 21 acute care hospitals in Japan. Patients included were adults aged 18 or older who had been hospitalized from January 1, 2012, to December 31, 2016 due to DKA or HHS. The data were extracted from patient medical records. A four-group comparison (mild DKA, moderate DKA, severe DKA, and HHS) was performed to evaluate outcomes.

RESULTS

A total of 771 patients including 545 patients with DKA and 226 patients with HHS were identified during the study period. The major precipitating factors of disease episodes were poor medication compliance, infectious diseases, and excessive drinking of sugar-sweetened beverages. The median hospital stay was 16 days [IQR 10-26 days]. The intensive care unit (ICU) admission rate was 44.4% (mean) and the rate at each hospital ranged from 0 to 100%. The in-hospital mortality rate was 2.8% in patients with DKA and 7.1% in the HHS group. No significant difference in mortality was seen among the three DKA groups.

CONCLUSIONS

The mortality rate of patients with DKA in Japan is similar to other studies, while that of HHS was lower. The ICU admission rate varied among institutions. There was no significant association between the severity of DKA and mortality in the study population.

TRIAL REGISTRATION

This study is registered in the UMIN clinical Trial Registration System (UMIN000025393, Registered 23th December 2016).

The silent diabetic decompensation epidemic during the SARS-CoV2 pandemic - The role of primary care in early diagnosis and prevention of severe diabetic decompensation

AIM/HYPOTHESIS

Efficiency in controlling chronic diseases, especially in the primary care setting, is associated with reduced rates of hospitalizations. Poorly controlled diabetes is associated with severe diabetic decompensation, such as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It is hypothesized that, in addition to the SARS-CoV2 pandemic, there was a parallel increase in decompensation of previously controlled chronic diseases, such as diabetes. In this work, the impact of the SARS-CoV2 pandemic on hospitalizations for severe diabetic decompensation in a Portuguese hospital was assessed.

METHODS

A retrospective study by hospital clinical file consultation was performed and a cohort of 177 patients admitted to a Portuguese hospital with a diagnosis of DKA or hyperosmolar hyperglycemic state HHS, excluding SARS-CoV2 infected patients, between 2019 and 2020 was analysed.

RESULTS

In the population not infected by SARS-CoV2, statistically significant differences were found in the relative number of hospitalizations (5.59 vs 3.79 hospitalizations for DKA/HHS per 1000 patients not infected with SARS-CoV2, p = 0.0093) and lethality due to DKA/HHS (0941 vs 0337 deaths from DKA/HHS per 1000 patients not infected with SARS-CoV2, p = 0.0251). This increase in hospitalizations and lethality was accompanied by a statistically significant increase in newly type 2 diabetes diagnosis in DKA/HHS hospital admissions (p = 0.0156) and by a statistically significant increase in average age of patients (56.3 ± 22.4 vs 69.1 ± 17.6, p < 0.001).

DISCUSSION AND CONCLUSIONS

These results show the empirical perspective that the consequences of the pandemic also had a considerable impact on the control of chronic diseases such as diabetes, with a higher percentage of hospitalizations due to severe decompensation, especially in the elderly population.

Risk Factors for Hyperosmolar Hyperglycemic State in Pediatric Type 2 Diabetes

Background

There is a paucity of data on the risk factors for the hyperosmolar hyperglycemic state (HHS) compared with diabetic ketoacidosis (DKA) in pediatric type 2 diabetes (T2D).

Methods

We used the national Kids' Inpatient Database to identify pediatric admissions for DKA and HHS among those with T2D in the years 2006, 2009, 2012, and 2019. Admissions were identified using ICD codes. Those aged <9yo were excluded. We used descriptive statistics to summarize baseline characteristics and Chi-squared test and logistic regression to evaluate factors associated with admission for HHS compared with DKA in unadjusted and adjusted models.

