DKA cases over the last three years: has anything changed?

BACKGROUND: Diabetic ketoacidosis (DKA) has been related mainly to type 1 diabetes mellitus (T1DM). However, it is not solely related to T1DM. The purpose of this study was to assess the prevalence of DKA among type 1 and type 2 patients with diabetes mellitus, who were hospitalized in our Clinic due to DKA, as well as to determine the etiology beyond DKA. PATIENTS AND METHODS: A cohort of 109 patients with DKA, 17-86 years of age, who were hospitalized in the Department of Endocrinology, Diabetes and Metabolism of our hospital between 2015 and 2017, were included in the study. RESULTS: Among the 109 patients, 50 (45.9%) had mild DKA, 48 (44.1%) had moderate DKA, whereas 11 patients (10%) had severe DKA. Sixty-five patients (60%) developed DKA as the first manifestation of T1DM, 30 patients (27%) developed DKA in the context of type 2 diabetes (T2DM), mainly due to the co-existence of serious infections, 11 patients (10%) had T1DM, but had omitted their insulin dosages, and 3 patients (3%) developed DKA due to unknown reasons. CONCLUSIONS: Most patients with DKA presented with mild and moderate DKA and only a minority presented with the severe form of the disease. The etiology of DKA was mainly T1DM and less frequent uncontrolled T2DM, usually due to the co-existence of severe infections, while only in a tiny minority, the causes remained unidentifiable.

Chronic idiopathic hyponatremia in an elderly patient due to inappropriate antidiuretic hormone secretion (SIADH) syndrome.

INTRODUCTION: The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a disorder which is characterized by the inability to suppress the secretion of antidiuretic hormone (ADH), leading to impaired water excretion and hyponatremia. The syndrome should be suspected in any patient with hyponatremia, hypo-osmolality and a urine osmolality >100 mOsm/kg, while urine sodium concentration is above 40 mEq/L. CASE DESCRIPTION: Herein, we present an 84-year-old female patient with chronic idiopathic hyponatremia due to SIADH. Her laboratory tests showed hyponatremia with serum sodium of 120 mEq/L, while urine sodium concentration was 83 mEq/L. Measured serum osmolality was 255 mOsm/kg and urinary osmolality 130 mOsm/kg. In addition to these, her serum glucose, potassium, uric acid, renal, and liver functions were normal, and there were no acid-base disorders. The patient's adrenal function (cortisol, adrenocorticotropic hormone, renin, and aldosterone) showed no abnormalities, as well as her thyroid function. DISCUSSION: The patient suffered from chronic idiopathic hyponatremia and osteoporosis, which often coexists in patients with chronic idiopathic SIADH and was treated with alendronate/cholecalciferol. The scenario of the presence of SIADH was further strengthened by the fact that hyponatremia did not improve after isotonic normal saline administration, but only with fluid restriction.  HIPPOKRATIA 2019, 23(1): 42-44.

Testicular abscesses due to Brucella melitensis.

Brucella may cause testicular masses, which may be confused with a testicular tumour. We present the case of a man with fever and oedema in the scrotum. Ultrasound and colour Doppler ultrasound with a 6 to 15 MHz high-frequency linear-array transducer was performed, revealing bilateral scrotal wall oedema, heterogeneous echo texture and slightly increased vascularization of the right testis, with hypoechoic lesions characterized by hypervascular margins and no flow within them. These findings were compatible with testicular abscesses. Three blood cultures grew Brucella melitensis, so the patient received treatment with doxycycline and rifampin for 8 weeks, which resulted in disappearance of the testicular abscesses.

Monitoring of patients with type 2 diabetes and nephropathy in a specialized diabetic nephropathy clinic seems to be beneficial.

