Mortality in diabetes: a retrospective analysis from a tertiary care hospital in North India

Clinical spectrum, etiology and outcome of infectious disease emergencies in adult diabetic patients in northern India

BACKGROUND AND AIMS

The patients with diabetes mellitus (DM) have an increased incidence of both common and unusual infections. Despite an increasing prevalence of DM in India, local data on the epidemiology and clinical spectrum of associated infections are lacking. We aimed to investigate the spectrum, etiology, and outcome of infectious disorders in adult patients with DM admitted in a medical emergency.

METHODS

A single-center retrospective observational study conducted between January 2018 to June 2019 in a tertiary care hospital in north India. Based on clinical presentation, radiological features, and microbiological or pathological evidence, 152 diabetic patients aged 12 years and above were diagnosed with the infectious syndrome.

RESULTS

Urinary tract infection was the most prevalent infectious syndrome (32.2%), followed by pneumonia and empyema (26.3%), skin and soft tissue infections (6.6%), sepsis of unknown primary source (6.6%), pulmonary tuberculosis (4.6%), rhinocerebral infections (4.6%), infectious diarrhea (3.9%), and viral encephalitis (2.6%). The majority of the infections were community-acquired (94.7%). 80.3% of study cases had type 2 DM. The common presenting symptoms were fever (46.1%), dyspnea (27.6%), and altered sensorium (25.7%). Shock and diabetic ketoacidosis were frequent, and each was seen in 27.6% of cases. The mortality rate was 27.6% and was higher with sepsis of unrecognized source (50.0%) and lung infections (30.0%). The presence of shock was the independent predictor of mortality on a multivariant analysis (p-value 0.000).

CONCLUSIONS

Urinary tract and lung infections remain common in DM. Establishing a microbiological etiology and identification of the source are necessary steps to reduce mortality.

Need for ethnic-specific guidelines for prevention, diagnosis, and management of type 2 diabetes in South asians

Noncommunicable diseases, including type 2 diabetes mellitus and cardiovascular diseases (CVDs), cause 7.9 million deaths every year in South Asia. India has nearly 65.1 million cases of diabetes, and Pakistan and Bangladesh are at the 12(th) and 13(th) positions in the global list of high prevalence countries, respectively. The prevalence in India is continuously increasing and is recently reported to be nearly 14% and 8% in urban areas and rural areas, respectively. Diabetes in South Asians is, in some manner, different from that in other races; it occurs nearly a decade earlier, at lower body mass index and waist circumference levels, and with more postprandial hyperglycemia, dyslipidemia, nephropathy, and CVD than in whites. Decision regarding prevention and management of diabetes should be taken in the background of heterogeneity of diet, attitudes, and cultural milieu in South Asia. A need for a low-cost, integrated, yet individualized approach specific for South Asian countries has been increasingly felt since escalating research has uncovered characteristic phenotype, dietary and socioeconomic patterns. Although most such guidelines formulated in developed countries such as the United States or the United Kingdom could be generally applied to developing South Asian countries, there are fundamental differences in applicability of lifestyle and diets (heterogeneous, different from western diets), availability and cost of drugs and insulins, monitoring methods and devices, and insulin pump. Moreover, the monitoring, education, care, and rehabilitation will differ according to different socioeconomic strata and levels of health care (primary, secondary, or tertiary). Some of the potential ethnic-specific modifications have been suggested in this review.

Clinical profile of long-term survivors and nonsurvivors with type 2 diabetes

OBJECTIVE

To compare clinical profile of long-term survivors and nonsurvivors with type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

After conducting a retrospective survey of >200,000 case records, we identified T2DM survivors (>40 years of duration) and age at diagnosis and sex-matched T2DM nonsurvivors. Prevalence of complications and causes of death were analyzed. Retinopathy was diagnosed by retinal photography. Microalbuminuria and macroalbuminuria, peripheral vascular disease based on ankle-brachial index <0.9, coronary artery disease based on history of myocardial infarction or coronary revascularization, and neuropathy based on vibration perception threshold >20 V were compared in both groups.

RESULTS

The mean duration of diabetes of survivors (n = 238) was 43.7 ± 3.9 years, and that of the nonsurvivors (n = 307), at time of death, was 22.4 ± 11.0 years (P < 0.001). Nonsurvivors had significantly higher systolic and diastolic blood pressures, plasma glucose, HbA1c, serum cholesterol, LDL cholesterol, and triglycerides and lower HDL cholesterol compared with long-term survivors (P < 0.001 for all parameters except systolic blood pressure, which was P = 0.027). Myocardial infarction (46.4%) and renal failure (16.6%) were the most common causes of death. Prevalence of most complications was higher among survivors because of longer duration and older age, as follows, for survivors versus nonsurvivors: retinopathy, 76 vs. 62%; microalbuminuria, 39.1 vs. 27.3%; macroalbuminuria, 8.4 vs. 23.7%; neuropathy, 86.5 vs. 63.5%; peripheral vascular disease, 23.1 vs. 11.4%; and coronary artery disease, 44.5 vs. 40.7%.

