Cause-specific mortality in a cohort of Brazilian patients with type 1 diabetes.

AIMS: To assess cause-specific mortality in a cohort of patients with type 1 diabetes (T1D) followed at an university hospital (tertiary level, Rio de Janeiro city) and an outpatient clinic (secondary level, Bauru city) both in Brazil's southeast, and associations of survival with gender, age at diagnosis, self-reported ethnicity and diabetes duration. METHODS: Our study is based on a cohort of patients with T1D whose vital status was determined as of December 31, 2015. The causes of mortality were determined by death certificates and outpatient clinic records. RESULTS: Among 986 patients, (54.4%) females, (74.8%) Caucasians, 886 (89.9%) were alive, 62 (6.3%) had died, and in 38 (3.9%) the vital status was unknown. Median age at death [interquartile range] and diabetes duration until death were 30.0 [13] and 15.6 [10] years, respectively. Considering those who died (n = 62), most patients (about 70%) died from end-stage renal disease, macrovascular disease or acute complications of diabetes, mainly diabetic ketoacidosis. The other causes of mortality were infections, fatal accidents and non-diabetes-related. The standardized mortality ratio was 3.13 [2.35-4.08] in those aged under 40. In a multivariate Cox model, "age < 40 years" and "year of diagnosis" were the only significant variables with hazard ratios of 6.259 [(3.100-12.639), p < 0.001] and 0.915 [(0.880-0.951), p < 0.001], respectively. CONCLUSIONS: Our study shows that patients with T1D had a threefold increase in mortality. The specific causes of mortality were mainly diabetes-related chronic complications; however, acute complications, especially diabetic ketoacidosis, persisted as an important cause of mortality.

Cetoacidosis diabética: Casuística 2008-2012, epidemiología y fisiopatología / Treatment of diabetic ketoacidosis using 2009 American Diabetes Association guidelines

Background: During 2009, new guidelines for the treatment of diabetic ketoacidosis were published by the American Diabetes Association. Aim: To assess the impact of new treatment guidelines on the evolution of patients treated for diabetic ketoacidosis (KAD). Patients and Methods: Anonymous data was obtained from computational medical records of patients treated for KAD at our institution two years before (“Traditional Protocol”) and TWO years after (“ADA-2009 Protocol”) the publication of the 2009 American Diabetes Association (ADA) KAD guidelines. Results: Twenty three patients aged 36.5 ± 15.1 years were treated with the traditional method and 23 patients aged 44.4 ± 21.1 years were treated following 2009 ADA guidelines. Among patients treated with the traditional protocol and treated following ADA 2009 guidelines, the diabetes type 1/type 2 ratio was18/5 and 19/16 respectively (p = NS), the glycosylated hemoglobin on admission was 12.6 ± 2.5 and 14.3 ± 2.7% respectively (p = 0.03), minimal blood pH was 7.15 ± 0.14 and 7.19 ± 0.09 respectively (p = NS), bicarbonate was required in seven and no patient respectively (p = 0.01), hypokalemia < 3.5 mEq/L occurred in 78.2 and 48.5% of patients (p = 0.03), the lapse until resolution was 28.7 ± 28.0 and 28.8 ± 20.6 hours (p = NS). Only one patient, treated following ADA 2009 guidelines, died. Conclusions: Introduction of the ADA-2009 protocol for the treatment of KAD resulted in decrease in the use of intravenous bicarbonate and a reduction in the incidence of hypokalemia. There was no impact neither in the lapse until resolution or lethality.

[Treatment of diabetic ketoacidosis using 2009 American Diabetes Association guidelines]. / Cetoacidosis diabética: Casuística 2008-2012, epidemiología y fisiopatología.

BACKGROUND: During 2009, new guidelines for the treatment of diabetic ketoacidosis were published by the American Diabetes Association. AIM: To assess the impact of new treatment guidelines on the evolution of patients treated for diabetic ketoacidosis (KAD). PATIENTS AND METHODS: Anonymous data was obtained from computational medical records of patients treated for KAD at our institution two years before ("Traditional Protocol") and TWO years after ("ADA-2009 Protocol") the publication of the 2009 American Diabetes Association (ADA) KAD guidelines. RESULTS: Twenty three patients aged 36.5 ± 15.1 years were treated with the traditional method and 23 patients aged 44.4 ± 21.1 years were treated following 2009 ADA guidelines. Among patients treated with the traditional protocol and treated following ADA 2009 guidelines, the diabetes type 1/type 2 ratio was 18/5 and 19/16 respectively (p = NS), the glycosylated hemoglobin on admission was 12.6 ± 2.5 and 14.3 ± 2.7% respectively (p = 0.03), minimal blood pH was 7.15 ± 0.14 and 7.19 ± 0.09 respectively (p = NS), bicarbonate was required in seven and no patient respectively (p = 0.01), hypokalemia < 3.5 mEq/L occurred in 78.2 and 48.5% of patients (p = 0.03), the lapse until resolution was 28.7 ± 28.0 and 28.8 ± 20.6 hours (p = NS). Only one patient, treated following ADA 2009 guidelines, died. CONCLUSIONS: Introduction of the ADA-2009 protocol for the treatment of KAD resulted in decrease in the use of intravenous bicarbonate and a reduction in the incidence of hypokalemia. There was no impact neither in the lapse until resolution or lethality.

