Estimated life expectancy in a Scottish cohort with type 1 diabetes, 2008-2010.

IMPORTANCE: Type 1 diabetes has historically been associated with a significant reduction in life expectancy. Major advances in treatment of type 1 diabetes have occurred in the past 3 decades. Contemporary estimates of the effect of type 1 diabetes on life expectancy are needed. OBJECTIVE: To examine current life expectancy in people with and without type 1 diabetes in Scotland. We also examined whether any loss of life expectancy in patients with type 1 diabetes is confined to those who develop kidney disease. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort of all individuals alive in Scotland with type 1 diabetes who were aged 20 years or older from 2008 through 2010 and were in a nationwide register (n=24,691 contributing 67,712 person-years and 1043 deaths). MAIN OUTCOMES AND MEASURES: Differences in life expectancy between those with and those without type 1 diabetes and the percentage of the difference due to various causes. RESULTS: Life expectancy at an attained age of 20 years was an additional 46.2 years among men with type 1 diabetes and 57.3 years among men without it, an estimated loss in life expectancy with diabetes of 11.1 years (95% CI, 10.1-12.1). Life expectancy from age 20 years was an additional 48.1 years among women with type 1 diabetes and 61.0 years among women without it, an estimated loss with diabetes of 12.9 years (95% CI, 11.7-14.1). Even among those with type 1 diabetes with an estimated glomerular filtration rate of 90 mL/min/1.73 m2 or higher, life expectancy was reduced (49.0 years in men, 53.1 years in women) giving an estimated loss from age 20 years of 8.3 years (95% CI, 6.5-10.1) for men and 7.9 years (95% CI, 5.5-10.3) for women. Overall, the largest percentage of the estimated loss in life expectancy was related to ischemic heart disease (36% in men, 31% in women) but death from diabetic coma or ketoacidosis was associated with the largest percentage of the estimated loss occurring before age 50 years (29.4% in men, 21.7% in women). CONCLUSIONS AND RELEVANCE: Estimated life expectancy for patients with type 1 diabetes in Scotland based on data from 2008 through 2010 indicated an estimated loss of life expectancy at age 20 years of approximately 11 years for men and 13 years for women compared with the general population without type 1 diabetes.

Short-term mortality risk in children and young adults with type 1 diabetes: the population-based Registry of the Province of Turin, Italy.

Short-term mortality risk in young diabetic people is an indicator of quality of care. We assessed this in the Italian incident population-based registry of Turin. The study base included 1210 incident cases (n=677 aged 0-14 years and n=533 aged 15-29 years) with diabetes, onset period 1974-2000 in the Province of Turin, Italy. The relevant timescale for analysis was the time since the onset of diabetes to death, or till 31 December 2003. Standardized mortality ratio (SMR) for all-cause mortality was computed using the Italian population as a standard, by 5 years, age group, sex, and calendar period. Mean attained age of the incident cohort was 29.7 years (range 5.2-49.7 years). During a mean follow-up period of 15.8 years (range 2.0-29.9 years), there were 19 deaths in 15,967. Nine person-years of observation (n=9.5 expected deaths), giving an all-cause mortality rate of 1.19/1000 person-years (95% CI 0.76-1.87) and an SMR of 1.96 (1.25-3.08). In no cases did death occur at the onset of diabetes or in childhood. Out of 19 deaths, 9 were diabetes related (n=6 coma and n=3 end-stage renal disease). In Cox regression analysis, the hazard ratio (HR) was higher in adult-onset than in childhood-onset diabetes (HR=3.90, 95% CI 1.14-13.39), independently of calendar period and gender. (1) Children and young adults with type 1 diabetes experienced a two-fold higher short-term mortality risk than Italian people of similar age and sex and (2) the risk was higher in adult-onset than in childhood-onset diabetes. The quality of diabetes care should be improved to prevent early deaths.

The spectrum of coma among people with diabetes in Cameroon: an appraisal of the implications and challenges at the Yaounde Central Hospital.