Results

We found 8,961 admissions for hyperglycemic emergencies in youth with T2D, of which 6% were due to HHS and 94% were for DKA. These admissions occurred mostly in youth 17-20 years old (64%) who were non-White (Black 31%, Hispanic 20%), with public insurance (49%) and from the lowest income quartile (42%). In adjusted models, there were increased odds for HHS compared to DKA in males (OR 1.77, 95% CI 1.42-2.21) and those of Black race compared to those of White race (OR 1.81, 95% CI 1.34-2.44). Admissions for HHS had 11.3-fold higher odds for major or extreme severity of illness and 5.0-fold higher odds for mortality.

Conclusion

While DKA represents the most admissions for hyperglycemic emergencies among pediatric T2D, those admitted for HHS had higher severity of illness and mortality. Male gender and Black race were associated with HHS admission compared to DKA. Additional studies are needed to understand the drivers of these risk factors.

Predicting readmission due to severe hyperglycemia after a hyperglycemic crisis episode

AIM

This study aimed to investigate the readmission pattern and risk factors for patients who experienced a hyperglycemic crisis.

METHODS

Patients admitted to MacKay Memorial Hospital for diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS) between January 2016 and April 2019 were studied. The timing of the first readmission for hyperglycemia and other causes was recorded. Kaplan-Meier analysis was used to compare patients with hyperglycemia and all-cause readmissions. Cox regression was used to identify independent predictors for hyperglycemia and all-cause readmission post-discharge.

RESULTS

The study cohort included 410 patients, and 15.3 % and 46.3 % of them had hyperglycemia and all-cause readmissions, respectively. The DKA and HHS group showed a similar incidence for hyperglycemia, with the latter group showing a higher incidence of all-cause readmissions. The significant predictors of hyperglycemia readmissions included young age, smoking, hypoglycemia, higher effective osmolality, and hyperthyroidism in the DKA group and higher glycated hemoglobin level in the HHS group.

CONCLUSIONS

Patients who experienced DKA and HHS had similar hyperglycemia readmission rates; however, predictors in the DKA group were not applicable to the HHS group. Designing different strategies for different types of hyperglycemic crisis is necessary for preventing readmission.

Association between heat exposure and hospitalization for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia in Japan

BACKGROUND

An increase in extreme heat events has been reported along with global warming. Heat exposure in ambient temperature is associated with all-cause diabetes mortality and all-cause hospitalization in diabetic patients. However, the association between heat exposure and hospitalization for hyperglycemic emergencies, such as diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hypoglycemia is unclear. The objective of our study is to clarify the impact of heat exposure on the hospitalization for DKA, HHS, and hypoglycemia.

METHODS

Data of daily hospitalizations for hyperglycemic emergencies (i.e., DKA or HHS) and hypoglycemia was extracted from a nationwide administrative database in Japan and linked with temperature in each prefecture in Japan during 2012-2019. We applied distributed lag non-linear model to evaluate the non-linear and lagged effects of heat exposure on hospitalization for hyperglycemic emergencies.

RESULTS

The pooled relative risk for hyperglycemic emergencies of heat effect (the 90th percentile of temperature with reference to the 75th percentile of temperature) and extreme heat effect (the 99th percentile of temperature with reference to the 75th percentile of temperature) over 0-3 lag days was 1.27 (95 %CI: 1.16-1.39) and 1.64 (95 %CI: 1.38-1.93), respectively. The pooled relative risk for heat effect on hospitalization for hypoglycemia and extreme heat effect over 0-3 lag days was 1.33 (95 %CI: 1.17-1.52) and 1.65 (95 %CI: 1.29-2.10), respectively. These associations were consistent by type of hyperglycemic emergencies and type of diabetes and were generally consistent by regions.

DISCUSSION

Heat exposure was associated with hospitalizations for DKA, HHS and hypoglycemia. These results may be useful to guide preventive actions for the risk of fatal hyperglycemic emergencies and hypoglycemia.