BACKGROUND: The purpose of this study was to evaluate the outcome of DM2 patients with nephropathy when they are under surveillance of a joined clinic run by endocrinologists & nephrologists. PATIENTS AND METHODS: A cohort of 106 patients with DM2, 42-83 years of age, and eGFR < 60 ml/min/m2 were included. Age, sex, duration of diabetes, duration of attending our clinic, smoking habits, BMI, data regarding ischemic heart disease and induction of hemodialysis, urine albumin excretion (UAE) levels, eGFR (MDRD equation) and values of various biochemical parameters were recorded too. Follow-up period ranged from one to 25 years. Paired samples t-test and non-parametrical Kruskal-Wallis test were used for the analyses of the data. RESULTS: Fifty percent of patients had no further progression, 25.9% improvement, while 24.1% had worsening of the UAE levels. During the follow-up in the joined clinic, there was a smaller than the expected from the medical literature decrease in median eGFR, i.e. 2,3 ml/min/m2 and a statistically significant improvement in glycosylated hemoglobin levels from 8.0% to 7.4% (p = 0.016). Time in years of follow-up in the joined clinic of our hospital appeared to be the most significant factor in the improvement or stabilization against deterioration of the UAE levels (p = 0.018). CONCLUSIONS: Close follow-up of DM2 patients with eGFR < 60 ml/min/m2 has resulted in a minor annual eGFR decrease. Monitoring of these patients in a specialized diabetic nephropathy clinic is beneficial for this group of patients for delaying the occurrence of end-stage renal disease.

Prevalence of macrolide, lincosamide, and streptogramin resistance among staphylococci in a tertiary care hospital in Athens, Greece.

The aims of the present study were to evaluate erythromycin, clindamycin, and streptogramin resistance rates, as well as the phenotypic and genotypic characteristics of erythromycin-resistant staphylococci in a Greek University Hospital. Macrolide, lincosamide, and streptogramin B-type resistance was investigated by double disk diffusion and the D-zone testing, while Minimal inhibitory concentration determination was performed among 656 erythromycin-resistant staphylococcal clinical consecutive isolates, too. The presence of the major genetic determinants ermA, ermB, ermC, and msrA were detected by polymerase chain reaction (PCR). The overall erythromycin resistance rate was 49·70%. One hundred and forty-six of the 322 Staphylococcus aureus were methicillin-resistant S. aureus (MRSA) (45·34%), whereas 176 were methicillin-susceptible S. aureus (54·66%). The macrolides, lincosamides, and streptogramin B-type antibiotics (MLSB)-constitutive phenotype was detected in 126 S. aureus strains (88·7%), whereas the inducible MLSB resistance phenotype was demonstrated in 16 S. aureus (11·3%). The MS phenotype was not detected. ErmC was the most frequently encountered gene responsible for macrolide resistance among S. aureus and coagulase negative staphylococci in this hospital. Pulsed-field gel electrophoresis (PFGE) analysis of SmaI DNA fragments revealed the presence of a single predominant clone among erythromycin-resistant S. aureus. The predominance of constitutive erythromycin resistance is a serious problem and limits the use of clindamycin for severe staphylococcal infections not only in this university hospital, but in many countries worldwide.

Pulmonary embolism as the first manifestation of multiple myeloma.

Multiple myeloma is considered a hypercoagulable state due to several mechanisms such as the increased IL-6 and immunoglobulins production, the defective fibrinolytic mechanism, and the acquired resistance to activated protein C that are involved in the pathogenesis and clinical futures of the disease. We describe a case of a female patient who presented to the hospital with pulmonary embolism as the first manifestation of the hypercoagulability of multiple myeloma.

Lower extremities and iliopsoas pyomyositis with concurrent septic arthritis and spinal epidural abscess in a diabetic patient.

Pyomyositis is a rarely encountered infection among diabetics, which usually affects lower extremities. Herein, we present a case of lower extremities and iliopsoas pyomyositis with concurrent septic arthritis and spinal epidural abscess in a patient with poorly controlled diabetes mellitus.

An unusual case of desmoid tumour presenting as haemorrhagic shock.

We report the case of a 22-year-old patient who presented to the emergency department with epigastric pain and vomiting. Haematological studies showed a rapid decrease in haemoglobin levels from 13.6 g/dl to 4.9 g/dl. Abdominal ultrasonography revealed the presence of fluid around the spleen and the patient was immediately referred for surgery. An intra-abdominal desmoid tumour presenting as a hemorrhagic shock has not previously been described. Given the relatively benign course of the disease and the young age at presentation, this clinical entity should not be overlooked as it has the potential to invade vessels and therefore be fatal.

Association between serum cystatin C, monocytes and other inflammatory markers.

