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Tanwar M, Singh A, Singh TP, Sharma S, Sharma P. Comprehensive Review on the Virulence Factors and Therapeutic Strategies with the Aid of Artificial Intelligence against Mucormycosis. ACS Infect Dis 2024; 10:1431-1457. [PMID: 38682683 DOI: 10.1021/acsinfecdis.4c00082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Mucormycosis, a rare but deadly fungal infection, was an epidemic during the COVID-19 pandemic. The rise in cases (COVID-19-associated mucormycosis, CAM) is attributed to excessive steroid and antibiotic use, poor hospital hygiene, and crowded settings. Major contributing factors include diabetes and weakened immune systems. The main manifesting forms of CAM─cutaneous, pulmonary, and the deadliest, rhinocerebral─and disseminated infections elevated mortality rates to 85%. Recent focus lies on small-molecule inhibitors due to their advantages over standard treatments like surgery and liposomal amphotericin B (which carry several long-term adverse effects), offering potential central nervous system penetration, diverse targets, and simpler dosing owing to their small size, rendering the ability to traverse the blood-brain barrier via passive diffusion facilitated by the phospholipid membrane. Adaptation and versatility in mucormycosis are facilitated by a multitude of virulence factors, enabling the pathogen to dynamically respond to various environmental stressors. A comprehensive understanding of these virulence mechanisms is imperative for devising effective therapeutic interventions against this highly opportunistic pathogen that thrives in immunocompromised individuals through its angio-invasive nature. Hence, this Review delineates the principal virulence factors of mucormycosis, the mechanisms it employs to persist in challenging host environments, and the current progress in developing small-molecule inhibitors against them.
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Affiliation(s)
- Mansi Tanwar
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Anamika Singh
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Tej Pal Singh
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Sujata Sharma
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Pradeep Sharma
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi-110029, India
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Johnson J, Drincic A, Buddenhagen E, Nein K, Samson K, Langenhan T. Evaluation of a Protocol Change Promoting Lactated Ringers Over Normal Saline in the Treatment of Diabetic Ketoacidosis. J Diabetes Sci Technol 2024; 18:549-555. [PMID: 38454546 PMCID: PMC11089871 DOI: 10.1177/19322968241235941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Current guidelines recommend normal saline (NS) for fluid resuscitation in the management of patients presenting with diabetic ketoacidosis (DKA). However, previous prospective studies have demonstrated improvement in patient-specific outcomes, including time to DKA resolution, when balanced crystalloid fluids are used. METHODS We conducted a single institution, retrospective cohort study of adult patients admitted with DKA before and after a protocol change within our institution, which shifted the default resuscitative and maintenance fluid in our DKA management protocol from NS to lactated Ringer's solution (LR). The primary outcome was time from DKA clinical presentation until DKA resolution. The secondary outcome was time to discontinuation of DKA protocol insulin drip. RESULTS Of 246 patients meeting inclusion criteria, 119 were in the NS group (preprotocol change, where NS was the default resuscitative fluid) and 127 to the LR group (postprotocol change, where LR was the default resuscitative fluid). Time to DKA resolution was significantly decreased in the LR group (mean = 17.1 hours; standard deviation [SD] = 11.0) relative to the NS group (mean = 20.6 hours; SD = 12.2; P = .02). Duration of DKA protocol insulin drip was shorter in the LR group (mean = 16.0 hours; SD = 8.7) compared with the NS group (mean = 21.4 hours; SD = 12.5; P < .001). CONCLUSIONS In this retrospective cohort study, protocolized DKA intravenous fluid management with LR resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.
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Affiliation(s)
- Jake Johnson
- Division of Diabetes, Endocrine, and
Metabolism, Department of Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Andjela Drincic
- Division of Diabetes, Endocrine, and
Metabolism, Department of Internal Medicine, University of Nebraska Medical Center,
Omaha, NE, USA
| | - Emma Buddenhagen
- College of Medicine, University of
Nebraska Medical Center, Omaha, NE, USA
| | - Kaitlyn Nein
- College of Medicine, University of
Nebraska Medical Center, Omaha, NE, USA
| | - Kaeli Samson
- Department of Biostatistics, University
of Nebraska Medical Center, Omaha, NE, USA
| | - Trek Langenhan
- Division of Hospital Medicine,
Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE,
USA
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Ata F, Khan AA, Khamees I, AlKodmani S, Al-Sadi A, Yaseen KB, Muthanna B, Godwin A, Beer SF, Bashir M. Prevalence and prognosis of fulminant type 1 diabetes mellitus in The Middle East: a comparative analysis in a 5-year nationwide cohort. BMC Endocr Disord 2024; 24:33. [PMID: 38462602 PMCID: PMC10926611 DOI: 10.1186/s12902-024-01559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 02/21/2024] [Indexed: 03/12/2024] Open
Abstract
PURPOSE To analyze the prevalence and progression of fulminant type 1 diabetes (FT1D) in Qatar. METHODS This retrospective study analyzed consecutive index- diabetic ketoacidosis (DKA) admissions (2015-2020) among patients with new-onset T1D (NT1D) in Qatar. RESULTS Of the 242 patients, 2.5% fulfilled the FT1D diagnostic criteria. FT1D patients were younger (median-age 4-years vs.15-years in classic-T1D). Gender distribution in FT1D was equal, whereas the classic-T1D group showed a female predominance at 57.6% (n = 136). FT1D patients had a mean C-peptide of 0.11 ± 0.09 ng/ml, compared to 0.53 ± 0.45 ng/ml in classic-T1D. FT1D patients had a median length of stay (LOS) of 1 day (1-2.2) and a DKA duration of 11.25 h (11-15). The median (length of stay) LOS and DKA duration in classic-T1D patients were 2.5 days (1-3.9) and 15.4 h (11-23), respectively. The FT1D subset primarily consisted of moderate (83.3%) and severe 916.7%) DKA, whereas classic T1D had 25.4% mild, 60.6% moderate, and 14% severe DKA cases. FT1D was associated with a higher median white cell count (22.3 × 103/uL) at admission compared to classic T1D (10.6 × 103/uL). ICU admission was needed for 66.6% of FT1D patients, compared to 38.1% of classic-T1D patients. None of the patients in the FT1D group had mortality, while two died in the classic-T1D group. CONCLUSION This is the first study establishing the existence of FT1D in ME, which presented distinctively from classic-T1D, exhibiting earlier age onset and higher critical care requirements. However, the clinical outcomes in patients with FT1D seem similar to classic T1D.
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Affiliation(s)
- Fateen Ata
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar.
| | - Adeel Ahmad Khan
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Khamees
- Department of Internal Medicine, University of Missouri, Kansas City, MO, USA
| | - Sham AlKodmani
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Anas Al-Sadi
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Bassam Muthanna
- Department of Medicine, Louis A. Weiss Memorial Hospital, Chicago, USA
| | - Angela Godwin
- Department of Laboratory Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohammed Bashir
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
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Parihar R, Rana S, Punthakee Z, Gerstein H, Braga M, Pigeyre M. Impact of COVID-19 Lockdown on Occurrence of Acute Complications of Type 1 and Type 2 Diabetes and Overall Glycemic Management. Can J Diabetes 2024; 48:120-124. [PMID: 38092244 DOI: 10.1016/j.jcjd.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/04/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES The association of diabetes, and COVID-19 infection has been studied extensively; however, the occurrence of diabetic ketoacidosis (DKA) or hyperglycemic/hyperosmolar states (HHS) in adults during the lockdown has not been well characterized. In this study, we aimed to identify the impact of the lockdown on occurrence and severity of DKA/HHS admissions and glycemic management. METHODS A retrospective chart review was conducted of patients admitted to Hamilton Health Sciences with a diagnosis of DKA or HHS from April to September 2019 (pre-lockdown) and from April to September 2020 (lockdown). Adult (≥18 years old) nonpregnant patients with a single admission in the study period were included for study. RESULTS There were 229 admissions related to diabetes, with 171 admissions meeting the inclusion criteria (n=92 pre-lockdown, n=79 lockdown). In the lockdown group, 51.8% of the patients had type 2 diabetes mellitus, with 96.2% of admissions secondary to DKA. When comparing the 2 periods, the lockdown group trended toward higher rates of death (5.4% vs 10.1%, p=0.247) and euglycemic DKA (17.6% vs 24.4%, p=0.403). There were more new diagnoses of type 1 diabetes mellitus in the lockdown group compared with the pre-lockdown group (7.3% vs 16.7%, p=0.230). The average glycated hemoglobin was lower in the lockdown group compared with the pre-lockdown group (11.8% vs 10.4%, p=0.032). CONCLUSIONS Overall, this study is among the first in Canada to assess the impact of the COVID-19 lockdown on admissions due to DKA and HHS. Although no significant differences were noted in severity of admissions, there was a trend toward more new diagnoses of type 1 diabetes mellitus presenting in DKA during the lockdown period.
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Affiliation(s)
- Richa Parihar
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada.
| | - Simrit Rana
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Zubin Punthakee
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel Gerstein
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Manoela Braga
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Marie Pigeyre
- Department of Medicine, Division of Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
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Leyden J, Uber A, Herrera-Escobar JP, Levy-Carrick NC. Psychiatric and Substance Use Disorders and Their Association With Clinical Outcomes in Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome. J Acad Consult Liaison Psychiatry 2024:S2667-2960(24)00027-2. [PMID: 38431209 DOI: 10.1016/j.jaclp.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/08/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND OBJECTIVE Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening conditions that send nearly 180,000 patients to the intensive care unit each year, with mortality rates up to 5-10%. Little is known about the impact of concurrent psychiatric disorders on specific DKA/HHS outcomes. Identifying these relationships offers opportunities to improve clinical management, treatment planning, and mitigate associated morbidity and mortality. METHODS We conducted a retrospective review including adult DKA/HHS admissions within a large Massachusetts hospital system from 2010 to 2019. We identified patients admitted inpatient for DKA or HHS, then filtered by International Classification of Disease-9-CM and International Classification of Disease-10-CM codes for psychiatric diagnoses that were present in patients electronic medical record at any point in this observational period. Outcomes included the number of inpatient admissions for DKA/HHS, age of death, rates of discharging against medical advice (AMA) from any inpatient admission, and end-stage renal disease/dialysis status. Multivariate regression was conducted using R software to control for variables across patients and evaluate relationships between outcomes and concurrent psychiatric disorders. Significance was set at P < 0.05. RESULTS Seven thousand seven hundred fifty-six patients were admitted for DKA or HHS, 66.9% of whom had a concurrent psychiatric disorder. Of these patients, 54.5% were male, 70.4% were White, and they had an average age of 61.6 years. This compares with 26.1% with concurrent psychiatric condition within the general diabetes population, 52.1% of whom were male, 72.1% were White, and an average age of 68.2 years. A concurrent psychiatric disorder was associated with increased odds of rehospitalization (adjusted odds ratio [aOR] = 1.62 95% confidence interval [CI] 1.35-1.95, P < 0.001), of being diagnosed with end-stage renal disease and on dialysis (aOR = 1.02 95% CI 1.002-1.035, P = 0.02), and of leaving AMA (aOR = 6.44 95% CI 4.46-9.63, P < 0.001). The average age of death for those with a concurrent psychiatric disorder had an adjusted mean difference in years of -7.5 years (95% CI -9.3 to 5.8) compared to those without a psychiatric disorder. CONCLUSIONS Of patients with DKA/HHS, 66.9% have a concurrent psychiatric disorder. Patients with a concurrent psychiatric disorder admitted for DKA/HHS were more likely to have multiple admissions, to leave AMA, to be on renal dialysis, and to have a lower age of mortality.
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Affiliation(s)
- Jacinta Leyden
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA.
| | - Amy Uber
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Juan P Herrera-Escobar
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
| | - Nomi C Levy-Carrick
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA; Department of Psychiatry, Harvard Medical School, Boston, MA
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Sharif A, Brewer JM, El Banayosy A, Mihu MR, Reaves Z, Swant LV, Schoaps RS, Benson C, Khalid MI, Maybauer MO. Extracorporeal membrane oxygenation in diabetic ketoacidosis-related cardiac and respiratory failure. Int J Artif Organs 2024; 47:35-40. [PMID: 38053302 DOI: 10.1177/03913988231214448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) is a common clinical problem. When patients develop severe shock and/or respiratory failure, extracorporeal membrane oxygenation (ECMO) may be considered. This case series describes the clinical presentation and outcomes of patients with DKA supported with ECMO. METHODS We conducted a retrospective and anonymized review of 15 patients with DKA who required ECMO at our institution. Demographic and ECMO-specific data were collected. Additional variables include ICU length of stay (LOS), acute kidney injury and use of continuous renal replacement therapy, disposition, and mortality. RESULTS All ECMO cannulations were performed by an intensivist using peripheral vascular access. The majority of patients were female (73%) with a median age of 27 (IQR = 21.5-45) years. A diagnosis of diabetes mellitus (DM) prior to ECMO was present in 11 (73%) patients. Venoarterial ECMO was the initial mode used in 11 (73%) patients. The median duration of ECMO support was 7 (IQR = 6-14) days. The median ICU LOS was 12 (IQR = 8.5-20.5) days, and the median hospital LOS was 21 (IQR = 11-36.5) days. Eight patients had cardiac arrest and underwent extracorporeal cardiopulmonary resuscitation (ECPR) of which 4 (50%) patients survived to discharge. Overall, 10 (66.7%) patients were successfully weaned from ECMO and survived to discharge. CONCLUSION This is the largest case series regarding the use of ECMO for patients with refractory shock, cardiac arrest, or respiratory failure related to DKA. The findings suggest that ECMO is a viable support option for managing these patients and has excellent outcomes, including patients with cardiac arrest.