What Is the Optimal Speed of correction of the Hyperosmolar Hyperglycemic State in Diabetic Ketoacidosis? An Observational Cohort Study of U.S. Intensive Care Patients

OBJECTIVE

The international guidelines for the treatment of diabetic ketoacidosis (DKA) advise against rapid changes in osmolarity and glucose; however, the optimal rates of correction are unknown. We aimed to evaluate the rates of change in tonicity and glucose level in intensive care patients with DKA and their relationship with mortality and altered mental status.

METHODS

This is an observational cohort study using 2 publicly available databases of U.S. intensive care patients (Medical Information Mart for Intensive Care-IV and Electronic Intensive Care Unit), evaluating adults with DKA and associated hyperosmolarity (baseline Osm ≥300 mOsm/L). The primary outcome was hospital mortality. The secondary neurologic outcome used a composite of diagnosed cerebral edema or Glasgow Coma Scale score of ≤12. Multivariable regression models were used to control for confounding factors.

RESULTS

On adjusted analysis, patients who underwent the most rapid correction of up to approximately 3 mmol/L/hour in tonicity had reduced mortality (n = 2307; odds ratio [OR], 0.21; overall P < .001) and adverse neurologic outcomes (OR, 0.44; P < .001). Faster correction of glucose levels up to 5 mmol/L/hour (90 mg/dL/hour) was associated with improvements in mortality (n = 2361; OR, 0.24; P = .020) and adverse neurologic events (OR, 0.52; P = .046). The number of patients corrected significantly faster than these rates was low. A maximal hourly rate of correction between 2 and 5 mmol/L for tonicity was associated with the lowest mortality rate on adjusted analysis.

CONCLUSION

Based on large-volume observational data, relatively rapid correction of tonicity and glucose level was associated with lower mortality and more favorable neurologic outcomes. Avoiding a maximum hourly rate of correction of tonicity >5 mmol/L may be advisable.

A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach

AIMS

To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patient-reported outcomes.

METHODS

We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals.

RESULTS

The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment.

CONCLUSIONS

We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

Clinical profile and outcomes in COVID-19 patients with diabetic ketoacidosis: A systematic review of literature

BACKGROUND AND AIM

To conduct a systematic literature review and analyze the demographic/biochemical parameters and clinical outcomes of COVID-19 patients with diabetic ketoacidosis (DKA) and combined DKA/HHS (hyperglycemic hyperosmolar syndrome).

METHODS

PubMed, Scopus, Embase, and Google Scholar databases were systematically searched till August 3, 2020 to identify studies reporting COVID-19 patients with DKA and combined DKA/HHS. A total of 19 articles reporting 110 patients met the eligibility criteria.

RESULTS

Of the 110 patients, 91 (83%) patients had isolated DKA while 19 (17%) had DKA/HHS. The majority of the patients were male (63%) and belonged to black ethnicity (36%). The median age at presentation ranged from 45.5 to 59.0 years. Most of the patients (77%) had pre-existing type 2 diabetes mellitus. Only 10% of the patients had newly diagnosed diabetes mellitus. The median blood glucose at presentation ranged from 486.0 to 568.5 mg/dl, being higher in patients with DKA/HHS compared to isolated DKA. The volume of fluid replaced in the first 24 h was higher in patients with DKA/HHS in contrast to patients with DKA alone. The in-hospital mortality rate was 45%, with higher mortality in the DKA/HHS group than in the isolated DKA group (67% vs. 29%). pH was lower in patients who had died compared to those who were discharged.

CONCLUSION

DKA in COVID-19 patients portends a poor prognosis with a mortality rate approaching 50%. Differentiating isolated DKA from combined DKA/HHS is essential as the latter represents nearly one-fifth of the DKA cases and tends to have higher mortality than DKA alone.

Multicentre analysis of hyperglycaemic hyperosmolar state and diabetic ketoacidosis in type 1 and type 2 diabetes

AIMS

To compare diabetes patients with hyperglycaemic hyperosmolar state (HHS), diabetic ketoacidosis (DKA), and patients without decompensation (ND).