BACKGROUND: Cystatin C is a marker of renal function that appears to be associated with inflammation. The aim of the present study was to investigate whether there is any relationship between cystatin C, total and differential leukocyte count and other inflammatory markers. METHODS: Cystatin C, creatinine, high sensitivity C-reactive protein (hs-CRP), haptoglobin, ferritin, serum albumin, glucose, total cholesterol, HDL and triglycerides together with total and differential leukocyte count were determined in 490 adults (46 ± 16 years, 40% men) who underwent a typical health examination. Glomerular filtration rate was estimated by the simplified Modification of Diet in Renal Disease formula. Anthropometric and lifestyle characteristics were also recorded. RESULTS: After adjustment for demographic risk factors, comorbid health conditions and renal function, a positive and independent relationship of serum cystatin C levels with peripheral monocyte blood count (regression coefficient ± SE: 12 ± 3.38, P < 0.001) and white blood count (0.616 ± 0.278, P= 0.027) was evident. In this multiple linear regression analysis, other inflammatory markers (i.e. hs-CRP, haptoglobin, ferritin, albumin) did not seem to affect cystatin C blood levels. CONCLUSION: The results of this study demonstrated that monocytes, which play an important role in chronic inflammation and atherosclerosis, were independently related with cystatin C concentrations. This finding may provide a plausible link for the usefulness of cystatin C in predicting increased cardiovascular risk.

Development, repeatability and validity regarding energy and macronutrient intake of a semi-quantitative food frequency questionnaire: methodological considerations.

BACKGROUND AND AIM: The aim of this work was to evaluate the repeatability and the validity of a food frequency questionnaire (FFQ), and to discuss the methodological framework of such procedures. METHODS AND RESULTS: The semi-quantitative FFQ included 69 questions regarding the frequency of consumption of all main food groups and beverages usually consumed and 7 questions regarding eating behaviors. Five hundred individuals (37 ± 15 yrs, 38% males) were recruited for the repeatability process, while another 432 (46 ± 16 yrs, 40% males) also completed 3-Day Diaries (3DD) for the validation process. The repeatability of the FFQ was adequate for all food items tested (Kendall's tau-b: 0.26-0.67, p < 0.05), energy and macronutrients intake (energy adjusted correlation coefficients ranged between 0.56-0.69, p < 0.05). Moderate validity of the FFQ was observed for "dairy products", "fruit", "alcohol" and "stimulants" (tau-b: 0.31-0.60, p < 0.05), whereas low agreement was shown for "starchy products", "legumes", "vegetables", "meat", "fish", "sweets", "eggs", "fats and oils" (tau-b < 0.30, p < 0.05). The FFQ was also valid regarding energy and macronutrients intake. Sensitivity analyses by sex and BMI category (< or ≥25 kg/m(2)) showed similar validity of the FFQ for all food groups (apart from "fats and oils" intake), as well as energy and nutrient intake. CONCLUSION: The proposed FFQ has proven repeatable and relatively valid for foods' intake, and could therefore be used for nutritional assessment purposes.

Prevalence of macrolide resistance genes among staphylococci in Cyprus.

The aims of the present study were to evaluate the frequency of macrolide-resistant staphylococci in Cyprus and to examine the phenotypic and genotypic characteristics of these isolates. Antimicrobial susceptibility testing was performed by broth microdilution method and the macrolide resistance determinants were detected by PCR. The relatedness among the isolates was examined by pulsed-field gel electrophoresis. Ninety-six (67.61%) of the 142 Staphylococcus aureus and 19 (59.4%) of the 32 coagulase-negative staphylococci were resistant to erythromycin. Among the 115 erythromycin-resistant staphylococci, 70 expressed the MLSB-inducible phenotype, 38 the MLSB-constitutive, and 7 the MS. The predominant genes associated with macrolide resistance were the ermA for S. aureus and the ermC for coagulase-negative staphylococci, detected in 90.62% and 47.37% of the isolates respectively. Dissemination of one clone carrying the ermA gene accounted for macrolide resistance in the majority of S. aureus isolates.

Prevalence of methicillin-resistant Staphylococcus aureus in infected and uninfected diabetic foot ulcers.

This study investigated the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in infected and uninfected diabetic foot ulcers of 84 patients with the two types of diabetes. S. aureus was the most common pathogen among the Gram-positive bacteria isolated from ulcers, and almost 50% of S. aureus isolates were MRSA. The prevalence of MRSA was significantly higher in patients with infected foot ulcers. MRSA infection or colonisation was not associated with factors (previous hospitalisation, use of antibiotics, etc.) known to predispose to MRSA colonisation or infection. The high prevalence of MRSA in patients with foot ulcers may reflect the increased prevalence of MRSA in the community.