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Affiliation(s)
- Ammar Sharif
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - J Michael Brewer
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Aly El Banayosy
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Mircea R Mihu
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
- Department of Medicine, Division of Cardiology, Oklahoma State University Health Science Center, Tulsa, OK, USA
| | - Zachary Reaves
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Laura V Swant
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Robert S Schoaps
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Clayne Benson
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Malik Ibithaj Khalid
- INTEGRIS Health Baptist Medical Center, Nazih Zuhdi Transplant Institute, Specialty Critical Care and Acute Circulatory Support, Oklahoma City, OK, USA
| | - Marc O Maybauer
- Department of Anesthesiology, Division of Critical Care Medicine, University of Florida College of Medicine, Gainesville, FL, USA
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
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Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a serious acute complication of both type 1 and type 2 diabetes that requires prompt management. Limited data exist supporting the use of a 2-bag DKA protocol in adult patients across all levels of care. OBJECTIVE To evaluate the efficacy and safety of a 2-bag DKA protocol in comparison with a traditional DKA management strategy. METHODS Retrospective review of patients admitted with DKA between January 1, 2021, and February 28, 2022, at a single center. Patients were separated into 2 cohorts, traditional or 2-bag. The primary outcome was time to anion gap closure and/or beta-hydroxybutyrate normalization. Secondary outcomes include length of hospitalization, insulin infusion time, and hypoglycemic events. RESULTS One hundred forty-three patients had a DKA order set initiated during their admission, 59 in the traditional cohort and 84 in the 2-bag cohort. Mean time to anion gap closure was shorter in the 2-bag cohort (12.7 vs 16.9 hours; P = 0.005) and beta-hydroxybutyrate normalization (15.6 vs 25.6 hours; P = 0.026). No difference in hospital length of stay (4 vs 6 days; P = 0.113), duration of insulin infusion (41.6 vs 40.6 hours; P = 0.455), or rates of hypoglycemia (6 vs 4; P = 0.872) was seen. CONCLUSION AND RELEVANCE Implementation of a 2-bag DKA protocol in the inpatient setting was associated with a shorter time to anion gap closure and beta-hydroxybutyrate normalization. These findings support the option of expansion of a 2-bag DKA protocol to adult patients across all levels of care irrespective of the admission diagnosis.
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Affiliation(s)
- Hannah E Gilchrist
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Colman J Hatton
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Matthew A Roginski
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Alyson M Esteves
- Department of Pharmacy, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Ata F, Khan AA, Khamees I, Iqbal P, Yousaf Z, Mohammed BZM, Aboshdid R, Marzouk SKK, Barjas H, Khalid M, El Madhoun I, Bashir M, Kartha A. Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis. Ann Med 2023; 55:533-542. [PMID: 36745515 PMCID: PMC9904305 DOI: 10.1080/07853890.2023.2175031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The increasing prevalence of diabetic ketoacidosis (DKA) related admissions poses a significant burden on the healthcare systems globally. However, data regarding the predictors of healthcare resource utilization in DKA is limited and inconsistent. This study aimed to identify key predictors of hospital length of stay (LOS), readmission and recurrent DKA episodes. METHODS We undertook a retrospective cross-sectional analysis of all DKA admissions from 2015 to 2021 across four hospitals in Qatar. The primary outcomes were the length of stay (LOS), 90-day readmission and 6-month and 1-year DKA recurrence. RESULTS We included 922 patients with a median age of 35 years (25-45). 62% were males with type-1 diabetes-mellitus (T1DM) and type-2 DM (T2DM), present in 52% and 48% of patients. The median LOS was 2.6 days (IQR 1.1-4.8), and the median DKA resolution time was 18 h (10.5-29). Male-gender, new-onset DM, higher Charlson Comorbidity Index (CCI), lower haemoglobin, sodium and potassium, higher urea, longer DKA duration and MICU admission predicted a longer LOS in a multivariate regression analysis. None of the factors were significantly associated with 90-day readmission. Patients with pre-existing T1DM were more likely to have a six-month DKA recurrence than pre-existing T2DM. Patients with a 6-month DKA recurrence, female gender and T1DM had higher odds of 12-month recurrence, whereas a consult with a diabetes educator at the index admission was associated with decreased odds of recurrence. CONCLUSIONS/INTERPRETATION This is the most extensive study from the Middle-East region reporting on LOS, readmissions and the recurrence of DKA. Results from this study with a diverse population may be valuable for physicians and healthcare systems to decrease the diabetes-related healthcare burden in DKA patients.
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Affiliation(s)
- Fateen Ata
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Adeel Ahmad Khan
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Khamees
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Phool Iqbal
- Department of Medicine, New York Medical College/Metropolitan Hospital Center, New York, NY, USA
| | - Zohaib Yousaf
- Department of Medicine, Reading Hospital-Tower Health, West Reading, PA, USA
| | | | - Reham Aboshdid
- Department of Geriatrics, Hamad Medical Corporation, Doha, Qatar
| | | | - Haidar Barjas
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Madiha Khalid
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ihab El Madhoun
- Department of Nephrology, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Bashir
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Anand Kartha
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar.,College of Medicine, Weill Cornell Medicine, Doha, Qatar
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Coetzee A, Hall DR, Langenegger EJ, van de Vyver M, Conradie M. Pregnancy and diabetic ketoacidosis: fetal jeopardy and windows of opportunity. Front Clin Diabetes Healthc 2023; 4:1266017. [PMID: 38047210 PMCID: PMC10693403 DOI: 10.3389/fcdhc.2023.1266017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/26/2023] [Indexed: 12/05/2023]
Abstract
Background Diabetic ketoacidosis (DKA) during pregnancy poses significant risks to both the mother and fetus, with an increased risk of fetal demise. Although more prevalent in women with Type I diabetes (T1D); those with Type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) can also develop DKA. A lack of information about DKA during pregnancy exists worldwide, including in South Africa. Objective This study examined the characteristics and outcomes associated with DKA during pregnancy. Methods The study took place between 1 April 2020 and 1 October 2022. Pregnant women with DKA, admitted to Tygerberg Hospital's Obstetric Critical Care Unit (OCCU) were included. Maternal characteristics, precipitants of DKA, adverse events during treatment, and maternal-fetal outcomes were examined. Results There were 54 episodes of DKA among 47 women. Most DKA's were mild and occurred in the third trimester. Pregestational diabetes dominated (31/47; 60%), with 47% having T1D and 94% requiring insulin. Seven women (7/47, 15%; T2D:6, T1D:1) had two episodes of DKA during the same pregnancy. Most women (32/47; 68%) were either overweight or obese. Yet, despite the T2D phenotype, biomarkers indicated that auto-immune diabetes was prevalent among women without any prior history of T1D (6/21; 29%). Twelve women (26%) developed gestational hypertension during pregnancy, and 17 (36%) pre-eclampsia. Precipitating causes of DKA included infection (14/54; 26%), insulin disruption (14/54; 26%) and betamethasone administration (10/54; 19%). More than half of the episodes of DKA involved hypokalemia (35/54, 65%) that was associated with fetal death (P=0.042) and hypoglycemia (28/54, 52%). Preterm birth (<37 weeks' gestation) occurred in 85% of women. No maternal deaths were recorded. A high fetal mortality rate (13/47; 28%) that included 11 spontaneous intrauterine deaths and two medical terminations, was observed. Conclusion Women with DKA have a high risk of fetal mortality as well as undiagnosed auto-immune diabetes. There is a strong link between maternal hypokalemia and fetal loss, suggesting an opportunity to address management gaps in pregnant women with DKA.
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Affiliation(s)
- Ankia Coetzee
- Department of Medicine, Division of Endocrinology Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - David R. Hall
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Eduard J. Langenegger
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mari van de Vyver
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Magda Conradie
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Choi AY, Park E. The impact of pediatric intensivists on the management of pediatric diabetic ketoacidosis in pediatric intensive care units. BMC Pediatr 2023; 23:562. [PMID: 37957591 PMCID: PMC10644449 DOI: 10.1186/s12887-023-04398-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023] Open
Abstract
INTRODUCTION The impact of pediatric intensivists on managing pediatric patients with diabetic ketoacidosis (DKA) remains unknown. This study aimed to evaluate the impact of pediatric intensivists on outcomes in pediatric intensive care units (PICUs). METHODS This was a two-institution retrospective study of patients with DKA admitted to the PICU between 2012 and 2023. Pediatric patients (< 19 years of age) were included if they met the moderate to severe DKA criteria on PICU admission. The patients were subsequently divided into two groups based on the presence or absence of a pediatric intensivist. The primary outcome was the PICU length of stay (LOS). Secondary outcomes were adverse events during DKA treatment, hospital LOS, and mortality. RESULTS Fifty-two patients admitted to the PICU with a median age of 13.00 years (range, 0-18 years) were included; 32 (61.54%) were female. Patients managed by pediatric intensivists had significantly shorter PICU LOS (2.52 vs. 3.69 days, p < 0.05). Also, adverse events during DKA treatment were significantly decreased in the high-intensity group compared to the low-intensity group (12.50% vs. 50.00%, p < 0.05). CONCLUSIONS High-intensity ICU staffing was associated with shorter PICU LOS and lower adverse events in pediatric patients with DKA. Our results suggest that dedicated pediatric intensivists can improve outcomes of critically ill pediatric patients with DKA.
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Affiliation(s)
- Ah Young Choi
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Esther Park
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Republic of Korea.
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea.
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Swaminathan K, Nanda PM, Yadav J, Malhi P, Kumar R, Sharma A, Sharma R, Dayal D. Cognitive Function in Early Onset Type 1 Diabetes in Children. Indian J Pediatr 2023:10.1007/s12098-023-04901-5. [PMID: 37930624 DOI: 10.1007/s12098-023-04901-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES To assess cognitive function and factors affecting it in Indian children with early-onset type 1 diabetes (T1D) (less than 6 y). METHODS This cross-sectional, single-centre study recruited children diagnosed with T1D before 6 y of age and having a disease duration of at least 2 y, as cases. Controls were age- and sex-matched apparently healthy children or siblings. Children with birth asphyxia, intellectual disability, syndromic children, or pre-existing psychiatric illness were excluded. Enrolled children underwent cognitive assessment using Malin's Intelligence Scale for Indian Children (MISIC), and scores in various subtests were compared between cases and controls. RESULTS A total of 60 children were enrolled in each group. When compared to controls, cases had significantly lower scores on most subtests, verbal, performance and overall Intelligence Quotient (IQ- 100.62 ± 3.26 vs. 103.23 ± 1.22). HbA1c >9%, severe hypoglycemia and lesser duration since the last diabetic ketoacidosis (DKA) episode significantly correlated with lower neurocognitive scores. CONCLUSIONS Children with early onset T1D showed significant deficits in various cognitive domains and IQ. Poor glycemic control, higher glycemic variability and exposure to severe hypoglycemia are risk factors for poor cognitive outcomes in these children. Further longitudinal studies could potentially aid in a finer understanding of factors affecting cognitive functioning in T1D children in developing countries.