CONCLUSIONS

Long-term survivors with T2DM had better glycemic and blood pressure control and more favorable lipid profiles.

Microbial profile and utility of soft tissue, pus, and bone cultures in diagnosing diabetic foot infections

OBJECTIVE

This study assessed the utility of pus, soft tissue, and bone specimens in diagnosing diabetic foot infections and the spectrum of the microbial flora and in vitro susceptibility to antibiotics.

SUBJECTS AND METHODS

This prospective study was carried out in 60 consecutive patients with diabetes having clinically infected foot ulcers. Detailed history, physical examination, and investigation were carried out to diagnose the presence of osteomyelitis and the microbial etiology of foot ulcers. Foot ulcers were classified as per Wagner's classification. Soft tissue, pus, and bone samples were obtained and cultured for aerobic and anaerobic bacteria, and antimicrobial susceptibility testing was carried out as per the standard protocol.

RESULTS

Causative bacteria were isolated in 55 of 60 patients, and 157 isolates were cultured from 117 specimens with an average of 1.34 isolates per cases; however, the number of isolates per specimen did not differ among the various types of samples (P=0.78). Pus and soft tissue had predominantly polymicrobial flora, whereas bone infections were monomicrobial. The isolates from soft tissue specimens were different from those from bone and pus in 57% and 54% of cases, respectively. The common bacterial isolates from 117 specimens included Escherichia coli (21%) and Proteus species (15.9%). Nearly 70% of Staphylococcus aureus isolates were methicillin sensitive. All S. aureus and Enterococcus isolates were sensitive to vancomycin. Susceptibility of Gram-negative organisms to ciprofloxacin was 50%.

CONCLUSIONS

Diabetic foot infections are mostly polymicrobial with Gram-negative predominance. Multiple sampling from superficial and deep tissues, including bone, when involved, yields more relevant information diagnostically and therapeutically.

Cause-specific mortality in diabetes: retrospective hospital based data from south India

BACKGROUND

India lacks comprehensive mortality data in individuals with diabetes. The present retrospective case-control study compared the causes of death in diabetic and non-diabetic inpatients in a tertiary care hospital in 2007.

METHODS

Deaths in diabetic patients (n = 315) were compared with 307 randomly selected controls. Medical chart review established the primary cause of death, demographics, and clinical data. Data were summarized using descriptive statistics and comparative analyses were performed.

RESULTS

Of the 79 067 inpatient admissions during 2007, diabetes of any type was recorded for 6517 (8.2%). There were 2017 inpatient deaths registered, 315 (15.6%) in diabetic patients and 1702 (84.4%) in non-diabetic patients, corresponding to mortality rates of 48.3/1000 admissions for diabetic patients and 23.4/1000 admissions for non-diabetic patients. The mean duration of hospitalization prior to death in diabetic versus non-diabetic patients was 6.4 vs 7.7 days (P = 0.015). Causes of death in diabetic patients were vascular disease (38.4%), infection (34.3%), renal failure (8.9%), and malignancy (8.9%); diabetic patients had significantly higher odds of death from vascular disease (odds ratio [OR] 4.05, 95% confidence interval [CI] 2.67-6.16; P ≤ 0.0001), renal causes (OR 7.39, 95%CI 2.53-29.27; P ≤ 0.001) and infection (OR 1.61, 95% CI 1.12-2.32; P ≤ 0.0001). Comparing cases and controls after stratifying by age (<56 and ≥56 years), the greater odds of vascular death among diabetics remained significant in both age categories.

CONCLUSIONS

We report vascular disease as the leading cause of death among diabetic hospital inpatients in one tertiary care center in India, in contrast with previous hospital-based studies from India.

Management of diabetes-related hypoglycemia

Iatrogenic hypoglycemia is the main factor limiting aggressive and optimal diabetes management. Rather than being an inevitable consequence of optimal glycemic control, however, hypoglycemia is avoidable and generally straightforward to manage when it occurs. Professional caregivers, patients, and their families are often fearful of hypoglycemia, even though most episodes are minor and easily self-treated. Understanding the factors contributing to hypoglycemia risk and how to minimize its occurrence is an essential part of diabetes care. Building on the physiologic fundamentals presented in the accompanying review, the incidence, mortality/morbidity, clinical symptoms, severity classification, and psychosocial impact of hypoglycemia are described here. Appropriate selection and titration of therapeutic agents, including insulin analogs with more predictable time-action profiles than human insulin formulations, can reduce hypoglycemia risk. Patient education about hypoglycemia prevention, including symptom recognition and necessity of rapid treatment, behavioral modification, and the importance of frequent blood glucose monitoring should accompany all therapeutic interventions.