The present study was undertaken to assess the prevalence and prognosis of comas, the most serious acute complications of diabetes, among people with diabetes in Cameroon. The medical records of diabetic patients admitted to the endocrinolgy service of the Yaounde Central Hospital between November 1999 and October 2002 were reviewed. For each patient, data were collected on past medical history, clinical parameters, results of laboratory investigations, treatment received, and outcome. Coma was found to account for 10.2% (52) of the 509 admissions of diabetic patients, and to be responsible for a diagnosis of diabetes in 11 patients. The underlying causes of the comas were hypoglycaemia (28.8%), ketoacidosis (25%), hyperosmolar syndrome (25%), stroke (5.8%), uraemic syndrome (5.8%) and meningitis (5.8%). Hypoglycaemia was treated with intravenous (10%) glucose. Careful rehydration and subcutaneous injections of low doses of regular insulin were used to manage the hyperglycaemic crises, and broad-spectrum antibiotics were used to treat the infections. Despite the treatments, 11 of the coma cases died in hospital, six (55%) of the deaths being ultimately attributed to infection. Diabetic comas are relatively frequent in Yaounde and sometimes the first indication that an individual is diabetic. Associated deaths are regularly the result of infection. The management of the comas, using techniques that are not particularly aggressive, generates outcomes similar to those reported elsewhere.

Causes of death in children with insulin dependent diabetes 1990-96.

BACKGROUND: Mortality rates in children with insulin dependent diabetes (IDDM) in the UK are unknown and the causes of death not well documented. AIM: To determine the mortality rate and causes of death in children with IDDM. METHODS: The Office of National Statistics (England and Wales) and the General Register Office (Scotland) notified all deaths under 20 years of age from 1990 to 1996 with diabetes on the certificate. Further details were provided by coroners, pathologists, and clinicians. RESULTS: 116 deaths were notified and 83 were caused by diabetes. The standardised mortality ratio was 2.3 (95% confidence interval (CI), 1.9 to 2.9), being highest in the age group 1-4 years, at 9.2 (95% CI, 5.4 to 14.7). Of the 83 diabetic deaths, hyperglycaemia/diabetic ketoacidosis (DKA) was implicated in 69 and hypoglycaemia in 7. Cerebral oedema was the most common cause of death in young children (25 of 36 diabetes related deaths in children under 12 years of age). 34 young people (10-19 years; 24 male) were either found dead at home (n = 26) or moribund on arrival at hospital (n = 8). In 24 of these, it appeared that DKA was the cause of death, in four hypoglycaemia was likely. Nine of these were found "dead in bed". CONCLUSIONS: Children with IDDM have a higher mortality than the general population. Cerebral oedema accounts for most hospital deaths in young children. There are a large number of young men dying at home from neglected IDDM. Early diagnosis of IDDM in children and closer supervision of young people might prevent some of these deaths.

Causes of death and associated factors among patients with non-insulin-dependent diabetes mellitus in Taipei, Taiwan.

A cohort of 766 patients with non-insulin-dependent diabetes mellitus (NIDDM) from a general teaching hospital in Taipei, Taiwan were followed prospectively to assess survival experience and associated risk factors. Data were abstracted from the medical records and additional information was obtained from patients or their closest relatives using a structured questionnaire. Date and cause of death were determined from death certificates. Standardized mortality ratios were calculated by the direct method. Chi2-Square test and Cox's proportional hazard analysis were used to control for potential confounders. During a median follow-up of 3.5 years (range 1 month to 4.6 years), 131 deaths occurred. Of these, 29.8% were due to cardiopulmonary disease (ICD 401-429), 13.0% due to cerebrovascular disease (ICD 430-438), 13.0% due to acute diabetes metabolic complications (250.1, 250.2), and 11.4% due to nephropathy (580-589). Adjusted for age, people with NIDDM had 2.2 (95% CI 1.6-2.9) times the risk of death than members of the general population, and cause-specific standardized mortality ratios were: CPD 4.6, nephropathy 8.8, cerebrovascular disease 1.9, and neoplasm 0.7. Age, fasting plasma glucose, hypertension, and proteinuria were positively and independently associated with all-cause mortality (P < 0.05 for each). Thus, NIDDM patients have higher mortality rates than the general population in Taiwan, and age, fasting plasma glucose, hypertension, and proteinuria are associated with this excess risk. Proper application of available interventions may control these factors with a consequent reduction in mortality. Particular attention is needed to prevent deaths from the acute metabolic complications of diabetes.