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Affiliation(s)
- K Swaminathan
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pamali Mahasweta Nanda
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jaivinder Yadav
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Prahbhjot Malhi
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rakesh Kumar
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Akhilesh Sharma
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rajni Sharma
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Devi Dayal
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Albedaiwi FB, Alshammari M, Algeffari M, Alfouzan A, Alfouzan Y, Siddiq H, Hussein O. Diabetic Ketoacidosis After COVID-19 Vaccine in Patients with Type 1 Diabetes Mellitus. Int J Endocrinol Metab 2023; 21:e135866. [PMID: 38694238 PMCID: PMC11061715 DOI: 10.5812/ijem-135866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/31/2023] [Accepted: 08/28/2023] [Indexed: 05/04/2024] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) vaccine is one of the few vaccines that obtained emergency authorization to combat the fatal pandemic. Despite the fact that some available literature addressed its short-term side effects, there are still limitations on its effects on type 1 diabetes mellitus (T1DM). Objectives The aim of the present study was to assess the association between COVID-19 vaccination and diabetic ketoacidosis (DKA) among individuals with T1DM. Additionally, the study aimed to determine the effects of the vaccine on glucose control, variability, and risk of hypoglycemia. Methods This retrospective study was conducted at King Fahad Specialist Hospital (KFSH) in Qassim Region, Saudi Arabia. Diabetic ketoacidosis cases admitted to the hospital within February 2020 and August 2022 were included in the study based on specific inclusion criteria. Finally, a total of 49 patients were included in statistical analyses. Results Out of the 62 patients admitted to the hospital, 49 met the diagnostic criteria for DKA and agreed to participate in the study. The majority of the remaining patients (n = 13) refused to participate, and only a few of them lacked complete documentation. Of the 49 patients who were included in the study, 46 cases had a history of T1DM; nevertheless, 3 patients were newly diagnosed with T1DM. Additionally, among these participants, 16 (32.7%), 19 (38.8%), and 14 (28.6%) patients had mild, moderate, and severe DKA, respectively. There were 27 male (55.1%) and 22 female (44.9%) patients. About 91% of the patients were vaccinated against COVID-19, 30.6% of whom were vaccinated within 29 days of being diagnosed with DKA. The pH and bicarbonate levels were observed to be significantly high among those who were diagnosed with DKA within 29 days of vaccination, with p-values of 0.031 and 0.037, respectively. Similarly, pH and random blood sugar (RBS) were observed to be significantly higher among the vaccinated patients than in the non-vaccinated subjects (P = 0.044 and P = 0.032, respectively). Conclusions The study findings revealed that some of the DKA indicators were evident among the vaccinated patients. However, larger-scale and multi-center studies are recommended in order to have more conclusive evidence and generalize the findings.
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Affiliation(s)
| | | | - Metab Algeffari
- Department of Family and Community Medicine, Collage of Medicine, Qassim University, Buraydah, Saudi Arabia
| | | | - Yasmeen Alfouzan
- College of Medicine, Qassim University, Buraydah, Al-Qassim, Saudi Arabia
| | - Hassan Siddiq
- Diabetes and Endocrinology Center, Buraydah, Al-Qassim, Saudi Arabia
| | - Omaima Hussein
- Diabetes and Endocrinology Center, Buraydah, Al-Qassim, Saudi Arabia
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Kashfi K, Anbardar N, Asadipooya A, Asadipooya K. Type 1 Diabetes and COVID-19: A Literature Review and Possible Management. Int J Endocrinol Metab 2023; 21:e139768. [PMID: 38666042 PMCID: PMC11041820 DOI: 10.5812/ijem-139768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 04/28/2024] Open
Abstract
Context Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection normally damages the respiratory system but might likewise impair endocrine organs' function. Thyroid dysfunction and hyperglycemia are common endocrine complications of SARS-CoV-2 infection. The onset of type 1 diabetes (T1D) and associated complications, including diabetic ketoacidosis (DKA), hospitalization, and death, are thought to have increased during the coronavirus disease 2019 (COVID-19) pandemic. The aim of this study was to review the available data about the incidence rate of T1D and accompanying complications since the beginning of the COVID-19 pandemic. Evidence Acquisition A literature review was conducted using the electronic databases PubMed and Google Scholar. The keywords "T1D, T1DM, Type 1 DM or Type 1 Diabetes", "Coronavirus, SARS-CoV-2 or COVID-19" were used to search these databases. Titles and abstracts were screened for selection, and then relevant studies were reviewed in full text. Results A total of 25 manuscripts out of 304 identified studies were selected. There were 15 (60%) multicenter or nationwide studies. The data about the incidence rate of T1D, hospitalization, and death are not consistent across countries; however, DKA incidence and severity seem to be higher during the COVID-19 pandemic. The present study's data collection demonstrated that COVID-19 might or might not increase the incidence of T1D. Nevertheless, it is associated with the higher incidence and severity of DKA in T1D patients. This finding might indicate that antivirals are not fully protective against the endocrine complications of SARS-CoV-2 infection, which promotes the application of an alternative approach. Conclusions Combining medications that reduce SARS-CoV-2 entry into the cells and modulate the immune response to infection is an alternative practical approach to treating COVID-19.
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Affiliation(s)
- Kebria Kashfi
- Department of Clinical Medicine, Florida International University AUACOM, Florida, USA
| | - Narges Anbardar
- Department of Clinical Medicine, SMUSOM, Cleveland Clinic Lerner College of Medicine, Ohio, USA
| | - Artin Asadipooya
- Department of Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Kamyar Asadipooya
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, Kentucky, USA
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Alqarihi A, Kontoyiannis DP, Ibrahim AS. Mucormycosis in 2023: an update on pathogenesis and management. Front Cell Infect Microbiol 2023; 13:1254919. [PMID: 37808914 PMCID: PMC10552646 DOI: 10.3389/fcimb.2023.1254919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Mucormycosis (MCR) is an emerging and frequently lethal fungal infection caused by the Mucorales family, with Rhizopus, Mucor, and Lichtheimia, accounting for > 90% of all cases. MCR is seen in patients with severe immunosuppression such as those with hematologic malignancy or transplantation, Diabetes Mellitus (DM) and diabetic ketoacidosis (DKA) and immunocompetent patients with severe wounds. The recent SARS COV2 epidemy in India has resulted in a tremendous increase in MCR cases, typically seen in the setting of uncontrolled DM and corticosteroid use. In addition to the diversity of affected hosts, MCR has pleiotropic clinical presentations, with rhino-orbital/rhino-cerebral, sino-pulmonary and necrotizing cutaneous forms being the predominant manifestations. Major insights in MCR pathogenesis have brought into focus the host receptors (GRP78) and signaling pathways (EGFR activation cascade) as well as the adhesins used by Mucorales for invasion. Furthermore, studies have expanded on the importance of iron availability and the complex regulation of iron homeostasis, as well as the pivotal role of mycotoxins as key factors for tissue invasion. The molecular toolbox to study Mucorales pathogenesis remains underdeveloped, but promise is brought by RNAi and CRISPR/Cas9 approaches. Important recent advancements have been made in early, culture-independent molecular diagnosis of MCR. However, development of new potent antifungals against Mucorales remains an unmet need. Therapy of MCR is multidisciplinary and requires a high index of suspicion for initiation of early Mucorales-active antifungals. Reversal of underlying immunosuppression, if feasible, rapid DKA correction and in selected patients, surgical debulking are crucial for improved outcomes.
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Affiliation(s)
- Abdullah Alqarihi
- Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA, United States
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States
| | - Ashraf S Ibrahim
- Division of Infectious Diseases, The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles (UCLA) Medical Center, Torrance, CA, United States
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Ata F, Khan AA, Khamees I, Mohammed BZM, Barjas HH, Muthanna B, Bashir M, Kartha A. Differential evolution of diabetic ketoacidosis in adults with pre-existent versus newly diagnosed type 1 and type 2 diabetes mellitus. BMC Endocr Disord 2023; 23:193. [PMID: 37700308 PMCID: PMC10496170 DOI: 10.1186/s12902-023-01446-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) was once known to be specific to type-1 diabetes-mellitus (T1D); however, many cases are now seen in patients with type-2 diabetes-mellitus (T2D). Little is known about how this etiology shift affects DKA's outcomes. METHODS We studied consecutive index DKA admissions from January 2015 to March 2021. Descriptive analyses were performed based on pre-existing T1D and T2D (PT1D and PT2D, respectively) and newly diagnosed T1D and T2D (NT1D and NT2D, respectively). RESULTS Of the 922 patients, 480 (52%) had T1D, of which 69% had PT1D and 31% NT1D, whereas 442 (48%) had T2D, of which 60% had PT2D and 40% NT2D. The mean age was highest in PT2D (47.6 ± 13.1 years) and lowest in PT1D (27.3 ± 0.5 years) (P < 0.001). Patients in all groups were predominantly male except in the PT1D group (55% females) (P < 0.001). Most patients were Arabic (76% in PT1D, 51.4% in NT1D, 46.6% in PT2D) except for NT2D, which mainly comprised Asians (53%) (P < 0.001). Patients with NT2D had the longest hospital length of stay (LOS) (6.8 ± 11.3 days) (P < 0.001), longest DKA duration (26.6 ± 21.1 h) (P < 0.001), and more intensive-care unit (ICU) admissions (31.2%) (P < 0.001). Patients with PT1D had the shortest LOS (2.5 ± 3.5 days) (P < 0.001), DKA duration (18.9 ± 4.2 h) (P < 0.001), and lowest ICU admissions (16.6%) (P < 0.001). CONCLUSIONS/INTERPRETATION We presented the largest regional data on differences in DKA based on the type and duration of diabetes- mellitus (DM), showing that T2D is becoming an increasing cause of DKA, with worse clinical outcomes (especially newly diagnosed T2D) compared to T1D.
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Affiliation(s)
- Fateen Ata
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, 3050, Doha, Qatar.
| | - Adeel Ahmad Khan
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Ibrahim Khamees
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | - Bassam Muthanna
- Department of Geriatrics, University of Illinois College of Medicine, Chicago, USA
| | - Mohammed Bashir
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, 3050, Doha, Qatar
- Qatar Metabolic Institute, Doha, Qatar
| | - Anand Kartha
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
- Weill Cornel Medicine, Doha, Qatar
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Stuhr K, LeeMaster R, Hickman AW, Reachi B, Pace W, Meek C. Subcutaneous Insulin Versus Traditional Intravenous Insulin Infusion in Treatment of Mild to Moderate Diabetic Ketoacidosis. J Emerg Med 2023; 65:e221-e228. [PMID: 37689412 DOI: 10.1016/j.jemermed.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/11/2023] [Accepted: 06/13/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Intravenous (IV) insulin infusions are the current standard of care for treatment of diabetic ketoacidosis (DKA). Subcutaneous (SQ) insulin, however, may also be a safe and effective alternative. OBJECTIVE The purpose of this study was to compare patient-centered outcomes related to the treatment of mild to moderate DKA using two different protocols: an SQ insulin protocol and an IV insulin infusion protocol with an initial bolus (IVB) or without a bolus (IVNB). METHODS We retrospectively conducted a multicenter cohort study evaluating SQ vs. IV insulin for the treatment of mild to moderate DKA. The primary outcome was time to DKA resolution. Secondary outcomes included time to glucose correction, hospital length of stay (LOS), intensive care unit LOS, hypoglycemia events, readmission rates, and IV insulin use. RESULTS Within the study time frame, 257 patients were included in the multivariate Cox proportional hazards regression analysis. There was no significant difference in the time to DKA resolution between the IVB (p = 0.603) or IVNB (p = 0.269) groups compared with the population who received SQ insulin only. Hospital LOS was significantly longer when comparing the SQ group with the IVNB group (p < 0.001), but not when comparing it with the IVB group (p = 0.259). The IV protocols had significantly more hypoglycemic events compared with the SQ protocol (IVB vs. SQ, p < 0.001; IVNB vs. SQ, p = 0.001). CONCLUSIONS SQ insulin may be an effective alternative option for treating mild to moderate DKA with fewer hypoglycemic effects.
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Affiliation(s)
| | | | | | | | | | - Curtis Meek
- Intermountain Healthcare System, Salt Lake City, Utah
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17
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Ata F, Khan AA, Khamees I, Bashir M. Incidence of diabetic ketoacidosis does not differ in Ramadan compared to other months and seasons: results from a 6-year multicenter study. Curr Med Res Opin 2023; 39:1061-1067. [PMID: 37522377 DOI: 10.1080/03007995.2023.2231306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/17/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a life-threatening adverse complication of patients with diabetes mellitus (DM). It is postulated that fasting during Ramadan can increase the risk of DKA; however, there are contradicting data in this regard. Furthermore, studies from Western countries have suggested a seasonal variation in the incidence of DKA. This study examines the differences in the number of DKA episodes during Ramadan compared to the rest of the year in patients with type 1 DM (T1D) and type 2 DM (T2D). Besides, we aim to examine the seasonal difference in the incidence of DKA. METHODS We included consecutive index-DKA admissions from 2015 to 2021 and used descriptive statistics to compare the episodes of DKA in Ramadan vs other months and seasons. RESULTS Of 922 patients, 480 (52%) had T1D, whereas 442 (48%) had T2D. The median age (IQR) was 35 (25-45) years, with the majority being Arab (N = 502, 54.4%). There were 94 DKA admissions in six collective Ramadan months, whereas the DKA admissions ranged from 61 to 88 episodes in other months (p = .3). The highest DKA admissions were observed in Autumn (N = 236) and the lowest in Spring (N = 226) with no statistically significant difference (p = .4). There were no differences in DKA severity or new-onset diabetes rates when analyzed based on Hiji months, Roman months, or seasons. CONCLUSIONS DKA occurrence is not increased during Ramadan. We found no evidence of seasonal variations in the rates of DKA in the State of Qatar.