METHODS

In total, 500,973 patients with type 1 or type 2 diabetes of all ages registered in the diabetes patient follow-up (DPV) were included. Analysis was stratified by age (≤ / > 20 years) and by manifestation/follow-up. Patients were categorized into three groups: HHS or DKA-during follow-up according to the most recent episode-or ND.

RESULTS

At onset of diabetes, HHS criteria were met by 345 (68.4% T1D) and DKA by 9824 (97.6% T1D) patients. DKA patients had a lower BMI(-SDS) in both diabetes types compared to ND. HbA1c was higher in HHS/DKA. During follow-up, HHS occurred in 1451 (42.2% T1D) and DKA in 8389 patients (76.7% T1D). In paediatric T1D, HHS/DKA was associated with younger age, depression, and dyslipidemia. Pump usage was less frequent in DKA patients. In adult T1D/T2D subjects, metabolic control was worse in patients with HHS/DKA. HHS and DKA were also associated with excessive alcohol intake, dementia, stroke, chronic kidney disease, and depression.

CONCLUSIONS

HHS/DKA occurred mostly in T1D and younger patients. However, both also occurred in T2D, which is of great importance in the treatment of diabetes. Better education programmes are necessary to prevent decompensation and comorbidities.

Seasonal variation of diabetes with hyperosmolarity hospitalizations and its characteristics in mainland Portugal

AIMS

The family physician devotes a part of his care to the surveillance of diabetic patients. Hyperosmolarity is a severe acute complication. The aim of this study was to analyse seasonal variation of type 2 diabetes with hyperosmolarity hospitalizations, regarding their occurrence, mortality, length of stay, Charlson comorbidity index and its factors.

METHODS

The authors analysed all hospitalizations in Portuguese Mainland public sector hospitals between 2000 and 2015 with primary diagnosis of type 2 diabetes with hyperosmolarity (ICD-9-CM codes 250.20 or 250.22), using a national administrative database. Cases were classified into four seasons according to date of admission. The authors compared the occurrence, length of stay, in-hospital mortality and Charlson comorbidity index and its factors.

RESULTS

A total of 6596 hospitalization episodes were included. The authors found that admissions occurred more in winter, being 23% more common. No seasonal statistically significant differences were found considering the other variables.

CONCLUSIONS

There is an increased occurrence of this acute metabolic complication during the winter in patients with type 2 diabetes. These results should be taken into account by the family physician when planning surveillance to this risk group.

Managing People with Diabetes Fasting for Ramadan During the COVID-19 Pandemic: A South Asian Health Foundation Update

The month of Ramadan forms one of the five pillars of the Muslim faith. Adult Muslims are obligated to keep daily fasts from dawn to sunset, with exceptions. This year Ramadan is due to begin on 23 April 2020 and the longest fast in the UK will be approximately 18 hours in length. In addition, due to the often high-calorie meals eaten to break the fast, Ramadan should be seen as a cycle of fasting and feasting. Ramadan fasting can impact those with diabetes, increasing the risk of hypoglycaemia, hyperglycaemia and dehydration. This year, Ramadan will occur during the global COVID-19 pandemic. Reports show that diabetes appears to be a risk factor for more severe disease with COVID-19. In addition, the UK experience has shown diabetes and COVID-19 is associated with dehydration, starvation ketosis, diabetic ketoacidosis and hyperosmolar hyperglycaemic state. This makes fasting in Ramadan particularly challenging for those Muslims with diabetes. Here, we discuss the implications of fasting in Ramadan during the COVID-19 pandemic and make recommendations for those with diabetes who wish to fast.

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.

Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies.

Cerebral edema among adults with diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome: Incidence, characteristics, and outcomes

Ischemic stroke is an uncommon complication among adults with DKA, that confers a worse prognosis. Traditional risk factors for stroke including older age, stroke history, hypertension and hyperlipidemia appear to predict the risk of IS in these patients. Demographic and clinical characteristics of patients with diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome patients, with and without cerebral edema.

