Predictors and outcomes of recurrent diabetic ketoacidosis in Israeli adults.

AIMS: To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies. METHODS: Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2). RESULTS: 385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112-3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04-0.742; p = 0.018). CONCLUSION: High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.

Outcomes of diabetic ketoacidosis in a tertiary centre with restricted intensive care unit bed capacity.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute metabolic condition, sometimes requiring admission to an intensive care unit (ICU). AIMS: To investigate the outcomes of DKA patients admitted to a hospital with restricted ICU capacity. METHODS: We included all DKA patients above age 18 who were admitted to a tertiary hospital during 2004-2017. We conducted multivariate logistic regression analysis adjusted for ICU bed availability to analyse parameters associated with ICU admission, and a composite outcome of mortality, DKA recurrence and mechanical ventilation. RESULTS: Among 382 DKA patients in our cohort, 94 (24.6%) were admitted to the ICU. The in-hospital mortality was 4.7%. Low bicarbonate (<10 mmoL/L) and pH (<7) levels at presentation were associated with ICU admission (P < 0.001 for both). In multivariate models availability of beds in the ICU was not associated with ICU admission, mortality or DKA recurrence of any type. CONCLUSION: In a setting of limited ICU capacity, DKA treatment does not necessarily require admission to the ICU. When the rising rates of diabetes mellitus and the associated elevated rates of DKA are taken into account, our results highlight the importance of including step-down units when devising local protocols for care of these patients.

Clinical and Epidemiological Characteristics of Diabetic Ketoacidosis in Older Adults.

OBJECTIVES: Much of the research previously done on diabetic ketoacidosis (DKA) was based on a young population with type 1 diabetes mellitus (type 1 DM). But substantial numbers of DKA episodes occur in patients with a prior history of type 2 diabetes mellitus (type 2 DM). There is a lack of Data are lacking about DKA in older adults. The aims of this study were to analyze the clinical characteristics and outcomes of older adult patients with DKA. DESIGN: Retrospective matched cohort study of adult patients hospitalized with DKA between 2004 and 2017. SETTING: Soroka University Medical Center, Be'er Sheva, Israel. PARTICIPANTS: The clinical characteristics of DKA patients 65 years and older were compared with patients younger than 65 years. MEASUREMENTS: The primary outcome was in-hospital mortality. RESULTS: The study cohort included 385 consecutive patients for whom the admission diagnosis was DKA: 307 patients (79.7%) younger than 65 years (group 1), and 78 patients (20.3%) older than 65 years (group 2). Patients in group 2 compared with group 1 had a significantly higher Charlson index (6 [6-6] vs 6 [6-7]; P < .0001) and DM with target organ damage (24.4% vs 6.2%; P < .0001). Patients in group 2 compared with group 1 had more serious disease according to results of laboratory investigations. The total in-hospital mortality rate of patients in group 2 was 16.7% compared with 1.6% in patients in group 1 in a sex and co-morbidities matched analysis (P = .001). CONCLUSIONS: DKA in older adults is a common problem. The serious co-morbidities and precipitating factors such as infection/sepsis, myocardial infarction, and cerebrovascular accidents, may explain the severity of the problem of DKA in older adults and the high rate of mortality of these patients. DKA appears to be a lifethreatening condition in older adults. The alertness of physicians to DKA in older adults, timely diagnosis, proper treatment, and prevention are cornerstones of care. J Am Geriatr Soc 68:1256-1261, 2020.

Recurrent diabetic ketoacidosis

ABSTRACT Objective The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. Materials and methods Review article. Results Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. Conclusions Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Recurrent diabetic ketoacidosis.

OBJECTIVE: The purpose of this study is to examine risk factors for recurrence of diabetic ketoacidosis and determine interventions to prevent future admissions. MATERIALS AND METHODS: Review article. RESULTS: Recurrent diabetic ketoacidosis is a serious and not uncommon health problem. Diabetic ketoacidosis is associated with severe morbidity and mortality and hospital admissions due to this problem constitute a serious economic burden on the healthcare system. Younger age at diabetic ketoacidosis onset, poor baseline glycemic control and elevated HbA1C, patient comorbidities, depression, alcohol or substance abuse, particularly active cocaine use, have been associated with recurrent diabetic ketoacidosis. In addition, socioeconomic factors (such as ethnic minority status, use of public health insurance and underinsurance), psychosocial, economic, and behavioral factors (including financial constraint, stretching a limited insulin supply, and homelessness) have been all reported to be associated with readmission among diabetic ketoacidosis patients. CONCLUSIONS: Identifying high-risk patients during the first diabetic ketoacidosis admission and performing relevant interventions (repeated instructions of insulin use, social help and involvement of family members in medical treatment, collaboration with the patient's primary care physician in order to establish a close and frequent follow up program) may help prevent future admissions. Further studies need to take place to determine whether early interventions with those factors prevent future admissions.