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Affiliation(s)
- Fateen Ata
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Adeel Ahmad Khan
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Khamees
- Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Bashir
- Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar
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Robertson C, Dunn T. "A ghost doesn't need insulin," Cotard's delusion leading to diabetic ketoacidosis and a body-mass index of 15: a case presentation. BMC Psychiatry 2023; 23:551. [PMID: 37525179 PMCID: PMC10391858 DOI: 10.1186/s12888-023-05039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 07/20/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Cotard's Syndrome (CS) is a rare clinical entity where patients can report nihilistic, delusional beliefs that they are already dead. Curiously, while weight loss, dehydration, and metabolic derangements have been described as discussed above, a review of the literature revealed neither a single case of a severely underweight patient nor a serious metabolic complication such as Diabetic Ketoacidosis. Further, a search on PubMed revealed no articles discussing the co-occurrence of Cotard's Delusion and eating disorders or comorbid metabolic illnesses such as diabetes mellitus. In order to better examine the association between Cotard's Delusion and comorbid eating disorders and metabolic illness, we will present and discuss a case where Cotard's delusion led to a severe metabolic outcome of DKA and a BMI of 15. CASE PRESENTATION Mr. B is a 19 year old transgender man admitted to the hospital due to diabetic ketoacidosis secondary to Type 1 Diabetes Mellitus. Mr. B had a history of Obsessive-Compulsive Disorder, Major Depressive Disorder, and Post-Traumatic Stress Disorder. The primary pediatric team discovered that Mr. B had not been using his insulin appropriately and was severely underweight, and they believed this could be due to his underlying mental illness. The psychiatric consultation/liaison service found that Mr. B was suffering from Cotard's delusion leading him to be noncompliant with his insulin due to a belief that he was already dead. Cotard's delusion had in this case led to a severe metabolic outcome of DKA and a BMI of 15. CONCLUSIONS This case provides clinical insight into the interactions of eating disorders and Cotard's delusion as well as the potential medical complications when Cotard's delusion is co-morbid with medical conditions such as Diabetes Mellitus. We recommend that clinicians routinely screen patients for Cotard's delusion and assess whether the presence of which could exacerbate any underlying medical illness. This includes clinicians taking special care in assessing patient's caloric and fluid intake as well as their adherence to medications both psychiatric and medical. Further research could be conducted to explore the potential overlap of Cotard's delusion and eating disorder phenomenology.
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Affiliation(s)
| | - Thomas Dunn
- Behavioral Health - Adolescent Outpatient, Denver Health, 723 Delaware St., Pavilion M, Denver, CO, 80204, USA
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Barth KE, Spottiswoode N, Hurabielle C, Subbaraj L, Calfee CS, Matthay MA, French S, Connolly A, Hewitt SM, Vannella KM, Barnett C, Langelier CR, Patterson S. Clinical and biological heterogeneity of multisystem inflammatory syndrome in adults following SARS-CoV-2 infection: a case series. Front Med (Lausanne) 2023; 10:1187420. [PMID: 37484839 PMCID: PMC10357379 DOI: 10.3389/fmed.2023.1187420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Importance Multisystem inflammatory syndrome in adults (MIS-A) is a poorly understood complication of SARS-CoV-2 infection with significant morbidity and mortality. Objective Identify clinical, immunological, and histopathologic features of MIS-A to improve understanding of the pathophysiology and approach to treatment. Design Three cases of MIS-A following SARS-CoV-2 infection were clinically identified between October 2021 - March 2022 using the U.S. Centers for Disease Control and Prevention diagnostic criteria. Clinical, laboratory, imaging, and tissue data were assessed. Findings All three patients developed acute onset cardiogenic shock and demonstrated elevated inflammatory biomarkers at the time of hospital admission that resolved over time. One case co-occurred with new onset Type 1 diabetes and sepsis. Retrospective analysis of myocardial tissue from one case identified SARS-CoV-2 RNA. All three patients fully recovered with standard of care interventions plus immunomodulatory therapy that included intravenous immunoglobulin, corticosteroids, and in two cases, anakinra. Conclusion MIS-A is a severe post-acute sequela of COVID-19 characterized by systemic elevation of inflammatory biomarkers. In this series of three cases, we find that although clinical courses and co-existent diseases vary, even severe presentations have potential for full recovery with prompt recognition and treatment. In addition to cardiogenic shock, glucose intolerance, unmasking of autoimmune disease, and sepsis can be features of MIS-A, and SARS-CoV-2 myocarditis can lead to a similar clinical syndrome.
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Affiliation(s)
- Kaia E. Barth
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Natasha Spottiswoode
- Division of Infectious Diseases, University of California, San Francisco, San Francisco, CA, United States
| | - Charlotte Hurabielle
- Division of Rheumatology, University of California, San Francisco, San Francisco, CA, United States
| | - Lakshmi Subbaraj
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | | | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Michael A. Matthay
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Sarah French
- Division of Rheumatology, University of California, San Francisco, San Francisco, CA, United States
| | - Andrew Connolly
- Department of Pathology, University of California, San Francisco, San Francisco, CA, United States
| | - Stephen M. Hewitt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Kevin M. Vannella
- Emerging Pathogens Section, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
- Laboratory of Virology, National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States
| | - Christopher Barnett
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States
| | - Charles R. Langelier
- Division of Infectious Diseases, University of California, San Francisco, San Francisco, CA, United States
- Chan Zuckerberg Biohub, San Francisco, CA, United States
| | - Sarah Patterson
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- Division of Rheumatology, University of California, San Francisco, San Francisco, CA, United States
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Sharma PP, Ramirez-Berlioz AM, Weisz AD. Diabetic Ketoacidosis in a Patient With Type I Diabetes Treated With a Closed-Loop Sensor-Augmented Insulin Infusion System. AACE Clin Case Rep 2023; 9:116-121. [PMID: 37520760 PMCID: PMC10382613 DOI: 10.1016/j.aace.2023.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 08/01/2023] Open
Abstract
Background/Objective Closed-loop insulin infusion systems (CLSs) such as Tandem t:slim with Control-IQ (t:slim CIQ) improve glycemic control and decrease diabetic ketoacidosis (DKA) risk in type 1 diabetes mellitus (T1DM). We report a case of CLS failure, likely from tirzepatide-induced volume depletion, leading to DKA. Case Report A 36-year-old woman with T1DM on t:slim CIQ CLS was prescribed tirzepatide for weight loss. Three months later, 4 days after the last tirzepatide injection, she presented with worsening nausea, vomiting, 50-lbs weight loss, minimal oral intake for 3 days, and positive urine ketone result. Her heart rate was 137 beats/min and respiratory rate was 35 breaths/min, and she had Kussmaul breathing, with dry oral mucosa indicating volume depletion. Laboratory examination showed a fingerstick glucose level of 289 mg/dL, serum glucose level of 322 mg/dL, bicarbonate level of 12 mmol/L, and anion gap of 21 mmol/L confirming high-anion-gap metabolic acidosis, suggesting DKA. A concurrent continuous glucose monitor (CGM) reading was 40 mg/dL. The CLS and CGM were removed. DKA resolved within 72 hours (serum glucose level of 143 mg/dL, anion gap of 8 mmol/L, bicarbonate level of 24 mmol/L) on intravenous insulin and fluids. The CLS and CGM were restarted with good glycemic control. Tirzepatide was discontinued to avoid future episodes of volume depletion. Discussion Volume depletion affects interstitial fluid glucose levels due to compensatory mechanisms. This may result in CLS failure due to CGM dependence on interstitial glucose measurements, precipitating DKA. Conclusion Patients on CLS therapy should be cautioned against CLS failure in volume-depleted states with interstitial glucose-level changes. A back-up plan with multiple daily insulin injections should be discussed.
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Haas NL, Sell J, Cranford JA, Korley FK, Bassin BS. The Two-Bag Method for Management of Adult Diabetic Ketoacidosis-Experience With 634 Patients. J Intensive Care Med 2023:8850666231175387. [PMID: 37170641 DOI: 10.1177/08850666231175387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method. MATERIALS AND METHODS This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t-tests for continuous variables and χ2 tests for binary variables. RESULTS We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P = .16. CONCLUSIONS For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.
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Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Jordan Sell
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
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Abstract
The discovery of the lactate shuttle (LS) mechanism may have two opposite perceptions, It may mean very little, because the body normally and inexorably uses the LS mechanism. On the contrary, one may support the viewpoint that understanding the LS mechanism offers immense opportunities for understanding nutrition and metabolism in general, as well as in a sports nutrition supplementation setting. In fact, regardless of the specific form of the carbohydrate (CHO) nutrient taken, the bodily CHO energy flux is from a hexose sugar glucose or glucose polymer (glycogen and starches) to lactate with subsequent somatic tissue oxidation or storage as liver glycogen. In fact, because oxygen and lactate flow together through the circulation to sites of utilization, the bodily carbon energy flow is essentially the lactate disposal rate. Consequently, one can consume glucose or glucose polymers in various forms (glycogen, maltodextrin, potato, corn starch, and fructose or high-fructose corn syrup), and the intestinal wall, liver, integument, and active and inactive muscles make lactate which is the chief energy fuel for red skeletal muscle, heart, brain, erythrocytes, and kidneys. Therefore, if one wants to hasten the delivery of CHO energy delivery, instead of providing CHO foods, supplementation with lactate nutrient compounds can augment body energy flow.
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Affiliation(s)
- George A Brooks
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA 94720, USA
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Tian Y, Hu W, Yan Q, Feng B. Benefit or Risk in Patient with Type 1 Diabetes Based on Appropriated Dosage of Dapagliflozin: A Case Report. Medicina (Kaunas) 2023; 59:medicina59050827. [PMID: 37241059 DOI: 10.3390/medicina59050827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023]
Abstract
Purpose: Dapagliflozin has been used extensively in patients with type 2 diabetes mellitus (T2DM). However, due to the potential diabetic ketoacidosis (DKA) risk of dapagliflozin, its use in type 1 diabetes mellitus (T1DM) is limited. Here, we reported an obese patient with T1DM and inadequate glycemic control. We carefully recommended she use dapagliflozin as an insulin adjuvant to achieve better glycemia control and to assess possible benefits and risks. Methods and Results: The patient was a 27-year-old female who had underlying T1DM for 17 years with a body weight of 75.0 kg, body mass index (BMI) of 28.2 kg/m2, and glycated hemoglobin (HbA1c) 7.7% when admitted. To treat her diabetes, she had used an insulin pump for 15 years (the recent dosage of insulin was 45 IU/d) and oral metformin for 3 years (0.5 g qid). In order to decrease body weight and achieve better glycemic control, dapagliflozin (FORXIGA, AstraZeneca, Indiana) was administered as an insulin adjuvant. The patient presented sever DKA with a euglycemia (euDKA) after two days of the administration of dapagliflozin at a dose of 10 mg/d. euDKA occurred again after the administration of dapagliflozin at a dose of 3.3 mg/d. However, after using a smaller dose of dapagliflozin (1.5 mg/d), this patient achieved better glycemia control, with a significant reduction in daily insulin dosage and gradual weight loss, without significant hypoglycemia or DKA occurring. At the sixth month of the administration of dapagliflozin, the HbA1c was 6.2% for the patient, her daily insulin dosage was 22.5 IU, and her body weight was 60.2 kg. Conclusions: The appropriate dose of dapagliflozin is critical for a patient with T1DM patient therapy in order to find a correct balance between the benefits and risks.
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Affiliation(s)
- Yan Tian
- Department of Endocrinology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200120, China
| | - Weiting Hu
- Department of Endocrinology, The Second Hospital of Shanxi Medical University, Shanxi Medical University, Taiyuan 030002, China
| | - Qun Yan
- Department of Endocrinology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200120, China
| | - Bo Feng
- Department of Endocrinology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai 200120, China
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24
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Stamatiades GA, Galbiati F, Fitzgerald AC, McDonnell ME, Lassey SC, Palermo NE. Diabetes Mellitus Type 1 Presenting in the Setting of Diabetic Ketoacidosis and Acute SARS-CoV-2 Infection in Pregnancy. AACE Clin Case Rep 2023; 9:S2376-0605(23)00091-3. [PMID: 37363439 PMCID: PMC10102535 DOI: 10.1016/j.aace.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/10/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023] Open
Abstract
Background/Objective Diabetic ketoacidosis (DKA) during pregnancy is an obstetric emergency associated with a higher rate of maternofetal morbidity and mortality. Pregnancy itself is a ketosis-prone state and several unique mechanisms predispose to the development of insulin resistance, which can be further exacerbated by acute stressors such as infection. Thus, pregnant patients who additionally contract COVID-19 may be at an even higher risk of development of DKA. Case Report A 32-year-old patient, with no prior history of impaired glucose tolerance, presented at 27 weeks of gestation with a 3-day history of shortness of breath, congestion, loss of taste and smell, polyuria, and polydipsia. Biochemical evaluation was consistent with DKA. Subsequently, she was diagnosed with acute SARS-CoV-2 infection. Treatment included intravenous hydration, electrolyte replacement, and insulin infusion. Postpartum phenotypic evaluation confirmed autoimmune diabetes (positive GAD-65 and zinc T8 antibodies) with residual β-cell function. Six months postpartum, glycemic control remains at goal with basal- bolus insulin regimen. Discussion This case describes the peculiar ability of SARS-CoV-2 infection to potentially rouse autoimmunity and how COVID-19 and DKA in pregnancy can be particularly challenging given the risk of significant maternal and fetal morbidity and mortality. Conclusion Prompt diagnosis and evaluation of DKA in pregnancy as well as a higher level of suspicion is needed in the setting of SARS-CoV-2 infection. Additionally, this case depicts the need for closely monitoring the postpartum period for patients at risk of autoimmune disease, which may have been blunted in pregnancy.