Inverse relationship between ambient temperature and admissions for diabetic ketoacidosis and hyperglycemic hyperosmolar state: A 14-year time-series analysis

This study aimed to investigate the association of admissions for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) with ambient temperature and season, respectively in patients with diabetes mellitus (DM), after excluding known co-morbidities that predispose onset of acute hyperglycemia events. This was a time series correlation analysis based on medical claims of 40,084 and 33,947 episodes of admission for DKA and HHS, respectively over a 14-year period in Taiwan. These episodes were not accompanied by co-morbidities known to trigger incidence of DKA and HHS. Monthly temperature averaged from 19 meteorological stations across Taiwan was correlated with monthly rate of admission for DKA or HHS, respectively, using the 'seasonal Autoregressive Integrated Moving Average' (seasonal ARIMA) regression method. There was an inverse relationship between ambient temperature and rates of admission for DKA (β=-0.035, p<0.001) and HHS (β=-0.016, p<0.001), despite a clear decline in rates of DKA/HHS admission in the second half of the study period. We also noted that winter was significantly associated with increased rates of both DKA (β=0.364, p<0.001) and HHS (β=0.129, p<0.05) admissions, as compared with summer. On the other hand, fall was associated with a significantly lower rate of HHS admission (β=-0.016, p<0.05). Further stratified analyses according to sex and age yield essentially similar results. It is suggested that meteorological data can be used to raise the awareness of acute hyperglycemic complication risk for both patients with diabetes and clinicians to further avoid the occurrence of DKA and HHS.

Acute necrotizing pancreatitis in an adolescent with type 2 diabetes

PURPOSE OF REVIEW

The demographics of diabetes among adolescents are changing, with an increasing prevalence of type 2 diabetes. Since adolescents with type 2 diabetes are susceptible to the same complications that accompany type 2 diabetes in adults, pediatricians are now encountering new diagnosis entities.

RECENT FINDINGS

A 16-year-old Hispanic male presented to the emergency room with new onset diabetes. Laboratory evaluation revealed the diagnosis of hyperglycemic hyperosmolar nonketotic state. Within the next 24 hours, the patient's clinical status deteriorated with multi organ failure, followed by asystole. At autopsy, the pancreas demonstrated acute necrotising pancreatitis. Hyperglycemic hyperosmolar nonketotic state is a life-threatening emergency among adults with type 2 diabetes, and is now occurring more frequently among adolescents. Acute pancreatitis should be considered as a precipitating event, particularly in those with severe hypertriglyceridemia.

SUMMARY

This case illustrates the changing morbidity of diabetes in adolescents and the need to consider acute pancreatitis and hyperglycemic hyperosmolar nonketotic in adolescents with severe metabolic decompensation. Since hypertriglyceridemia is a known risk factor for acute pancreatitis, patients should be monitored, and treated as needed.

Hyperglycemic hyperosmolar non-ketotic syndrome in children with type 2 diabetes*

OBJECTIVE

Hyperglycemic hyperosmolar non-ketotic (HHNK) syndrome is thought to be a rare entity in the pediatric population, associated with significant mortality based on case reports in the literature. As obesity and type 2 diabetes in childhood grow in prevalence, such related complications may also increase. This study will serve to provide updated information regarding typical clinical course and sequelae of HHNK syndrome in childhood.

METHODS

Patients diagnosed with type 2 diabetes at Children's Hospital of Philadelphia (CHOP) over a period of 5 yr were screened retrospectively for any laboratory evidence of previous episodes of HHNK syndrome. The standard diagnostic criteria of blood glucose >600 mg/dL and serum osmolality >330 mOsm/L with only mild acidosis (serum bicarbonate >15 mmol/L and small ketonuria 15 mg/dL or less) were utilized.