Low morbidity and mortality in children with diabetic ketoacidosis treated with isotonic fluids.

OBJECTIVE: To assess current rates of complications of diabetic ketoacidosis (DKA), particularly cerebral edema, in a large tertiary-care pediatric hospital with a consistent management protocol. STUDY DESIGN: We report our single-center retrospective experience with 3712 admissions with DKA in 1999-2011. Our DKA protocol features a "3-bag" system using 2 bags of rehydration fluids, identical except for the presence in 1 bag of 10% dextrose, to allow rapid adjustment of glucose infusion rate. The third bag contains insulin. Fluids are administered at a total rate of 2-2.5 times "maintenance" fluid requirements. Total electrolyte concentration is kept approximately isotonic. Billing and medical records databases at Children's Medical Center Dallas were examined for cases of DKA, cerebral edema, other morbidities, and death. RESULTS: We ascertained 20 cases of cerebral edema (0.5%). Most presented early (median duration of treatment 2 hours). Only 10 of 20 computed tomography scans were graded as moderate edema or worse. Only 10 patients received treatment other than routine DKA management. There was 1 death in a patient with sickle cell trait who developed intravascular sickling. Two patients had neurologic sequelae at hospital discharge but both recovered fully. CONCLUSIONS: Compared with data in recent consensus statements, the Dallas protocol is associated with extremely low rates of death and disability (0.08% vs 0.3%) from DKA.

Predictors of hyperglycaemic crises and their associated mortality in Jamaica.

The objective of the study was to determine the clinical characteristics and mortality of patients with hyperglycaemic hyperosmolar syndrome (HHS) and diabetic ketoacidosis (DKA) at a Jamaican tertiary care hospital. In a retrospective study of 1560 admissions for diabetes during the period 1998-2002, 980 dockets were reviewed and 164 individuals met the ADA diagnostic criteria for DKA or HHS. Patients with HHS were older than DKA patients (64.5 years [95% CI: 60.7-68.4] versus 35.9 years [95% CI: 30.2-41.6]), but were not more likely to be non-compliant with medications, infected, or male. Overall, 24% had a mixed DKA/HHS syndrome. Most DKA patients had type 2 diabetes (62%). Only 2% of HHS and 6% of DKA/HHS patients had type 1 diabetes. Syndrome specific mortality was: DKA 6.7%, HHS 20.3%, and DKA/HHS 25% (p for trend=0.013). Mortality increased significantly with age, especially in patients > or =50 years. Significant univariate predictors of mortality were altered mental status on admission, co-existing medical disease, increasing age, older age at onset of diabetes, acute stressors, and DKA/HHS. In multivariate models, only altered mental status was significant (OR=3.59; 95% CI: 1.24-10.41). Hence, hyperglycaemic crises in a Jamaican tertiary care hospital are associated with significant mortality especially in patients who are older or with altered mental status.

Morbimortalidad por cetoacidosis diabética en la unidad de cuidados intensivos / Morbimortality from diabetic ketoacidosis in the Intensive Care Unit

Se realizó un estudio descriptivo transversal para caracterizar la morbilidad y mortalidad por cetoacidosis diabética en la sala de Cuidados Intensivos del Hospital Provincial Manuel Ascunce Domenech de Camagüey, desde junio de 2001 a mayo de 2004. El universo y la muestra fueron de 72 pacientes, predominaron los grupos de edades entre 16 y 35 años (58 por ciento) y el sexo femenino (66.6 por ciento). Las infecciones fueron la primer causa desencadenante (33.3 por ciento), seguida por los errores en la administración del tratamiento (25 por ciento) y como forma de debut de la diabetes (20.8 por ciento). La insulinoterapia (37.5 por ciento) y la combinación de insulina con hipoglicemiantes orales (16.66 por ciento) constituyeron las formas de tratamiento que llevaban más de la mitad de los pacientes. Los vómitos (75 por ciento), el dolor abdominal (54.1 por ciento) y el estupor ligero (50 por ciento) fueron los síntomas y signos más representativos de todos los encontrados con más del 50 por ciento. La hiperglucemia (79.16 por ciento), el bicarbonato sérico bajo (70.83 por ciento) y la acidemia (66.6 por ciento) fueron los hallazgos de laboratorio más evidentes. Sólo el 20.84 por ciento de los pacientes fallecieron, el tromboembolismo pulmonar fue la principal complicación (8.33 por ciento)

Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema.