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Affiliation(s)
- George A Stamatiades
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Francesca Galbiati
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah C Lassey
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Aly HH, De Franco E, Flanagan SE, Elhenawy YI. MNX1 mutations causing neonatal diabetes: Review of the literature and report of a case with extra-pancreatic congenital defects presenting in severe diabetic ketoacidosis. J Diabetes Investig 2023; 14:516-521. [PMID: 36586106 PMCID: PMC10034954 DOI: 10.1111/jdi.13968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/21/2022] [Accepted: 12/12/2022] [Indexed: 01/01/2023] Open
Abstract
The MNX1 gene encodes a homeobox transcription factor found to be important for pancreatic beta cell differentiation and development. Mutations of the MNX1 gene that cause permanent neonatal diabetes mellitus (PNDM) are rare and have been reported in only two cases. Both cases presented with hyperglycemia, with one case having isolated PNDM while the other had PNDM and multiple neurologic, skeletal, lung, and urologic congenital anomalies resulting in death in early infancy. We describe the genetic and clinical features of a preterm male infant with a homozygous [c.816C > A p.(Phe272Leu)] MNX1 mutation. Our proband is the first case to present in severe diabetic ketoacidosis (DKA), indicating severe insulin deficiency. Unlike the previously reported female case who had the same mutation and presented with isolated PNDM, our proband had hypospadias and congenital umbilical hernia and showed poor growth on follow up. Our case suggests that MNX1 mutations causing NDM can result in a range of extra-pancreatic features and a variable phenotype, similar to other transcription factors causing NDM such as GATA6 and GATA4 mutations. We also cannot exclude the possibility of sex-biased expression of MNX1 gene (which was recently reported for other monogenic/neonatal diabetes genes such as the NEUROD1 and HNF4A in humans) since the two male cases had associated multiple anomalies while the female case had isolated PNDM. Our report further defines the phenotype caused by recessive homozygous MNX1 mutations and explores potential new mechanisms regulating MNX1 gene expression which should be further explored.
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Affiliation(s)
- Hanan Hassan Aly
- Department of Pediatrics, Division of Pediatric Diabetology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Elisa De Franco
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Yasmine I Elhenawy
- Department of Pediatrics, Division of Pediatric Diabetology, Ain Shams University Faculty of Medicine, Cairo, Egypt
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26
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Bak LB. Diabetic Ketoacidosis Related to Hypertriglyceridemia-Induced Pancreatitis: A Case Report. AACN Adv Crit Care 2023; 34:33-38. [PMID: 36877651 DOI: 10.4037/aacnacc2023337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Both diabetic ketoacidosis and acute pancreatitis can result in critical illness. Although not the most common cause of acute pancreatitis, hypertriglyceridemia can account for up to 10% of cases. One source of hypertriglyceridemia is unrecognized diabetes and resultant hyperglycemia. Identifying the underlying cause of acute pancreatitis can guide the most appropriate therapy to resolve this critical illness. This case report addresses the use of insulin infusions to treat hypertriglyceridemia-induced pancreatitis in the setting of concomitant diabetic ketoacidosis.
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Affiliation(s)
- Leigh B Bak
- Leigh B. Bak is Diabetes Clinical Nurse Specialist, Yale New Haven Hospital, 1450 Chapel St, New Haven, CT 06511
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27
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Gal A, Odunayo A. Diabetes Ketoacidosis and Hyperosmolar Hyperglycemic Syndrome in Companion Animals. Vet Clin North Am Small Anim Pract 2023; 53:531-550. [PMID: 36898859 DOI: 10.1016/j.cvsm.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Diabetes mellitus is a common endocrinopathy in dogs and cats. Diabetes ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening complications of diabetes resulting from an imbalance between insulin and the glucose counter-regulatory hormones. The first part of this review focuses on the pathophysiology of DKA and HHS, and rarer complications such as euglycemic DKA and hyperosmolar DKA. The second part of this review focuses on the diagnosis and treatment of these complications.
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Affiliation(s)
- Arnon Gal
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, 1008 West Hazelwood Drive, Urbana, IL 61820, USA.
| | - Adesola Odunayo
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, 2015 Southwest 16th Avenue, Gainesville, FL 32608, USA
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Faruqi J, Balasubramanyam A. COVID-19 and diabetes mellitus: a review of the incidence, pathophysiology and management of diabetes during the pandemic. Expert Rev Endocrinol Metab 2023; 18:167-179. [PMID: 36797835 DOI: 10.1080/17446651.2023.2176300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has changed the landscape of modern medicine on a global scale. An emerging concern is the recognition of a bidirectional relationship between COVID-19 and diabetes. Diabetes is a risk factor for severe COVID-19 illness. Intriguingly, recent epidemiological and in vitro studies suggest that infection with SARS-CoV-2, the causative viral agent of COVID-19, is associated with new-onset diabetes and worsening diabetes control. These factors have affected the management of diabetes. AREAS COVERED This review provides an overview of our current understanding of the incidence and prevalence of diabetes in relation to the COVID-19 pandemic, highlights studies evaluating SARS-CoV-2's beta cell tropism and its effects on insulin secretion and sensitivity and evaluates the impact of the pandemic on diabetes management and metabolic control. EXPERT OPINION Epidemiological studies have noted an increase in the incidence of new-onset diabetes associated with COVID-19 in patients with phenotypes of type 1 diabetes, type 2 diabetes and Ketosis-Prone Diabetes. Prospective studies are needed to fully elucidate the association between COVID-19 and diabetes and to characterize persons at risk of developing diabetes after SARS-CoV-2 infection, identify those who should be screened for diabetes, and determine the natural histories of different forms of diabetes associated with COVID-19.
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Affiliation(s)
- Jordana Faruqi
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
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29
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Dam P, Cardoso MH, Mandal S, Franco OL, Sağıroğlu P, Polat OA, Kokoglu K, Mondal R, Mandal AK, Ocsoy I. Surge of mucormycosis during the COVID-19 pandemic. Travel Med Infect Dis 2023; 52:102557. [PMID: 36805033 PMCID: PMC9940844 DOI: 10.1016/j.tmaid.2023.102557] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/07/2022] [Accepted: 02/15/2023] [Indexed: 02/22/2023]
Abstract
Patients with respiratory viral infections are more likely to develop co-infections leading to increased fatality. Mucormycosis is an epidemic amidst the COVID-19 pandemic that conveys a 'double threat' to the global health fraternity. Mucormycosis is caused by the Mucorales group of fungi and exhibits acute angioinvasion generally in immunocompromised patients. The most familiar foci of infections are sinuses (39%), lungs (24%), and skin tissues (19%) where the overall dissemination occurs in 23% of cases. The mortality rate in the case of disseminated mucormycosis is found to be 96%. Symptoms are mostly nonspecific and often resemble other common bacterial or fungal infections. Currently, COVID-19-associated mucormycosis (CAM) is being reported from a number of countries such as the USA, Turkey, France, Mexico, Iran, Austria, UK, Brazil, and Italy, while India is the hotspot for this deadly co-infection, accounting for approximately 28,252 cases up to June 8, 2021. It strikes patients within 12-18 days after COVID-19 recovery, and nearly 80% require surgery. Nevertheless, the mortality rate can reach 94% if the diagnosis is delayed or remains untreated. Sometimes COVID-19 is the sole predisposing factor for CAM. Therefore, this study may provide a comprehensive resource for clinicians and researchers dealing with fungal infections, intending to link the potential translational knowledge and prospective therapeutic challenges to counter this opportunistic pathogen.
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Affiliation(s)
- Paulami Dam
- Chemical Biology Laboratory, Department of Sericulture, Raiganj University, North Dinajpur, West Bengal, 733134, India
| | - Marlon H Cardoso
- S-inova Biotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, Campo Grande, Brazil; Centro de Análises Proteômicas e Bioquímicas, Programa de Pós-Graduação em Ciências Genômicas e Biotecnologia, Universidade Católica de Brasília, Brasília, Brazil; Instituto de Biociências (INBIO), Universidade Federal de Mato Grosso do Sul, Cidade Universitária, Campo Grande, Mato Grosso do Sul, Brazil
| | - Sukhendu Mandal
- Laboratory of Molecular Bacteriology, Department of Microbiology, University of Calcutta, 700019, India
| | - Octávio L Franco
- S-inova Biotech, Programa de Pós-Graduação em Biotecnologia, Universidade Católica Dom Bosco, Campo Grande, Brazil; Centro de Análises Proteômicas e Bioquímicas, Programa de Pós-Graduação em Ciências Genômicas e Biotecnologia, Universidade Católica de Brasília, Brasília, Brazil
| | - Pınar Sağıroğlu
- Department of Medical Microbiology, School of Medicine, Erciyes University, Kayseri, Turkey
| | | | - Kerem Kokoglu
- Department of Otolaryngology, Erciyes University School of Medicine, Kayseri, Turkey
| | - Rittick Mondal
- Chemical Biology Laboratory, Department of Sericulture, Raiganj University, North Dinajpur, West Bengal, 733134, India
| | - Amit Kumar Mandal
- Chemical Biology Laboratory, Department of Sericulture, Raiganj University, North Dinajpur, West Bengal, 733134, India; Centre for Nanotechnology Science (CeNS), Raiganj University, North Dinajpur, West Bengal, 733134, India.
| | - Ismail Ocsoy
- Department of Analytical Chemistry, Faculty of Pharmacy, Erciyes University, Kayseri, 38039, Turkey.
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30
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Alsakarneh S, Jaber F, Mittal A, Abughazaleh S, Abboud Y, Campbell J. Acute Esophageal Necrosis or Black Esophagus in the Setting of Diabetic Ketoacidosis. J Investig Med High Impact Case Rep 2023; 11:23247096231217852. [PMID: 38097376 PMCID: PMC10725137 DOI: 10.1177/23247096231217852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/15/2023] [Accepted: 11/12/2023] [Indexed: 12/18/2023] Open
Abstract
Acute esophageal necrosis (AEN) or black esophagus is a rare cause of mortality in patients with gastrointestinal bleeding. We present a case of a 54-year-old female who presented with diabetic ketoacidosis (DKA) and developed melena eventually attributed to AEN. The esophagogastroduodenoscopy (EGD) identified severe inflammation with black discoloration consistent with acute esophageal necrosis in the middle and lower esophagus. The patient was managed with intravenous pantoprazole and total parenteral nutrition (TPN) until she was able to tolerate an adequate diet. Black esophagus should be added to the differential diagnosis of patients with DKA who develop gastrointestinal bleeding. This need is stressed by the fact that early treatment is essential to reducing complications and mortality associated with the condition.
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Affiliation(s)
- Saqr Alsakarneh
- University of Missouri–Kansas City School of Medicine, Kansas City, MO, USA
| | - Fouad Jaber
- University of Missouri–Kansas City School of Medicine, Kansas City, MO, USA
| | - Anika Mittal
- University of Missouri–Kansas City School of Medicine, Kansas City, MO, USA
| | | | | | - John Campbell
- University of Missouri–Kansas City School of Medicine, Kansas City, MO, USA
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31
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Namatame K, Igarashi Y, Nakae R, Suzuki G, Shiota K, Miyake N, Ishii H, Yokobori S. Cerebral edema associated with diabetic ketoacidosis: Two case reports. Acute Med Surg 2023; 10:e860. [PMID: 37346084 PMCID: PMC10280603 DOI: 10.1002/ams2.860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/15/2023] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
Background Diabetic ketoacidosis (DKA) is associated with a high mortality rate, especially if cerebral edema develops during the disease course. It is rarer and more severe in adults than in children. We present cases of two patients with cerebral edema-related DKA. Case presentation The first patient was a 38-year-old man with diabetes mellitus who presented with DKA-related disturbed consciousness. Although glycemic correction was performed slowly, he showed pupil dilation 11 h later. He underwent emergency ventricular drainage, but died of cerebral herniation. The second patient was a 25-year-old woman who presented with impaired consciousness secondary to DKA. Head computed tomography showed subarachnoid hemorrhage and cerebral edema. No related intraoperative findings were observed; it was concluded that the first computed tomography scan revealed pseudo-subarachnoid hemorrhage. Conclusion Diabetic ketoacidosis-related cerebral edema develops despite treatment according to guidelines and is difficult to predict. Therefore, adult patients should be treated cautiously during DKA management.