RESULTS

The records of all patients with type 2 diabetes mellitus (DM) diagnosed over a 5-yr period were reviewed (n=190). Seven patients were found to have one episode of HHNK syndrome by diagnostic criteria (five males, mean age at presentation 13.3 yr, age range 10.1--16.9 yr), yielding a frequency of 3.7%. All were African-American. HHNK syndrome was the clinical presentation at diagnosis of new onset diabetes for all seven children. Three of seven children had a previously diagnosed developmental delay. The average Glasgow Coma Scale (GCS) score at presentation was 13 (range 9--15). Mean body mass index (BMI) at presentation was 32.7 kg/m(2) (n=6). Mean serum osmolality was 393 mOsm/L (n=7), and mean blood glucose was 1604 mg/dL (n = 7). The average time until mental status returned to baseline among survivors was 3 d (range 1--7 d). The average number of hospital days for survivors was 10 (range 5--24 d). Four of seven patients had an uncomplicated course. One patient developed multisystem organ failure and died on hospital day 4. The case fatality rate was 14.3% (one of seven). Survivors had no appreciable neurodevelopmental sequelae.

CONCLUSIONS

This retrospective chart review provides updated information regarding the entity of HHNK syndrome in children. This study supports the need for increased awareness of type 2 diabetes in children so that morbidity and mortality related to HHNK syndrome can be prevented.

Acute hyperglycemic crisis in the elderly

The geriatric population is at particular risk for developing hyperglycemic crises with the development of diabetes. With increasing age, insulin secretory reserve, insulin sensitivity, and thirst mechanisms decrease. The elderly are particularly vulnerable to hyperglycemia and dehydration, the key components of hyperglycemic emergencies. If recognized early, hyperglycemia can frequently be treated in the outpatient setting even with moderate or large ketonuria, provided patients can take fluids, monitor blood glucose frequently, and follow standard "sick day rules." With increased diabetes surveillance and aggressive early treatment of hyperglycemia and its complications, morbidity and mortality from acute diabetic crises in the geriatric population can be greatly reduced.

A survey of reports of quetiapine-associated hyperglycemia and diabetes mellitus

OBJECTIVE

To explore the clinical characteristics of hyperglycemia in patients treated with quetiapine.

METHOD

A pharmacovigilance survey of spontaneously reported adverse events in quetiapine-treated patients was conducted using reports from the U.S. Food and Drug Administration MedWatch program (January 1, 1997, through July 31, 2002) and published cases using the search terms hyperglycemia, diabetes, acidosis, ketosis, and ketoacidosis.

RESULTS

We identified 46 reports of quetiapine-associated hyperglycemia or diabetes and 9 additional reports of acidosis that occurred in the absence of hyperglycemia and were excluded from the immediate analyses. Of the reports of quetiapine-associated hyperglycemia, 34 patients had newly diagnosed hyperglycemia, 8 had exacerbation of preexisting diabetes mellitus, and 4 could not be classified. The mean +/- SD age was 35.3 +/- 16.2 years (range, 5-76 years). New-onset patients (aged 31.2 +/- 14.8 years) tended to be younger than those with preexisting diabetes (43.5 +/- 16.4 years, p = .08). The overall male:female ratio was 1.9. Most cases appeared within 6 months of quetiapine initiation. The severity of cases ranged from mild glucose intolerance to diabetic ketoacidosis or hyperosmolar coma. There were 21 cases of ketoacidosis or ketosis. There were 11 deaths.

CONCLUSION

Atypical antipsychotic use may unmask or precipitate hyperglycemia.

UPDATE

An additional 23 cases were identified since August 1, 2002, the end of the first survey, by extending the search through November 30, 2003, bringing the total to 69.

[Diabetic hyperosmolality. Retrospective study of 60 cases]

AIMS AND METHODS

Our aims were to determine the frequency of diabetic hyperosmolality (DH) in our Department, its causes, therapeutic implications and evolution. A five-years retrospective study was performed in 60 patients regarding age, sex, type and duration of diabetes mellitus (DM), previous antidiabetic therapy, underlying diseases, biochemical data, precipitating factors, therapeutic management and outcome.