OBJECTIVE: To investigate the relation between outcomes of children with diabetic ketoacidosis (DKA)-related cerebral edema and baseline clinical features and therapeutic interventions for treatment of cerebral edema. STUDY DESIGN: All children

Mortalidad por trastornos metabólicos agudos en personas con diabetes de ciudad de la habana en el período 1994-1995 / Mortality from acute metabolic disorders in persons with diabetes in Havana City from 1994 to 1995

Se revisaron los certificados de defunción de los pacientes diabéticos fallecidos en Ciudad de La Habana, durante 1994 y 1995, que obran en poder de la Dirección Nacional de Estadísticas del Ministerio de Salud Pública, para conocer los fallecidos por trastorno metabólico agudo, principalmente la cetoacidosis y evaluar la calidad de la atención médica. Se detectaron 91 fallecidos por este tipo de complicación, de ellos: 39, por cetoacidosis; 35, por hipoglicemia y 17, por coma hiperosmolar. Se comparó con el año 1993 y se observó disminución del número de fallecidos en todos los trastornos metabólicos. Se detectaron 13 pacientes fallecidos por cetoacidosis que al ser verificados en el área, se comprobó una elaboración inadecuada del certificado de defunción por parte del médico de atención primaria. En general, los hospitales con mayor número de fallecidos fueron ®Carlos J. Finlay¼ (23 porciento), ®Miguel Enriquez¼ (19,2 porciento), ®Joaquín Albarrán¼ y ®Salvador Allende¼ (11,6 porciento). Entre los hallazgos necrópsicos en los fallecidos por cetoacidosis (20 casos), las complicaciones más frecuentes fueron nefropatía diabética, 25 porciento; sepsis, 25 porciento y bronconeumonía, 20 porciento. Entre las deficiencias más frecuentemente detectadas por cetoacidosis se encontraron la no utilización del esquema de microdosis de insulina simple y dificultades en la determinación de la hemogasometría y de cuerpos cetónicos en orina. Se concluyó que es necesario continuar incrementando la educación diabetológica del personal relacionado con la atención al diabético, así como mejorar la disponibilidad de la hemogasometría y reactivo de Imbert y amoníaco (o mejor tiras reactivas para cetonuria) e insistir en lograr el llenado correcto del certificado de defunción por el personal médico

Análisis de los egresos hospitalarios por cetoacidosis y coma diabético / Analysis of hospital outputs due to ketoacidosis and diabetic coma

Es una revisión retrospectiva de los egresos y defunciones que ocurrieron en las unidades hospitalarias del Instituto Mexicano del Seguro Social de 1980 a 1993. Los diagnósticos de egreso y defunción fueron codificados de acuerdo con la lista tabular de la Clasificación Internacional de Enfermedades. Se consideraron el número de casos, egresos y defunciones por grupo de edad y sexo. Se calcularon tasas específicas por 1,000 egresos y por 100 defunciones hospitalarias. La tendencia fue calculada a través del análisis de regresión por mínimos cuadrados. Los resultados del análisis mostraron que la cetoacidosis representó el 3.02 y 6.47 por ciento del total de egresos y defunciones por diabetes y el 1.07 y 5.60 por ciento respectivamente en coma diabético. La tendencia de ambas afecciones mostró una reducción no significativa durante el periodo analizado. Los pacientes menores de 24 años de edad fueron el grupo predominante en los egresos por cetoacidosis y coma, pero en mortalidad los grupos de 25 a 34 años, y menores de 1 año y de 35 a 44 años en cetoacidosis y coma fueron los más representativos. En ambos grupos hubo un predominio en el sexo femenino (56 por ciento). El análisis del promedio de días de estancia hospitalaria no mostró cambios significativos durante este tiempo, aunque los casos de muerte en ambas enfermedades mostraron los promedios más bajos. Estos hallazgos indican que las complicaciones agudas no representan un problema mayor en la casuística de la diabetes mellitus, aunque un mejor control podría disminuir su frecuencia. Finalmente se hacen algunas consideraciones sobre los resultados del estudio y se toman en cuenta algunos puntos importantes en la fisiopatología, complicaciones y posibles causas de muerte

[Incidence and fatality of the acute and chronic complications of diabetes mellitus in Mexico]. / Incidencia y letalidad de las complicaciones agudas y crónicas de la diabetes mellitus en México.

OBJECTIVE: To analyze the secular trend of the incidence and fatality rates of diabetic complications in Mexico. MATERIAL AND METHODS: All diabetes mellitus(DM)-related hospital records for the 1985-1994 period, from the Mexican Institute for Social Security were reviewed. RESULTS: An increasing trend in the incidence of diabetic complications was observed for the last decade. The most frequent complication is diabetes-related end-stage renal disease, followed by peripheral arterial disease. There is an important age effect in the occurrence of diabetic complications. Diabetic ketoacidosis is the most common complication in the early years of life. Fatality due to DM has decreased, mainly that due to acute complications. CONCLUSIONS: Diabetic complications have increased due to the increase in the incidence of DM and in the life expectancy of diabetics. There is a need to study the true incidence of DM and of diabetic complications in Mexico, and to insist in an adequate metabolic control to delay or avoid their occurrence.