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Affiliation(s)
- Kaoru Namatame
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Ryuta Nakae
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Go Suzuki
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
- Department of Emergency and Critical Care MedicineKawaguchi Municipal Medical CenterSaitamaJapan
| | - Kohei Shiota
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Nodoka Miyake
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Hirotomo Ishii
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Shoji Yokobori
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
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32
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Fadeyi O, Katamreddy Y, Dang V, Topacio A. Devastating Effects of Combined DKA and Acute Pancreatitis in Select Patients: Two Cases. J Investig Med High Impact Case Rep 2023; 11:23247096231165734. [PMID: 37039385 PMCID: PMC10107958 DOI: 10.1177/23247096231165734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Most cases of acute pancreatitis are routinely managed in the hospital without complications. However, management could become very complicated when patients present with a combination of acute pancreatitis and diabetic ketoacidosis (DKA). In fact, triad of acute pancreatitis, DKA, and hypertriglyceridemia in patients could result into systemic complications which may lead to fatal consequences. We report 2 cases in which patients presented with acute pancreatitis and DKA. Clinical course was complicated for both cases. While one of the patients expired, the other patient could not be extubated. This combination must be avoided at all costs because the clinical outcome for affected patients is difficult to predict.
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Wayne Lewis C, Butorin Y, de Koning L, Paul HA, Gifford JL, Venner AA, Seiden-Long I. Low partial pressure of oxygen causes significant and unrecognized under-recovery of glucose on blood gas analyzers. Clin Biochem 2023; 111:60-65. [PMID: 36279904 DOI: 10.1016/j.clinbiochem.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/06/2022] [Accepted: 10/11/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Blood gas analyzers employing glucose-oxidase biosensors under-recover glucose when pO2 is low. The manufacturer of the GEM®Premier™ series of analyzers introduced an algorithm to detect specimens at risk of low pO2 interference. We investigated the reliability of this algorithm. METHODS Whole blood specimens were tested by GEM®Premier™ 4000 (GEM 4000) and 5000 (GEM 5000). Specimens with an incalculable ("incalc") error code for glucose result or that had a glucose ≥ 20 mmol/L were retested on a second analyzer of the same type within 5 min over the course of 30 months in 5 hospitals in Calgary, Alberta. Discordant retests were defined as either: 1) paired numeric results with a difference >10 %, or 2) an "incalc" code that yielded a numeric result upon retesting. Glucose recovery in relation to pO2 level was assessed by comparing specimens experimentally depleted of pO2 between GEM 5000 and a laboratory analyzer (Siemens Vista®). RESULTS Of 1,776 glucose tests repeated on the GEM 5000 or 1,544 on GEM 4000, 10% were discordant. GEM 5000 produced twice as many discordant numeric retests versus the GEM 4000 [5.9% (98/1,651) vs 2.7% (38/1,391)]. The majority of "incalc" error codes repeated with a numeric glucose result on both GEM analyzers [(79.7% (122/153) vs 75.2% (94/125)]. Among specimens experimentally depleted of pO2, the GEM 5000 under-recovered glucose by up to 30% compared to the Siemens Vista and were not flagged by an "incalc" code. CONCLUSIONS The algorithm in the GEM®PremierTM series of analyzers that flags specimens at risk for glucose under-recovery due to low pO2 does not reliably detect specimens at risk for glucose under-recovery.
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Affiliation(s)
- Cody Wayne Lewis
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Yury Butorin
- Alberta Precision Laboratories, Red Deer, Alberta, Canada
| | - Lawrence de Koning
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Heather A Paul
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jessica L Gifford
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Allison A Venner
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Isolde Seiden-Long
- Alberta Precision Laboratories, Calgary, Alberta, Canada; Department of Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
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Mastromauro C, Polidori N, Blasetti A, Comegna L, Chiarelli F, Mohn A, Giannini C. Insulin resistance relates to DKA severity and affects insulin requirement in children with type 1 diabetes at onset. Pediatr Diabetes 2022; 23:1613-1620. [PMID: 36183171 PMCID: PMC10092633 DOI: 10.1111/pedi.13424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/09/2022] [Accepted: 09/27/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fluid and insulin treatments are the cornerstones of DKA management and indications on dosages are available. However, according to possible confounding factors, relevant data are still required to explain the different insulin dosages adopted at diabetes onset, particularly based upon insulin sensitivity. OBJECTIVE We aimed to explore whether DKA severity is related to different insulin sensitivity states, thus resulting in different insulin requirement at diabetes onset. METHODS Retrospective data from hospital records of 62 newly diagnosed children with type 1 diabetes with DKA were analyzed. The population was divided into three groups: severe, moderate, and mild DKA. Anthropometric, laboratory test, insulin, and glucose administration data were analyzed. The Glucose Infusion Rate (GIR), Insulin Infusion Rate (IIR), and GIR/IIR were calculated and used as indexes of insulin sensitivity. The area under the curve (AUC) for insulin and glucose infusion was calculated. RESULTS Moving among the three groups, IIR decreased while GIR and GIR/IIR increased from severe to mild DKA group (all p < 0.01). A similar trend was documented for AUC-insulin and AUC-glucose as well as AUC-glucose/AUC-insulin ratio. The Spearman correlation showed a negative correlation between pH and both IIR and AUC-Insulin as well as a positive correlation between pH and both GIR/IIR and AUC-glucose/AUC-insulin ratio. CONCLUSIONS Subjects with severe DKA have a higher insulin requirement compared to those with less severe DKA. Significant differences in terms of insulin sensitivity might be documented according to the severity of DKA, which might result in tailored insulin pH requirement in children with new onset type 1 diabetes.
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Affiliation(s)
| | - Nella Polidori
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | | | - Laura Comegna
- Department of Pediatrics, University of Chieti, Chieti, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
| | - Angelika Mohn
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
| | - Cosimo Giannini
- Department of Pediatrics, University of Chieti, Chieti, Italy.,Center for Advanced Studies and Technology - CAST (ex CesSI-MeT), University of Chieti, Chieti, Italy
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Chaudhry A, Roels C, Lee J. Sodium-Glucose Cotransporter-2 Inhibitor-associated Euglycemic Diabetic Ketoacidosis: Lessons From a Case Series of 4 Patients Undergoing Coronary Artery Bypass Grafting Surgery. Can J Diabetes 2022; 46:843-850. [PMID: 36068154 DOI: 10.1016/j.jcjd.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/06/2022] [Accepted: 06/15/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Euglycemic diabetic ketoacidosis (DKA) is a potentially life-threatening adverse condition associated with use of sodium-glucose cotransporter-2 inhibitors (SGLT2i). This risk is further pronounced in the perioperative period. There is no consensus for when SGLT2i should be held preoperatively, and recommendations from various organizations have evolved from 1 day to 3 to 4 days in the latest American Diabetes Association guidelines. Further study of patients with perioperative euglycemic DKA is required to help clarify the optimal timing of preoperative discontinuation of SGLT2i agents. METHODS In this retrospective, single-centre case series we examined 4 patients who developed postoperative euglycemic DKA after coronary artery bypass grafting, 3 of whom underwent semiurgent surgery. We characterized their clinical course, predisposing factors and treatment characteristics. RESULTS The SGLT2i were held for 1 to 5 days preoperatively, with times since last dose before surgery being 54, 79, 80 and 151 hours. Surgery was semiurgent for 3 patients, and elective for 1 patient. Three patients were diagnosed with euglycemic DKA within 24 hours after surgery. The fourth patient developed euglycemic DKA on postoperative day 3 in the context of significant hypovolemia and exhibited potential signs of protracted SGLT2i action at 7 days since the last dose. CONCLUSIONS The duration of SGLT2i action and risk for DKA is variable and complex. Providers should hold SGLT2i at least 3 days before elective major surgery, with potentially longer times in high-risk patients. Careful vigilance should be used for perioperative DKA development in all patients recently exposed to SGLT2i.
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Affiliation(s)
- Ahsen Chaudhry
- Division of Endocrinology, Department of Medicine, University of British Columbia, Burnaby, British Columbia, Canada.
| | - Craig Roels
- Lower Mainland Pharmacy Services, Fraser Health Authority, New Westminster, British Columbia, Canada
| | - Julie Lee
- Division of Endocrinology, Department of Medicine, University of British Columbia, Burnaby, British Columbia, Canada
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Hurissi E, Alameer M, Ageeli F, Allami M, Alharbi M, Suhail H, Albeishy H, Oraibi O, Somaili M, Hummadi A, Alhazmi AH. The Association between SARS-CoV-2 Infection and Diabetic Ketoacidosis in Patients with New-Onset Diabetes: A Retrospective Study from a Diabetic Center in Saudi Arabia. Pediatr Rep 2022; 14:519-27. [PMID: 36548203 DOI: 10.3390/pediatric14040060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Various reports described new-onset diabetes during or after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in patients with no previous history of diabetes or glucocorticoid use. Further, SARS-CoV-2 could increase the risk of diabetes, including diabetic ketoacidosis (DKA). However, data on the relationship between new-onset diabetes and COVID-19 are still limited in our region. Thus, we aimed in this study to evaluate the association between new-onset diabetes and DKA in patients with COVID-19. METHODS A retrospective, cross-sectional study was conducted at a diabetic center in Jazan province, Saudi Arabia, between 2020 and 2021. Demographic data, COVID-19 status, and DKA incidence were collected and verified manually from diabetic patients' medical records. Data were analyzed using a t-test and chi-square test. RESULTS We included 54 diabetic patients diagnosed during the COVID-19 pandemic, with a median age of 17 years. The majority of patients were females (57.4%). About 38.8% were diagnosed with COVID-19, and 16.6% reported having DKA. About 33.3% of the patients who experienced DKA reported being COVID-19-positive. However, only 6% of patients who denied contracting SARS-CoV-2 developed DKA (p-value = 0.020). CONCLUSIONS Patients with newly diagnosed diabetes due to COVID-19 seem at a higher risk of developing DKA. Further epidemiological and molecular studies are required for a better understanding of the correlation between DKA in patients with diabetes and COVID-19.
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Abstract
BACKGROUND Use of real-time continuous glucose monitoring (rtCGM) in ambulatory settings improves overall glycemic control and reduces the incidence of diabetic ketoacidosis (DKA) in adults and children/adolescents with type 1 diabetes (T1D). However, the use of rtCGM in children with DKA has not been well studied. METHOD This prospective, single-arm, single-center study assessed the accuracy, reliability, and feasibility of a commercially available rtCGM device compared with point-of-care (POC) capillary and serum glucose values in pediatric patients admitted to the pediatric intensive care unit for DKA. The primary outcome was the accuracy of rtCGM glucose values compared with POC capillary and serum glucose values during standard treatment of DKA as assessed by Clarke Error Grid (CEG) analysis. Secondary outcomes were assessment of the relationship between rtCGM readings and degree of acidosis and mean length of hospital stay (LOS). RESULTS Data from 35 hospitalized children (mean ± SD age, 11.9 ± 4.1 years) with DKA were included in our analysis. Five hundred twenty-four time-matched glucose values between serum glucose and rtCGM and 91 time-matched glucose values between POC capillary glucose and rtCGM were obtained. The effect of acidosis on accuracy CEG analysis showed 95.4% of the 524 matched CGM/POC pairs and 95.6% of the 91 matched CGM/serum glucose pairs in the clinically acceptable A + B zones. The average LOS was 1.32 ± 0.73 days. Serum bicarbonate level did not appear to affect the accuracy of rtCGM in the setting of DKA. CONCLUSIONS Continuous glucose monitoring use in inpatient pediatric DKA treatment was found to be feasible and reliable.