RESULTS

The hyperosmolar coma was responsible for 90% of the metabolic comas and for 3% of the diabetic patients. The median age of the cohort was 54.6 +/- 9.4 years, being females 61.7% and males 38.3% In 40% no prior diagnosis of DM was made and in the remaining patients the previous antidiabetic therapy was unknown in 61%. Altered consciousness was found in 90%, being 28% in coma. The metabolic acidosis was detectable in 22.2%, the average glycaemia was 956 +/- 267 mg/dl and the osmolality was 349.4 +/- 34.3 mosm/l. The precipitating factors were: poor metabolic control in all patients (HbA1C 12.5 +/- 2.75%), infections in 76.6%, suspension of antidiabetic therapy in 10% and concomitant hyperglycaemic drugs in 6.6% of patients. The global mortality was 20%.

CONCLUSIONS

The majority of the situations could be preventable if an attempted screening and diagnosis of DM was made and precipitating factors avoid or promptly treated.

Public cost and access to primary care for hyperglycemic emergencies, Clark County, Nevada

Diabetes mellitus accounts for 5.8% of the total health care costs of citizens of the United States. Hospitalization expenses produce 40.5% of these costs. We sought to determine the public expenditure and major precipitators of admissions for uninsured diabetic hyperglycemic emergencies at a large public hospital. Of 247 diabetic emergency admissions over a 30 month period 49% (n = 121) of these patients had no medical insurance. The uninsured patients were younger and had relatively mild disease in comparison to the insured patients. These patients identified a primary physician in only 6% of the cases and had a higher incidence of admissions associated with lack of medications. We conclude that public funds to provide access to primary care and enhancement of employer-sponsored health insurance programs may decrease the numbers and costs of hospitalizations due to hyperglycemic emergencies in uninsured patients with diabetes mellitus.

Rhabdomyolysis in diabetic emergencies

Rhabdomyolysis (RM) is a clinical and laboratory syndrome resulting from leakage of muscle cell contents into plasma. The increased plasma concentration of the substances released such as creatine kinase (CK) permits the clinician to diagnose this syndrome. Non-traumatic RM has occasionally been reported in patients with diabetic decompensation. We encountered about 44 cases of RM in 265 diabetic emergencies (including DKA or hyperosmolar, or both) during the period from 1984-1 to 1990-6, diagnosed based on (1) serum creatine kinase (CK) > 1000 IU/l and (2) the absence of acute myocardial infarction, stroke and end-stage renal disease. On admission, those who presented with RM had significantly higher concentration of blood urine nitrogen (BUN) (83.3 +/- 5.9 vs. 58.8 +/- 2.4 mg/dl, P < 0.05), creatine (4.45 +/- 0.4 vs. 2.97 +/- 0.1 mg/dl, P < 0.05) and serum osmolarity (386.5 +/- 5.2 vs. 351.6 +/- 2.4 mOsm/kg, P < 0.05). The mortality within 1 week of diabetic emergencies (38.5% for DKA, 35.5% for HHNK) was higher in patients with RM than those without RM (9.7% for DKA, 26.7% for HHNK). There was a correlation (r = 0.49, P < 0.05) between the levels of serum creatinine and CK in patients with RM.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperosmolarity and acidosis in diabetes mellitus: a three-year experience in Rhode Island

OBJECTIVES

Diabetic acidosis (DA) and the diabetic hyperosmolar state (DHS) are generally considered to be two distinct clinical entities. However, clinical experience and the literature suggest that there may be some overlap. The purposes of this study were 1) to establish the proportion of overlap cases, 2) to identify any occurrence of DHS in diabetic patients under the age of 30 years (likely type I) and any occurrence of DA in diabetic patients over the age of 60 years (likely type II), 3) to describe clinical factors associated with the development of DA and DHS, and 4) to identify factors that influence the prognosis of DHS.

