Surge of mucormycosis during the COVID-19 pandemic.

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.

DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic

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.

DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic.

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.

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.

Diabetic ketoacidosis at diagnosis in Austrian children: a population-based analysis, 1989-2011.

OBJECTIVE: To analyze the effect of a community-based, poster-focused prevention program on the frequency of diabetic ketoacidosis (DKA) at diabetes onset in Austria. STUDY DESIGN: All newly diagnosed patients with diabetes ≤ 15 years of age were registered prospectively by the Austrian Diabetes Incidence Study Group. Registered data included initial blood glucose, pH, and ketonuria. DKA was defined as pH < 7.3 and severe DKA as pH < 7.1. Data between 1989 and 2011 were available. In autumn, 2009, a community-based prevention program similar to the Parma Campaign, in which posters were dispensed broadly, was initiated. The frequency of DKA at the onset of diabetes in the years 2005-2009 and 2010-2011 was compared. RESULTS: During the study period, 4038 children were registered. A total of 37.2% presented with DKA; 26% had a mild and 11.2% a severe form. The frequency of DKA was negatively associated with age at onset. In the years before the intervention program, 26% had mild DKA compared with 27% after the intervention (not significant). The prevalence of severe DKA in the years before the campaign was 12% compared with 9.5% thereafter (not significant). No significant change in the DKA rate at onset by the prevention program could be found when we compared age groups <5, 5 to <10, and 10 to <15 years, neither for mild nor for severe DKA. CONCLUSION: The frequency of DKA in children with newly diagnosed type 1 diabetes in Austria is high and did not change despite the efforts of a community-based information program.

Cerebral hyperemia measured with near infrared spectroscopy during treatment of diabetic ketoacidosis in children.

OBJECTIVE: To use near infrared spectroscopy (NIRS) to evaluate the timing of onset and duration of cerebral hyperemia during diabetic ketoacidosis (DKA) treatment in children, and to investigate the relationship of cerebral hyperemia to intravenous fluid treatment. STUDY DESIGN: We randomized children aged 8-18 years with DKA to either more rapid or slower intravenous fluid treatment (19 total DKA episodes). NIRS was used to measure rSo2 during DKA treatment. NIRS monitoring began as soon as informed consent was obtained and continued until the patient was transferred out of the critical care unit. RESULTS: rSo2 values above the normal range (>80%) were detected in 17 of 19 DKA episodes (mean rSo2 during initial 8 hours of DKA treatment: 86% ± 7%, range 65%-95%). Elevated rSo2 values were detected as early as the second hour of DKA treatment and persisted for as long as 27 hours. Hourly mean rSo2 levels during treatment did not differ significantly by fluid treatment group. CONCLUSIONS: During DKA treatment, children have elevated rSo2 values consistent with cerebral hyperemia. Hyperemia occurs as early as the second hour of DKA treatment and may persist for ≥ 27 hours. Cerebral rSo2 levels during treatment did not differ significantly in patients treated with slower versus more rapid intravenous rehydration.

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.

Acute limb ischaemia in a septic patient with diabetic ketoacidosis / Isquemia aguda de miembros en un paciente septico con cetoacidosis diabetica

This is a patient with septicaemia and diabetic ketoacidosis who developed an acute ischaemic lower limb from an arterial thrombus. The patient had decreased protein S function.

Se trata de un paciente con septicemia y cetoacidosis diabética que desarrolló una isquemia aguda en un miembro inferior a partir de un trombo arterial. El paciente presentaba función disminuida de la proteína S.