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Affiliation(s)
- Thomas Pott
- Division of Pediatric Critical Care, Helen DeVos Children's Hospital, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Nemours Children's Hospital, Orlando, FL, USA
| | - Jose Jimenez-Vega
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
- Division of Endocrinology, Helen DeVos Children's Hospital, Spectrum Health, Grand Rapids, MI, USA
| | - Jessica Parker
- Division of Bioinformatics, Spectrum Health, Grand Rapids, MI, USA
| | - Robert Fitzgerald
- Division of Pediatric Critical Care, Helen DeVos Children's Hospital, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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Phelan H, Hanas R, Hofer SE, James S, Landry A, Lee W, Wood JR, Codner E. Sick day management in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:912-925. [PMID: 36093857 DOI: 10.1111/pedi.13415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Helen Phelan
- Pediatric Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla Hospital, Uddevalla, and Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Steven James
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Petrie, Queensland, Australia
| | - Alanna Landry
- Department of Paediatrics, Oak Valley Health, Markham, Ontario, Canada
| | - Warren Lee
- Dr. Warren Lee's Paediatrics, Growth & Diabetes Centre, and KK Hospital, Singapore, Singapore
| | - Jamie R Wood
- University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ethel Codner
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile
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Wilkinson K, Sanghamitra S, Nair P, Sanchez J, Ambati S. Utility of head CT scan in treatment decisions for suspected cerebral edema in children with DKA. J Pediatr Endocrinol Metab 2022; 35:1257-1263. [PMID: 36168879 DOI: 10.1515/jpem-2022-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cerebral edema (CE) remains one of the most feared complications of diabetic ketoacidosis (DKA) with severe morbidity and mortality. The use of computerized tomography (CT) scan in the setting of suspected cerebral edema in DKA has been minimally studied. The objective of our study was to evaluate the utility of CT scans in children with suspected cerebral edema, and secondarily to analyze the various patient characteristics of those with and without cerebral edema. METHODS We performed a retrospective chart review of all the children with DKA secondary to T1DM admitted to our tertiary PICU in order to obtain demographic data, laboratory results, and their treatment course. Differences between the groups of suspected CE and no suspected CE were compared using linear and logistic regression for continuous and binary variables respectively. RESULTS We identified 251 patients with DKA, 12 of which had suspected CE; 67% (8/12) of those patients received head CT and 87.5% (7/8) of them were read as normal. On the other hand, 33% (4/12) did not receive CT scan of head, and yet three of the four patients were treated for CE. CONCLUSIONS In our cohort of patients, CT results did not influence CE treatment or lack thereof; most patients with suspected CE were treated with or without head CT findings of CE, indicating that imaging has very little utility in our cohort of patients. In some cases, the use of head CT delayed the onset of treatment for CE.
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Affiliation(s)
| | - Sinha Sanghamitra
- Division of Neonatal-Perinatal Medicine, Brown University, Providence, USA
| | | | - Javier Sanchez
- Department of Pediatrics, Albany Medical Center, Albany, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, USA
| | - Shashikanth Ambati
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albany Medical Center, Albany, USA
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Shati AA, Al-Asmari OJ, Alhayani AA, Alqahtani YA, Alshehri SA, Alhelali IA. Supraventricular tachycardia associated with severe diabetic ketoacidosis in a child with new-onset type 1 diabetes mellitus. Cardiol Young 2022; 32:1677-80. [PMID: 35094738 DOI: 10.1017/S1047951122000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Diabetic ketoacidosis is one of the most serious and common complications of diabetes, with between 15 and 70% of new-onset type 1 diabetes mellitus worldwide presented with diabetic ketoacidosis. Supraventricular tachycardia, however, is an infrequent complication of diabetic ketoacidosis. We present the case of a child with a new-onset type 1 diabetes mellitus with supraventricular tachycardia as a complication of paediatric diabetic ketoacidosis. The patient received intravenous fluid resuscitation, insulin, and potassium supplementation and subsequently developed stable supraventricular tachycardia initially, confirmed on a 12-lead electrocardiogram despite a structurally normal heart and normal electrolytes. Vagal manoeuvers failed to achieve sinus rhythm. The patient went into respiratory distress and was intubated, for mechanical ventilation. She received one dose of adenosine with successful conversion to sinus rhythm and a heart rate decreased from 200 to 140 beats per minutes. We conclude that supraventricular tachycardia can occur as a complication of diabetic ketoacidosis, including in new-onset type 1 diabetes mellitus. Furthermore, a combination of acidosis, potassium derangement, falling magnesium, and phosphate levels may have precipitated the event. Here, we report a case of supraventricular tachycardia as a complication of paediatric diabetic ketoacidosis.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Leiva-Gea I, Fernández CA, Cardona-Hernandez R, Lozano MF, Bahíllo-Curieses P, Arroyo-Díez J, León MC, Martín-Frías M, Barreiro SC, Delgado AM, Sánchez JP; Diabetes Group of the Spanish Pediatric Endocrinology Society (SEEP). Increased Presentation of Diabetic Ketoacidosis and Changes in Age and Month of Type 1 Diabetes at Onset during the COVID-19 Pandemic in Spain. J Clin Med 2022; 11:4338. [PMID: 35893428 DOI: 10.3390/jcm11154338] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 07/19/2022] [Indexed: 01/08/2023] Open
Abstract
Objective: To assess the impact of the COVID-19 pandemic and lockdown measures on the presenting characteristics (age at diagnosis, severity, monthly distribution) of newly diagnosed type 1 diabetes in Spanish children. Research Design and Methods: An ambispective observational multicenter study was conducted in nine Spanish tertiary-level hospitals between January 2015 and March 2021. Inclusion criteria: new cases of type 1 diabetes in children (0–14 years) recording age, sex, date of diagnosis, presence of diabetic ketoacidosis (DKA) at onset, and severity of DKA. Data were compared before and during the pandemic. Results: We registered 1444 new cases of type 1 diabetes in children: 1085 in the pre-pandemic period (2015–2019) and 359 during the pandemic (2020–March 2021). There was a significant increase in the group aged ≤4 years in the pandemic period (chi-squared = 10.986, df 2, p = 0.0041). In 2020–2021, cases of DKA increased significantly by 12% (95% CI: 7.2–20.4%), with a higher percentage of moderate and severe DKA, although this increase was not significant. In 2020, there was a sharp decrease in the number of cases in March, with a progressive increase from May through November, higher than in the same months of the period 2015–2019, highlighting the increase in the number of cases in June, September, and November. The first three months of 2021 showed a different trend to that observed both in the years 2015–2019 and in 2020, with a marked increase in the number of cases. Conclusions: A change in monthly distribution was described, with an increase in DKA at onset of type 1 diabetes. No differences were found in severity, although there were differences in the age distribution, with an increase in the number of cases in children under 4 years of age.
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Nimri R, Rachmiel M, Yackobovitch-Gavan M, Brener A, de Vries L, Fisch Shvalb N, Lazar L, Oren A, Jacobi-Polishook T, Shefer Averbuch N, Tenenbaum A, Mel E, Krepel Volsky S, Mouler M, Demol S, Shalitin S, Bello R, Phillip M, Lebenthal Y. Symptoms and Glycemic Control in Young People With Type 1 Diabetes Following SARS-CoV-2 Infection: An Observational Study. J Clin Endocrinol Metab 2022; 107:e3264-e3272. [PMID: 35524727 PMCID: PMC9129169 DOI: 10.1210/clinem/dgac288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Indexed: 02/07/2023]
Abstract
CONTEXT Data is needed regarding the effect of SARS-CoV-19 infection on young people with established type 1 diabetes. Identifying the disease outcomes, short and long-term sequelae may help to establish an evidence-based prevention and education policy for sick days management and DKA prevention. OBJECTIVE This work aims to describe clinical manifestations of SARS-CoV-2 infection in children, adolescents, and young adults with established type 1 diabetes (T1D) and explore the effects of COVID-19 on glycemic control and disease course. METHODS An observational study was conducted at 3 pediatric diabetes clinics in Israel between mid-March 2020 and mid-March 2021. Included were young people with established T1D, age younger than 30 years, who tested positive for SARS-CoV-2 (quantitative real-time polymerase chain reaction). Data were collected from medical files, diabetes devices, and COVID-19 questionnaire. Outcome measures were analyzed by the presence/absence of clinical symptoms (symptomatic/asymptomatic) and by age group (pediatric, < 19 years/young adults, 19-30 years). RESULTS Of 132 patients, mean age 16.9 ± 5.3years, with COVID-19-confirmed infection, 103 (78%) had related symptoms; the most common were headaches, fatigue, fever, and loss of sense of smell. All had a mild disease course, but 4 required hospitalization and 2 cases were directly related to COVID-19 infection (pleuropneumonia in a patient with immunodeficiency syndrome, 1 case of diabetic ketoacidosis). Logistic regression analysis showed that age (odds ratio [OR] = 1.11; 95% CI, 1.01-1.23; P = .033), elevated glucose levels (OR = 5.23; 95% CI, 1.12-24.41; P = .035), and comorbidities (OR = 8.21; 95% CI, 1.00-67.51; P = .050) were positively associated with symptomatic infection. Persistent symptoms occurred in 16.5% of the cohort over a median of 6.7 months; age (OR = 1.14; 95% CI, 1.01-1.29; P = .030) and elevated glucose levels (OR = 3.42; 95% CI, 1.12-10.40; P = .031) were positively associated with persistent symptoms. Usually, no change was reported in glucose levels (64%) except for a temporary deterioration in glycemic control during the short infection period. CONCLUSION Young people with established T1D experience mild COVID-19 infection. Elevated glucose levels during COVID-19 infection and older age were associated with prolonged disease course.
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Affiliation(s)
- Revital Nimri
- Correspondence: Revital Nimri, MD, The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, 14 Kaplan St, Petah Tikva, 49202, Israel. ;
| | - Marianna Rachmiel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Harofeh) Medical Center, Tzrifin,70300, Israel
| | - Michal Yackobovitch-Gavan
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Avivit Brener
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv,6423906, Israel
| | - Liat de Vries
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Naama Fisch Shvalb
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Liora Lazar
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Asaf Oren
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv,6423906, Israel
| | - Talia Jacobi-Polishook
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Harofeh) Medical Center, Tzrifin,70300, Israel
| | - Noa Shefer Averbuch
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Ariel Tenenbaum
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Eran Mel
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
| | - Sari Krepel Volsky
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Marie Mouler
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Sharon Demol
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Shlomit Shalitin
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Rachel Bello
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children’s Medical Center of Israel, Petah Tikva 49202, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
| | - Yael Lebenthal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel
- Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Childrens Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv,6423906, Israel
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Abstract
BACKGROUND It is estimated that 16 to 25% of patients in hospital have diabetes and 1 in 25 inpatients with Type 1 Diabetes develop diabetic ketoacidosis (DKA). It is vital that non-specialist doctors recognize and appropriately manage diabetes emergencies. Simulation training is increasingly being used in healthcare and virtual reality (VR) based educational resources is transforming medical education. This study aimed to evaluate the use of virtual reality to help non-specialist clinicians manage clinical scenarios related to diabetes. METHODS This pilot project, titled 'DEVICE' (Diabetes Emergencies: Virtual Interactive Clinical Education) was developed in collaboration with Oxford Medical Simulation. Fully interactive immersive VR scenarios were created to stimulate real life diabetes emergencies. Users then received personalized feedback and performance metrics. Feedback surveys were provided before and after the participation in the VR scenario. Kirkpatrick's training evaluation model was used. RESULTS Thirty-nine participants from 2 hospitals in UK provided feedback up to 3 months after attending the VR education sessions. Overall feedback was extremely positive, and participants found this immersive teaching experience very helpful. After use of virtual reality scenarios, the mean trainee confidence in managing DKA (on an 8-point Likert scale) increased from 3.92 (3.38-4.47) 95% CI to 5.41 (4.79-6.03) 95% CI (statistically significant). The VR study demonstrates Kirkpatrick level 3 in the follow up survey. CONCLUSION VR based training scenarios in this pilot project increased confidence in managing diabetes emergencies and demonstrated positive changes in their behavior. VR education is a safe, useful and a well-liked training tool for diabetes emergencies.
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Affiliation(s)
- Ritwika Mallik
- Clinical Research Fellow in Diabetes
and Endocrinology, Royal London Hospital, Barts Health NHS Trust, London, UK
- Ritwika Mallik, MBBS, DNB, MRCP (UK),
Clinical Research Fellow in Diabetes and Endocrinology, Royal London Hospital,
Barts Health NHS Trust, London E1 1BB, UK.
| | - Mayank Patel
- Consultant in Diabetes and Acute
Medicine, University Hospital Southampton, Southampton, Hampshire, UK
| | - Ben Atkinson
- Consultant in Emergency Medicine,
Wessex Emergency Medicine Simulation Lead, Emergency Department, Portsmouth Hospital
University NHS Trust, Cosham, Portsmouth, UK
| | - Partha Kar
- National Specialty Advisor, Diabetes
with NHS England, Consultant in Diabetes & Endocrinology, Portsmouth Hospital
University NHS Trust, Cosham, Portsmouth, UK
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Clapin H, Smith G, Vijayanand S, Jones T, Davis E, Haynes A. Moderate and severe diabetic ketoacidosis at type 1 diabetes onset in children over two decades: A population-based study of prevalence and long-term glycemic outcomes. Pediatr Diabetes 2022; 23:473-479. [PMID: 35218122 DOI: 10.1111/pedi.13327] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/13/2022] [Accepted: 02/15/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To investigate in a population-based pediatric cohort: prevalence of moderate-severe diabetic ketoacidosis (DKA) at type 1 diabetes (T1D) diagnosis over two decades and its association with long-term glycemic control. RESEARCH DESIGN AND METHODS Children <16 years diagnosed with T1D in Western Australia 2000-2019 were included and followed up for ≤14 years. Moderate-severe DKA at diagnosis was defined as serum pH < 7.2 or bicarbonate<10 mmol/L with hyperglycemia and ketosis. HbA1c was measured ~3-monthly. Trend in prevalence of moderate-severe DKA at diagnosis was investigated using a logistic regression model adjusting for sex, age, socioeconomic status, and area of residence. Long-term glycemic control associated with DKA at diagnosis was investigated using linear mixed models adjusting for the same variables and also for visit frequency, CGM and pump use. RESULTS Moderate-severe DKA occurred in 534 of 2111 (25.3%) participants. Odds of presenting with moderate-severe DKA increased by 4.1% (95% CI: 2.3, 5.9; p < 0.001) per year. Patients with moderate-severe DKA at diagnosis had higher HbA1c levels than other patients initially; the groups were similar between 2 and 6 years duration; from 7 years HbA1c levels tracked higher in the group with moderate-severe DKA at diagnosis with significant differences at 8 and 12 years (p < 0.05). CONCLUSION The increasing prevalence of DKA at diagnosis of pediatric T1D is concerning and highlights the need for early detection programs. Unlike a similar US study, this study did not find a consistent, clinically significant relationship between DKA at diagnosis and long-term HbA1c, raising important questions about the influence of other factors on long-term glycemic outcomes.