PATIENTS AND METHODS

613 cases were identified by retrospective chart review, using discharge information from all 15 Rhode Island community hospitals during 1986, 1987, and part of 1988. DA alone [serum glucose (glu) greater than 300 mg/dL, bicarbonate (HCO3) less than 15mEq/L, calculated total serum osmolarity (osm) less than or equal to 320 mOsm/L] was the diagnosis for 134 subjects (22%), DHS alone (glu greater than 600 mg/dL, HCO3 greater than or equal to 15mEq/L, osm greater than 320 mOsm/L), for 278 subjects (45%), and a mixed case (glu greater than 600 mg/dL, HCO3 less than 15 mEq/L, osm greater than 320 mOsm/L), for 200 subjects (33%). Information about serum or urinary ketones was available for 109 subjects who had DA alone [103 had diabetic ketoacidosis (DKA)] and 144 subjects who had mixed DA and DHS (131 had mixed DKA and DHS). All the data were also analyzed using the effective osmolarity and a cutoff of 310 mOsm/L for this alternative case definition.

RESULTS

Patients with DA alone were younger (mean age 33 years) and patients with DHS alone were older (mean age 63 years). However, 28 (10%) of the 278 cases of DHS alone and 72 (36%) of the 200 cases of mixed DA and DHS occurred in patients under the age of 30. Eighteen cases (13%) of DA alone and 62 cases (31%) of mixed DA and DHS occurred in patients over the age of 60. The results were not substantially changed when effective osmolarity greater than 310 mOsm/L was used to define hyperosmolarity and when only cases with documented DKA were included. An infection was the most common precipitating factor of DA (30%), DHS (27%), and mixed cases (32%). Other common associated factors included noncompliance with treatment (20% for DA, 12% for DHS, and 22% for mixed cases) and previously undiagnosed diabetes (24% for DA, 18% for DHS, and 10% for mixed cases). Nursing home residents accounted for 0.7% of DA cases, 18% of DHS cases, and 4.5% of mixed cases. Mortality was 4% for DA, 12% for DHS, and 9% for mixed cases. The mortality for DHS is the lowest reported in the literature, continuing a downward trend that began in the 1970s. Nonsurvival was associated with older age, higher osmolarity, and nursing home residence. Survival was associated with the presence of an infection.

CONCLUSIONS

1) many patients experience mixed DA (DKA) and DHS rather than either condition alone, 2) both DA (DKA) and DHS occur in young and old diabetic persons, 3) infection is the most common predisposing factor for either condition, and 4) higher osmolarity, older age, and nursing home residence are associated with nonsurvival in DHS.

Epidemiological studies on renal papillary necrosis with diabetes mellitus in Japan

Eighty-six cases of renal papillary necrosis (RPN) published in Japan over the years 1949-1980 were studied. While several hundreds cases of RPN were reported in certain European countries and the USA, only 5 cases were published in Japan up until 1960. However, the number of case reports has increased to 28 over the 5 year period of 1976-1980. The ratio of diabetics (62 cases) to nondiabetics (24 cases) is about 2.6:1 and is the same as that reported by Lauer in the USA. In diabetics, RPN was more frequently seen in females (3.4:1) and at more advanced age. Frequency of bilateral occurrence was high (47.5%). The prevalence of the association of glomerulosclerosis (75.0%) was higher than that reported by Silverman et al. in the USA (47.1%). The Incidence of the association of disturbances of consciousness (29.5%) was similar to that reported by Edmondson et al.. It was concluded that the number of cases of RPN with diabetes mellitus in Japan started to increase about 20 years later than in the USA, and that the frequency of the association between RPN and diabetic glomerulosclerosis in Japan seems to be higher than in the USA. Furthermore, it was noted that RPN was frequently associated with hyperosmolar nonketotic diabetic coma.

The role of race and environment in the development of hyperosmolar hyperglycaemic non-ketotic coma

In a retrospective study of patients presenting with hyperosmolar hyperglycaemic non-ketotic coma no evidence was obtained to suggest that the condition occurs more commonly in black patients. Suspicions that poor social background rather than race predisposes patients to the condition are borne out by the fact that 10 of the 13 patients were socially isolated.