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.

Complications and prognosis of children with IDDM.

There was a marked reduction in the prevalence of complications in, and mortality status of, Japanese children with IDDM in the past 20 years. It is apparent that the improvement in medical treatment as well as social circumstance surrounding childhood diabetes in recent years contributed greatly to this change. However, when one compares Japanese data with those for Europe or the U.S., the present status is not yet satisfactory. In order to prevent the early development of diabetic complications followed by premature death associated with IDDM, an evenly distributed high-level medical system throughout Japan is required in addition to tight control of diabetes and patient education. Moreover, a population-based ongoing IDDM registry should be established from which risk factors for the progression of complications could be identified.

Causes of death in Japanese diabetic patients examined by autopsy.

Autopsy records have been published annually by the Japan Society of Pathology. We collected diabetic autopsy cases from these records (1958-1985) and analysed the causes of death. Vascular diseases comprised 38-48% of all causes of death, malignant neoplasms 16-23% and infections 16-23%. Among vascular diseases, the incidence of coronary artery diseases has increased from 6.0 to 17%, but the frequency of nephropathy and cerebrovascular diseases has remained relatively stable since 1970. Diabetic coma and tuberculosis has decreased as a cause of death, while vascular diseases and malignant neoplasm have increased during these periods. These changes reflect the trend of changing disease structure in the general population, which is partly due to the changes in age distribution of the population.

[Diabetic coma--an unnecessary death]. / Diabeteskoma--en onödig död.

Diabetic ketoacidosis remains a significant cause of death in cases of insulin-dependent diabetes mellitus (IDDM). Among patients hospitalised for diabetic ketoacidosis, the death rate is 5-10 per cent, cardiovascular disease, infection, and ARDS (adult respiratory distress syndrome) being major contributory factors, whereas the degree of acidosis does not differ from that among survivors. Ketoacidosis is a major determinant of the two-fold higher mortality among the youngest age-groups of IDDM patients. The age-specific incidence of ketoacidosis among patients under 20 years of age is several time higher than that among patients over 50. Intensified insulin treatment, using multiple injections or insulin pumps, probably results in an increased risk of insulin deficiency owing to the smaller insulin depots. Thus, there is a need of intensified testing for ketonuria and improved education of patients, physicians and other health care personnel, in order to promote the prevention or rapid, effective treatment of diabetic ketoacidosis.

Clinical analysis of STA-SCA bypass for vertebrobasilar occlusive disease.

In order to clarify the effectiveness of extracranial- intracranial bypass in cases of vertebro-basilar occlusive disease, we investigated the operative complication, clinical course and follow-up study of 30 cases undergoing superficial temporal artery-superior cerebellar artery (STA-SCA) bypass surgery. Postoperative angiogram showed the patency of the anastomoses in all cases. No serious surgical complications were observed. The outcome on discharge was excellent, with no morbidity and one mortality which was due to cardiac infarction. In the follow-up study, there were four cases with ischemic symptoms, two with transient ischemic attack and two with completed stroke, one of which was a supratentorial infarction due to internal carotid artery occlusion and the other was a small infarction of pons. There were also two deaths due to cardiac infarction and diabetes mellitus. Favorable outcomes were obtained for the remaining cases. The present study suggests that, STA-SCA bypass, can be performed without surgical and systemic complications and used as an effective therapy for vertebrobasilar ischemia.

Deaths associated with diabetic ketoacidosis and hyperosmolar coma. 1973-1988.