The relationship between age and healthcare expenditure among persons with diabetes mellitus

Few studies have examined how a person's age is related to healthcare expenditure among individuals with chronic conditions. The authors reviewed and examined the association between age and healthcare expenditure among persons with diabetes. Crude healthcare expenditure increases with age. Excluding expenditure associated with long-term and home healthcare, medical costs per person peaks at approximately 80 years of age. For males, persons aged 19-34 years had the lowest per-person medical costs, but, for females, those aged 0-18 years had the lowest per-person medical cost. Healthcare expenditure associated with long-term care and home care increased exponentially beyond 65 years of age. There were considerable differences between sexes in terms of the association of age with healthcare expenditure. Age is not a cause for increased healthcare costs; it is the ageing process and the increased likelihood of morbidity and mortality that comes with increasing age that lead to an increase in costs. The three dominant factors that mediate the positive relationship between age and healthcare expenditure are i) the high medical cost associated with death and the increasing likelihood of death with age; ii) increasing long-term and home care with age, particularly among the very elderly; and iii) the rising number and severity of diabetes-related complications with age. A person's age has no effect or a minimal positive effect on a person's demand for healthcare and total healthcare spending, after adjusting other covariates among persons with diabetes. The aging of populations should have a small impact on future healthcare expenditure. Including non-traditional factors in the cost model, such as proximity to death and prevalence of future diabetes-related complications, would improve the prediction of future healthcare expenditure for persons with diabetes.

Instant 99mTc-ciprofloxacin scintigraphy for the diagnosis of osteomyelitis in the diabetic foot

BACKGROUND

The diagnosis of osteomyelitis of the foot in patients with diabetes mellitus remains a challenge. This study was conducted to evaluate bone infections using scintigraphy with instantly prepared single-vial kit, radio-labeled ciprofloxacin (Diagnobact TM) in comparison to a bacterial culture taken from the involved site.

METHODS

Twenty-five patients with type 2 diabetes mellitus having foot ulcers, including six with superficial ulcers and positive 99mTc-methylene diphosphonate (MDP) bone scan as a control, were subjected to 99mTc-ciprofloxacin scan and subsequent bacteriological culture.

RESULTS

99mTc-ciprofloxacin scan was positive in 13 patients and negative in 12 patients, including the six with superficial ulcers. Bacterial culture was positive in 18 patients and negative in seven, including one with osteomyelitis on bone biopsy only. 99mTc-ciprofloxacin scan showed "true positive" results in 12, "true negative" in six, "false positive" in one, and "false negative" in six. The specificity and sensitivity of the test were 66.7% and 85.7%, respectively. The positive and negative predictive values and an accuracy of 92.8%, 50% and 72%, respectively. Staphylococcus aureus and Escherichia coli were the most frequently isolated organisms.

CONCLUSION

99mTc-ciprofloxacin is a sensitive and specific marker to diagnose bone infection in patients with diabetes mellitus, but care must be taken in case of fastidious organisms and ciprofloxacin-resistant bacterial flora in which false results may be obtained.

Urinary tract infection in diabetes

PURPOSE OF REVIEW

The aim of this article is to review recent publications relevant to understanding the interaction of urinary tract infection and diabetes mellitus, including epidemiology, pathogenesis, microbiology, and treatment.

RECENT FINDINGS

The largest number of identified reports described aspects of epidemiology, including defining the incidence and outcomes of urinary infection in patients with diabetes. In several reports, mortality and risk of hospitalization for urinary infection were not increased with diabetes, although length of hospitalization may be prolonged. Other reports quantify the increased incidence of cystitis or pyelonephritis in persons with diabetes, but remain subject to potential biases which could overestimate the occurrence in diabetic relative to non-diabetic populations. Several reports suggest that resistant bacteria are more frequently isolated from diabetic outpatients with urinary infection, but it is not clear how this is directly attributable to diabetes. There are no recent clinical trials which enhance our understanding of optimal treatment of symptomatic urinary infection, although several review articles acknowledge the appropriateness of the non-treatment of asymptomatic bacteriuria in diabetic women.

SUMMARY

Recent reports exploring diabetes and urinary tract infection provide some insights, particularly for risks of infection and outcomes, but there are no recent large advances in the knowledge base. Questions related to incidence, optimal treatment, and role of metabolic control still need to be addressed to expand the knowledge base and enhance management of this common problem.