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Affiliation(s)
- Helen Clapin
- Department of Diabetes and Endocrinology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Children's Diabetes Centre, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Grant Smith
- Children's Diabetes Centre, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Sathyakala Vijayanand
- Department of Diabetes and Endocrinology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Timothy Jones
- Department of Diabetes and Endocrinology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Children's Diabetes Centre, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Elizabeth Davis
- Department of Diabetes and Endocrinology, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Children's Diabetes Centre, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Aveni Haynes
- Children's Diabetes Centre, Telethon Kids Institute, Perth, Western Australia, Australia
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46
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Taylor RM, Baca JT. Feasibility of Interstitial Fluid Ketone Monitoring with Microneedles. Metabolites 2022; 12:metabo12050424. [PMID: 35629928 PMCID: PMC9146213 DOI: 10.3390/metabo12050424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 12/10/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is one of the most dangerous and costly complications of diabetes, accounting for approximately 50% of deaths in diabetic individuals under 24 years. This results in over 130,000 hospital admissions yearly and costs the USA over USD 2.4 billion annually. Earlier diagnosis, treatment, and management of DKA are of critical importance to achieving better patient outcomes and preventing prolonged hospital admissions. Diabetic patients undergoing stress from illness or injury may not recognize early ketosis and often present advanced ketoacidosis, requiring intensive care admission. We have recently developed a microneedle-based technology to extract dermal interstitial fluid (ISF) from both animals and humans, which could enable wearable sensors to rapidly detect ketosis. Metabolite concentrations in ISF may differ in urine and blood and could likely represent local metabolic conditions in the surrounding tissue. Development of a wearable ketone detector will require an understanding of ketone concentrations and kinetics in ISF. Here, we report data that is first of its kind, with regard to the ketone concentrations present in the dermal ISF of rats, their correlation to blood, and the possible impact on the development of a wearable ISF "early warning system" to prevent morbidity from DKA. We extracted ISF, using minimally invasive microneedle arrays, from control Sprague Dawley rats and 17 h fasted rats. ISF and blood ketone levels were measured using a common glucose/ketone meter and strips. Local tissue concentrations of glucose were similar to those of blood, with an average blood to ISF glucose ratio of 0.99 ± 0.15 mg/dL. ISF ketones (0.4 ± 0.3 mM) were significantly higher (p = 4.2 × 10-9), compared with blood ketones (0.0 ± 0.0 mM). Although the fasted animals had slightly higher ISF ketones (1.3 ± 1.1 mM) compared with blood ketones (1.0 ± 1.0 mM), the difference was not significant (p = 0.3). This suggests ISF could possibly be useful as a surrogate for blood when determining ketone levels within a clinical setting.
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Luciano TM, Halah MP, Sarti MTA, Floriano VG, da Fonseca BAL, Del Roio Liberatore R, Antonini SR. DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic. Arch Endocrinol Metab 2022; 66:88-91. [PMID: 35029857 PMCID: PMC9991034 DOI: 10.20945/2359-3997000000433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We assess the severity and frequency of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) patients and in patients with previous diagnosis of T1D in a referral Brazilian university hospital in the first five months of the COVID-19 pandemic. We also compare the data with data from pre-pandemic periods. Forty-three new-onset T1D patients were diagnosed between April and August of the years 2017, 2018, 2019, and 2020. During the COVID-19 pandemic, the number of new-onset T1D was over twice the number of new-onset T1D in the same period in the three previous years. All the 43 patients survived and are now on outpatient follow-up. We also compared the characteristics of the T1D patients hospitalized between April and August of the years 2017, 2018, and 2019 (32 hospitalizations) to the characteristics of the T1D patients hospitalized between April and August/2020 (35 hospitalizations; 1 patient was hospitalized twice in this period). Fourteen of the 34 patients admitted during the pandemic presented with COVID-19-related symptoms (any respiratory symptom, fever, nausea, vomiting, and diarrhea), but only one had positive SARS-CoV-2 RT-PCR test. Samples from 32 out of these 34 patients were assayed for SARS-CoV-2 antibodies, and four patients were positive for total antibodies (IgM and IgG). In agreement with recent reports from European countries, we observed increased frequency of DKA and severe DKA in new-onset and previously diagnosed T1D children and adolescents in a large referral public hospital in Brazil in the first five months of the COVID-19 pandemic. The reasons for this outcome might have been fear of SARS-CoV-2 infection in emergency settings, the more limited availability of primary healthcare, and the lack of school personnel's attention toward children's general well-being.
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Affiliation(s)
- Thais Milioni Luciano
- Divisão de Endocrinologia Pediátrica, Departamento de Pediatria, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Mariana Peduti Halah
- Divisão de Endocrinologia Pediátrica, Departamento de Pediatria, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Mariana Teresa Alves Sarti
- Divisão de Endocrinologia Pediátrica, Departamento de Pediatria, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Vitor Gonçalves Floriano
- Divisão de Doenças Infecciosas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brasil
| | - Benedito Antônio Lopes da Fonseca
- Divisão de Doenças Infecciosas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brasil
| | - Raphael Del Roio Liberatore
- Divisão de Endocrinologia Pediátrica, Departamento de Pediatria, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Sonir Rauber Antonini
- Divisão de Endocrinologia Pediátrica, Departamento de Pediatria, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil,
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48
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Brown M, Roberts J, Smith C, Eash D. Safety and Effectiveness of the Use of an Electronic Glucose Monitoring System Versus Weight-Based Dosing Nomogram for Treatment of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Syndrome in a VA Hospital. J Diabetes Sci Technol 2022; 17:727-732. [PMID: 35128975 DOI: 10.1177/19322968221074710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study is to assess the safety and effectiveness of an electronic glucose monitoring system (eGMS) versus paper-based protocols (PBPs) to manage diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) within the VA setting. METHODS This study is a retrospective chart review of patients on an insulin drip, treated in the emergency department (ED) or intensive care unit (ICU) at Veteran Health Indiana for DKA or HHS. The primary outcome was evaluating the percentage of patients with hypoglycemia (blood glucose [BG] level <70 mg/dL) in patients admitted with DKA and HHS comparing an eGMS versus a PBP. A total of 168 patients were included in the analysis, with 84 patients in each group. RESULTS The primary outcome comparing rates of hypoglycemia in the eGMS group versus the PBP group showed a lower rate of hypoglycemia in the eGMS group (0.024%) compared with the PBP group (0.060%); however, this difference was not found to be statistically significant (P = .90). Statistically significant secondary outcomes include the percentage of glucose checks drawn within the protocol recommendation (80.7% vs 52.6%, P = .02). CONCLUSIONS While the primary endpoint of decreased hypoglycemia was not found to be statistically significant, it did reduce the overall number of hypoglycemia events in the eGMS group compared with the PBP group which may be clinically significant. This demonstrates that eGMS use has the potential to minimize hypoglycemia and glycemic variability in a critically-ill Veteran population by individualizing insulin drip titration based on a variety of patient-specific factors and providing reminders for staff to obtain BG checks in a timely manner.
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Affiliation(s)
| | | | - Cole Smith
- Veteran Health Indiana, Indianapolis, IN, USA
| | - Dakota Eash
- Veteran Health Indiana, Indianapolis, IN, USA
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49
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Gruber N, Rathaus M, Ron I, Livne R, Sheinvald S, Barhod E, Hemi R, Tirosh A, Pinhas-Hamiel O, Tirosh A. Fatty acid-binding protein 4: a key regulator of ketoacidosis in new-onset type 1 diabetes. Diabetologia 2022; 65:366-374. [PMID: 34806114 DOI: 10.1007/s00125-021-05606-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/06/2021] [Indexed: 02/05/2023]
Abstract
AIMS/HYPOTHESIS Fatty acid-binding protein 4 (FABP4) is an adipokine with a key regulatory role in glucose and lipid metabolism. We prospectively evaluated the role of FABP4 in the pathophysiology of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes. METHODS Clinical and laboratory data were prospectively collected from consecutive children presenting with new-onset type 1 diabetes. In addition to blood chemistry and gases, insulin, C-peptide, serum FABP4 and NEFA were collected upon presentation and 48 h after initiation of insulin treatment. In a mouse model of type 1 diabetes, glucose, insulin, β-hydroxybutyrate and weight were compared between FABP4 knockout (Fabp4-/-) and wild-type (WT) mice. RESULTS Included were 33 children (mean age 9.3 ± 3.5 years, 52% male), of whom 14 (42%) presented with DKA. FABP4 levels were higher in the DKA group compared with the non-DKA group (median [IQR] 10.1 [7.9-14.2] ng/ml vs 6.3 [3.9-7] ng/ml, respectively; p = 0.005). The FABP4 level was positively correlated with HbA1c at presentation and inversely correlated with venous blood pH and bicarbonate levels (p < 0.05 for all). Following initiation of insulin therapy, a marked reduction in FABP4 was observed in all children. An FABP4 level of 7.22 ng/ml had a sensitivity of 86% and a specificity of 78% for the diagnosis of DKA, with an area under the receiver operating characteristic curve of 0.78 (95% CI 0.6, 0.95; p = 0.008). In a streptozotocin-induced diabetes mouse model, Fabp4-/- mice exhibited marked hypoinsulinaemia and hyperglycaemia similar to WT mice but displayed no significant increase in β-hydroxybutyrate and were protected from ketoacidosis. CONCLUSIONS/INTERPRETATION FABP4 is suggested to be a necessary regulator of ketogenesis in insulin-deficient states.
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Affiliation(s)
- Noah Gruber
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Moran Rathaus
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Idit Ron
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Rinat Livne
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Sharon Sheinvald
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Ehud Barhod
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Rina Hemi
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Amit Tirosh
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel
| | - Orit Pinhas-Hamiel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amir Tirosh
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- The Dalia and David Arabov Diabetes Research Center, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Tel-Hashomer, Israel.
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50
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Maseko NF, van Zyl D, Adam S. A 10-Year Audit of Pregnancies Affected by Diabetic Ketoacidosis at the Pretoria Academic Complex. Int J Gynaecol Obstet 2022; 158:557-563. [PMID: 34997592 DOI: 10.1002/ijgo.14093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/24/2021] [Accepted: 01/06/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) during pregnancy is associated with increased rates of maternal and perinatal mortality and morbidity. DKA management guidelines are designed to ensure optimal management and minimise adverse outcomes. OBJECTIVES To determine the level of adherence to DKA management guidelines at a tertiary centre in Pretoria, South Africa and report on maternal and perinatal outcomes of the pregnancies complicated by DKA. METHODS This was a retrospective clinical record audit using the SEMDSA guidelines against documented management. Adherence to three cornerstones of therapy: intravenous fluids, insulin therapy and management of electrolytes was measured. RESULTS Fifty-six records of pregnancies that were complicated with DKA over a 10-year period were reviewed. Mean age was 29.6 years (range 20-43). Thirty-six (64.3%) women had Type 1 diabetes mellitus. DKA was categorised into mild (n=26, 46.4%), moderate (n=22, 39.3%) and severe (n=8, 14.3%). The study demonstrated lack of adherence to the three cornerstones of therapy. Of the 49 (85.7%) women with recorded perinatal outcomes, 30.6% had stillbirths. Severe maternal DKA (pH < 7.0) demonstrated adverse perinatal outcomes (p=0.005). CONCLUSION Despite the availability of guidelines, DKA is sub-optimally manged in pregnancy which may contribute to adverse maternal and perinatal outcomes.
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Affiliation(s)
- Ncamsile F Maseko
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Danie van Zyl
- Department of Internal Medicine, University of Pretoria, Diabetes Research Centre, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Sumaiya Adam
- Department of Obstetrics and Gynaecology, University of Pretoria, Diabetes Research Centre, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
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