We assessed the possibility of improvements in the management of the potentially fatal acute hyperglycaemic complications of diabetes by a review of all deaths in patients who presented to the Alfred Hospital, Melbourne, with diabetic ketoacidosis or hyperosmolar coma during the 16 years, 1973-1988. All late deaths of patients during hospitalization were included in the mortality data. In the 610 episodes of diabetic ketoacidosis (pH, 7.30 or lower) or hyperosmolar coma (osmolality, 350 mOsmol/kg or greater), only one death occurred as a result of the acute metabolic disturbance--in a patient who had suffered a cardiac arrest before admission to hospital. The over-all mortality rate was 6.2% (38 deaths). The mortality rate was 4.9% (26 deaths) for 528 episodes of diabetic ketoacidosis and 14.6% (12 deaths) for 82 episodes of hyperosmolar coma. Patients with diabetic ketoacidosis who died were older than were those who survived (64 +/- 13 years compared with 40 +/- 21 years, respectively; P less than 0.001). Mortality in patients with hyperosmolar coma did not relate to age, initial blood-glucose level or osmolality. Twelve deaths resulted from bacterial pneumonia and two deaths resulted from aspiration pneumonia. Other major causes of death were mesenteric and iliac thromboses (six cases), myocardial infarction (eight cases) and cerebral haemorrhage (two cases). Of the 26 deaths that were associated with diabetic ketoacidosis, only two deaths--as a result of aspiration pneumonia and bowel infarction, respectively--were assessed as potentially avoidable after the patient's admission to hospital. Eight of the 12 hyperosmolar-coma-associated deaths occurred in newly recognized diabetic patients in whom there were avoidable delays in diagnosis. We conclude that further improvements in outcome will be difficult to achieve, but that efforts should be directed towards the earlier diagnosis of diabetes and the earlier recognition and treatment of associated acute pulmonary and vascular complications.

Diabetic hyperosmolar non-ketotic decompensation.

To assess whether the outcome of hyperosmolar non-ketotic decompensation has changed in the past 20 years with modern medical management, a retrospective study analysis was performed of all patients presenting with the syndrome to a large teaching hospital during the period 1982 to 1986. Twenty-two patients were identified of whom 68 per cent had no previous history of diabetes mellitus. The immediate mortality rate (within 72 h of presentation) was 36 per cent (eight of 22), the overall mortality rate was 41 per cent (nine of 22) and vascular thromboembolism was common. A comparison was made of the early deaths (n = 8) and survivors (n = 14) in an attempt to identify favourable prognostic factors. The two groups could not be distinguished either by clinical or laboratory variables at presentation nor by treatment regimen; however there was a significant delay in establishing the diagnosis in some of the patients who died. Our results indicate there has been no improvement in the outcome of the hyperosmolar non-ketotic decompensation syndrome in the last two decades and that a high index of suspicion is required to identify patients presenting with this condition.

Interpreting survival rates for the treatment of decompensated diabetes: are we saving too many lives?

Discussion of the case of a patient admitted to hospital with decompensated diabetes revealed a conflict in attitudes to resuscitation of the patient from that disorder and from cardiac arrest. A survey was sent to 200 diabetologists and 200 cardiologists in the United Kingdom, asking about their management of diabetes and their therapeutic approaches to cardiac arrest for 3 elderly patients admitted with severe decompensated diabetes. The response rate was poor (27%) but the answers showed that all 3 patients were more likely to be resuscitated from decompensated diabetes than from cardiac arrest. Possible reasons for a different approach to the two conditions are discussed, and suggestions are put forward for a greater involvement by patients in decisions about future resuscitation.

Prognostic factors in the diabetic hyperosmolar state.

To evaluate the current outcome of patients hospitalized with diabetic hyperosmolar state (DHS), we retrospectively studied 135 patients admitted to two general hospitals over an 11-year period. Mortality was 17%. Patients who died had a mean age of 77 years, compared to 68 years for the survivors (P = 0.008). They were also more likely to be nursing home residents (48 versus 23%, P = 0.01). Additionally, mean serum osmolality was significantly higher among those who died (383 versus 358 mosm/L, P less than 0.0001) as was blood urea nitrogen (81.3 versus 62.3 mg/dl, P = 0.006) and sodium (148 versus 137.4 mEq/L, P less than 0.001). However, mean glucose level and anion gap were similar among patients who died and patients who survived (1068 versus 1092 mg%; 23 versus 24 mEq/L, respectively). The presence of a chronic disease or an acute comorbid illness was not associated with mortality. Diminished physiologic reserve, attendant comorbidity, or functional disability may explain the effect of age and nursing home residence. High osmolality may indicate a greater water deficit and a more advanced stage of DHS at the time of diagnosis.