Euglycemic diabetic ketoacidosis.

Euglycemic DKA (eu-DKA) is a life-threatening emergency. It may occur in patients with both type 1 and type 2 DM, and characterized by milder degrees of hyperglycemia with blood glucose level < 200 mg/dl, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences. Following the wide introduction of the sodium glucose transporter 2 inhibitors (SGLT2i) in therapeutic practice for DM type 2 treatment the amount of eu-DKA increased and therefore, interest to this entity rose. Other causes associated with eu-DKA include pregnancy, decreased caloric intake, heavy alcohol use, insulin use prior to hospital admission, cocaine abuse, pancreatitis, sepsis, chronic liver disease and liver cirrhosis. Patients with eu-DKA as well as with DKA need immediate referral for emergency evaluation and treatment. The treatment includes rapid correction of dehydration, correction electrolyte abnormalities, and use of insulin drip until the anion gap, and bicarbonate levels normalize. Increased glucose administration using higher percentages of dextrose (10 or 20%) are required to facilitate the concomitant administration of the relatively large amounts of insulin that are needed to correct the severe acidosis in these patients.

Comparison of Clinical Characteristics and Prognosis in Patients with Right- and Left-sided Infective Endocarditis.

OBJECTIVE: Right-sided endocarditis (RSE) accounts for 5%-10% of all cases of infective endocarditis (IE) and frequently has different etiological, pathogenetic, and clinical presentations compared with left-sided endocarditis (LSE). The aims of this study were to evaluate the epidemiologic and clinical characteristics and prognosis of RSE patients and to compare them with those of LSE patients. This study's importance relates to the local understanding of RSE and LSE, since Israeli demographics are different compared to the Unites States and Europe with regard to intravenous drug abuse and rheumatic valvular disease prevalence. MATERIAL AND METHODS: A retrospective cohort study of 215 patients with infective endocarditis was performed. The primary outcome was in-hospital mortality. The secondary outcomes were duration of hospitalization, recurrent hospitalization, recurrent infective endocarditis, and one-year mortality. RESULTS: Of the 215 patients in the study, 176 had LSE and 39 had RSE. The RSE patients were younger than the LSE patients (48.1±18.9 years versus 61.8±17.0 years, P<0.001). The most common pathogen in both groups was Staphylococcus aureus, which occurred more in the RSE group (51%) versus the LSE group (19%). In-hospital mortality was lower among patients with RSE (2.6% versus 17%, P<0.037). CONCLUSIONS: Our study demonstrated an increasing percentage of RSE compared to LSE among patients with IE. Pacemaker lead infection has become the leading cause of RSE in intravenous drug users (IVDU), although less common in Southern Israel. The etiological and clinical differences between RSE and LSE are noteworthy. Patients with RSE have a better prognosis than those with LSE.

Basal insulin for the management of diabetic ketoacidosis.

Due to its pharmacokinetic properties, it has been suggested that long-acting insulin analogues may have a role in facilitating the transition from continuous intravenous insulin infusion to subcutaneous maintenance therapy in patients with DKA for prevention of rebound hyperglycemia, particularly if there are high insulin requirements. Concomitant administration of basal insulin analogues with regular insulin infusion accelerates ketoacidosis resolution and prevents rebound hyperglycemia. Several studies have investigated the use of basal insulin in the management of DKA. Studies have been instituted on pediatric patients and adult patients. These studies reveal that co-administration of basal insulin in combination with an insulin infusion in the acute management of DKA is feasible. Basal insulin co-administration with regular insulin infusion was well tolerated, associated with faster resolution of acidosis without any adverse effects; patients required a shorter duration of intravenous insulin infusion and had a lower total dose of intravenous insulin and significantly decreased hyperglycemia after discontinuation of the intravenous insulin. This could potentially lead to a shorter ICU length of stay and reduced costs in the treatment of DKA. However, this approach may be associated with an increased risk of hypokalemia. The current literature on this management approach is incomplete, due to its many limitations (retrospective nature, small sample size, nonrandomized design). Additional prospective randomized studies are needed on this new therapeutic approach in the management patients with DKA.